USS Hartford Lessons Learned
VADM Donnelly, COMSUBFOR, made some extemporaneous remarks recently about lessons learned from the March 2009 USS Hartford (SSN 768) collision. Excerpts:
Speaking Wednesday at the annual Naval Submarine League meeting, Submarine Force commander Vice Adm. Jay Donnelly described a control room with “a lot of informality” and a “series of personnel failures” he blamed on the sub’s leadership.Another reminder that submarining is always dangerous, no matter how good you think you are.
The collision, which happened at night, came as the sub was making a submerged transit to Jebel Ali, its last port call before heading home to Groton, Conn.
The crew had just finished an intense operational phase of its deployment and “everybody let down their guard” for what was actually one of the most challenging phases, crossing the strait at periscope depth, he said.
“There was a great deal of complacency involved in the crew,” he said. “They had been at sea for 63 days operating in areas with high contact density.”
Update 1049 31 October: Turned off comments.
posted by Bubblehead at 9:09 AM
12 Comments:
Complacency
www.Google.com/Dictionary
1 : self-satisfaction especially when accompanied by unawareness of actual dangers or deficiencies
2 : an instance of complacency
http://www.google.com/dictionary?langpair=en%7Cen&q=complacency+&hl=en&aq=f
Complacency is being complacent about a situation. N-UNCOUNT disapproval
a worrying level of complacency about the risks of infection from AIDS. + 'about'
She warned that there was no room for complacency on inflation. + 'on'
the feeling you have when you are satisfied with yourself; "his complacency was absolutely disgusting"
wordnetweb.princeton.edu/perl/webwn
Contentment (also called complacence) is the neuro-physiological experience of satisfaction and being at ease in one's situation, bodymind (cf. John Money), body, and/or mind.
en.wikipedia.org/wiki/Complacency
A feeling of contented self-satisfaction, especially when unaware of upcoming trouble; An instance of self-satisfaction
en.wiktionary.org/wiki/complacency
complacent - contented to a fault with oneself or one's actions; "he had become complacent after years of success"; "his self-satisfied dignity"
wordnetweb.princeton.edu/perl/webwn
complacent - Uncritically satisfied with oneself or one's achievements; smug
en.wiktionary.org/wiki/complacent
10/29/2009 5:08 PM
WTF Mulligan -
That's plaugarism....Have your own thoughts for a change!
AND KEEP THEM TO YOURSELF!
ASS HAT
10/29/2009 5:14 PM
I think we have all had a moment of "Been there, done that" at one point or another. These guys just had that moment at the wrong time, and they got bit.
The rest of us have been lucky.
10/29/2009 5:32 PM
Accidents come about because a intensifying cloud of local and systemic opaqueness with a organization, within cooperating organization or accommodating related organizations. The organization is in a self protection mode and generally based on altruism for us all...they increasingly withhold information to the outsiders and the community. Generally the opaqueness is institutionalize through legislation, policies and rules...the I hate the government and the political vehicle of deregulation and privacy.
What happens, is as they withhold more information to the public, the inside behavior artificially looks like it is improving. An agency like the NRC is forced through a set of rules changes, the inspectors are severely regulated...they have to follow policies and rules that pushes out a pleasing public view of plant and industry conditions. A nuclear plant knows the public sees less...so they take increasing chances and greater risk. I think they get immune to the increasing risk of a accident or how the public will interpret secret corrupt like behavior...that the rules and policies facilitate.
I will tell you a truth, when we keep secrets about ourselves to outsiders...we are really keeping secrets from ourselves. When we as a organization keep secrets from outsiders...we are really limiting the open communication within the organization.
I think we normalize risk talking and then we down play a change of culture, in the environment around us, our relationships and the increasing indication seen within the components and systems. We numb ourselves until we fall off the cliff. Complacency is not the disease, it is untransparency and secrets that caused TMI and Davis Besse. It is the essence of withholding information to the outsiders...it is what this causes us to become. I think this disconnection to the community, this cloud of secrets, it exhaust us and demoralizes us. I think that is what we call complacency.
In the end, whether it is TMI or Davis Besse, after the accident, we always say retroactively that the organizational behavior was severely degraded before the accident even began. Nobody at the plant and the regulators could see the serious and dangerous defects in the cultural developing before the accident. There is outright lying and deception on a host of levels, but everyone denied there was even a problem until many months after the accident. Post accident, we go back and find many document and incidences that condemns the plant’s and the regulator prior to the accident.
It is this darkening cloud of untransparency and the pull back of communication in order to keep secrets...that rationalizes our interpretation of complacency. To the one, that darkening of the communication cloud, that intensification of the organizational fog, chasing short term profits and running away from budget problems, or operational problems, plant design or construction problems, is always the genesis of withholding information to outsiders. When we withhold information to outsiders, normalize it, we increasingly keep secrets within the organization. The organization blinds themselves more that they blinds the outsiders...it is a process of self blindness. ( So a nuclear plant chases short term profits, the submarine fleet and the navy as a whole chases short term operational necessities with insufficient resources. That is what causes these accidents not complacency)
That is how really stupid accidents in hindsight comes out of no where. That is how two professional pilots end up focusing on their laptop while flying a airplane...it is untransparcy that causes numbness, what we call as complacency that causes accidents.
10/29/2009 6:58 PM
I am just trying to figure out if complacence or complacency is the right word...we know during the work up to the TMI accident they had terrible issues with construction problems and the early plants' had terrible and costly early operational problems...a terrible operational capacity fleet wide. It was chaos and disorder, and a bridge too far, that rained down on the nuclear industry. How could you be complacent during those times...how could complacency be the mechanism of TMI? Complacency is just the wrong word.
You see what I am getting at with the new fleet of nuclear plants, is the war about complacency or is it about non transparency or opaqueness...about communications?
I hate using the term “root cause” but if there is a root cause in common with all these events it is the opaquely of the system that has caused these accidents. If we seen what actually was going on, we would never tolerate this kind of behavior. I mean you have to have hope for humanity, if we seen it we wouldn’t tolerate it. What if we seen the disorder and we collectively said who cares. I have seen that too. It’s that scary or what. I just think when humans get behind barriers, we end up playing word games and increasingly work towards the ends of our self interest, chaos and disorder erupts, we go into this destructive rationalization process, many times a competitive rationalization process, we become numb and exhausted, we become immune to seeing the changes around us...then the stupid accident occurs that nobody can explain. Well, actually we explain it as complacency.
We go into secrets and withholding information when we can't directly face up to our problems with clear eyes. Is non transparency a unstoppable progressive disease process, does it change the circuits of our brains...is it a disease of the organization or the collative? Don’t get me talking about our denial process and rationalization? Is organizational opaqueness and non transparency a mental virus, a meme or thought virus, does it shutdown our immune system, I mean the thought process or mental process of doing what is good for us all.
The think I have talked about this before...the phrase “perception is reality”...the word compacency remind me of this. Doesn’t that worry you about us engineering our collective reality for our own ends.
I mean, is complacency the new buzz word in our culture, is it a cop out of the highest order?
http://news.bbc.co.uk/2/hi/uk_news/8329117.stm
"Its production is a story of incompetence, complacency and cynicism.
http://www.navytimes.com/news/2009/10/navy_hartford_lessons_102809w/
"Admiral: Complacency caused sub collision"
http://www.nrc.gov/reading-rm/doc-collections/commission/speeches/2009/s-09-030.html
“The Foundations of Nuclear Regulation in the 21ST Century:
Safety, Security, and Global Communication”
Commissioner Dale E. Klein, PhD
U.S. Nuclear Regulatory Commission
(He was talking about what caused Three mile Island.)
"This accident revealed the presence of regulatory and industry weaknesses we now understand are inherent in any regulatory environment: success breeds complacency. Complacency is the primary enemy of an effective regulatory program."
Thanks,
Mike
10/29/2009 7:06 PM
Bubblehead:
Pls edit or delete this thread....not befitting of TSSBP!
10/29/2009 7:26 PM
Mike Mulligan said...
Accidents come about because a intensifying cloud of local and systemic opaqueness with a organization, within cooperating organization or accommodating related organizations.
Thanks Dilbert.
10/29/2009 7:36 PM
I think MM's perception is a very clouded version of our reality. I think there may be some kind of chemicals in that cloud.
10/30/2009 8:13 AM
Mulligan- your communication skills are terrible. I don't know what your objective is, but unless it is irritating other netizens or being ignored by same, you should work on your message delivery. Elsewhere. Please.
-3383
10/30/2009 2:59 PM
@Mulligan, no-one but no-one who's been on this blog before is going to bother read any post of yours longer than your limp dick, let alone the novels above - so you might as well save yourself the carpal-tunnel and exercise some self-control, and we can save ourselves excessive scrolling...
10/30/2009 5:26 PM
One would assume most who post here are fairly intelligent. Yet day after day, Mulligan will spew nonsense, then worse, the usual chorus of knuckleheads will directly respond in kind.
Remember dummies, the stupid shall be punished.
Carry on.
10/30/2009 9:39 PM
Methinks the Hartford has been covered enough here. TSHBP...never forget, but time to move on.
10/31/2009 3:01 AM
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