http://www.sunderlandecho.com/news/MoD3 ... 5106445.jp
MoD's 'complacency' led to sub deaths
25 March 2009
By Tim Booler
A Culture of complacency at the Royal Navy and Ministry of Defence led to the death of submariner Anthony Huntrod.
The 20-year-old, from Town End Farm, and crewmate Paul McCann, 32, from the West Midlands, died when a Self-Contained Oxygen Generator (Scog), exploded aboard HMS Tireless when the nuclear submarine was on an exercise beneath the Arctic ice caps.
After a six-week inquest at Doxford Park's Regus Centre, city coroner Derek Winter recorded a narrative verdict, saying "systematic failures led to the contamination and damage" of the Scogs on board, "which in turn caused the explosion".
He listed a catalogue of what the grieving families labelled "distressing errors" – particularly in logistics, handling and storage of Scogs – which contributed to the tragedy, which happened two years ago last Friday.
Returning 996 Scogs from a hazardous waste store to submarines without testing or proper inspection.
Failure to heed manufacturer's safety warnings about the storage, handling and inspection of Scogs.
"Confusing and inconsistent" statements about Scog use in operating manuals.
Scogs being roughly handled on board and at risk of being dropped.
Storage requirements relaxed, leaving Scogs stowed in unsuitable locations.
Failure to investigate a fire caused by contamination when oxygen candles were first trialed in the 1990s.
Failure to investigate or highlight other Scog fires on subs, including one aboard Tireless two days before the two submariners were killed.
In addition, the 44-minute rescue operation to reach the submarinerswas hampered because:
Submariners did not have a crowbar to open the buckled hatch door and were not aware for much of the time that one was available.
They had not been trained to break through metal obstacles in such situations, even though they were foreseeable.
Communications were impaired due to radio failures.
There were insufficient couplings for emergency breathing apparatus and inaccessible masks added to confusion at the centre of the rescue attempt.
Mr Winter said it might have been possible to save Mr McCann if he had been brought out sooner.
In summary, he said there was a "culture of complacency regarding the risks posed by Scogs and a tolerance of practices likely to increase thos risks".
The inquest also heard of another reason why the tragedy could have been avoided.
A large Scogs had to be used while Tireless was on a training exercise with the U.S. Navy in March 2007, because its low pressure electrolysers – the main source of oxygen – repeatedly froze.
Yet this could have been "remedied by a relatively simple and inexpensive procedure which would have reduced the need for Scogs to be used," said Mr Winter.
"If that problem had been rectified, the explosion would probably have been prevented."
Mr Winter said the MoD had addressed many of the problems associated with Scogs, but evidence at the inquest showed more action needed to be taken.
He vowed to write to the Secretary of State for Defence and the Minister for Armed Forces with recommendations to prevent such a tragedy happening again.
Meanwhile, Anthony Huntrod's dad has called for a civil servant to resign for his part in the chain of errors which led to the deaths.
The inquest heard that a batch of Self Contained Oxygen Generators (Scogs) in a hazardous waste depot in Devonport were returned to Royal Navy service in 2006.
Civil servant Christopher Clark decided to bring them back into use to cut costs for the MoD.
However, he did not give any consideration to safety – particularly as the Scogs, which provided emergency oxygen on board submarines – were stored at risk from contamination or damage, and he failed to arrange any specialised inspection or safety test.
"This was serious omission which was emblematic of a wider failure in assessment and management of Scogs," said Sunderland Coroner Derek Winter. "His decision was inappropriate."
Anthony's dad Alan said Mr Clark should resign, and urged the MoD should use ex-submariners instead of untrained civil servants to deal with technical equipment in stores.