the ehime maru tragedy an exercise in human performance lance sawyer pg&e, diablo canyon power...
TRANSCRIPT
The Ehime Maru TragedyAn Exercise in Human Performance
Lance Sawyer
PG&E, Diablo Canyon Power Plant
June 15, 2001
USS GreenevilleFebruary 9, 2001
You are the crew of one of the US Navy’s modern nuclear Submarines. Our mission today is to demonstrate the performance capabilities of this incredible machine to a group of civilians.
• Builders: Newport News Shipbuilding Co.; General Dynamics Electric Boat Division. Christened by Tipper Gore on September 17, 1994.
• Power Plant: 33 year lifetime nuclear reactor, one shaft
• Displacement: Approx. 6,900 tons
• Speed: 20+ knots (23+ miles per hour)
• Crew: 16 Officers, 126 Enlisted
• Improvements: hardened sail and retractable bow planes for surfacing through the ice during Arctic missions.
Statistics for the Los Angeles class
Plan of the Day – DV Cruise0230 Brief and Startup Reactor
0715 Station Maneuvering Watch
0800 Underway
1000 Dive/Deep Dive (Classified Depth, not normally done for Civilians)
1100 Lunch
1230 Angles and High Speed Maneuvers
1300 Emergency Blow
1330 Station Maneuvering Watch
1500 Back in Port
Coming To Periscope Depth
• It is critical to verify the surface is clear prior to surfacing
• Fire Control will verify location of surface contacts prior to coming to PD
• Standing Orders for coming to PD– Two good TMA legs
– Periscope brief with FT, Sonar, and others
– Report to CO and obtain permission
Distinguished Visitors
• We will have 15 visitors, mostly Executives and their wives, escorted by Captain BrandHeuber.
• They will be allowed to operate controls, but must be under the strict direct control of the watchstander.
• They can tour the boat forward of the Reactor Compartment, but should be in the Control Room when design maneuvers begin.
Mission Information
• We had a four month overhaul followed by a month at sea, getting back last week, but, hey it’s Friday, and we’re in beautiful Honolulu!
• I know we were supposed to be at sea for the next few days, but that is delayed until Monday due to this DV group tour.
• Skies are hazy and off-white. Seas are choppy, with swells of 6 feet or more.
• Man the stations with whoever you have available, as many of our crew are off today.
Tailboard• Any Error Precursors?
• Any Error Likely Situations?
• Any Flawed Defenses?
• Remember:– Safety
– Efficiency
– Backup
Tracking Surface Contacts
• Sonar is passive, listening for ships on the surface
• Difficult to acquire when changing directions rapidly
• Visual Display in Control Room is out of commission, no formal compensatory action taken
Ehime Maru
• Crew: 67Gross tonnage: 741Length: 58 m Breadth: 9.3 mMain engine: Akasaka E28BFDMax Trail Speed: 15.05knotsColor: White
• Training and research ship for Uwajima Fisheries High School, used for cadet training and for fisheries and oceanographic research.
• Built at Hashihama Works, completed and delivered in June 1996.
• Yusuke Terata, student, 17
• Toshiya Sakashima, student, 17
• Takeshi Mizuguchi, student, 17
• Katsuya Nomoto, student, 17
• Hirotaka Segawa, crewman, 60
• Hiroshi Nishida, crewman, 49
• Toshimichi Furuya, chief engineer, 47
• Hiroshi Makizawa, teacher, 37
• Jun Nakata, teacher, 33
Casualties
What happened?
• Artificial urgency
• Disregarded policies and procedures
• Failure of ship’s contact management team to work together and pass information
• Command climate
• Distracted by civilian guests
• Overconfidence
• Complacency
• Short of people and use of Unqualified Watchstander
• Briefs not done
Questions
• Do you think that they had operated in this manner in the past?
• When they did, do you think they felt like they were doing the right thing?
• Do you think they ever thought anything like this could happen?
Comparisons to a Nuclear Power Plant
• Team Dynamics
• Situational Awareness
• Tailboards
• Participation by everyone
• Distractions that may not be obvious
• Time pressure