2. The Ehime Maru Tragedy An Exercise in Human Performance Lance Sawyer PG&E, Diablo Canyon Power Plant June 15, 2001

4. USS Greeneville February 9, 2001 You are the crew of one of the US Navy’s modern nuclear Submarines. Our mission today is to demonstrate the performance capabilities of this incredible machine to a group of civilians.

5. Builders: Newport News Shipbuilding Co.; General Dynamics Electric Boat Division. Christened by Tipper Gore on September 17, 1994. Power Plant: 33 year lifetime nuclear reactor, one shaft Displacement: Approx. 6,900 tons Speed: 20+ knots (23+ miles per hour) Crew: 16 Officers, 126 Enlisted Improvements: hardened sail and retractable bow planes for surfacing through the ice during Arctic missions. Statistics for the Los Angeles class

6. Plan of the Day – DV Cruise 0230 Brief and Startup Reactor 0715 Station Maneuvering Watch 0800 Underway 1000 Dive/Deep Dive (Classified Depth, not normally done for Civilians) 1100 Lunch 1230 Angles and High Speed Maneuvers 1300 Emergency Blow 1330 Station Maneuvering Watch 1500 Back in Port

7. Emergency Blow (Two Types shown)

8. Quick Personal Tour Exclusive look inside the Greeneville

9. Quick Personal Tour

10. Coming To Periscope Depth It is critical to verify the surface is clear prior to surfacing Fire Control will verify location of surface contacts prior to coming to PD Standing Orders for coming to PD –Two good TMA legs –Periscope brief with FT, Sonar, and others –Report to CO and obtain permission

11. Where are we going to be operating? East of the “Submarine Test and Trial Area” south of Honolulu

12. Distinguished Visitors We will have 15 visitors, mostly Executives and their wives, escorted by Captain BrandHeuber. They will be allowed to operate controls, but must be under the strict direct control of the watchstander. They can tour the boat forward of the Reactor Compartment, but should be in the Control Room when design maneuvers begin.

13. Mission Information We had a four month overhaul followed by a month at sea, getting back last week, but, hey it’s Friday, and we’re in beautiful Honolulu! I know we were supposed to be at sea for the next few days, but that is delayed until Monday due to this DV group tour. Skies are hazy and off-white. Seas are choppy, with swells of 6 feet or more. Man the stations with whoever you have available, as many of our crew are off today.

14. Tailboard Any Error Precursors? Any Error Likely Situations? Any Flawed Defenses? Remember: –Safety –Efficiency –Backup

15. Okay, let’s go!

16. Tracking Surface Contacts Sonar is passive, listening for ships on the surface Difficult to acquire when changing directions rapidly Visual Display in Control Room is out of commission, no formal compensatory action taken

17. Ehime Maru Crew: 67 Gross tonnage: 741 Length: 58 m Breadth: 9.3 m Main engine: Akasaka E28BFD Max Trail Speed: 15.05knots Color: White Training and research ship for Uwajima Fisheries High School, used for cadet training and for fisheries and oceanographic research. Built at Hashihama Works, completed and delivered in June 1996.

18. Size Comparison

19. Ship’s Paths 1300 Hours

20. Ship’s Paths 1330 Hours

21. Ship’s Paths 1340 Hours

22. Ship’s Paths 1343 Hours

23. Collision

24. Yusuke Terata, student, 17 Toshiya Sakashima, student, 17 Takeshi Mizuguchi, student, 17 Katsuya Nomoto, student, 17 Hirotaka Segawa, crewman, 60 Hiroshi Nishida, crewman, 49 Toshimichi Furuya, chief engineer, 47 Hiroshi Makizawa, teacher, 37 Jun Nakata, teacher, 33 Casualties

25. Return to Pearl Harbor

26. Into Drydock for Repairs

27. Recovery of the Ehime Maru

28. What happened? Artificial urgency Disregarded policies and procedures Failure of ship’s contact management team to work together and pass information Command climate Distracted by civilian guests Overconfidence Complacency Short of people and use of Unqualified Watchstander Briefs not done

29. Questions Do you think that they had operated in this manner in the past? When they did, do you think they felt like they were doing the right thing? Do you think they ever thought anything like this could happen?

30. Comparisons to a Nuclear Power Plant Team Dynamics Situational Awareness Tailboards Participation by everyone Distractions that may not be obvious Time pressure

31. Conclusion Good people with good intentions make mistakes Catching and correcting errors and bad practices when the consequences are low will prevent more serious mistakes If you have a concern, or something doesn’t feel right, vocalize it