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Figures3and4 (p.36)arecontrolchartsdepictingthe

normalized SUBSUNK and normalized submarine fatalities, respectively.

Nelson (1986) developed control chart analysis

rules that center on identifying special causes from the following eight tests:

1) One point is more than three sigma from the

mean, also known as afreak.

2) Nine or more points are in a row on the same

side of the mean, suggestingbias.

3) Six or more points in a row continuously

increasing or decreasing, indicating atrend.

4) Fourteen or more points in a row oscillate or

alternate in direction.

5) Two or more points out of three points are

more than two sigma from the mean.

6) Four or more points out of five points are more

than one sigma from the mean.

7) Fifteen points in a row are all within one sigma

of the mean on either side.

8) Eight points in a row exist with none within

one sigma of the mean.

Using these tests, both control charts for SUB-

SUNK and submariner fatalities were observed to

SUNK, and 1972 to 1992 for submarine fatalities.

E FVb UcVnD :CAB

The freak at 1968 was indicative of the worst year of five operational submarines (Alvin, K-129, Scorpion,

Dakar, Minerve) and 362 deaths. Each accident is

described in more detail in the following discussion.

Alvinsank after two cables snapped during a

recovery operation and water entered the sphere through an open hatch (Ballard, 2000; Kaharl, 1990). The two occupants managed to scramble to safetyInterestingly, while the number of sub- marines peaked at around 950 in the mid-

1990s,itisnowfewerthanpost-WorldWar

IIlevels,whilethenumberofnationsoper-

ating submarines has steadily increased to morethandoublewhatitwasin1946.This has ultimately resulted in more nations with smaller submarine fleets.

It should be stressed that the subma-

rine accident database has gaps. Aside from the fact that some countries do not admit to incidents or do not provide inci- dent details, one attribute, cause, has been tricky to assign for several reasons: •therootcauseforasunkensubmarine at sea generally goes down with the boat (although forensic engineering of recov- ered wreckage can be enlightening re- garding potential causes); •as the gravity of the incident diminish- es, data quality and availability degrade.

To date, this database contains more

than 560 entries and another 90 to 100 entries remain under investigation.

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Table 1 (p. 34) presents a small excerpt of data on incidents that resulted in a submarine being sunk between 1946 and 2005. Twenty-two of these acci- dents occurred with submarines that had already been decommissioned and were awaiting disposal.

While these represent losses, the damage they

incurred largely affected the vessel itself (which still normally affect personnel.

The remaining 55 operational submarines that

sunk, otherwise referred to as SUBSUNK (standard

North Atlantic Treaty Organization terminology

of further study since they typically incurred more losses due to the fact that they were crewed and the fact that the platforms represented a significant cap- ital expenditure for their owners.

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Figure 2 (p. 35) depicts a bar chart of the normal- ized SUBSUNK and submarine fatalities that occurred between 1946 and 2005. To interrogate this data, advanced statistical process control (SPC) tech- niques were employed. Run and control charts can identify unusual variations in data (special causes) over and above the normal variation expected (com- mon causes). Identifying when these special causes occur is important insofar as analyzing their origins with a view to risk mitigation, hazard elimination or risk acceptance.

While run charts can provide a valuable overview

of a process, control charts focus more on acceptable able information regarding special causes. This is done by depicting runs of data against time, with the mean and three standard deviations superimposed. *(41& *(41&

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The number of oper.

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E0643 >= eD68 CO6 BPLP 4(7>C> B5 0=3 2>=C8=D4B C>

B4@D4=C ;0D=274B 0=3 A42>E4A84B F4A4 <034 F8C7 C74

70C27 B7DC8

+74 >C74A 5>DA 022834=CB 0A4 B7A>D343 8=

0=36 C74A45>A46 BD1942C C> 2>=942CDA4 A460A38=6 C74

20DB4B8

+74 A40B>=B 5>AK-129"s34<8B4 ?>8=C C> >=4 >5 C74

5>;;>F8=6R

K0= 4G?;>B8>= 40<= >A 10CC4AH5S

K0 50D;CH B=>AC 4384B4;7?>F4A43 BD1<0A8=4B6

F74= 38E43 0=3 270A68=66 8=3D2C 2><1DBC8>= 08A

C7A>D67 0 <0BC F8C7 0 5;>0C E0;E4 34B86=43 C> ?A47 E4=C 8=6A4BB >5 F0C4A 8= C74 4E4=C C70C C74 E4BB4; ?;D=64B 3D4 C> 740EH F40C74A >A ?>>A CA8<<8=65

F8C7 BD1B4@D4=C 20A1>= <>=>G834 ?>8B>=8=6 4B8<87

;0A C> F70C 8B 14;84E43 C> 70E4 >22DAA43 F8C7 h78=4B4 BD1<0A8=43618= CAAE5S bfgpj B bfgpj B

Péhjutw sk Ofwf sr axgqfunrjv axro

Mjwzjjr BJEF " CAAF

aThe term0C B40refers to a vessel that has deployed to open water as opposed to being0;>=6B834in harbor, at anchor, etc. Decommissioned

infers a vessel that is no longer operational and is destined for disposal or some alternative use.

Rhoto 9I

-8E79re. coyered from C-888 ft after sit. ting for 9

1ear on the

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