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The previous three articles discusses Rickover’s “key elements” to achieving safety in the Navy’s nuclear program. They are:

  1. Technical Competence
  2. Total Responsibility
  3. Facing the Facts

In addition to these three keys that Rickover testified to Congress about, he had 18 other elements that he said were also indispensable. I won’t describe them in detail, but I will list them here:

  1. Conservatism of Design
  2. Robust Systems (design to avoid accidents and emergency system activation)
  3. Redundancy of Equipment (to avoid shutdowns and emergency actions)
  4. Inherently Stable Plant
  5. Full Testing of Plant (prior to operation)
  6. Detailed Prevent/Predictive Maintenance Schedules Strictly Adhered To
  7. Detailed Operating Procedures Developed by Operators, Improved with Experience, and Approved by Technical Experts
  8. Formal Design Documentation and Management of Change
  9. Strict Control of Vendor Provided Equipment (QA Inspections)
  10. Formal Reporting of Incidents and Sharing of Operational Experience
  11. Frequent Detailed Audits/Inspections by Independent, Highly Trained/Experienced Personnel that Report to Top Management
  12. Independent Safety Review by Government Authorities
  13. Personal Selection of Leaders (looking for exceptional technical knowledge and good judgment)
  14. One Year of Specialized Technical Training/Hands-On Experience Prior to 1st Assignment
  15. Advanced Training for Higher Leadership Positions
  16. Extensive Continuing Training and Requalification for All Personnel
  17. Strict Enforcement of Standards & Disqualification for Violations
  18. Frequent Internal Self-Assessments

Would like to review what Rickover had to say about them? See his testimony here:

Rickover Testimony

Now after the description of the excellence of Rickover’s program, you might think there was nothing to be improved. However, I think the program had three key weaknesses. They are:

  1. Blame Orientation (Lack of Praise)
  2. Fatigue
  3. Needed for Advanced Root Cause Analysis

Let me talk about each briefly.

BLAME ORIENTATION

The dark side of a high degree of responsibility was a tendency to blame the individual when something went wrong. Also, success wasn’t celebrated, it was expected. The result was burnout and attitude problems. This led to fairly high turnover rate among the junior leaders and enlisted sailors.

FATIGUE

Want to work long hours? Join the Nuclear Navy! Eighteen hour days, seven days a week, were normal when at sea. In port, three section duty (a 24 hour day every third day) was normal. This meant that you NEVER got a full weekend. Many errors were made due to fatigue. I remember a sailor was almost killed performing electrical work because of actions that just didn’t make sense. He had no explanation for his errors (they were multiple) and he knew better because he was the person that trained everyone else. But he had been working over 45 days straight with a minimum of 12 hours per day. Was he fatigued? It never showed up in the incident investigation.

ADVANCED ROOT CAUSE ANALYSIS

Root Cause Analysis in the Nuclear Navy is basic. Assign smart people and they will find good “permanent fixes” to problems. And this works … sometimes. The problem? The Nuke Navy doesn’t train sailors and officers how to investigate human errors. That’s where advanced root cause analysis comes in. TapRooT® has an expert system that helps people find the root causes of human error and produce fixes that stop the problems. Whenever I hire a Navy Nuke to work at System Improvements, they always tell me they already know about root cause analysis because they did that “on the boat.” But when they take one of our courses, they realize that they really had so much to learn.

Read Part 7:  Statement of Admiral Rickover in front of the Subcommittee on Energy Research and Production of the Committee on Science and Technology of the US House of Representatives – May 24, 1979

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