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March 25, 2009

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Systemic failures led to fatal sub explosion

A culture of complacency regarding the risks posed by self-contained

oxygen generators (SCOGs) led to a fatal explosion on board a nuclear

submarine, a coroner’s inquest has heard.

The conclusion yesterday (Tuesday) of the six-week inquest into the deaths of operator maintainer, Anthony Huntrod, and leading operator maintainer, Paul McCann, on board the HMS Tireless in March 2007 saw Sunderland coroner, Derek Winter, return a narrative verdict.

The explosion, which occurred in a forward-escape compartment while the vessel was operating under the Arctic ice cap, was caused by a faulty SCOG. This formed part of the back-up generator, which was lit during a routine drill.

The inquest heard that a batch of nearly 1000 SCOGs were left in a hazardous-waste depot in Devonport but later returned to Royal Navy service. Mr Winter highlighted that “systemic failures led to the contamination and damage” of the SCOGs, “which, in turn, caused the explosion”. He added that it was “a significant possibility” that the faulty SCOG was one that had originally been sent to the dump, but this could not be confirmed, owing to an incomplete method of tracking and accounting for SCOGs.

Criticising the way the SCOGs were handled, stored and managed, Mr Winter said: “There was a culture of complacency regarding the risks posed by SCOGs and a tolerance of practices likely to increase those risks.”

Following the verdict, Armed Forces minister Bob Ainsworth offered his “deepest sympathies” to the families of the two crewmen, stressing that “the Ministry of Defence and the Royal Navy are committed to doing everything possible to prevent any recurrence of this tragedy”.

He said the coroner’s findings would be looked at in detail before the MoD responds in full.

Speaking on behalf of the First Sea Lord, the Royal Navy and the submarine service, Commodore Moores also offered his condolences, and highlighted that a number of measures to improve the safe handling of SCOGs had been completed.

He said: “The Royal Navy Police, Ministry of Defence Police, and the Board of Inquiry team conducted exhaustive investigations, the conclusions of which have been borne out by the coroner’s verdict.

“All those recommendations identified relating directly to the safe operation of self-contained oxygen generators have been completed. Emergency oxygen generators of a new and safer design have been deployed on all operational submarines. These are the only oxygen generators that can now be used.”

Mr Huntrod’s mother, Brenda Gooch, described the verdict as a “miscarriage of justice”. In a statement she said: “We believe the disregard shown by the MoD and its contractors towards the safety of our son can only lead to the judgment that he was unlawfully killed.”

She continued: “When will this Government and the MoD realise they are not above the law. The safety of all Forces personnel must be paramount at all times, regardless of whether they are in ‘war situations’, or undertaking ‘peace-time operations’.”

Asked whether the HSE would be taking any enforcement action in relation to possible health and safety failures, a spokesperson was non-committal but did say the regulator “would be reviewing the evidence of the inquest” to determine its “final decision”. It has already carried out an investigation at the Devonport base and had discussions with the MoD and the MoD Police.

The Armed Forces’ Crown immunity in relation to the HSWA limits any enforcement action to the form of Crown censures.

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