One sticks out very far above the others.
Most people in the general public would probably agree with you. Same with other accidents, for example the duck boats, it’s simple to find the person in authority closest in space and time to the incident to blame. This tendency is called fundamental attribution error.
What many accidents on small passenger vessels have in common however is the lack of a SMS.
The lack of a formal SMS lets the owner/operators and regulators off the hook which is the way they like it.
Google something like Conception boat fire “safety management system” and plenty will come up including recommendations from the NTSB prior to the Conception dive boat fire.
It’s been argued the reason for not using a SMS is that owners/operators oppose it on grounds of poor cost/benefit. But the owners benefit from the ambiguity, for one it allows them to escape blame.
#11 Organizations are ambiguous, often intentionally, about the relationship between production targets, efficient use of resources, economy and costs of operations, and acceptable risks of low and high consequence accidents. All ambiguity is resolved by actions of practitioners at the sharp end of the system. After an accident, practitioner actions may be regarded as ‘errors’ or ‘violations’ but these evaluations are heavily biased by hindsight and ignore the other driving forces, especially production pressure.
From here.
1 Like
You make it sound like any such finding MUST be an “error” in assessing any particular human at fault even in an intentional violation of a safety rule. To the abstracted world of safety management systems, and professionals discussing such arcana, even blatant violations are errors of the system not the human under the same theory. One can understand this approach, but since it ultimately relies on a concept that free will can be, should be, totally overcome in a perfect system it is unsatisfying, if not horrifying in implication. If I shoot you, the system of laws and protocols to prevent people being shot has failed, and i am just part of that system error revealing itself and that jury is guilty of fundamental attribution error if they convict. System theorists nod their heads in agreement, but people in society suddenly feel, indeed they are, much less safe…
Applied to casualty investigation, it is important to not so limit investigation or determine recommendations to the nearest human, sure, but to go to this case, NTSB hasn’t and the changes they recommend (if adopted) will subject industry actors that may otherwise haven’t failed to observe the rules will endure additional burden while changes are implemented that themselves will not ensure complete safety; it may even introduce new possibilities for error.
Sometimes, it absolutely is proper to blame the nearest human while recognizing that the system can be improved, but accountability emphasizing the human responsibilities to the system is not a bad thing and indeed people want accountable and responsible operators. Some here seem to want it from plan reviewers and regulation project leaders from two decades ago more than the system operator of the process onboard that night and you can simply waive this process analysis at that in the same way and call such attribution an error too (with more certainty, I’d say) and so everyone looking for accountability will be directed to exclusively dig into the ‘system’ documentation with a program debugger’s fixations.
The Captain, the human in this system willfully ignored a system required practice and violated law in the process. This system “failed” because of the amount of trust placed on one individual that they would follow the rule for posting the required night watch. System relied on trust, a violation of that trust had lethal consequences, let’s add verification steps to the system for watch setting, a log? a communication to a shore base or CG? These systems will also rely on a trust, but it will be a trust that requires more effort to violate or conceal but it will still be trust. The system will be tweaked as new regulations appear, and so it will go on.
But a crime has been committed, and that system must work as well. It’s function is complementary to the laws and regulations governing this “system”. Measures that recognize free will, emphasize responsibility, duty and create consequences for violation (and even human error) are more grounded and accessible concepts for the humans who work in systems since there are structural limits in establishing/revising laws and regulations as errors show up across a regulated industry. A concerned responsible owner can of course tweak his own in house safety management practices in attempts to achieve perfect system function, that system will be at work in a competitive environment tho and how long will it compete when the standard is not universal and the humans have no accountability even when wildly negligent or malicious, and negligent and malicious acts then force system reviews and new system promulgations? That’s gonna be a busy owner…
1 Like
Of course after a serious incident people in positions of authority/responsibility should be held accountable.
Put the captain in prison and throw away the key but the point is simply focusing on errors made by individuals is not a reliable way to reduce the risk of incidents in the future. Human error is inevitable. The goal of a SMS is to reduce risk by making the whole more robust in trapping errors.
That was the lesson of the Herald of Free Enterprise which was over 30 years ago.
The responsible party as you say, will never be found guilty. it would set a presidents (sp?) among other mistakes,
they have physically run over private pleasure craft which concluded the death of an adult and infant. the helmsmen was found guilty of a dereliction of duty. They are untouchable.
I will not go further with my comment because their standard SOP would be to call their friends at the IRS and have you audited which is what they do when they have trouble with commercial fishermen as a lot of there business is CASH
NTSB encourages operators of vessels with overnight accommodations to:
- Install smoke detectors in all accommodation spaces and ensure they are interconnected so when one detector goes off, they all do. While the Conception berthing space did have smoke detectors, they were the only ones on the vessel and would only alarm locally in the berthing space and not throughout the entire vessel.
- Ensure that the primary and secondary emergency escape paths do not lead to the same space, which can be blocked by a single hazard. The Conception had two means of escape from the lower deck bunk room, but both led into the salon on the deck above, which was filled with heavy smoke and fire. Tragically, the salon compartment was the only escape path to the outside weather deck. Because there was fire in the salon, the passengers and a crew member were trapped below.
- ?Vessel owners and operators should review the requirements of the Certificate of Inspection (COI) and ensure they adhere to the conditions of operation such as designating and maintaining roving patrols at all times when bunks or berthing spaces are occupied. Our investigation found that the Conception fire was uncontrollable by the time it was discovered because no crew members were assigned roving patrol duties on board the Conception, even though it was a condition of operation on their COI.
- Keep escape routes unobstructed at all times.
- Implement a safety management system. Had an SMS been implemented, Truth Aquatics could have identified unsafe practices and fire risks on the Conception and taken corrective action before the tragedy occurred.
We’re not saying wildly dissimilar things, i’m just pointing out the incongruity that your posts evince by bouncing into systems engineering philosophy and back into the world in a thread devoted to a discussion of serious charges in a court of law in which you used phraseology that suggests you think it can be described an “error” to blame the human.
I pointed out that when taken to the abstractions of systems analysis and engineering, such errors can exist but there are limits and absurdities to intentionally avoiding human attribution because that’s an “error”. If there is a “fundamental attribution error”, the subject can be human or system. Judgement is called for to determine if it’s an error, though the paper you link sure makes it hard to see they allow themselves the possibility, when the closest I think they come is in a footnote: “ 1 A systems-centered approach need not suspend responsibility from individuals—in this case trained and licensed professionals”
1 Like
With fundamental attribution error the term “error” is used in a similar way as it is used in “measurement error”, an example being compass error.
Compass error, for example, can be measured relatively precisely and a correction applied. However fundamental attribution error cannot be measured precisely so the error adds to the uncertainty and should lessen the confidence level of any conclusions wrt blame or assignment of responsibly.
Hindsight bias adds in still more uncertainty.
Edit: The most probable direction of the error (or bias) is known, the error would tend towards people focusing on the proximate cause, in this case the captain’s inaction, while neglecting other factors in this case the role of the company and regulators.
It is improper to describe this as “inaction”, it was a willful action to disobey a regulation, that regulation was communicated, understood and the roles of the regulator fulfilled by establishing and communicating the rule in the COI (their sole role in analyzing this incident and it was performed without error).
How much longer you intend to beat this horse?
I could swear I saw it twitch. @Kennebec_Captain: your point of view is somewhat analogous to this situation: You’re following traffic in a long line of cars going 55mph in a 45mph zone as it does every day on your commute. A cop pulls you over and gives you a ticket for speeding. You attribute fault partly to the people who set the limit without regard to how fast the traffic normally moves along that road, partly the fault of those authorities because they failed to monitor the situation more closely and physically force people to slow down and partly the fault of the cop for singling you out and not ticketing every other car proceeding at the same speed. Good luck getting out of that ticket if that is the defense you present to proclaim you innocence in court.
4 Likes
The dive boat captain was driving at 55 in a 45 just like all the other dive boats always do. No cop (USCG) had ever shown up to say slow down or we’ll give you a ticket.
Its not even possible for any person to know every rule of law in our society. There are too many rules. It would be impossible to function in society if every rule were strictly interpreted and enforced.
Common expressions:
“It’s a rule most often observed in the breach.”
“Rules are made to be broken.”
No one in the dive boat industry ever paid any attention to the roving watch rule because the USCG never enforced it. Nor did they require enough crew on the COI to make it possible to follow the rule.
This doesn’t mean that the csptain, the company, and the USCG are not responsible for what happened. They should be. It’s just not a simple or clear as banging your fist on the table and saying “they broke the rule.”
3 Likes
The only thing decided by the Judge was whether the criminal indictment for “seaman’s manslaughter” – a criminal case – adequately alleged all the required “elements” of the offense. He held – without prejudice – it was inadequate because it did not allege “gross negligence.” It’s legally notable because the statute does not say gross negligence is required, but common law and analogous statutes do include that requirement. I don’t do criminal defense, but on the civil side “without prejudice” means you get a “do-over.” Rewrite it to allege the missing elements. This decision does not interpret adequacy in performing duties imposed by Coast Guard licensing, civil liability for ordinary negligence, or whether someone else might have their own liability. It was a tragedy, there were screw ups, but does the Captain (former Captain?) go to jail? Link to Court Decision
This thread has already shown this is untrue and it excuses nothing on the part of this Captain.
Go ahead. Trice him up.
Yes, I like your analogy. Most drivers are aware that if stay below 5 mph over very little chance of getting pulled over. Greater chance at 10 mph over and so forth.
But five over is still illegal, however if someone is getting paid by the load/trip and they may soon learn they can’t make costs unless they push it. I understand that’s the case with driving log trucks on some roads here in Maine and I assume elsewhere.
That’s where the ambiguity comes in. Company might make a driver sign a paper saying to obey all laws and regulations. that might cover their ass but four legal trips a day don’t cut it. Need five.
As far as this captain, likely he’s in serious legal jeopardy.
3 Likes
The log truck driver is a very fitting analogy. I even wrote it down for future reference.
The Captain of a voyage where 100% of the passengers died (horribly) and 100% crew survived and he was the first to jump… it deserves a folk song.
1 Like
I agree. Call Gordon Lightfoot.
deleted
It is.
“ignorantia juris non excusat.” “Ignorance of the law is no excuse” is a well known legal tenet. Nevertheless, under certain conditions, a person accused of a minor infraction may find relief with a sympathetic judge by claiming ignorance of the law.
A captain licensed by the CG ignoring his mandate and the directives of the COI posted in his wheelhouse won’t be able to get away with it, at least not scott free. Since the captain cannot claim ignorance, a prosecutor will be able to prove intent.
I have been in this captain’s shoes and I’m sympathetic to his predicament. There but for the grace of God go I, but it’s a legal matter. To excuse his disregard for federal regulations by pointing out conditions that were tolerated because the industry has been able to sweep them under the rug is like not charging a speeding log truck driver when he runs over a bunch of hikers and then points the finger at bad logging roads and his boss’s unreasonable demands.
He’s in a bad place. If there is punishment, it won’t fall on regulators.
3 Likes