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The board of inquiry set out the background to an explosion in the forward escape compartment of HMS Tireless on 21 March 2007, while she was undertaking an exercise under the ice near north Alaska. The explosion caused the death of two of the ships company and filled the forward end of the submarine with smoke. Small fires followed the explosion which, had they taken hold and a major conflagration ensued, would have had even more serious consequences. Instead, however, the extensive training and preparation undertaken by all submariners proved their worth, and owing to the professional conduct of the ships company, and in
particular the stamina and presence of mind of one member, who was already seriously injured, the incident was rapidly contained. The integrity of the submarine and the power plant remained secure at all times.
The board concluded that the explosion was caused by a self-contained oxygen generatora SCOGwhich had been wholly appropriately activated by one of those who lost their lives. It has not been possible to determine beyond doubt what caused the oxygen generator to explode. However, the board did identify the most likely cause as significant internal contamination of the generators canister with oil, probably enabled by cracking within the canister solids. Organic contaminants are a known hazard for these oxygen generators, which are manufactured with protective seals, but cracking had not been previously identified as a contributing risk factor. In the event, the board was not able to establish how any contamination occurred, but oil would certainly have been present in the submarine environment, and this, it says, is the most likely cause of the contamination.
The board of inquiry has exposed an inadequate appreciation of the risks of contamination and a number of shortcomings in the logistic handling of these generators. The shortcomings identified include SCOGs being left, unprotected, on the dockside and SCOGs being stowed on board submarines in a manner that left them at risk of contamination. The board of inquiry also found that there were a number of SCOGs that had previously been earmarked to be taken out of service which were returned for use on submarines. This was achieved by changing the paperwork. The board established that it could not be known for certain whether any of these SCOGs subsequently ended up on HMS Tireless.
These events are unacceptable and it is clear from the board of inquiry, and other work to date, that the Ministry of Defence must accept responsibility for what happened. My right hon. Friend the Secretary of State and I therefore consider that it is right for me to apologise unreservedly, on behalf of the Department, for the actions or omissions that contributed to this tragic incident. I am extremely sorry, particularly to the families of those who lost their lives, and to those who were injured.
We have already investigated whether any of the shortcomings were such that criminal negligence was involved. The Crown Prosecution Service has advised that the evidence does not support a prosecution, although it directed that the Health and Safety Executive must be made aware of the findings. This has been done and the Health and Safety Executive will now examine the reports and recommendations and see whether an investigation is required under its own powers.
In addition, the Defence Equipment and Support organisation is carrying out a detailed investigation into the acquisition, manufacture, storage, submarine stowage and logistic management of SCOGs, to ensure that any further lessons are identified. Given that ongoing investigation, the House will understand that at this stage it would not be right for me to comment in detail on issues that remain the subject of an investigation.
We have taken urgent action to seek to ensure that there is no recurrence of this tragedy. All the board of inquirys recommendations have been accepted and have been, or are being, implemented. In addition, we put
action in hand immediately after the accident to minimise the risk associated with oxygen generators. Their use has been tightly restricted to an emergency-only basis since the incident. These emergency oxygen generators are stowed separately and handled less frequently on board a submarine than those that were assigned for routine use.
All emergency oxygen generators have been inspected for any signs of damage or possible contamination since the incident. This is to ensure that risks are minimised, should oxygen need to be generated in the unlikely event of an emergency situation. Developments have already been made to upgrade the design of the canisters further to reduce risks, and we have already started to replace the emergency stocks with an upgraded design. We are also working towards developing an alternative solution to meet future operational requirements.
It will never be possible to eliminate every risk to those who serve our country in our armed forces so selflessly, but I can assure the House that my right hon. Friend and I do and will continue to do everything we can to minimise those risks wherever possible. I will make copies of the board of inquiry report available in the Library of the House. Action continues to implement its recommendations. I will update the House as further developments emerge.
Dr. Julian Lewis (New Forest, East) (Con): I begin by thanking the Minister for advance sight of his statement and of the board of inquiry report. That is a long, detailed and thorough document which does not pull its punches. It is not surprising that it took longer than the originally anticipated four months to complete, but can the Minister explain why it has taken fully 15 months to complete, for the information not only of the House but above all for the families of those who lost their lives?
Despite careful handling within service channels, the story broke in the media before all the next of kin had been informed and before . . . staff had been able to contact the next of kin of the remainder of Tirelesss crew.
Can the Minister throw light on how that happened, and explain to the House what safeguards have been agreed with the media on not reporting military fatalities before the families have been told, and whether such safeguards were flouted on this occasion?
If it had not been for the outstanding efforts of
the consequences of this incident may have been much worse.
the vessel was never in any danger?
injured by the initial blast and thrown to the deck . . . recovered himself despite his injuries, placed an emergency breathing mask on his face and, in complete darkness and zero visibility due to the smoke, extinguished the numerous small fires in the compartment and allowed access to the fire-fighting and medical teams.
The report reveals that owing to the buckling of the bulkhead doors, it took 44 minutes before anyone was
able to get into the compartment, and the conditions in which that seaman was operating can barely be imagined.
The injured submariner who is reported to have acted so heroically has not been named in the report. I wonder why that is. Is he one of the seven submariners who have been honoured with their commander-in-chiefs commendation so far? Is he to be separately honoured? If he cannot be named for security reasons, does the Minister agree that that should not prevent his bravery being appropriately rewarded?
Turning to the self-contained oxygen generators, I understand that these have been fitted in Trafalgar class submarines since 2001. Will the Minister tell us whether they have also been fitted to the Vanguard class submarines that carry the nuclear deterrent; if so, what is the status of such SCOGs on these particularly important vessels in the Royal Navy?
We understand that, on this occasion, the accident occurred some distance away from the nuclear reactor in the submarine, but are SCOGs fitted to other parts of the submarine that are closer to the nuclear reactor? How near was the explosion to the cruise missilesconventionally armed cruise missiles, which are the standard main armament of Trafalgar class submarines such as HMS Tirelessand how near was it to other explosive hardware carried by the submarine? Are there any other combustible products deployed on Her Majestys submarines similar to SCOGs to which similarly lax procedures as described by the Minister have applied?
shortcomings in the acquisition, manufacture, transport, storage, stowage and logistics management of SCOGs.
The existing population... should be withdrawn from service
MoD-approved quality control checks and acceptance processes
introduced to ensure that the manufacturer supplies sodium chlorate candles that are free from contamination and physical damage.
Logistics management for the SCOG replacement must ensure that guidance is clear about when the equipment is to be designated unserviceable.
Sufficient approved stowages should be identified,
which suggests that there were not enough stowages for those dangerous products in the submarines, so I would be grateful if the Minister updated us on that point. If, as I have already alluded to, the bulkhead doors jammed shut, that is really a design fault that I would not have thought could happen in a modern nuclear-powered submarine.
Significant sections of the report have been redacted, perhaps out of consideration for the families. Is the Minister satisfied that the arrangements made for the return of the deceased to the United Kingdom were handled correctly?
Finally, I would like to say that the tributes to the two young men have shown what outstanding personalities they were. Paul McCann, from Halesowen, was a keen sportsman with an inspirational personality, who was about to leave the service to marry his American fiancée last August. Tony Huntrod from Sunderland was a live wire with great charm and a fine sense of humour. They both join the roll of more than 5,000 submariners commemorated in the constituency of my hon. Friend the Member for Gosport (Peter Viggers). We should all be very proud of them and very grateful to them and their families.
Mr. Ainsworth: I shall try to answer as many of the hon. Gentlemans questions as I can. The report took 15 months to complete. We have been everywhere in the effort to understand the detail of what happened. When I first approached the matter without knowing the detail, I wondered why it was taking so long and I was worried about the impact on the families. We went all the way, however, and even involved NASAthese vessels and the expertise associated with them are associated with the space programmein order to understand all the ramifications. In the circumstances, I am sure that everyone would agree that thoroughness was more important than timeliness, although it is indeed unfortunate that these things take as long as they do.
We struggled to make contact with the families, and it took longer than it should have done. Record keeping was part of the difficulty. None the less, that does not excuse the media behaving as they did. I wish that they always honouredthey often doour kin-informing processes. We should all encourage them to do so, not only because of the distress caused to the individuals concerned, but because of the worry caused to the whole of the rest of the fleet in this case, or to our people on operations in other cases.
On whether the vessel was in any danger, I am assured that it was not, but that does not detract from the fact that the conflagration could have been far worse had it not been for the actions of one particular individual. As I said, he was injured at the time, yet he struggled on and did a magnificent job. He has not been named because the wishes of that individual must be paramount over the views of anybody else. It is up to the individual himself how he wants to handle this.
The problem was not, contrary to what has been reported, the jamming of the bulkhead door; it was another door into the compartment that jammed and took 40-odd minutes to get open. That door has been replaced by a mesh door, which will now be rolled out throughout the fleet. The board of inquiry exposed other issues about the adequacy of the equipment on board to break into the compartment in an emergency. That is being looked at and the recommendations are being implemented.
On whether the SCOGs were beyond their sell-by date, they have a 15-year life expectancy and the Navy imposes a 10-year life expectancy in order to put some redundancy into the position. These SCOGs were introduced only in 2003, so the sell-by date of the equipment is not an issue here, although I have said yes about other serious issues.
Stowage on board submarines was one of the issues flagged up. The generators for emergency use are stowed in different circumstances in different conditions and are not moved on and off submarines, so they are in good condition. As I have already said, they were all inspected. The generators used to add to the oxygen requirements, however, are routinely removed from submarines and have not been stowed on submarines where they would be safe from contamination from oil.
There were issues about the handling of the bodies which have caused great distress to the families concerned. I do not wish to go into further detail on that, although there are lessons to be learned. I have discussed the matter privately, as has the Chief of the Naval Staff, with the families.
Bill Etherington (Sunderland, North) (Lab): It goes without saying that no one gets any joy out of speaking in such a harrowing debate as this one. I join my right hon. Friend the Minister in expressing condolences to both the families of the deceased. I have dealt with one of the familiesthat of the late Mr. Huntrodand I would like to place on record my great appreciation of the courtesy and caring attitude of the Minister in his dealings with my office. I thank him most sincerely.
Nick Harvey (North Devon) (LD): I thank the Minister for making the statement today, giving an unreserved apology and accepting the Ministrys responsibility for what has gone wrong. When there is a responsibility of that sort, it is right to accept it, and I commend him for doing that today. I also pay tribute to Paul McCann and Anthony Huntrod, and echo the condolences that have been offered to their families.
I know from having been on board a Royal Navy submarine that the culture of safety is paramount in everyones mind. I welcome the assurances that we have been given that neither the vessel nor the nuclear power plant was at any point endangered, even if that was, in some sense, down to the heroic actions of one individual.
I have not had access to the report, only the statement, for which I thank the Minister. He talked at considerable length about the oxygen generators and has described the measures that will be taken to try to ensure that the problem does not arise again. I would like to ask him about a slightly separate matter. Ever since the incident, accounts have emerged that it happened close to some of the sleeping quarters on board the submarine, that members of the crew emerged from their sleep, in understandably minimal clothing, into a smoky and hot atmosphere, and that adequate supplies of breathing equipment and points to plug it into and fire-retardant clothing were not available.
Those shortcomings, as well as the points that the hon. Member for New Forest, East (Dr. Lewis) made about the lack of next-of-kin information being readily available, cause me some surprise, as they both seem fairly basic. I would welcome from the Minister an acknowledgement that such problems have been identified
and a description of what steps will be taken to remedy what sound like fairly straightforward but rather important shortcomings, both on the Tireless and any other vessel.
Mr. Ainsworth: I apologise to the hon. Gentleman: it was certainly my intention that he, like the official Opposition spokesman and the Chairman of the Defence Committee, receive the board of inquiry document along with a copy of my statement. If that has not happened, I can only apologise to him. He will be able to get a copy of the document from the Library, although I appreciate that it is now too late.
The hon. Gentleman raised issues relating to sleeping quarters that are covered in the board of inquiry report. There are sleeping facilities in every part of our submarinessubmarines are not endowed with a great deal of space, as anyone can see when they go on board. Yes, there were issues. There is an emergency oxygen capability, which it seems some members of the crew did not use: the issue there is their confidence in those emergency provisions. There are also plug-in oxygen providers: we need to increase the number of access points, as the board of inquiry has proposed, in order to prevent delays in accessing that second safety measure in good order and good time. The hon. Gentleman can see those matters set out in the board of inquiry document. I can only apologise again for his not receiving it.
On next-of-kin informing, we took longer to get to people than we should have. We went to addresses that proved to be incorrect, which caused distress. That is a problem, and we must try to do better.
Linda Gilroy (Plymouth, Sutton) (Lab/Co-op): I, too, thank my right hon. Friend for his full statement to the House. As others have said, uppermost in our minds must be the families. I was therefore pleased to hear my hon. Friend the Member for Sunderland, North (Bill Etherington), who has dealt with my right hon. Friends office in connection with one of the families, say how sympathetic he has been.
We have also heard about how the submariners have been appropriately honoured. We in Devonport have a proud record of serving the Navys submarines and service ships. However, I am deeply disturbed by the content of some of my right hon. Friends statement, particularly in respect of the logistical management of such important items. I appreciate that he can say only a limited amount while the Health and Safety Executive and the Defence Export Services Organisation are looking into the situation. However, will he offer an assurance that the HSE will take a wide view of how such matters are handled? Many people who have worked in Devonport will be shocked by what has come out today. The whole community will want to know that the same thing cannot happen in any other aspect of logistic management, as well as the specifics of what he has reported today.
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