1. 6th International HRO Conference 9-11 April 2013 Ralph T. Soule, Captain, US Navy, retired Strategic Reliability ralph.soule@gmail.com www.ralphsoule.me Tragedy to High Reliability DISTRIBUTION STATEMENT A: Approved for public release; distribution is unlimited.

2. Presentation Name Patient Safety and Quality 8 February 2013 History - Loss of THRESHER High Reliability Lessons: Submarine Safety (SUBSAFE) and other maintenance processes 2

3. Presentation Name Patient Safety and Quality 8 February 2013  Laid down, 28 May 1958, at Portsmouth Naval Shipyard, Kittery, ME.  Launched on 9 July 1960.  13 th 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 3 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

4. Presentation Name Patient Safety and Quality 8 February 2013 4 Submarine Buoyancy and Ballast Tanks

5. 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

6. Presentation Name Patient Safety and Quality 8 February 2013 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 6

7. Presentation Name Patient Safety and Quality 8 February 2013 Investigation Conclusions 7 Loss of propulsion power Flooding in the engine room Unable to secure from flooding Spray on electrical switchboards Unable to blow ballast tanks

8. Presentation Name Patient Safety and Quality 8 February 2013 8 SUBSAFE PROGRAM LOSS of THRESHER Overhaul/Construction MAINTENANCE PROCESS CHANGES Inception of the SUBSAFE and Significant Culture Change

9. Presentation Name Patient Safety and Quality 8 February 2013 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 9

10. Presentation Name Patient Safety and Quality 8 February 2013 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 10 Key Lessons

11. Presentation Name Patient Safety and Quality 8 February 2013 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... 11

12. Presentation Name Patient Safety and Quality 8 February 2013 Getting it Wrong

13. Presentation Name Patient Safety and Quality 8 February 2013 Checklists Work Model: training, procedures, supervision Critiques/Fact Sheets Risk Management Audits/Surveillances Pre-operative safety briefings Post-event/procedure debriefs 13 Navy Maintenance Tools for High Reliability

14. Presentation Name Patient Safety and Quality 8 February 2013 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 14 Post-action reviews (informal)

15. Presentation Name Patient Safety and Quality 8 February 2013 15 ACCIDENT TIME SAFETY LEVEL Minimum Optimum Understanding the Challenge - Actual - Perceived THE BATTLE WHERE YOU THINK YOU ARE WHERE YOU REALLY ARE

16. Presentation Name Patient Safety and Quality 8 February 2013

17. Presentation Name Patient Safety and Quality 8 February 2013 “Those who cannot remember the past are condemned to repeat it.” - George Santayana 17 “A good pre-event briefing beats an accident investigation any day.” - ADM Kinnaird R. McKee

18. Presentation Name Patient Safety and Quality 8 February 2013 Questions 18

19. Presentation Name Patient Safety and Quality 8 February 2013  Bierly and Spender (1995). Culture and High Reliability Organizations: The Case of the Nuclear Submarine. Journal of Management: Vol. 21, no. 4, pp. 639-656. Holzmann, Mischari, Goldberg, and Ziv (2012). New tools for learning: a case of organizational problem analysis derived from debriefing records in a medical center. The Learning Organization: Volume 19, Issue 2, pp. 148-162. http://rtsoule.squarespace.com/ralph-soule- blog/2009/12/6/what-we-really-learned-from- thresher.html Loss of the USS Thresher, Hearings Before the Joint Committee on Atomic Energy (http://www.perfectpr.com/Thresher2.html) What Sank the Thresher? Dean J. Golembeski Managing the Unexpected, Weick and Sutcliffe 19 References

20. Presentation Name Patient Safety and Quality 8 February 2013 BACK-UP SLIDES 20

21. Presentation Name Patient Safety and Quality 8 February 2013 Culture- Key Element of Success Submarine Safety Approach  Technical  Cultural 21

22. Presentation Name Patient Safety and Quality 8 February 2013  Work Discipline  Knowledge of and Compliance With Requirements  Material Control  Correct Material Installed Correctly  Documentation  Design Products (Specs, Drawings, Maintenance Standards, etc.)  Objective Quality Evidence (OQE)  Compliance Verification  Inspections, Surveillance, Technical Reviews, Audits  Continual Training 22 Culture- Key Element of Success The Fundamentals

23. Presentation Name Patient Safety and Quality 8 February 2013 Culture is a word for people’s “way of life”, meaning the way they do things. A Group of people has a separate culture when that group sets itself apart from others through its actions. 23 Culture- Key Element of Success SUBSAFE Culture