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Action Taken On Oxygen Generators after Deaths of Two Submariners

HMS Tireless surfaces from testing submarine operability and war fighting capabilities in the Arctic waters of the North Polar Ice Cap region on 19 March 2007
HMS Tireless's crew after the submarine surfaced through the Arctic ice

The Ministry of Defence has today released the Board of Inquiry (BOI) report into the tragic loss of two Royal Navy Submariners, and the injury of a third, following an explosion onboard HMS Tireless on 21 March 2007.

The BOI concluded that the explosion which caused the death of Leading Operator Mechanic Paul McCann and Operator Mechanic Anthony Huntrod, was caused by a faulty self-contained oxygen generator (SCOG) which was part of the backup generator and was lit during a routine drill.

The Board has not determined precisely what caused the SCOG to explode. The report identified the most likely cause as significant internal contamination of the cannister with oil, possibly exacerbated by cracking within the cannister. The BOI concluded that the contamination could have occurred in storage on land or onboard submarines, with the latter being the most likely source.

Minister for the Armed Forces Bob Ainsworth said:

"Two members of the Royal Navy lost their lives and I want to extend my deepest sympathies to the families of Leading Operator Maintainer Paul McCann and Operator Maintainer Anthony Huntrod, and to their friends and colleagues, at this very difficult time.

"The bravery and professionalism shown by all of the Ship’s Company of HMS Tireless following the explosion cannot be underestimated and all those onboard should be very proud of their response to this incident which ensured that the situation was brought under control as quickly as possible and the submarine was able to surface safely.

"What the BOI has made clear to me is that this incident was brought about by a number of failings that were avoidable and for which the MOD is responsible. I would like to apologise again, unreservedly, and in public, to the families of Anthony Huntrod and Paul McCann for those failings, and for any actions or omissions that contributed to this tragic incident.

"I would like to reassure you that we have left no stone unturned in seeking to establish the causes of this incident in order that we may learn the lessons and ensure that there is no recurrence of this tragedy. We put action in hand immediately after the incident to minimise the risk associated with the use of oxygen generators. We have accepted all of the BOI recommendations, and they have been, or are being, implemented.

"I hope that the knowledge that we are committed to preventing a recurrence of this tragic incident brings some small comfort to the families and friends of Paul McCann and Anthony Huntrod."

Admiral Sir Jonathan Band, First Sea Lord and Chief of the Naval Staff said:

"As Minister Armed Forces has said, the accident onboard HMS Tireless on 21 March of last year resulted in the very tragic death of two Royal Navy personnel. As the professional head of the Royal Navy may I say first how very saddened I, and the entire Royal Navy feel when we lose members of our service.

"In doing so may I pay a specific and heartfelt tribute to the families and friends of Leading Operator Maintainer Paul McCann and Operator Maintainer Anthony Huntrod, for whom today must be particularly difficult. On behalf of the Royal Navy, I join with Minister Armed Forces in expressing to them our very sincere sympathies for their very sad loss.
"I would wish also pay tribute to the Ship's Company of HMS Tireless. Operating deep under the Arctic Ice Cap in a submarine is one of the more demanding and challenging environments that our Armed Forces operate in, and, as such, is one in which very few navies in the world can operate.

"We do so because we pride ourselves in being able to operate anywhere in the world, and to do it we train hard and comprehensively to ensure that the risks we take are minimised, and are indeed commensurate with the need to maintain our fighting edge.

"As you know in March of last year, HMS Tireless suffered an explosion in her forward escape compartment. The Commanding Officer and his Ship's Company fought to extinguish the fires caused by the explosion, deal with the incident and then, manoeuvred the submarine 2 miles to where there was a thin area of ice above and carefully and safely brought the submarine to the surface through the ice so that the noxious fumes in the front half of the submarine could be ventilated out.

"The sheer professionalism demonstrated by the Ship’s Company of HMS Tireless, in what where very challenging circumstances was exemplary and is testament to their teamwork and their training.

"While the explosion created fires and smoke in the submarine, submarines carry emergency fire fighting equipment and all members of the Ship’s Company complete rigorous training to enable them to deal with such circumstances. As a consequence, and notwithstanding the seriousness of the incident, at no time was the submarine’s water tight integrity or buoyancy threatened.

"The Royal Navy and its Submarine Service is one of the finest in the world and its training is considered by other navies to be of the highest standard and one to which they might aspire. It is very tragic that we lost 2 of our service during this incident and we owe it them and their families to learn the lessons - and put matters right.

"As the Minister has already said we are doing exactly that, and that while serving in the Armed Forces does not come without some risk, we must do our utmost to reduce those risks and to prevent incidents such as the one that occurred onboard HMS Tireless."

Representing the Chief of Defence Materiel, Vice Admiral Trevor Soar of Defence Equipment and Support (DE&S) highlighted the main points of the report:

"I would like to explain how Defence Equipment and Support responded to the tragic events on HMS Tireless, the Board of Inquiry, and to explain what further investigation I have underway. As a submariner myself I understand the very close community that the submarine service generates and how the loss of LOM Paul McCann and OM2 Anthony Huntrod will be keenly felt by all who served with them.

"The Royal Navy and its Submarine Service is one of the finest in the world and its training is considered by other navies to be of the highest standard and one to which they might aspire. It is very tragic that we lost 2 of our service during this incident and we owe it them and their families to learn the lessons - and put matters right.

"As the Minister has already said we are doing exactly that, and that while serving in the Armed Forces does not come without some risk, we must do our utmost to reduce those risks and to prevent incidents such as the one that occurred onboard HMS Tireless."

"Since the HMS Tireless accident DE&S have worked closely with the BOI team and the Royal Navy in actively progressing a number of actions that arose from both the immediate aftermath of the accident, and as facts have emerged, from the BOI comprehensive investigations.

"First of all to address the immediate safety issue, within days of the incident we issued instructions not to use Self Contained Oxygen Generators onboard any submarine with the only exception being for emergency escape.
 
"Secondly DE&S have, as the facts arose, re-designed and manufactured an improved SCOG with enhanced protection from hydro-carbon contamination, better labelling and which are subject to an enhanced quality control regime, these again will only be authorised for use in emergency situations.

"The first batch has already been delivered last Friday to the submarine flotilla and I expect the roll-out to be complete by the end of the year.

"Thirdly, drawing on the full lessons learnt from the enquiry, including recent forensic results, we are working with NASA to develop an entirely new design of SCOG which can be used on a more routine basis. We aim to get this into service next year.

"Finally, the Royal Navy and DE&S are taking forward the full list of recommendations from the BOI. Of the 25 recommendations that involve DE&S all are either complete or have a firm action plan in place. [9/25 complete]

"Let me now turn to the DE&S investigation. The publication of the BOI report raised a number of issues in relation to the logistic management of SCOGs. In conjunction with Babcock Marine in Devonport we are conducting our own detailed investigation into the acquisition, manufacture, storage, submarine stowage and logistic management of SCOGs which will also include the management for their return and subsequent disposal.

"The investigation, conducted by our own subject matter experts, will determine if any further issues need resolving, make recommendations for potential improvements and determine if there are any grounds for further action.

"It is too soon to say what the outcome will be but I am determined to ensure that DE&S addresses every issue that has arisen as fully and quickly as possible."