Ministry of Defence thinking over the risks of an explosion on an oxygen generator used in the Royal Navy's submarine fleet was "flawed", an official report concludes.
The investigation followed an explosion on HMS Tireless in March last year which killed two crew members and injured a third.
The blast occurred when a self-contained oxygen generator (SCOG) – used to provide oxygen in an emergency – exploded whil
e the vessel was under the Arctic ice off Alaska.
Leading Operator Mechanic Paul McCann, 32, of Halesowen, West Midlands, and Operator Maintainer Anthony Huntrod, 20, from Sunderland, died in the blast.
The inquiry, which looked at the procurement, supply and management of the generators, found the MoD to be "complacent" about improvements in safety regarding the introduction of SCOGs.
It highlighted "shortcomings" in the way the MoD handled and managed SCOGs and said logistics processes were "neither consistently applied nor comprehensively followed".
A Board of Inquiry report published in June concluded that the blast was caused by a faulty SCOG during a routine drill. The Board identified the most likely cause as "significant internal contamination of the SCOG canister with oil, possibly exacerb-ated by cracking within the canister."
Yesterday Armed Forces Minister Bob Ainsworth said the subsequent investigation found the MoD had mistakenly believed the new unit delivered a "substantial improvement" in safety.
It also wrongly thought a cap and seal in the new design would prevent any contamination.
He said: "The investigation has, however, made it clear that this belief, and therefore the resultant understanding of any risk of explosion, was flawed and that we were complacent about the improvement in safety the new SCOGs delivered."
Mr Ainsworth said the MoD was replacing the SCOGs across the fleet "as quickly as practicable". It was hoped replacement oxygen generators would be fitted by the end of the year.
The investigation has made 14 recommendations for improvements across the logistics process including in handling, storage and tracking of SCOGs.
Tireless is a nuclear-powered Trafalgar-class submarine and does not carry nuclear weapons, but is armed with five tubes capable of firing Tomahawk missiles.
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