Will the El Faro Cause a Rethink of BRM/MRM* Training?


#21

We had a potentially dangerous engineering casualty on a ship I just signed off of. We made the right phone call, did not freak out and got the Chief down there out of bed and we had everything straight in a few minutes. Not surprisingly, the bridge did not inform the Capt right away. Very disconcerting. Things must change. Get the old man out of the sack, that’s what he or she is getting paid big money for.

A sea change must happen. It must happen in that void between the ears first.


#22

In my experience this is common. It’s a well known problem the stovepipe.

A stovepipe organization has a structure which largely or entirely restricts the flow of information within the organisation to up-down through lines of control, inhibiting or preventing cross-organisational communication.

It seems like a problem with the bridge watch but if it’s not surprising that it happend maybe the chief shouldn’t have trusted that path. He could have told the bridge to call the captain.


#23

Yeah, nothing like sitting down to breakfast and hearing “heard you had a problem last night Chief/Captain” and not having a clue what they’re talking about.


#24

This is a big deal for me. The “problem” of running a ship is a nut best cracked by evaluating situations with people who do not think alike.

Almost anytime a non-routine situation comes up I at least give the chief the outlines. Same thing with the E/R stuff.

If we were going to encounter a hurricane the chief would ask for an explanation of principles of avoidance. Then he would use that information to evaluate the actual plan. The chief will do a far better job at poking holes in the plan than the mates.


#25

A couple of personal anecdotes. I am not sure where they fit into the overall subject of this thread but it has to do with interpersonal relationships aboard ship.

When I was a young 3rd I got a job on a ship where the Chief was considered a real asshole and hard to get along with. That is probably how I got the job as no one else threw in for it. I ended up getting along extremely well with him. I found the key to getting an idea across was to present it in such a way that he could claim some degree of ownership of that idea. The conversation usually started off along the lines of “Chief, what do you think of …?” [ mitigated speech] He also had very high standards and did not put up with sloppy workmanship but that is another subject.

There was an incident when I was Relief Chief that involved a small oil spill. There was a mechanical failure when the barge was blowing out their hose which caused some oil to go in the water. It didn’t help that it was raining to boot which just added to my inconvenience. After getting the situation stabilized I made the required notifications to the USCG and the company’s oil spill response contractor. When I called the captain his response was, “What are you calling me for?” I told him I figured he might want to know.
The next day I was ashore to face the music with the Head of Engineering. I assumed I would be canned. By that time he had heard back from a repair contractor he sent down to check things out. He said" I firmly believe everyone should be afforded one mistake." He then looked down at the repair contractor’s report. “This wasn’t your fault (re: oil spill) but you just had your one mistake.”


#26

On many/most workboats you don’t call the captain when he’s off watch. I’m used to handling everything on my own, manifests, paperwork, arrival/departure, and engineering casualties. When I switched to working on ships I had a hard time knowing what exactly required me to call.


#27

Personally, as a Chief, I would have phoned the old man or find him and explain the situation to him directly as I had to do when we had a little leak in the ER. In that way we were off station and heading for shore whilst we then dury rigged a repair. Once the old man knows he can contact the bridge or is that too much to ask?


#28

Personally, I have my guys call me when I’m off watch. They may be able to handle it without me coming up, but the one thing that will get my blood boiling is the aforementioned “heard you had a bit of an issue last night” over breakfast that I knew nothing about. I tell my guys when they sign on, “I have a phone in my room for a reason, part of my job is to answer that night or day when you or the office calls it. Just have fresh coffee brewing for me if I need to come up there and there’s time.”

Nine times out of ten, I don’t really need to go up and the issue is already handled, but even still I’ll usually pop my head up to make sure it didn’t get a whitewashing (and shit is still hitting the fan), or just to check on things anyway.


#29

Oh, but I love (/sarcasm) getting calls from the bridge that “the engine room called and (major equipment) broke and needs to be fixed…” ‘ok, did Chief say how long it’ll be?’ “They haven’t called him about it…”

That gets some door pounding happening and reminding the Chief that his/her guys need to be calling him themselves and not passing the buck to the bridge or me to call him out in the night.


#30

Maybe y’all can help me out here.

What Bridge Resource Management reforms would help the situation when you’re 25 miles from the eye of a Category 3+ hurricane on a beat-down old rust-bucket that has had repairs “kicked the can down the road” since President Carter was in office?

I mean it’s groovy that we’ll have covered lifeboats to go with our Gumby Suits, but I would have thought that the idea was to NEVER have to use those things.

Just sayin’ that it would seem that the “reform” had to happen somewhere considerably further away than the Bridge.


#31

I am 2/3s of the way through “Into The Raging Sea”. If that book is even 50% accurate, BRM would have been like handing out sunscreen after an atomic bomb went off. BRM was just one of 1,000 problems at what looked like an utterly dysfunctional outfit.


#32

The fact that the focus is on something as absurdly “late in the game” as BRM “reform” is indicative that everyone concerned wants to put the entire blame for the SS El Faro on the people that went down with her…how VERY convenient! They’re all DEAD, so whatever penalties that might be imposed upon them are all mooted, aren’t they?


#33

That wasn’t my point at all, can’t speak for anyone else.
From what I am reading the entire company was a giant mess, not just the crew on the ship.


#34

Anybody coming late to this party will be faced with the need to read the 500 odd pages of the NTSB or the USCG reports or one or more of the books written about the disaster. But if you want to get a quick update, earlier this year I read through both reports and published a summary (of about 4000 words) on my website. I’m not advertising but I am still trying to provide information that will help keep people alive out there. The El Faro story


#35

It’s true that there were many factors involved, there were many decisions made which could have changed the outcome had they been made differently.

But that overlooks the fact that not all the decision made are of a similar nature.

With one exception, all the critical decisions were driven by costs, the ruling that changing to RO/CON was not a major conversion was cost driven as was the raising of the load line, the neglect of maintenance, the fact that the company had no operation department, no evaluation of risk, no ability to vet the captains and so forth, each decision based on cost vs risk.

The single exception to the rule that all the decisions were cost based is the one decision to navigate the ship into the so-called dangerous side of the eye wall of Joaquin. There was no upside here, nothing except unacceptable risk, no possible cost or schedule gains to be made. It was a blunder.

This weather routing error was the error of a single person, the captain, and it was based on his failure to correctly comprehend information that was readily available on the ship at the time.

This information however was understood by other crew members. This was absolutely a glaring failure of the captain to properly manage the bridge team.

This is from Bowditch: Managing the Bridge Team

Most transportation accidents are caused by human error, usually resulting from a combination of circumstances, and almost always involving a communications failure. Analysis of numerous accidents across a broad range of transportation fields reveals certain facts about human behavior in a dynamic team environment:

Better decisions result from input by many individuals
Success or failure of a team depends on their ability to communicate and cooperate
More ideas present more opportunities for success and simultaneously limit failure
Effective teams can share workloads and reduce stress, thus reducing stress-caused errors
All members make mistakes; no one has all the right answers
Effective teams usually catch mistakes before they happen, or soon after, and correct them

These facts argue for a more inclusive and less hierarchical approach to bridge team management than has been traditionally followed. The captain/navigator should include input from bridge team members when constructing the passage plan and during the pre-voyage conference, and should share his views openly when making decisions, especially during stressful situations. He should look for opportunities to instruct less experienced team members by involving them in debate and decisions regarding the voyage. This ensures that all team members know what is expected and share the same mental model of the transit

This thread is not about the loss of the El Faro, instead it is about the failure of schools that are conducing leadership / management and BRM classes. What they are teaching is not based on "certain facts about human behavior in a dynamic team environment" but instead the classes are just a reinforcement of the status quo.

That needs to change, it’s past time for the maritime industry including the schools to acknowledge “certain facts about human behavior”.