USS Fitzgerald & ACX Crystal To Blame or Not To Blame?

If there was an accident the probable cause is the driver’s failure to stop. The distractions created by his passengers are a contributing cause as might be the personal issues related to his being laid off. His blaming the president is irrelevant but it does bring his emotional state into question.

At this point it probably is not too difficult to write the probable cause for the Fitz crash, it was a failure of the bridge team to follow proper procedures in the performance of their duties, most likely creating a breakdown of communications and crew coordination. The litany of contributing factors will include a whole boatload of stuff that the Navy guys probably won’t be too happy to read …but that is just speculation isn’t it?

Words of Wisdom:

“Blame is the enemy of safety.”

“Human error is a symptom, not a cause.”

– Prof Nancy Leveson

“For [a crew] to fail, someone else has to fail too.”

– Kevin Lacy, drilling expert.

FWIW, IMHO, YMMV and all that.

Cheers,

Earl

A comparison between what occurred against some standard would be objective. In the case of getting a ticket for a rolling stop, by law the standard is a full stop. However in practice the percentage of rolling stops would vary, presumably by location, time of day and other factors such as the presence of law enforcement.

Which standard to use is often the basis for discussion at this forum. Take the MSV Fennica for example, the discussion was which standard to apply to Alaskan pilots, should they have local knowledge of depths or is using the charted depths the standard?

Or the El Faro, what is the standard for tropical cyclone avoidance?

The area where the incidence took place , early in the morning, it reminds me lot with few factors that contributed the accident…Haze condition during the Northern Summer period -starts fm May,dense traffic with crossing situation within normal traffic lane from Uraga Suido( Tokyo bay ports) to Irago Suido ( Nagoya or adjacents ports), speedy vessels with PCC/Container coupled with Japan coaster-Kinkai vessels , intend to pick up pilots early in the morning.Wondering how the USS navy ship following the normal Commercial busy lane where no VTIS coverage similar to Singapore strait…they shud be slightly out of lane to avoid such incidence. Regret to say, Navy personnel are poor in Navigation in all nationality with factors that compiled by Captain Conrad are very legitimate based on my 30 yrs sailing exp with at least 20 yrs of exp within the waters where incidence took place

I think the standard is to avoid. Not avoiding can be found to be the probable cause or a contributing factor in the event of a storm related casualty.

I don’t see a great deal of maneuvering room in these things, we have all gotten away with bad choices or knowingly taken risks for any number of reasons that we knew might be difficult to defend if the outcome was not what we were confident would follow. When we take a risk or an action that is contrary to defined procedures or policy and results in a negative outcome we shouldn’t be surprised or dismayed when we are blamed for our acts or omissions.

1 Like

I don’t think many people are surprised, it’s fully expected.

What to you think Prof Nancy Leveson means by “Blame is the enemy of safety.” ?

Many moons ago I worked with a guy in the oilfield, a wise man from the FL panhandle, who had a great understanding of this principle and an equally great way of explaining it: “When you start out getting ready to do something you’ve got to imagine it all going to shit on you somehow, then start with the lawsuit and work your way backwards. If at any time while you’re explaining what you did and why you did it you start to feel stupid, or you have to make excuses, then you definitely need a different plan.”

Notwithstanding the usual outside pressures to do stupid stuff, that’s a pretty good way of keeping yourself honest and preventing self-inflicted wounds, if you have enough discipline to always do it.

3 Likes

It’s a good quote. simple and to the point.
She followed it with.
Human error is a symptom, not a cause.

Human factors

She probably wrote a whole book on the subject and teaches an entire course.

All humans make errors. Usually quite frequently. Blaming the human who made the error. Doesn’t usually prevent another human making a similar error later.

2 Likes

I usually ask myself

So Mr Uricane. Tell me just exactly WTF were you thinking when? If I can answer its ok, if not? its probably a good indication its a bad idea.

That’s a good way of putting it.

There is a difference between blame and understanding an incident.

In the case of the Fitz there was a flurry of posts based on the location of damage on the stbd side of the Fitz and the port bow of the Crystal. That’s driven by an intense desire to know which ship is at fault. Several post saying both ships are at fault etc.

If you are more interested in a good understanding of what happened the COLREGS are just the bare bone basics. The good info comes from mariners familiar with the area or the procedures aboard ships. To the blame crowd this information is going to look like making excuses when it just trying to find the reasons behind the collision beyond basic COLREGS.

2 Likes

Just like what occurred during the Washington State Ferry discussion.

During the discussion on the El Faro the subject of the NWS forecast and how they may have shaped perception of the weather situation, a legitimate topic in my view. One member however posted that we shouldn’t blame the NWS. Didn’t occur to me to “blame” the NWS. If they have some responsibility it would be a matter of checking to see if they meet NWS standards. Beyond that perhaps the standards need to be changed which the NTSB recently recommended.

Here is an example of what should be an objective an analysis being seen as an attempt to shift the blame. An article in Palm Beach Post about the NTSB report. From that article:

The report notes that investigators have yet to determine the probable cause of, or contributing factors in, El Faro’s sinking, but says “factual data on the official forecasts for Hurricane Joaquin and other recent tropical cyclones suggest that a new emphasis on improving hurricane forecasts is warranted.”

Here is the comment left at that site:

Hmmmm… They didn’t have top notch navigational systems… And the idea of keeping a better eye on the forcast. No one will ever be able to tell 100% where and when storms will be… Thats. I think someone dropped the their responsibility on the ship and putting blame elsewhere. So they dont get in trouble . thats just my opinion. I dont think NOAA should get blame.

From technical standpoint improving TC forecasts and communications to ships independent of what happened on the El Faro seems like a good recommendation. That the NTSB would want to improve safety at sea seems reasonable. That the NTSB is attempting to shift the blame to NOAA seems like nonsense.

It looks like the Navy has finally assigned some blame:

The removal of those three people is almost a given.

I’m certain you will see Article 15 (i.e. Admiral’s Mast) and/or Courts Martial punishment for other watchstanders directly involved in this incident.

It’d be more accurate to say that the Navy is holding personnel in postions of authority accountable.

Here on the forum posters are blaming the the way the Navy organizes bridge teams, training, general incompetence, corruption and excess politial correctness. Elsewhere others are blaming lack of ships, budget cuts and increased operational tempo.

In fact some in the upper Navy ranks may be publicly holding subordinates accoutable while in private blaming factors such as excess PC culture etc.

1 Like

Blame, accountability … synonymous.

1 Like

Go back to the studies of anthropology or animal behaviour or tribal behaviour or group dynamics or organisational behaviour.
It is normal chemistry that any failure in an organisation leaves a bad taste in its wake. The organisation cannot bounce back until someone is blamed and removed. Or removed with implications of blame attached. Or if he resigns himself after a nice mea culpa speech. Whatever!
The removal of at least one person gives the organisation a nice feeling of renewal, even if nothing much changes immediately or at all.

I came across this obscure book… and thought some people might have found it useful. The price may seem high, but still cheaper than the alternative.

https://www.abebooks.co.uk/servlet/BookDetailsPL?bi=18899531912&searchurl=tn%3DAvoid%2BHuge%2Bships%26sortby%3D17%26an%3DTrimmer&cm_sp=snippet--srp1--image5