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HMS Tireless

My right honourable friend the Minister of State for the Armed Forces (Bob Ainsworth) has made the following Written Ministerial Statement. Following my Statement on 12 June 2008 about the incident that took place on board HMS Tireless in March 2007, I would like to inform the House today that the investigation undertaken on behalf of the Chief of Defence Materiel to consider issues relating to the procurement, supply and management of oxygen generators has concluded.  This investigation has shown that, when the Ministry of Defence introduced the self-contained oxygen generator (SCOG) into service on submarines, it assessed that the new unit delivered a substantial improvement to the safe generation of emergency oxygen over the previously used mark V candle. The cap and seal present in the new design was believed to be proof against contamination.  The investigation has, however, made it clear that this belief and therefore the resultant understanding of any risk of explosion were flawed and that we were complacent about the improvement in safety the new SCOGs delivered. The investigation has also identified a number of shortcomings in the way we handled and managed SCOGs. In particular, it has demonstrated that logistics management processes were in some places ambiguous and as a result were neither consistently applied nor comprehensively followed.  The investigation found that these shortcomings existed across the logistics management system. The investigation also looked at the issue of individual culpability. It concluded that, although individuals had made mistakes, the errors made did not amount to negligence and as a result disciplinary action is not justified. Although no individual was found to be personally culpable, it is clear that we were complacent, and, as I said in my Statement on 12 June, the Ministry of Defence must bear responsibility for this tragic incident. As part of that responsibility it is our duty to ensure that the necessary changes are made to prevent a reoccurrence. The DE&S investigation has made fourteen recommendations for improvements across the logistics management process, including for the handling, storage and tracking of SCOGs. These recommendations have been accepted in full and are being implemented, along with those made by the board of inquiry, which consulted a range of organisations, including NASA, while it looked into this incident. The Ministry of Defence has already put in place a number of improved processes, guidance and equipment-related measures since the explosion on HMS Tireless.  An interim replacement for the generation of emergency oxygen which is better protected than the SCOG has been introduced. This is being supplied to the submarine fleet as quickly as practicable. We have already fitted replacement oxygen generators to two of the fleet and expect to have rolled them out to the rest by the end of the year.  These, along with any pre-existing SCOGs which remain in use over the next few months, will only be used in an emergency situation and are being handled appropriately.  Work is also under way to develop and introduce a replacement oxygen-generating capability for routine and emergency use in the future. The outcome of this further investigation, its recommendations and the improvements that are already being put in place do not change the fact that as a result of this tragic incident two submariners died and another was seriously injured. I would again like to offer my sincere sympathies to their families, friends and colleagues and assure them that the action we have taken significantly reduces the risk of such a tragedy happening again.  My department is continuing to provide the coroner with every assistance possible and is keeping the Heath and Safety Executive fully informed. I am today placing a copy of the investigation report in the Library of the House.