1AD AD-E401 893

Special Publication ARASM-SP-88003

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ROOT CAUSE ANALYSIS, TANK FIRE PROBLEM, MiAl MAIN BATTLE TANK

ITI

MAJ John Dowalgo

February 1989

SE

U.S. ARMY ARMAMENT RESEARCH, DEVELOPMENT ANP ENGINEERING CENTER

Advanced Systems Concept Office
&COMSAL=MAD
AVRAA*W UffXMPicatinny

Arsenal, New Jersey

CENM~ ARAMENT WOE

Approved for public release; distribution unlimited.

The views, opinions, and/or findings contained in this report are those of the author(s) and should not be construed as an official Department of the Army position, policy, or decision, unless so designated by otner documentation. The citation in this report of the names of commercial firms or commercially available products or services does not constitute official endorsement by or approval of the U.S. Government. Destroy this report when no longer needed by any method that will prevent disclosure of contents or reconstruction of the document. Do not return to the originator.

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Special Publication ARASM-SP-88003

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ARDEC,ASCO
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Mission Area Division Picatinny Arsenal, NJ 07806-5000

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10. SOURCE OF FUNDING NUMBERS PROGRAM PROJECT NO. TASK NO.

ELEMENT NO.

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ACCESSION NO.

ROOT CAJSE ANALYSIS, TANK FIRE PROBLEM, MiAl MAIN BATTLE TANK
12. PERSONAL AUT.40R(S) 13a. TYPE OF REPORT

MAJ John Dowalgo

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16. SUPPLEMENTARY NOTATION

17.

COSATI CODES,-

----

FIELD

GROUP

SUB-GROUP

1Tank

18. SUBJECT TERMS ICONTINUE ON REVERSE IF NECESSARY AND IDENTIFY BY BLOCK NUMBER)

120-mm ammunition, fires / M865 ammunition,

Catcher box /
Cartridge case base

Root cause analysis

M1 Al tank fires. ,

19. ABSTRACT (CONTINUE ON REVERSE IF NECESSARY AND IDENTIFY BY BLOCK NUMBER)

This analysis identifies the root cause of two M1A1 tank fires involving 120 mm M856 target practice cone stabilized discarding sabot tracer (TPCSDS-T) ammunition during tank gunnery exercises in Germany. The first fire, 4 July 1988, did not involve any personal injury. The fire on 14 August 1988 was lethal, killing the tank commander and gunner. The failure investigation strategy (described in the report) is a method for increasing the assurance that the root cause of the problem is identified, and provides a detailed record of the study which can be reviewed by management or impartial review boards. This case study provides a summary of the major activities performed by the root cause analysis team. The methodology identified the most probable root cause of the tank fire problem. .
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CONTENTS Page Executive Summary Introduction Background 120 mm Gun Catci ter Box 120 mm Ammunition Description (M865) Diagnostic Strategy Methodology Implementation Conclusions 4 July Fire 14 August Fire Manprint Issues and Recommendations Safety Human Factors Engineering Training Overall Team Performance Appendixes A Gun System Description B Root Cause Analysis Charts C Ignition Data D Root Cause Analysis Team Charter Distribution List 21 25 61 77 81 1 2 2 2 2 2 2 2 2 6 6 6 6 6 8 8 9

FIGURES Page 1 Gun breech 2 Cartridge case base catcher box 3 M865 TPCSDS-T 4 M865 Cartridge Exploded View 11 12 13 14 15 16 17 18 19 20

5 Fault category chart 6 Root cause analysis chart instruction format

7 4 July 1988 fire 8 14 August 1988 fire

9 Catcher box seam 10 Commander's hatch

Accession For ?NiS-- GRA& I DTlC TAB Unannounced
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EXECUTIVE SUMMARY A Background

1. Recently two MiAl tank fires involving 120mm M865 Target Practice Stabilized Discarding Sabot Tracer (TPCSDS-T) ammunition occurred during tank gunnery exercises in Germany. The first fire, 4 July 88, did not involve any personnel injury. The fire on 14 August 88 was lethal, killing the tank commander and gunner.
UUii

2. The failure investigation strategy (described in section III) is a method for increasing the assurance that the root cause of the problem is identified, and provides a detailed record of the study which can be reviewed by management or impartial review boards. Thi c:ase study provides a summary of the major activities performed by the Ro 7-usp Analysis Team. The methodology iuentified the most probable root causc if the tank fire problem. B. Findings

1. The root cause of both tank fires was the hot cartridge case base primers from th M865 120mm round making contact with th? cartridge case or propellent from another round. a. The most likely cause of the 4 July 88 fire was propellent spilling from a damaged or defective M865 round during the loading process. The fire erupted when loose propellent contacted a hot case base primer in the case base catcher box. b. The 14 August 88 fire most likely occurred when the loader mishandled a M865 round and it fell onto a hot primer lying on the turret floor. The catcher box was not installed. C. Comments

1. The hot M865 cartridge case primer is the root cause, the ignition source, for both fires. It is strongly recommended that a design modification be developed to reduce or eliminate this threat. 2. The case base catcher box with all proposed fixes is inadequate. It has an open top and does not prevent any combustible material, such as a combustible cartridge case, from making contact with a hot primer. A design change directive is highly recommended. 3. Improvements for crew protection and evacuation need to be implemented. Crew members shnuld be issued fire protective clothing. Improvements to the driver's compartment, commander's hatch and gunners seat should be developed to enhance evacuation during an emergency. 4. Crew actions definitely contributed to the 14 August 88 fire and may have been involved with the 4 July 88 fire. Training must emphasize proper ammunition handling and Icading procedures. Equipment involving safety, such as the catcher box, should be a readiness reportable item. Inspections should be initiated to insure all equipment is operational prior to ary gunnery exercise.

INTRODUCTION In September of 1931, the Department of the Army approved a block modification proposal to upgrade the M1 Tank. The modification included a German 120mm gun and various survivability enhancements. The vehicle was type The first production vehicle classifed standard as the MlAl in August 1984. was delivered in August 1985. II. BACKGROUND

Two MIAl tank fires occurred on 4 July 1988 and 14 August 1988 involving M865 TPDSCS-T 120mm ammunition during gunnery exercises in Germany. The second fire killed the gunner and tank commander. These are the only fires involving 120mm tank ammunition since the tank was fielded in 1985. A. 120mm Gun- The MlA1 main battle tank is equipped with a 120mm smooth bore German designed gun which is also utilized on the Leopard II tank. A
unique feature of the gun is the combustible cased ammunition it fires. When

the gun fires, the cartridge case is consumed except for a small cartridge case base. The cartridge case base is ejected from the breech, ricochets off a deflector on the loading tray (fig.l)and is directed downward into a case base catcher box (fig.2). Additional details of gun operation are provided in appendix A. B. Catcher Box- Also unique to the MIAl tank is the case base catcher box, mounted on the turret floor under the gun breech (fig.2). The ejected cartridge case base contacts a flipper (paddle wheel) which acts as an energy attenuator, allc'wing the base to 'gently' fall into the box. C. III. A. 120mm Ammunition Description (M865)- (fig. 3 and 4) DIAGNOSTIC STRATEGY Methodology

A root cause diagnostic team was assembled to review the MlA1 fires. Root Cause Analysis is a rigorous and disciplined methodology for the independent examination of possible failure modes, within a system. The technique employs a standard format to classify and isolate relevant information, and in this mdner, focuses the attention of the problem solver on the distinctions or the gaps in information. References 1 and 2 describe the methodology in detail. B. 1. Implementation Root Cause Team Assignment

The specific mission assigned the Root Cause Analysis Team included revipwing all credible failure modes. Special emphasis was also placed on a review of current procedures/designs to assure that the best corrective measures are identified and implemented to prevent reoccurrence of the problem. MANPRINT domains were considered during the conduct of the assesment.

2.

Organization

The Root Cause Analysis was conducted by a task team with interdisciplinary skills. The team memberships crossed oconsiderable lines to form a matrix organization. The Root Cause Analysis Team consisted of ten members, convened on 27 September 1988, and completed its efforts on 28 October 1988. a. The team members were: MAJ JOHN DOWALGO JOSEPH CORALLO JOHN BANKS WILLIAM WILLIVER JAMES RUTKOWSKI ROGER BILLINGTON JACK CAPLOCK ROBERT ALLAN CPT GEORGE SMITH SFC ROBERT VTOLFORD SMCAR-ASM(Chairman) AMSMC-QAT-M(Co-Chairman) SMCAR-SF SMCAR-CCH-V SMCAR-AEE-BP AMCPM-TMA-105 SLCHE-AR AMSMC-LSA(D) AMSMC-ASR ATSB-WP-GD (MASTER GUNNER) ARDEC ARDEC ARDEC ARDEC ARDEC PM- TMAS HEL AMCCOM AMCCOM FT KNOX

b. PM Tank Main Armament System was very supportive of the effort. Mr. Ken Russell provided the team with information gathered during initial inquiries. He also gave a thorough briefing on 120mm ammunition design and was available to answer questions generated during the course of the investigation. Additionally, Honeywell and ARDEC invested a considerable amount of time and effort to create cook-off time lines for 120mm cartridge cases and propellent. This information was also provided by PM TMAS. Augustine Magistro, author of references 1 and 2, briefed the team on Root Cause methodology and provided guidance throughout the investigatioi. 3. Failure Analvsis Procedures

The Root Cause Analysis process examined all the credible failure modes of the M865 round, including its effect on related systems to establish a la't of candidate causes. a. Furnished with the initial data and tentati:e problem statements, the team listed every conceivable area which could cause a tank ammunition fire. Discussions and ideas freely evolved and were recorded without evaluation. This procedure permitted a large quantity of failure possibilities to be recorded in a short period of time; therefore, the broadest view of the problem was obtained. This process produced 33 failure modes which could have contributed to the tank immunition fire problem. b. Next, the team constructed a chart depicting all possible failure modes, conditions or events which may have contributed to a tank fire (fig. 5). Each contributing failure mode, condition or event was categorized into one or four major problem areas, defined as follows: crew (1.0), ammunition (2.0), gun(3.0), and turret(4.0). Failure modes are indicated by three digit numbers and all 33 failure modes were categorized.

4.

Root Cause Analysis Format

Subsequent to the identification of the candidate failure modes, failure sequences were postulated for each candidate failure mode and recorded in a standard columnar format. This format. called the root c use analysis chart, was employed to classify and isolate relevant information related to the failure scenarios (fig. 6). The presentation of information in this format allowed each failure mode description and its supporting and refuting data to be quickly recorded, reviewed and evaluated. The root cause analysis charts for the MiAl tank fires are depicted in Appendix B, charts 1 through 33. 5. Failure Mode Ranking

The team ranked each root cause for each incident by a voting method and the results are shown in table 1. TABLE 1 First Tank Fire (4 July 88)

Probability Chart # 2.07 4.03 1.11 2.02 1.12 2.01 1.06

Failure Sequence Protruding Hot Primer Catcher Box Design Loader Damaged Round Glue Joint Failure Previously Damaged Round Flaming Case Base Loader's Tray Adjustment All Others Second Tank Fire

Rank Order 1 2 3 4 5 6 7 8-33 (14 Aug 88) 1 2 3 4 5 6 7 8 9-33

Estimate ML* ML ML VL L L L U

2.07 1.03 1 .04 4.03 1.14 1.07,1.10 1.08,1.13 3.01,3.03

Protruding Hot Primer Catcher Box Missing Failure to Follow Procedures Catcher Box Design Dropped Round Safe/Fire procedures Loader's Tray Adjustment Loader's Tray Malfunction All Others

ML* ML ML ML ML L L L U

Root Cause

ML=MOST LIKELY CAUSE VL=VERY LIKELY CAUSE L=LIKELY CAUSE U=UNLIKELY CAUSE

6.

Logic Diagram/Root Cause Analysis Chait Relationship

Figure 5 provided a road map to guide the team to each postulated cause t)f failure and the root cause analysis charts present a scenario for each of the candidate causes. All the data required to reach a conclusion concerning the likelihood of each scenario is presented n the root tduse analysis chart. The zoot cause analysis charts were reviewed and analyzed to determine -he most likely cause of each tank fire. Logic diagrams, illustrated in figs. 7 a,,-.! depict the most likley sequence of events that resulted in ea,.h fir,. 7. Failure Analysis Chronology and

The failure analysis cycle, followed by the Root Cause Aialysis Team described herein, includes the following events: a. b. C. d. e. f. g. h. i. j. k. 1. m. PROBLEM SURFACED PROBLEM STATEMENT MANAGEMENT DECISION-"ROOT CAUSE" REQUIRED ROOT CAUSE ANALYSIS TEAM FORMALLY ESTABLISHED POSTULATED CANDIDATE CAUSES FAULT CATEGORY CHART PREPARED (FIG.5)

INITIATED ROOT CAUSE FORMAT-ONE FAILURE SEQTTFNCE PER SHEET (APPENDIX B. OBTAINED CONFIRMING/REFUTING DATA EVALITATED DATA SPECIFIED ADDITIONAL DATA OR TESTS REQUIRED CATEGORIZED MOST LIKELY/VERY LIKELY/LIKELY/UNLIKELY (TABLE 1) ESTABLISHED "ROOT CAUSES" (figs. 7 and 8)

ADDRESSED MANPRINT DOMAINS AND MADE RECOMMENDATIONS FOR CORRECTIVE ACTIONS

IV.

C "

US!ONS

The conclusions herein are brief summaries. Facts supporting the conclusions are contained on the root cause analysis charts. A. 4 July Fire The Root Cause Analysis Team has determined that the cause of the 4 July 88 fire was mostly design related, supplemented with human error During a tank gunnery exercise, the loader either damaged a M865 TPCSDS-T round while loading or drew a defective/damaged round from the bustle. The round separated, allowing propellent to spill throughout the bustle and crew compartment. Some of the propellent fell into the cartridge case base catcher box, and contacted the hot case base primers. The propellent ignited, the loader panicked, drapped the round, and a larger fire started. B. 14 August Fire The second fire was caused by a combination of crew actions and design shnrtommings. The tank was engaged in a multiple target rapid fire gunnery exercise. The cartridge case base catcher box was not installed and all hot case bases were falling to the turret floor. Round #3 of the exercise was fired. The loader immediately chambered round #4 and drew round number #5 from the turret bustle. With round #5 in the loader's hands, he noticed that round #4 was not fully seared in the breech. While attempting to seat round /4, the loader lost cun troL of round #5 and let it fall onto a hot case base primer from a previously tfred round which initiated the fire. V. MANPRINT lS47ES AND RECOMMENDATIONS A. Safety

1. Hat Case Base Priners The root cause of both fires is believed to be hot .ase base primers. The 120mm M865 TPCSDS-T training round and the M829 APFSDS-T service round both have long primers which protrude from the case base. The primers are ejected from the gun breech with a calculated temperature approaching 700 degrees fahrenheit. ARDEC is studying the feasibility of eliminating this source of ignition by insulating the primer, changing the primer body material, changing to a combustible or consumable primer body, or possibly by eliminating the long primer body. A high priority has been given to this issue. 2. Inadequate Catcher Box Design The catcher box is large and open on the top Cfig. 2) and dues not prevent a nest of hot case base primers from contanting c ombustible material such as loose propellent or a combustible !art: ide case. With the catcher box properly installed in a MlAl tank, it is "nc ,ivahl, that a loader can lose control of a 120mm,. round, espccially while traversing rcgh '-rrain, and drop it into the open catcher box. The box also has a large seam whith can allow a hot primer to protrude (fig. 9), exposing the loader to a danger. Additionally, tank crews do not like the box because it interferes with movement and is unreliable

The flipper (paddle wheel) which acts as an energy attenuator :~r . bases, frequently sticks or jams. As a result crew members have ,n., remove the box, allowing case bases to fall to the floor. PM Abram-es . the initiative to correct some of the deficiencies with the present a': design. Corrective actions include eliminating interference with th r a:. lock, improving flipper reliability, and reducing the gap where p4 protrude. The ROOL Cause Analysis Team has concluded that the pres, .t with all proposed fixes, is still inadequate from a safety standpn: the open top. The possibility of crew error and/or propellent si present. The case base catcher must isolate hot primers from the r-w .i potential fuel source. A new design is strongly recommended, 11 factors expertise as stated in paragraphs 5.6, 5.6.3, and 5.7 oi 1472C. 3.
4),

Strengthen the Combustible Cartridge Case

The gluec join:,

a:

case cover and cap assembly is attached to the combustible carti!

is suspect of separation and may have been a contributor to the cc u' tank fire. Research to improve the joint is in progress. Efforts nave addressed process controls, quality, testing, and improved strength. Additionally, researchers should evaluate the possibility of strengthenin:;' propellent containment bag, especially where the bag is attached to the projectile.

4. Crew Member Liability Per review of conversations of soldiers i: Germany with Mr. Ken Russell (PM Tank Main Armament Systems) and Master j:at Ft Knox, KY with the Root Cause Analysis Team, soldiers are being they will be held pecuniarily liable for damaged rounds. There are infi that crew concerns over liability for damaged ammunition may have leo rounds being fired. This policy should be eliminated except for arcr. es negligence or abuse. Additionally, ammunition turn-in procedures should U;r changed v eliminating the apparent harrassment (from a soldier's point a vio: at ammunition supply points. Rather than being subjected to questions, lengthy delays and threats of liability, soldiers would rather shoot or hide opened ammunition rather than turn it in. It is understood that there is a no
questions asked turn in policy at ASP #1 Grafenwoehr. Special efforts must .e

taken to insure that soldiers are aware o. this policy. areas should consider similar procedures.

Also, all training

5. Absence of Protective Clothing Tank crew members are not being issued fire protective clothing. The tank commander from the 14 August 88 fire, h,) exited the tank and subsequently died from his burns, may have survived: hac 1't been wearing protective clothing. The Root Cause Analysis Team highly recommends issuing tank crew members, especially those assigned to MIAI ta fire protective clothing. 6. Driver Cannot Escape The driver cannot exit- when the gun is dprt ., over the front center of the tank. This gun position is common when shooting
from a hull defilade position. Additionally, the Ml series tank is not erJui' with a driver's escape hatch. The driver could be trapped if the crew in 'he

turret is disabled from an accident or by enemy action. Recommend an engineering review to determine the feasibility of improving driver egres.

The conmander's hatch is heavy and requires a 7. Heavy Commander's Hatch considerable amount of pressure to open. When locked in a partially open (open protected) position, the commander's hatch may not open if pressure is applied to the hatch before pulling the release lever. This is considered a very likely action during a panic situation and could have contributed to the tank commander's death on 14 August 88. Design changes, per a PM Abrams directive, have been initiated to alleviate the problem (fig. 8). The Human Engineering Laboratory should be a role player in the effort. 8. Gunner's Seat The fixed gunner's seat back hinders evacuation. In order to exit, the gunner has to climb over the back of the seat. Recommend a human factors engineering assessment to determine what actions can be taken to make it easier for the gunner to evacuate the tank. 9. Water in Bustle Environmental seals on M1 are not adequate, allowing water (sometimes in large quantities) to enter the bustle where ammunition is stored. Combustible cartridge cases could absorb moisture, swell, and not chamber properly. Additionally, moisture can have an effect on the combustion of the case, degrading performance and creating residue which could enter the turret. The structural integrity of the case may also be adversely affected by excessive moisture. PV Abrams has taken steps to correct this deficiency, both on the production line and by issuing field-fix instructions for older tanks. Command emphasis should be directed toward insuring corrective action is accomplished in an expeditious manner. 10. Tanks not Fully Operational Insure all equipment, in particular the case base catcher box, is properly installed and fully operational prior to commencing gunnery exercises. Equipment should be inspected by a safety Officer/NCO before tanks are allowed to participate in live firing exercises. All equipment which affects crew safety, especially the case base catcher box, should be a readiness reportable item. B. Human Factors Engineering 1. Loading Tray The loading tray requires frequent adjustment. An improperly adjusted tray can interfere with the loading and case base ejection processes. PM Abrams has an engineering change proposal in process to address the problem. C. Training 1. Evacuation Procedures not Rehearsed Crew members should be instructed and tested in proper evacuation procedures, especially during basic armor training. They also should be required to undergo periodic drills. It is strc..gly recommended that command emphasis be placed on this frequently neglected training issue. 2. Ammunition Handling Procedures Training must strongly emphasize proper loading procedures to include the inspection of munitions before firing and the dangers of mishandling. Of particular concern is a technique of the loader drawing another round before the gun is fired. Warnings should be added to technical manuals prohibiting loaders from withdrawing a round from the bustle until the previous round is fired and the gun is placed in safe. ARDEC has submitted recommended manual changes to TACOM.

VI.

Overall Team Performance

The Root Cause Analysis Team's overall performance was excellent and their adherence to the concepts and methodology described in references 1 and 2 contributed significantly to the success of the activities.

References 1. Augustine Magistro, Class Notes, "Failure Analysis Seminar: Techniques and Teams, Vol. 1" US Army Armament Research and Development Command, Dover, NJ, March 1979. 2. Augustine Magistro and Lawrence R. Seggel, "Root Cause Analysis-A Diagnostic Failure Analysis Technique for Managers", Report Number RF-75-2, US Army Missile Command, Huntsville, AL, 26 March 1975.

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M865 TPCSDS-T
Because of a unique cone stabilizer design, the M865 provides normal projectile velocity to the maximum target range, with a sharp velocity decay after that point. This safety feature allows use of M865 practice rounds on U.S. and European ranges where permissible projectile travel is limited.

CHARACTERISTICS
CARTRIDGE
Length Weight Propellant Type Propellant Weight Chamber Pressure 881 mm (34.7 in) 19 kg (41.9 Ib) Single Base 8.3 kg (18.3 Ib) 4850 bar (70325 psi)

PROJECTILE
Type Length Weight Muzzle Velocity Range TPCSDS-T 468.5 mm (18.4 in) 3.2 kg (7.1 Ib) 1700:1 12 m/s (5578 39 ft/sec) 2500 m

Figure 3. M865 TPCSDS-T

13

As with all 120mni rounjds, a containment bag prev -nts Propellant spillage in the event of a case rupture.

120mm TPCSDS-T Roun('

CARTRIDGE CASE BASE

0 Cone Assembly
Steel Rod (core)

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Case Cover and Cap Assembly

Three-Segment Sabot

Figure 4. M865 cartridge exploded view

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Figure 10. Commander's hatch

APPENDIX A GUN SYSTEM DESCRIPTION

APPENDIX A SUBJECT: GUN SYSTEM FUNCTIONING, INTERACTION, AND MALFUNCTILNI

SUQUENCE OF OPERATION: i INITIAL CONDITIONS : Breech Closed, Chamber Battery Positio.n, Safe/Armed Handle in tb-e safe position. 2. The Loader engages the breech operating handle operating shaft and lifts the handle which opens the breech. block is now held open by the cartridge case extractors which n mating surface on the breech block. As the breech is opened, deflector follows the block down. 3. The Loader now inserts the round into the chamber.

s As t.-

round nears its chambered position, the rim on the stub base rc:.he th-l extractors forward and disengages them from the breechblock. -he breec' closing spring then causes the cross shaft and crank to rotate an. block and stub base deflector. Once the block has reached it I position, the crank continues to rotate, driving the fiwith the primer and locking the breech shut. Additiona!lv,reaches its full up position, the ignition circuit betweand block is established. The Loader then moves the Sa t armed or up positivn. 4. The Gunner now fires the chambered rosud. starts to move, the cannon begins to recoil. As the prc Ie, bore evacuator jets, a fraction of the propellant gas cnt . . chamber. The projectile now exits the muzzle and the hot (composed largely of hydrogen, carbon monoxide, carbon : encounter the air surrounding the muzzle. The gases aut,:*"": the muzzle flash. This muzzle flash very often causes tre in the tube to ignite and burn at the surface where oxygen the proiectile leaves the ;un , the gases stored in tue start to reenter the tube. Since the evacuator jets are, , ,,,a muzzle, they tend to eject the gases remaining in the n : tube and cause a partial vacuum at the rear of the tube. 5. As the gun recoils, it is slowly decelerate: '.v tiv.
hraking recoil spring act ion of the recoil system and spring. A! so as the gun recoils, loaded breech opening ('am out of the compression the breech o eri the way. At.max C': o ..

, reverses direction and is aceclc tt forward by the cou er- 1 t The breech opening crank then strikes the opening cam whi9h u to rotate and open the breech block. During the initial stacese motion, several things occur simultaneously. The breech e ne. unlocks the breech block and withdraws the firing pin. Th is i s

order to avoid firing pin breakage. During the final stages motion, tne block strikes the camming surface of te extr-a them -,) rotate, extract, and ejert the spent case base rt The case base th.,o encounters the c asp base deflect or. ",.ean,.' ,:-.

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caused by this discharge draws turret air into the tube during the case ejection. The deflector has been held in the up position by a latch controlled by the Safe/Arm Handle. The deflector forms a chute which guides the case into the containment box. Meanwhile, the cam continues to hold the breech block down. 6. The loader, prior to loading the next round, places the Safe/Arm Handle in the safe position which simultaneously causes two action to occur: 1. The breech operating cam now moves out from underneath the opening crank and allows the breech closing mechanism to raise the block to be caught by the extractors. 2. The deflector is now unlocked and is allowed to fall to the bottom of the breech block. The cannon is now ready to be reloaded.

Roger Billington

24

APPENDIX B ROOT CAUSE ANALYSIS CHARTS

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APPENDIX C IGNITION DATA

61

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29 July 1988

Cookoff Studies

120mm Combustible Cartridge Case - KE (Lot VEII6-1100-P) Coated Side in Contact With Hot Plate

Ignition Temperature OF

Time to Ignition (sec)

Avg 375 400 425 450 475 500 525 550 575 600 625 99.6 39.1 22.3 10.4 9.5 5.2 2.6 2.1 1.8 1.3 1.1

Std Dev 28.3 4.1 3.1 2.3 1.8 1.3 0.3 0.1 0.2 0.2 0.1

63

68

COOKOF STUDIES

21 July 88

LKL Propellant - Lot No. RAD 8K001S195

ignition Temperature
OF

Propellant Grain on End

Time to Ignition (sec)

Propellant Grain on Side Time to Ignition (sec)

Avg 375 425 475 525 575 625 675 700 145.4. 44.2 11.6 6.2 3.1 1.9 1.3 0.9

Std Dev 23.3 3.6 2.9 3.3 1.0 0.1 0.2 0.3

AvE 187.8 45.4 11.1 3.4 2.9 2.0 1.1 0.8

Std Dev 27.9 10.4 2.8 0.5 0.6 0.6 0.1 0.4

FIGURE E7

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APPENDIX D ROOT CAUSE ANALYSIS TEAM CHARTER

77

DISPOSITION FORM
For use of this form, see AF, 340-15 the proponent agency is TAGO REFERENCE OR OFFICE SYMBOL SUBJECT

SMCAR-TD
TO FROM

Red Team Charter

DATE CMT 1

SMCAR-ASM
(MAJ Dowalgo)

SMCAR-TD
(Mr. Lindner)

SE

3 1988

1. Recently two tank fires involving 120ram ammunition occured in the MIAl Main Battle Tank during Tank Gunnery Exercises in Germany. The most recent fire on 14 Aug 88 involved the deaths of two soldiers. 2. This DF will serve as your Charter to investigate this failure. You will serve as Leader of this Red Team and will conduct a critical assessment in an effort to identify al! likely conditions that may have contributed to the problem. Special emphases will also be placed on a review of current procedures/designs in order to assure that the best corrective measures are utilized to prevent reoccurance of the problem. Special attention will be given to the MANPRINT domains in the conduct of the assessment. 3. Your Red Team will consist of the foliuwing members, all of whom will bring expertise to this problem resolution process, while still providing an independent view of the failure under consideration: Name MAJ John Dowalgo (chairman) Organization Advanced Systems Concepts Office Product Assurance Directorate Safety Close Combat Armaments Center Armament Engineering Directorate PM-Tank Main Armament Systems Human Engineering Lab Master Gunner, FT Knox AMCCOM HQS Advanced Systems Concepts Office W4 Abrams Tank Main Armament Systems Extenstion AV 888-6044

Joseph Corallo (co-chairman) John Banks William Williver James Rutkowski

AV 880-5666 AV 888-4550 AV 880-6729 AV 880-5514

Roger Billington Jack Carlock SSG Robert Wolford CPT George Smith Augustine Magistro (consultant)

AV 880-2648 AV 880-3227 AV 464-1736 AV 793-4366 AV 880-6844

CPT Thomas Kidwell (consultant) Ken J Russell (consultant)

AV 786-6735 AV 888-4375

4. The urgency of this problem requires full commitment from you and the team on a full time basis for the period 10 Sep thru 31 Oct 88. It is imperative that an expeditious transfer of information takes place between the Systems Engineers, the User Community and your Red Team. Therefore you are afforded the authority to utilize any ARDEC resources that would be required in order to accomplish your mission. DlA FORM FORM DA AUG 80
, .... K , ...... ,4

24679

PREVIOU,'

BE

USED

SMCAR-TD SUBJECT:

Red Team Charter

5. A fund cite to cover travel and other expenses associated with this Red Team investigation is provided by PM Tank Main Armaments Systems. The fund cite number is 2182040- b-4000-P643639-S28Ol7 211A/219A. Sales Order number is Q8XJ-01-120. Cost Center is 692. Request a copy of all orders, referencing the Red Team, be send to PM-TMAS ATTN: AMCPM-TMA (Jim Richards). Questions about funding should be directed to Jim Richards at AV 880-2646. 6. Root cause analysis methodology will be utilized to identify all possible failure modes, the data to include supporting or refuting arguments and the potential preventative solutions. Your activity will be considered complete when the root cause of each failure mode is determined and a final report is prepared and published. 7. Major milestones in this Red Team investigation will be as follows: a. b. c. d. e. f. Form Team 14 - 26 Sep 88. (Provides for administration time.) review of incident 27 - 29 Sep 88. (ARDEC)
-

Background and preliminary technical

Review training proceedures and hands-on review 5 Perform final azcessmcnt and technical review 11 Draft report 21 Oct 88. Final report 31 Oct 88.
-

6 Oct 88.(FT. KNOX) 12 Oct 88. (ARDEC)

8. A final written report is required which will not only serve to document the problem and its resolution, but also provide for a transfer of data to others outside the immediate sphere of the team. The terms "Red Team" and/or "Root Cause Analysis" will be contained in either the report title or specified as a key phrase on the Report Documentation Page, DD Form 1473, at such time as the report is presented to the Technical Library. You may refer to the following reference materials for guidance: Root Cause Analysis - A Diagnostic Failure Analysis Technique for Managers, Technical Report RF-75-2. Augustine E. Magistro/ Lawrence R. Seggel, 26 March 75 Root Cause Analysis A New Failure Analysis Technique, Augustine E. Magistro, March 76

Red Team Guidelines, Augustine E. Magistro, 12 May 76

VICTOR LIRDNgR Acting Technical Director

80

DISTRIBUTION LIST Commander Armament Research, Development and Engineering Center U.S. Army Armament, Munitions and Chemical Command ATTN: SMCAR-IMI-I (5) SMCAR-AE SMCAR-AEE-BP, James Rutkowski SMCAR-ASM (20), MAJ J. Dowalgo SMCAR-CC SMCAR-CCH-V, William Williver SMCAR-FS SMCAR-SF, John Banks Picatinny Arsenal, NJ 07806-5000 Commander U.S. Army Armament, Munitions and Chemical Command ATTN: AMSMC-GCL AMSMC-LSA, Robert Allen AMSMC-QAT-M, Joseph Corallo Picatinny Arsenal, NJ 07806-5000 Office of the Project Manager Tank Main Armament Systems ATTN: AMCPM-TMA AMCPM-TMA-105, Roger Billington Picatinny Arsenal, NJ 07806-5000 U.S. Army Human Engineering Lab Det ATTN: SLCHE-AR, Jack Carlock Picatinny Arsenal, NJ 07806-5000 Administrator Defense Technical Information Center ATTN: Accessions Division (12) Cameron Station Alexandria, VA 22304-6145 Director U.S. Army Materiel Systems Analysis Activity ATTN: AMXSY-MP Aberdeen Proving Ground, MD 21005-5066

81

Commander Chemical Research, Development and Engineering Center U.S. Army Armament, Munitions and Chemical Command ATTN: SMCCR-MSI Aberdeen Proving Ground, MD 21010-5423 Commander Chemical Research, Development and Engineering Center U.S. Army Armament, Munitions and Chemical Command ATTN: SMCCR-RSP-A Aberdeen Proving Ground, MD 21010-5423 Director Ballistic Research Laboratory ATTN: AMXBR-OD-ST Aberdeen Proving Ground, MD 21010-5423 Chief Benet Weapons Laboratory, CCAC Armament Research, Development atd Engineering Center U.S. Army Armament, Munitions and Chemical Command ATTN: SMCAR-CCB-TL Watervliet, NY 12189-5000 Commander U.S. Army Armament, Munitions and Chemical Command ATTN: SMCAR-ESP-L Rock Island, IL 61299-6000 Director U.S. Army TRADOC Systems Analysis Activity ATTN: ATAA-SL White Sands Missile Range, NM 88002 Commander U.S. Army Armor School ATTN: ATZK-CO ATSB-WP-GD, SFC Wolford Ft. Knox, KY 40121

82

Commander U.S. Army Armament, Munitions and Chemical Command AMSMC-CG ATTN: AMSMC-ASR-A, CPT Smith AMSMC-RT AMSMC-AP Rock Island, IL 61299-6000 Program Executive Officer Close Combat Vehicles ATTN: AMCPEO-CCV U.S. Army Tank Automotive Command Warren, MI 48397-5000 Project Manager for Abrams Tank Systems AMCPM-ABMS ATTN: U.S. Army Tank Automotive Command Warren, MI 48397-5000

83