A System Failure: Explosion and sinking of Indian Navy Submarine Sindhurakshak

Explosion and sinking of INS Sindhurakshak, a conventional Indian Submarine in Mumbai harbor shocks the world. Is it another case of system failure?

The recent explosion on an Indian Navy submarine in Mumbai (Bombay) harbor and its subsequent sinking with the tragic loss of 18 service men of the elite submarine force of India has been in the news. Before migrating to the USA I saw served in the Indian Navy's submarine arm including on India's first nuclear submarine. The views in subsequent paragraphs are based on my experience and now my expertise on the system approach.

The submariners in India have for long not been recognized or given the respect due to them. There are several reasons for this, what goes up can be seen and is glamorous as the Indian Air Force (IAF).  The Indian Army has visibility; it has been the guardian of the country and perhaps the only insurance against the corrupt and unscrupulous politicians in keeping India secure. So there is respect for the army, and to an extent a commitment to supporting it.  In the case of the Indian Navy the understanding of its need and the national commitment to it has been scanty and inconsistent.

India is a peninsula jutting into the ocean with an ocean named after it. No other country really has an ocean named after it. India has this privilege. Has always had it, but never realized it and consequently appreciated the value of protecting the sea front. The strategies of keeping sea lanes open have not been appreciated by the intelligentsia, then what to talk of the large population living in poverty and preoccupied in making two ends meet.

Submarining and its risks are not really appreciated by the mass of India. There are virtually no family members of any elite or politicians in the armed forces then what to talk of any of them serving in the submarines. The elitist respect comes from the public understanding and appreciating the sacrifices of those at sea and more so under water. What goes up may come down, but what goes down may never come down!

In Russia, where I trained with the command team for the first nuclear submarine, in every house the third toast is drunk to all those at sea and then to submariners. Armed forces from Chandragupta Maurya's time were respected and integral to the advice provided by Chanakya to the rulers.  The degradation of the political set up has over the period put those in power who do not really value the services. Some of them laugh at them forgetting that they are secure to play their dirty games because the services keep the nation secure.

Some of India's politicians and rich and affluent visiting the US should spend less time in malls and perhaps a few hours in the Arlington Cemetery! The next time they are in US they should spend time studying the respect any great nation should have for those who protect the nation. I say all this not out of context to this tragic incidence, but because this lack of support from the nation has a great bearing on such accidents. The scenario results in a demotivated service, always thinking of those all around enjoying the bliss of corruption. Sometimes even regretting the choice of their careers, whilst these committed submariners go around Mumbai on their bicycles cursing the misery of their difficult life with no national support to them or their families. This results in mediocrity in services. No one or very few really joins the service as a first choice.

The weaponry and platforms are sophisticated and require a committed manpower enjoying what they do.

Against that backdrop consider the responsibilities the services have.  Every time India has lost her freedom it has been when she was attacked from the sea. Those who came from the land routes invariably stayed and got absorbed into the system. So there is this dichotomy between expectations and responsibilities on one side, and the demoralized work force trying to run around Mumbai competing with the rich and affluent.

These tragic accidents need to be analyzed against this back ground.

Torpedoes do not detonate and explode if the processes and procedures are correctly followed. If the officers and men work as a team. Train and drill with enthusiasm. These sad incidents are indicative of a system failure and do not auger well for the future unless the system is reviewed. The review of course must not start at the check stage of the P-D-C-A cycle (Plan- Do- Check- Act). It must take the country to the Plan stage and then back to what and how they want to implement a strong armed forces and then go on to the Check and Act stages.

Indian system has run since independence guaranteed as insurance by the efficiency of the armed forces. That the strategic thinking, the national policy should take this into account and be discussed by the intelligentsia, debated by the nation not only in its parliament but in public forums. For this clear policy then will create the organization ready to create the system which will ensure efficiency and meet national objectives.

Regrettably in India none of this is analyzed publicly. If anything everyone has a stake in hiding the truth. The bureaucrats and the services and the politicians will blame each other for not funding and talk about lack of spares et all or blame some individuals. Perhaps the Commanding Officer of the submarine or the Commodore commanding these submarines and so on will be blamed. And if at all they are to blame, then the system too must take the blame and admit they have placed incorrect personnel in positions of national decisions making. In case the system for the selection is incorrect then the individual cannot be at fault. The root cause has to be searched elsewhere. In either case the system is to blame. As Dr. Deming stated “a badsystem will defeat a good person every time”.

 The nation itself by and large does not involve itself in the discussion. If it did it would see that the sacrifice of these 18 soldiers who were doing their duty to the nation will not go waste. In my opinion this is not an individual failure. It is a system failure. The absolute top management should take the responsibility. The defense minister and then down the line should analyze the system failure which has its fountainhead at the Top Management.  The Defense Minister is the top management for the defense forces or not? Has the system failed or not?

It is not a system failure at the submarine level (INS Sindhurakshak – Protector of the Seas), or at the entire submarine arm level or at the navy level, but at a national level. The nation is failing the services and so the resourcing in every form (manpower or hardware or software) is lacking and being worsened by a deteriorating morale of the troops. Keeping the services in top form is a national commitment. When the nation is proud of its services and supports them and respects them and treats them distinctly with the privileges they deserve it is a lot easier to implement the rigors of discipline by setting example and leading the system.

I fear many more accidents and mishaps in every service, including perhaps the reluctance to fight can be the result if this system failure if analysis is not carried out on priority basis by India. The basics of the system approach in ISO 9001:2008 would help the country put the house in order.

No one likes to die. The military leadership leads the men by training in peace time to reach a level where the men have the morale to fight including to happily sacrifice for a cause. This demand for high morale in the troops is a national requirement and demands support at the national level.

I can sum it up with my past experience in the Indian Navy, including accidents seen by me in the Indian Navy’s submarine arm, including a nuclear accident which was never really publicly analyzed and would say that India may rise above from this tragedy a better force if the fundamentals of objectivity in using the system are utilized. India has operated submarines safely in the past. The Indian Submarine arms safety record is exemplary. It is because procedures were always followed howsoever uncomfortable and inconvenient. The subs are safe till complacency sets in and makes the crew forget that they can be dangerous!

What happened in this case may never really be made public. Though I think the SOPs (Standard Operating Procedures) may have been neglected. You cannot be arming the fish (torpedoes) or any other weaponry on a/ with a duty watch. The submarine should be at action stations. From the death toll it is apparent they were not at action stations. Easy then to blame the CO (Commanding Officer) for this blunder! Blame the individual and close the case. Hope not. Time to look at the system failure at the highest levels.

Training: A Luxury or Strategic Necessity?

Well-developed management systems are developed and implemented to drive efficiency in organizations.  These systems when implemented ensure that  the organization does not become vulnerable or lose its integrity when key personnel change as also during any mergers and splits in organizations. Just as technology is constantly upgraded, so must human potential. In any organization, large or small, training which needs the least investment can play a very important role given the critical contribution by human resources in ensuring efficiency. The necessity of training in building human potential and productivity to ensure optimization of human resources can hardly be emphasized.  

Top Management often go in for implementation of management systems without answering the employee’s question of “what is in it for me?” Training and exposing 10 to 15% of the manpower to management system related standards for efficiency (ISO 9001), risk management (ISO 33000), the environment management (ISO 14001) and security of the global supply chain (ISO 28000) quite prepares them for the system implementation. Some  organizations might choose to implement an integrated management system encompassing all or a combination of two or more of the above standards.

Organizations view training as a luxury and often not as a strategic necessity. A well trained manpower is a great asset in getting the “job done” . When budgets are cut training is often given a low priority. In difficult financial situations when all else costs the organizations so much more, a little investment in well trained manpower results in rich dividends and ensures human capital continues operating at their peak efficiency as a motivated work force even through bleak periods thus ensuring a continually efficient system. As a system is developed and put into place a trained workforce helps to better implement the system and results in a ‘buy in’ of the entire team. A team that appreciates the important role that a well implemented system plays in increasing the efficiency of a system while reducing non-conformities (NC).

As NCs are embraced to drive continual improvement the number of problems affecting the system reduce and the work force has its answer to "what is in it for me". This gives the organization strength in depth and provides more time to innovate and thus continually strive for new heights of excellence.

The benefits of training are intangible but below are listed a few: 

• Better output

• Higher Retention 

• Team Spirit 

• Improved corporate Image 

• Higher morale 

• Improved Profitability 

• Fewer Accidents

A small investment in training will ensure an oriented manpower, familiarized and ready to implement and meet the management’s system objectives and align them with the organizations aim of doing much more with much less.

ISO 9001 Certification versus ISO 9001 Conformity

All organizations can benefit from making sure their organizational management system conforms to ISO 9001.

Certification provides marketing benefits to organizations whose customers value the independent certificate and the registrar that issues it.  Certain new customers may provide a new supplier with a certified management system with an opportunity to prove they can fulfill their requirements.  Certification reduces the risk for a new customer trying out new suppliers.

Existing customers often are not impressed with certification because they already know how well your organization, as a system, performs.

For organizations that work in markets with customers who have no interest in certification it is better to quietly make sure your management system conforms to the standard.  This provides confidence that requirements will be fulfilled and are being fulfilled.  It also enables continual improvement of products, processes and the management system to prosper and grow.

Certification has initial cost and then recurring cost when the registrar comes in at least every 6 months. The benefit of conformance is the system is always ready and when marketing demands require you can go ahead with certification.

To learn more about the benefits you can email me at info@qmii.com

ISO 9001:2015 ... What can we expect?

In this fast moving global environment the flexibility permitted by the international standards, whereby interpretation of the standard, correctly makes it applicable to "all organizations, regardless of the type, size and product provided" - Clause 1.2 of ISO 9001. Never the less to keep the standards aligned it is essential that they are updated on a regular basis. TC-176 works on ISO 9001 and considers and evaluates the inputs from users and SMEs (Subject Matter Experts) in the intervening period. The ISO standards are generally revised every 5 years. ISO 9001:2008 is now due for a revision.

In 2015 we will have the revised standard which should come out as ISO 9001:2015. QMII keeps track of the changes and ensures our alumni and students are always updated.  The process involves submitting  our comments via bodies affiliated with BSI in the UK and ANSI in the USA.  The CD is available and there is a lot to sort out before it becomes the DIS. However I do see that lot of training providers have already put out the draft standard for review! In fact some are offering courses to learn it!!

We should really be waiting for the DIS. Once that happens we too will update our course material to prepare our students for the changes in 2015. There are no worries there for the current users of the Standard. As always every organization is given a period of two years to comply with the new standard. Thus ISO 9001:2008 should tentatively go out of date sometime in 2017.

You can review the scrubbed version here. Please remember it is for "Review Only" as an advance copy. I would encourage you, our readers, to challenge yourself by reviewing the scrubbed version and recognizing the changes compared to the ISO 9001:2008. You may comment on the differences here, on the scrubbed version link or by sending me an email at iarora@qmii.com.

Please watch this blog. I shall soon put my comments to keep you updated and advised.

The Recipe for a Successful Merger

Mergers and acquisitions challenge the system. The system goes through a phase where integrity of the system can be affected if meticulous planning is not carried out. While having experienced and capable personnel to lead this evolution is essential and desirable, we must not forget that "A bad system will let down a good person every time". Therefore the emphasis on looking carefully at the existing systems and then designing the new system based on the "AS-IS" of the system led by a clear policy from the Top Management is essential. Every merger brings  a sense of excitement within the organization. There is prospect of growth, not only for the organization but also for all the personnel employed. It is not surprising that not all mergers are successful. There have been many a case of failed mergers, some having failed within a few months. The value and benefits of a well implemented process based management system cannot be stressed enough. This applies equally across all industries.

A well-developed process based management system ensures that all processes are established and functioning well and will not be adversely affected as the merged organizations place the new personnel in their roles of responsibility. The authorities and responsibilities need to be well defined. The policy should be seen in the light of the revised organization and should put in place clear measurable objectives and goals. The system should help identify non-conformities (NC). Most companies fear NCs not realizing their importance. Although initially there might seem to be an increase in reported NCs in a well integrated and implemented system these NC’s will eventually lead to a culture of Preventive Action opposed to Correction & Corrective Action post an incident/accident.

Is it merely enough to have a system in place though? At QMII we work with our clients hands on to recognize the  "As-IS" of the systems and meticulously work to integrate them into a harmonized system so that the integrity of the system is not lost as the merger progresses. The lack of ‘buy-in’ by Top Management (TM) to the new system creation or the TM saving pennies at the P stage of the P-D-C-A (Plan-Do-Check-Act) cycle can have adverse consequences and are the precursor for a dysfunctional system in the future resulting in losses. The organization pays for the poor planning of the system.. It is important to have the Top Management lead the implementation of the new system and this will then filter down the ranks effectively.

For a maritime organization  a well-integrated Safety Management system complying with the ISM code ensures that all aspects of logistics services, cruise services, vessel management, ship maintenance, personnel training and commercial trading operations performed throughout the company fleet work effectively to ensure the success of the company.

This might sometimes involve developing a completely new system. However at QMII we strongly urge our clients and alumni to ‘Appreciate their Management System’. That respect for the existing system comes from avoiding templates (one fits all!) and instead going to the “As-Is” of the existing systems before integrating them. Then the gaps can be identified and effectively filled. (See our methodology). This makes it easier for all employees to ‘buy-in’ to the integrated system and leads to a successful merger!

Why should SME (Small and Medium Enterprises) implement ISO 14001?

Our senior consultant Tom Venafro has been working on EMS (Environmental Management Systems ) all his life. I was having a discussion with him and asked him, “Why should SME (Small and Medium Enterprises) implement ISO 14001?” In fact more, why are they reluctant to meet this responsibility. Are these companies even aware that just being efficient (using a system based on ISO 9001:2008) may ensure efficiency, however unless the byproducts and pollutants which are the result of a process are controlled the organizations will eventually see a declining “cash in the bank”. Going further, and learning from 9/11 we know that an efficient system should not only take care of the environment to be profitable and viable but must be secure. The implementation of  a system to protect the global supply chain based on ISO 28000 needs to be considered as an asset. Social responsibility is integral to good business today. On ISO 14001 Tom had the following views:

Small and medium business should be considering ISO 14001 EMS for their sustainability in more ways than one. Of course having a certified EMS will provide both a green "sustainable" future as well as a green "monetary" bottom line.

Aside from and implemented EMS being the right thing to do for the environment, it also reaps financial benefits.  Recycling programs means less waste to landfill, less regular waste pick-ups more money saved. The EMS will provide the framework for a company to be a good steward of the environment and help reduce its impact on the environment. This equates to more control over pollution sources and less fines from regulators and huge "cradle to grave" liability.

These items are just the tip of the iceberg. Beneath the water line the hidden benefits begin to pile up. Employee moral improves, process organization and efficiency increases. Employee awareness from a EMS seeps into employee's home lives furthering green living.  These combined activities begin to make an larger positive impact on society. This eventually trickles down to economics, meaning that the positive cumulative effect of pollution prevention contributes to keeping costs to taxpayers low.

An EMS is the guide organizations should use to trigger constructive environmental thought. For example, 14001 clause 4.4.7 Emergency Preparedness and Response is meant for an organization to consider the environmental impact that can be caused from an emergency or natural disaster. This is not a normal consideration that would not usually be made.

The standard requires that employees understand the aspects and targets the organization is trying to obtain. Most importantly, they require that employees and contractors understand the consequences of their departure from specified procedures or operational controls.

Of course the EMS has the same customer benefits in the marketplace as ISO 9001QMS does.  Customers will ask and require a certified EMS more going forward. Having an EMS is a case of "sustainability".

Does implementing a Process Based Management System put my job at risk?

Recently while working with some students in a Lead Auditor class for ISO 9001 one of the students came up with a serious concern about his being committed to ISO 9001! His questions was “With a  well-documented Process Based Management System (PBMS) in place everyone will know what I do. So how can I then ensure the security of my job?”  Over numerous classes that I have taught, this question often comes in one form or the other. This is particularly relevant when I work in other countries where jobs are hard to come by. I am sure there are others who have this job insecurity as their  company begins the process of implementing a PBMS based on a standard. Their worry is “what is in it for me?”

Clause 5.5.3 of the ISO 9001:2008 requires the management to ensure internal communications with regard to the effectiveness of the quality management system. These internal communications must explain and address the doubts of the employees. The employees must appreciate that a bad system can let down the best man every time. Without a system the blame culture will prevail and overall efficiency be adversely affected. Management will then invariably ask “Who?” – meaning blame the employee, instead of asking “How?” and or “Why”- meaning how and why did the system let down the employee. In real terms with the system the blame moves from the individual to the system. Even if the employee’s incompetence caused the deficiency the system failed in terms of ensuring competence either by incorrect hiring, or training or continued education and so on. The organization should improve the system which placed an incompetent employee in a position where he/she could not perform, instead of blaming the employee. Disheartened employees are the result of being always blamed for poor work and the results, leading to the work environment (clause 6.4) not being congenial for achieving product conformity. How can any organization achieve continual improvement (clause 8.5.1) if deficiencies are not addressed.

Employees often forget that their job security is dependent on the organization constantly improving with the continual improvement cycle to be productive and viable. Without the improvements the organization itself will go out of business and so the jobs will be lost. Investing in a system approach and addressing deficiencies by corrective action(clause 8.5.2) can against the recurrence of non-conformities. As the data base builds and the employees can get the information from the data and analyze it (clause 8.4) can they predict potential NCs (clause 8.5.3) and so add value and therefore sustain the organization to enable the organization to continue to meet the expectations of the manpower. After all benefits are an outcome of the “cash in the bank”.

As the PARs (Preventive Action Requests) start coming in and the employee participation increases the system stabilizes creating the environment for innovation. The organization immensely benefits from innovative products (story of Apple is a case in point) and is therefore able to pay its employees better. A system approach therefore not only is an investment in retaining the employees (job security) but a sure way to ensure better future prospects. The success of the organization then contributes to the well-being of the society and the ultimate prosperity of the nation. We could stretch the benefit of the system approach further and say it would meet the futuristic stability too and ensure conduct which is socially responsible (SR).