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6th International HRO Conference9-11 April 2013
Ralph T. Soule, Captain, US Navy, retiredStrategic Reliability
Tragedy to High ReliabilityTragedy to High Reliability
DISTRIBUTION STATEMENT A: Approved for public release; distribution is unlimited.
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Presentation Name Patient Safety and Quality8 February 20132
Outline
History - Loss of THRESHER
High Reliability Lessons: Submarine Safety (SUBSAFE) and other maintenance processes
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Presentation Name Patient Safety and Quality8 February 20133
Laid down, 28 May 1958, at Portsmouth Naval Shipyard, Kittery, ME.
Launched on 9 July 1960.
13th nuclear powered attack submarine.
The first ship of its Class; leading edge of US submarine technology:
combining nuclear power with modern hull design
newly-designed equipment and components
USS THRESHER (SSN-593)
USS THRESHER launching ceremonies at the Portsmouth Naval Shipyard, Kittery, Maine, 9 July 1960.
She was fast, quiet, and deep diving
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Presentation Name Patient Safety and Quality8 February 20134
Submarine Buoyancy and Ballast Tanks
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On April 10, 1963, while engaged in a deep test dive, approximately 200 miles off the northeastern coast of the United States, the U.S.S. THRESHER (SSN-593), was lost at sea with all persons aboard - 112 naval personnel and 17
civilians.
THRESHER wreckage: About 200 miles off Cape Cod in 8,400 ft of water
PNSY
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Presentation Name Patient Safety and Quality8 February 20136
Navy Response to Loss of USS THRESHER
Immediately limited diving depth of all submarines
Court of Inquiry THRESHER Design
Appraisal Board Focus:
Design Construction Operation
Testimony Before Congress
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Presentation Name Patient Safety and Quality8 February 20137
Investigation Conclusions
Loss ofpropulsion
power
Flooding in the engine room Unable to secure
from flooding
Spray on electricalswitchboards
Unableto blow
ballast tanks
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Presentation Name Patient Safety and Quality8 February 20138
SUBSAFEPROGRAM
LOSS ofTHRESHER
Overhaul/Construction
MAINTENANCEPROCESSCHANGES
Inception of the SUBSAFE and Significant Culture Change
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Presentation Name Patient Safety and Quality8 February 20139
Key Lessons
“The loss of the Thresher should not be viewed solely as the result of failure of a specific braze, weld, system, or component, but rather should be considered a consequence of the philosophy of design, construction, and inspection … it is important that we reevaluate our present practices where, in the desire to make advancements, we may have forsaken the fundamentals of good engineering. ” – ADM Rickover
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Presentation Name Patient Safety and Quality8 February 201310
• Safety must be part of process design, not an afterthought• Key systems were under-designed for knowable risks• Failure to bound an unexpected problem• An attitude that specifications were merely goals, did not need
to be taken literally, and HQ permission not needed for failure to meet them
• Impact of accumulated conditions, not a single failure• The Navy had not updated its way of doing business to meet
the requirements of updated technology and high-performance ships that could operate in riskier environments
• Processes are only as good as their audit plan
Key Lessons
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Presentation Name Patient Safety and Quality8 February 201311
Navy High Reliability Practices
It is expensive and costly to wait for mistakes to learn Use existing debriefing records to tune awareness
Safety is created in the moment, where work is done, by the people doing it “High reliability is a continuous, ongoing, dynamic
accomplishment." The blindness of hindsight bias short
circuits learning ...
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Presentation Name Patient Safety and Quality8 February 2013
Getting it Wrong
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Presentation Name Patient Safety and Quality8 February 201313
• Checklists• Work Model: training,
procedures, supervision• Critiques/Fact Sheets• Risk Management• Audits/Surveillances• Pre-operative safety briefings• Post-event/procedure debriefs
Navy Maintenance Tools for High Reliability
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Presentation Name Patient Safety and Quality8 February 201314
• Key: capturing each person’s perspective, follow up
• Was the desired outcome achieved?• Things to do more often• Things not to do next time• Hazards caught (which ones remain open?)• Assess work process tools (effectiveness/utility
of pre-briefs, procedure, especially things not covered, but should be, training/qualifications -> management credibility rests with follow up)
• What were the surprises and how were they identified?
• Things to do differently next time
Post-action reviews (informal)
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Presentation Name Patient Safety and Quality8 February 201315
ACCIDENT
TIME
SA
FE
TY
L
EV
EL
Minimum
Optimum
Understanding the Challenge
- Actual
- Perceived
THE BATTLETHE BATTLEWHERE YOU THINK YOU ARE
WHERE YOU REALLY ARE
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Presentation Name Patient Safety and Quality8 February 2013
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Presentation Name Patient Safety and Quality8 February 201317
“Those who cannot remember the past are
condemned to repeat it.”
- George Santayana
“A good pre-event briefing beats an accident
investigation any day.”
- ADM Kinnaird R. McKee
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Presentation Name Patient Safety and Quality8 February 201318
Questions