Lessons from the 1980 Titan II Nuclear Missile Accident (#148)

The Damascus Titan missile explosion (also called the Damascus accident) was a 1980 incident involving a Titan II Intercontinental Ballistic Missile (ICBM). The incident occurred on September 18–19, 1980, at Missile Complex 374-7 near Damascus, Arkansas. The Strategic Air Command silo in Damascus was one of eighteen silos under the command of the 308th Strategic Missile Wing (308th SMW), located at the Little Rock Arkansas Airbase.

41 years ago next month, the Damascus accident occurred when a U.S. Air Force Titan II ICBM, with a 9 megaton W-53 Nuclear Warhead, had a liquid fuel explosion inside its silo. The explosion destroyed the silo and its 700 ton door, and threw the nuclear warhead hundreds of yards out of the silo (the picture at the start of the blog post is of the destroyed missile silo). The warhead did not detonate and the US Air Force stated that there was no radiation released.

In 2013 Eric Schlosser wrote a great book called Command and Control: Nuclear Weapons, the Damascus Accident, and the Illusion of Safety on the disaster. PBS followed with an excellent documentary film titled Command and Control based on Schlosser's book. Both are worth your time if you or your company has a focus on safety.

Titan II Missile Complex Diagram

Five Lessons from the Titan II Nuclear Missile Accident

Here are five lessons I took away from the accident:

• The organization skills and safety culture surrounding nuclear weapons has been challenging to maintain for the US government. It is alarming to think about other nuclear armed countries safety culture or lack thereof. The Damascus accident was caused by a repairman dropping a 9 pound socket down the silo, which hit the missile and caused it to leak fuel. A series of poor decisions resulted in the fuel exploding a dozen hours later.

• The United States has had 32 acknowledged Broken Arrow events. A Broken Arrow is an an accidental event that involves nuclear weapons, warheads or components that does not create a risk of nuclear war. These include:

  • Accidental or unexplained nuclear explosion

  • Non-nuclear detonation or burning of a nuclear weapon

  • Radioactive contamination

  • Loss in transit of nuclear asset with or without its carrying vehicle

  • Jettisoning of a nuclear weapon or nuclear component

• Charles Perrow studied trivial events in nontrivial systems after the Three Mile Island nuclear plant meltdown in 1979. After reviewing hundreds of incidents and accidents, he concluded that human error wasn’t responsible for the accidents. The real problem was embedded in the technology and was impossible to solve. “Our ability to organize does not match the inherent hazards of some of our organized activities.” One-in-a-million events should be expected. They are normal.

• Dangerous systems require standardized procedures and centralized control to prevent mistakes during routine operations. But during an accident, Charles Perrow found that “the operators have to be able to take independent and sometimes quite creative action” to manage the uncertainty. Few bureaucracies can handle the paradox of needing routine centralized processes and creative flexibility during crises. I also saw this same paradox at play with the Chernobyl Nuclear Accident.

• General Curtis LeMay led the Strategic Air Command in its early days by implementing standardization with checklists and measures of effectiveness for every job and action. As he said “I can’t afford to differentiate between the incompetent and the unfortunate.” I am a strong believer in the power of checklists. Does your organization have a safety checklist? Do your people actually use the checklist?

Conclusion

If you ever in southern Arizona, near Sahuarita, you can visit the Titan Missile Museum which includes a missile silo and deactivated missile, a control room, a visitor center, a small museum, and a gift shop. There is not much left in Damascus, Arkansas since the US Air Force filled in the silo and turned the land back over to private owners).

Is your organization struggling to build leaders? Are you challenged to build a culture of safety in your team? Looking for something different to do as a training event for your team? TFCG offers the Atomic Leadership Workshop in Albuquerque, New Mexico; Las Vegas, Nevada; or at your location which uses the Titan II Missile Accident as one of its case studies. Want to know more? Click on one of the buttons to start the discussion.

In the meantime, go on the offense and use these five lessons from the Titan Missile Accident to improve your safety procedures