Professionalism/The Loss of USS Thresher

The USS Thresher (SSN-593) was a nuclear submarine that sank off of Cape Cod, Massachusetts on April 10th, 1963. The disaster made headlines nationwide and led to an extensive inquiry by both the Navy board and Congress. The inquiry's conclusions shed light on the professional responsibility of those building, commanding, and administering ships.

Normalization of Deviance
"Failures appear to be inevitable in the wake of prolonged success, which encourages lower margins of safety. Failures in turn lead to greater safety margins, and, hence, new periods of success." This quote epitomizes the social science concept of normalization of deviance, which was common in several aspects of the Thresher's design and operation.

Silver Brazing
A silver brazed pipe failure was one of the causes in the disaster. These failures were not uncommon; A breach in a silver brazed joint had led to a major flood several years earlier on the USS Barbel. There had also previous piping issues on the Thresher itself; even after overhaul work there was a significant percentage of sub-par connections. However, these shortcomings were considered normal in the Navy; According to testimony, the inspectors of the joints considered it "as good as any other ship". Nor was it only the silver brazed pipes that suffered from normalization of deviance. Admiral Rickover had gone out to inspect the ships and "found poor worksmanship all over." The shipyards were "using specifications as goals rather than requirements in certain cases." The silver brazed piping was a specific instance of low standards that was commonly accepted in the Navy.

Design Decisions
Several aspects of the Thresher's design also suffered from of normalization of deviance. The backup diesel generators were only designed to run emergency systems like lights. When a reactor scram occurred, the generators were not powerful enough to propel the ship. The ballast tanks were also undersized compared to previous submarines and unable to propel the ship to the surface from test depth. By design, the only way to recover from an emergency at test depth was to rely on the nuclear reactor. According to testimony, the submarine commanders "feel that their primary ability to recover lies in the fact that they have this tremendous power available". These decisions resulted from a lack of incidents regarding nuclear power; Since its first use on submarines in 1954 it had compiled a reliability record far exceeding the existing diesel technology. This overconfidence in nuclear power led to the looser safety standards for the backup systems, contributing to the loss of the ship.

Rescue Systems
Rescue Systems are a third example of lower standards. The state of the art underwater rescue system in 1963 was the McCann bell, which had been invented three decades before. Since it had only been used once in its lifetime, the Navy had elected not to design a replacement. Although the backup ship was not carrying this system, it would have been unable to help the men had they been trapped at test depth (~1300 ft.) because of the systems design depth (850 ft). After the disaster, the navy developed deep submergence rescue vehicles to ensure this would not happen again. This is an example of how disasters resulting from complacency can lead to increased safety standards.

Naval Management
Although the exact reason for the sinking of the Thresher is debated, mismanagement in the Thresher's construction certainly contributed to its sinking. These problems were exacerbated by a lack of central control for the submarine's construction.

Two Different Systems of Management
Two systems of management governed different portions of the Thresher: Admiral Rickover’s and the Bureau of Ships’ for the nuclear and non-nuclear portions of the submarine, respectively. According to Rickover, shipbuilding practices in the navy were sub par due to “the carelessness, looseness, and poor practices that have obtained in our shipbuilding business”, so he developed his own system to ensure quality control. Rickover’s standards were more stringent and the Navy thought it would be too costly to apply to the entire ship. For example, pipes in the nuclear propulsion system were welded rather than silver brazed because of previous piping failures, however, the rest of the ship had silver brazed pipes. No one was in charge of the entire submarine to enforce one standard and vision.

Safety vs. Mission Trade-Off
Thresher's management had a “mission above safety" attitude. Norman Friedman stated in an interview that according to the Navy, safety is beneficial only if it helps in accomplishing the mission. This attitude is evident in Thresher's management from Rear Admiral Curtze's statement:

"following Thresher’s loss, we must in all honesty say, as Rear Admiral Brockett, Chief of the Bureau of Ships, has already said, with respect to submarine design, we moved too fast and too far in areas of offensive and defensive capabilities. Submarine safety did not keep pace."

Lack of Communication
The Chief of Bureau of Ships sent a memo to the Commander of Portsmouth Naval Shipyard to create a test plan for piping system joints of the Thresher to address their inadequacies. The shipyard tested 145 out of 3,000 joints and found that 14 percent of them are “below standard.” The shipyard then stopped testing due to deadlines and increasing cost. After sending the memo, the Bureau of Ships did not hear back from the shipyard until after the Thresher sank. . They assumed testing went as planned. When asked about why the bureau did not follow up on the memo during the congressional hearing, Admiral Brockett replied, “I don’t believe it was considered to be a matter of priority.” This also illustrates that safety was not considered top priority in management of the Thresher.

Expectation vs. Reality
Management thought that the safety standards at the time were adequate, even though the Thresher was to undergo more stress than any submarine ever built. Friedman said, "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."

Connection to the Columbia Shuttle Incident
This case shares similar lessons with the Columbia shuttle case. Management pursued a philosophy that diminishes the importance of safety, which resulted in overlooking minor problems and reclassifying major problems to minor.

Influence of Organizational 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.

Disjointed Expertise
At the time, naval policy required officers to rotate to a new position every 2-3 years. This gave naval officers varied experience, but limited their expertise; As a result, the Thresher's construction quality suffered. In the approximately six years of design and construction, the shipyard had “three different commanders, three production officers, five planning officers, and three design superintendents.” After the disaster, Admiral Rickover rebuked the navy’s scattered responsibility, stating “You may delegate [responsibility], but it is still with you. Unless you can point your finger at the man who is responsible when something goes wrong, then you have never had anyone really responsible.” This level of responsibility was never present with the Thresher. Consequently, the commander and crew were ill prepared to recover at maximum depth when an incident occurred.

Defiance in the Military
Since most of the technical problems were known prior to the Thresher’s sinking, there were opportunities to blow the whistle. But whistle blowing has negative connotations of defiance against one’s organization, which is strongly discouraged by a strictly hierarchical military culture. Disobeying an order can result in court martial and dishonorable discharge, and the Military Whistleblower Protection Act did not exist until 25 years after the Thresher disaster. In a rare case of successful defiance in the military, [http://en.wikipedia.org/wiki/Hugh_Thompson,_Jr. Hugh Thompson] interrupted the mass murder of unarmed Vietnamese villagers during the Vietnam War, defying a superior officer and risking his own life in the process. The event earned Thompson death threats, and attempts to court martial him. While Thompson's courageous defiance eventually ended well for him, it shows how risks of defiance in the military. Claiming the Thresher was unfit for test depth pales in comparison to Thompson’s bravery, but would require bravery nonetheless. In the time leading up to the Thresher sinking, military organizational structure prevented anyone from calling out the unsafe conditions of the Thresher loudly enough to prevent the event.

Conclusion
Vast improvements to safety have since been made in submarine programs and throughout the Navy. But it took a disaster with expensive technology and many lives lost to provoke the Navy to change. 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."

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.