Part II

So much for the philosophy of root cause analysis. It suddenly occurred to us that Dietrich hadn't mentioned what he doing root cause analysis of. There was a big groan when he sheepishly admitted that his nephew's school work referred to the Kursk.

Getting a root cause analysis framework for the situation isn't too complicated -- we needed to know what happened, when and what area or service was impacted. SSGN Kursk was designed by Rubin Central Design bureau and launched in 1994 with a complement of 107 men. The submarine contained ten watertight compartments (emergency hatches in the first and ninth compartments), 24 cruise missiles, six torpedo tubes and cost 226 million Russian roubles. It set out from port on August 10 2000 with 118 men on board, to take part in scheduled war games with the rest of the Russian Northern Fleet. On 12 August 2000, the Kursk was scheduled to find a formation of ships and strike at its main target with a salvo of torpedoes. The Commander reported that the first task had been carried out, but the submarine did not make contact to report the completion of the second part of the task. There were two explosions at 11.29 and 11.31 (Moscow time). This information was confirmed by the Norwegian seismic array service, the three non-Russian submarines near the war games area, plus the Russian submarine and cruiser which were actually in the area.

The Kursk had suffered a huge explosion and sank in about two minutes. It was later realised that as at 13.00 on that date, 23 men had assembled in the ninth compartment. The escape hatch of that compartment had been damaged in the explosion and no one was able to escape. However, the men estimated that they could survive about ten days before rescue arrived. At 19.00 the same day, three submariners started to charge the regeneration unit to produce more oxygen to freshen the stale air. It was dark -- there was no electricity -- and water was leaking into the compartment. One of them dropped the regeneration plates into the water and there was an explosion which consumed all the oxygen and gave off huge amounts of carbon monoxide. As this explosion was unexpected, the submariners were not wearing the breathing gear they had by them. About five people were killed instantly by this explosion. The rest inhaled the carbon monoxide and fell unconscious into the water where they drowned.

Following intense pressure from the Russian media and the crew members' families, the part of the Kursk containing the ninth compartment was raised a year later by a Dutch consortium, Mammoet-Smit.

If we'd been keeping to the root cause analysis schedule, we should have been considering why the accident happened, looking at each step and how it contributed to the event, assessing the human, organisational, equipment and environmental factors, both controllable and uncontrollable, together with the human resource issues. Unfortunately, this is an area of few facts and many opinions, not to mention contradictory reports. Publicly available information was secondary and each author had his hidden agenda.

The knee-jerk reaction was to assume that the Kursk collided with another ship or submarine. There have been eleven documented collisions between Russian and NATO submarines between 1967 and 2000, eight of which occurred in that area of the Barents Sea. Between 1946 and 2001, there have been at least 115 incidents involving collisions between submarines and civilian ships and, since I'm spouting other people's statistics, six nuclear submarines, including the Kursk, have been lost at sea.

The idea that the Kursk was sunk by friendly fire was immediately rejected unanimously by the Russian experts. None of the missiles or torpedoes used in the war games contained real ammunition, on grounds of safety, lack of necessity and, especially, cost. The area was off limits to civilian ships and a subsequent examination of the submarine hull showed that no surface ship could inflict that sort of damage.

Whether the Kursk collided with another submarine is more difficult to assess. The accident occurred in very murky water with a strong cross-current. There were three non-Russian submarines near the area: the USS Memphis, USS Toledo, and HMS Splendid, as well as two intelligence ships: the USS Loyal and the Norwegian Marjata, all shadowing the Russian exercises. The Memphis appears to have been closest to the Kursk; immediately after the explosions, it withdrew from the area and subsequently headed towards Bergen for a courtesy visit or to replenish supplies or for repairs (sources vary) at the suspiciously low speed of between 5-9 knots per hour. A pair of Russian naval reconnaissance aircraft tracked the progress of the USS Memphis and very nearly caused an incident when they approached Norwegian airspace too closely without warning. The Russian government asked officially for a visual inspection of the Memphis' hull (also the Toledo's hull); this request was declined by the Pentagon and the Memphis shortly departed Bergen, possibly for Plymouth. I can't find a record of anyone wanting to see the Splendid's hull, but then the British government denied that there was a British submarine in the area anyway. (See what I mean about contradictory sources -- it's difficult to know what's true).

The case for suggesting a collision between two submarines is plausible. It could have happened by underwater ramming while the Russian submarine was moving up to the surface and the hypothetical other submarine was submerging. Something resembling a conning tower fairwater of the type mounted on US or UK submarines was discovered about 50 metres away from the Kursk, though there was no indication of whether it was recent or old wreckage. It was reported that a green and white rescue buoy was seen by the nuclear cruiser Peter the Great, but that later disappeared (the Russian navy use only red and white rescue buoys, but the UK, US and Norwegian navies use green and white ones). Initial investigation also allegedly reported a metallic anomaly near the wreck of the Kursk. Considering that the area had been the Northern Fleet's combat training range for many years, it is reasonable to assume that the investigators would be aware of any established wrecks. It was suggested by the Northern Fleet's commander, Admiral V Popov, that the anomaly had been making international SOS signals, produced by an automatic mechanism. He claimed that Russian submarines do not have this type of equipment.

There are several other theories, some of which run perilously close to the fantastic. One which seems quite reasonable refers to the torpedoes in the Kursk. The submarine was due to fire a torpedo on August 12. Although there were two torpedo designers on board, additional to normal crew, the torpedo to be used was the same sort which the Russian Navy has been using for about twenty years. However, the Kursk torpedo to be fired did have a new upgraded accumulator battery. UK torpedo designer Maurice Stradling has postulated that there might have been a leak of hydrogen peroxide, an oxidising agent in the torpedo, which caused the first explosion. He suggests that the second explosion could have been caused by a fireball detonation of the stored torpedoes. It's not totally unprecedented: a similar explosion apparently wrecked HMS Sidon at Devonport in 1955, killing 13 men. All this was aired in a BBC "Horizon" programme, which drew on "secret government documents".

Under normal circumstances, we'd have gone on to draw up an implementation plan and probably some fault trees. We might even have written out each cause on a separate piece of card (or electronic card) and linked them all with arrows of varying thickness depending on the importance and relevance of the links. We'd probably have fooled around re-enacting a submarine doing the killer whale jump. But Julio, who was bored, found an unusually sensational Russian press report which mentioned several previous documented leaks in the hydrogen peroxide and fuel tanks of the torpedo and that some official maintenance documents had been falsified and bore dummy signatures.

We all suddenly sat up, realising the quality implications of this. Speculating about a submarine accident when all we had to go on were memories of a childhood viewing of John Mills' film "Morning Departure" was one thing; realising that there had been deliberate quality fraud was another -- if it was true. We didn't know whether we could believe a report from a Russian newspaper which appeared to have been translated into English by a Frenchman. We didn't even know if the newspaper was an attention-seeking sensationalist tabloid or a serious broadsheet. All we knew was that our game of root cause analysis had gone sour, that Dietrich had got way more material than his nephew could possibly need for his school project and that we'd been shocked back into the ugly reality of the hurried, inadequately met deadlines of the real world. It was a sad ending to a pleasant evening: and all we had to look forward to tomorrow was Horace herding us downtown away from sumptuous restaurants and bars and into a picturesque cemetery.


  posted by Dovya R @ 12:26 PM :