Combatting the curse of complacency: How integrity and accountability save lives

COMBATTING THE CURSE OF COMPLACENCY: HOW INTEGRITY AND ACCOUNTABILITY SAVE LIVES

BY ANNA TAYLOR • PUBLIC AFFAIRS SPECIALIST PHOTOS BY TONY ANDERSON • NNSY PHOTOGRAPHER 20 • SERVICE TO THE FLEET • JUNE 2018

When he speaks about the events of April 10, 1963, Retired Navy Capt. Joe Yurso paints a vivid picture of what it was like after attack submarine USS Thresher (SSN 593) sank with 129 Sailors and civilians aboard.

During his visit to Norfolk Naval Shipyard May 7, Yurso, who was watch officer at Portsmouth Naval Shipyard during the accident, spoke to a group of Engineering and Planning Department (Code 200) employees about the implications of Thresher’s loss, most notably the Submarine Safety (SUBSAFE) Program.

Thresher was built during the Cold War. Soviet missiles in Cuba posed a real threat to U.S. cities, and the risk of active nuclear engagement motivated the Navy’s decision to focus on the construction of ballistic missile submarines (SSBNs).

“Thresher was built at a time when missile submarines were the top priority,” said Yurso. “As a result, an attack submarine like Thresher did not always get the proper attention from the shipyard.

Portsmouth did a magnificent job to get Thresher built at a time when it wasn’t the lead ship.”

As the length of its availability grew due to the lack of resources, the shipyard stopped conducting necessary inspections and postponed various alterations and improvements in order to get Thresher finished and delivered to the fleet. Among the jobs that didn’t get accomplished were the removal of blow system strainers and the inspection of many silver-brazed joints.

LEFT: Retired Navy Capt. Joe Yurso speaks in the Bldg. 31 Innovation Lab May 7. Yurso was the watch officer when USS Thresher (SSN 593) sank April 10, 1963. OPPOSITE AND ABOVE: Engineers gather to hear Yurso speak about how the Navy submarine program has changed since the tragedy.

Despite losing manpower and talent to USS Abraham Lincoln (SSBN 602) and USS John Adams (SSBN 620), which were also being built at Portsmouth Naval Shipyard, Thresher was commissioned August 3, 1961. Following its delivery to the fleet and while undergoing routine exercises, Thresher exceeded all expectations.

“Because it was the lead ship of the class, they put it through pretty severe shock trials,” explained Yurso.

“They made it to test depth more than 40 times.”

The submarine received a certain amount of prestige associated with being the newest, most advanced attack submarine in the Navy, and many project team members vied for spots aboard its next deep-diving test.

“There were contractors, shipyard employees, Submarine Force Atlantic representatives, the ship superintendent, the design superintendent, and on and on and on,” said Yurso.

“There were all kinds of people who wanted to ride it.”

There were also people who were supposed to be onboard that tragic day whose plans changed at the last minute. The reactor plant officer was tending to his sick wife in the hospital. A Sailor got booted from the sailing list because there were already too many people making the trip.

According to Yurso, who would later become Commanding Officer of Portsmouth Naval Shipyard, Thresher’s crew was also hastily and inadequately trained, which may have contributed to the confusion aboard the overcrowded submarine when it began to experience minor difficulties during the dive to test depth.

“After Thresher was lost, the Navy convened a court of inquiry with some of the most experienced naval officers of the time,” said Yurso. “One of the key findings was that a silver-brazed piping joint in a seawater system exposed to sea pressure most probably had failed in the engine room. The leak would have damaged an electrical panel, resulting in the reactor shutting down automatically. This meant the submarine was suddenly left without propulsion or electrical power and was operating on batteries alone.”

Thresher’s crew expelled seawater from the ballast tanks to return to the surface, but they stopped the “blow” as they began to ascend.

“Thresher had strainers installed in her blow system to protect delicate valves from debris and dirt,” said Yurso, who currently

serves as the Director of Technical Development for Q.E.D. Systems Incorporated. “When they attempted to blow again, the strainers collapsed because of moisture in the piping, resulting in no or limited airflow. With no propulsion, and unable to expel water from the ballast tanks, the submarine sank to collapse depth.”

Thesher’s loss was the result of a perfect storm of poor decisions, and following months of investigation and reflection, the Navy committed to ensuring the tragedy would not be repeated.

Stringent submarine safety and quality assurance standards were implemented and enforced across the enterprise. According to guidance provided by Naval Sea Systems Command (NAVSEA), the culture of the SUBSAFE Program was built on the foundational elements of responsibility, accountability and integrity with an understanding that the consequences of failure are unacceptable; the pressures of costs and schedule are great; and an honest mistake can kill you just as easily as malpractice can.

“I had the honor of knowing many of the crewmembers,” said Yurso. “When the first messages arrived at Portsmouth, I realized how serious the situation was. When I took over the watch that afternoon, the Chief Petty Officer showed me the pile of messages and on top is the Skylark’s message indicating they were unable to contact Thresher.

The message wasn’t received until that afternoon, even though Thresher was lost that morning. Once the Navy recognized the submarine was lost with all hands, the situation became chaotic. None of us were prepared for this. Even now, more than 50 years later, rarely a day passes when I do not think of the tragedy. Through my entire career, it’s been impossible to put Thresher out of my mind. It’s embedded in my soul.”

Yurso said he is particularly concerned about the number of young employees working on submarines who may not know the story of the Thresher.

“There’s nobody alive today working for the Navy who experienced the Thresher loss,” he said. “We have to remind people why the SUBSAFE program exists. And after all this time, I’m concerned that with the pressure of reducing cost and building submarines faster, we are tempted to take shortcuts. It’s easy to make mistakes and we can’t get complacent. The more successful you are, the more hazardous complacency becomes. For the Navy, it’s been 55 years since Thresher, and we’ve done a lot to make submarines safer.

But we can’t attenuate those safeguards.”

JUNE 2018 • SERVICE TO THE FLEET • 21