"*He* was the one in charge, he had the authority and the backing, and
apparently he had good managerial skills. And every Tuesday without
fail we and every nuclear contractor had to send a letter addressed to
him *personally* that would begin"
See USS Thresher. "Too far, too fast." and look up the term Scope of
Certification which came into use after that failure.
"The shipyard then stopped testing due to deadlines and increasing cost."
Relying on standards:
"What probably happened was that quality control and safety standards
were all right down to operating depths of pre-Thresher subs. But when
they built one to go much deeper, the standards just weren?t good
enough anymore? The implications of the deeper depth weren?t totally
grasped."
Living with the culture:
"One interpretation of the case is that the Navy acted rashly sending
the Thresher to test depth, knowing the low chances of survival and
impossibility of rescue if an incident occurred. But naval customs and
military indoctrination of strict chain of command diffused
responsibility among the Thresher's commanders, crew, and technicians.
This situation created either unawareness of dangerous conditions, or
unwillingness to assume the risk of reporting risks and defying orders."
Living with the failure:
"The loss of loved ones is always difficult to bear, but military
families typically take comfort knowing their loved ones died
valiantly serving their country. The Thresher incident was different:
the submarine sank during what should have been a routine test. But
even now, 50 years later, families of those lost in the Thresher
disaster take comfort in knowing that the incident provoked major
overhauls in naval safety. "We are so appreciative that something good
came of this, with the creation of the SUBSAFE that the Navy has
taught us about all of these years later. USS Thresher changed
history.""
Software is a very different business if you have to look into the
faces of people you will kill by being too self-centered and unable to
see the big picture.
What should we learn:
"There are several lessons from this case that shed light on
professionalism. Professionals must exercise constant vigilance to
avoid the effects of normalization of deviance. This is a personal
responsibility, but also must be ingrained in programs such as
SUBSAFE. Management must uphold consistent standards of quality,
without diffusing responsibility. Professionals must also be willing
and able to spotlight unsafe practices, despite personal risk."
Most of us are in the shoe business and aching feet are just a fact of
life. It's a bad attitude in any profession.
