Don’t have statistics to back me up, but when you look at the Safety Flashes that is sent out the most common fire starter on vessels today is charging of electronic devices onboard.
I always bring it up at fire drills that the crew must be observent on how they leave their cabin and to take out the power brick when done charging.
About this case I said my piece on how it was a cluster fuck in the first thread about this when it happend.
This is a good point. Brings to mind the Swiss Cheese Model of accident causation.
The hazard here being the Li-ion batteries.
The roving patrol layer failed because none was assigned. However even if one had been assigned there was the possibility they could have fallen asleep. A potential single point failure.
From Cook:
Complex systems are heavily and successfully defended against failure
Catastrophe requires multiple failures – single point failures are not enough.
In this case a single point failure was enough. That single point was the captain’s responsibly but the lack of other layers is a regulatory failure.
Even I don’t think a single point of failure was enough, but it’s indeterminate past a certain point. But indeed, someone removed a vital slice of swiss cheese in this incident and that was decisive in the worst outcomes.
To quote an famous DOD Secretary (Dept of Delicatessens) “you to go sandwich with the swiss cheese you have, not the swiss cheese you wish you had”
Want more cheese on your next sandwich? Buy more. You can’t add it to the last one. Someone took out a slice from the Conception’s sandwich, people may insist that if you just put it back in the next one, it’ll be fine, others will insist it won’t be. But that is a discussion for the change in regulations to improve outcomes going forward, not a sign of failure. The regulatory structure is the stack of swiss cheese on the sandwich, not any individual piece and the deli has had the same recipe for decades and can’t change it without approval from Jimmy John himself.
You could have stopped after the first paragraph. The analogy was thoroughly tortured by then. Whatever point you’re trying to make was lost in all the cheez.
That’s an extra sharp observation you make. Gouda you to do so.
You’re starting to look more and more like a troll but…
This discussion started in 2005 when the NTSB first recommended the USCG require all U.S.-flag passenger vessels to implement a safety management system
One important function of a SMS is for the company to identify risks before an incident takes place.
This discussion started above, not in 2005. As for the NTSB recommendation from 2005, people can speculate how that would affect safety going forward, but many are skeptical of the SMS being a perfect barrier against all hazards, especially when implemented by small operators without the resources and indeed incentives to be comprehensive when it would increase their costs. An SMS didn’t prevent the EL FARO. Even the NTSB conclusions on this investigation are speculative on the possible effectiveness, relying on language like “could”, “enhance”… as they reiterate their recommendation. People who see SMS in action will have different opinions on such effectiveness. I’d recommend equipment based solutions like sprinklers and detectors, maintained and tested.
I don’t think I’m a troll, if i was, the forum seems troll friendly in other threads but if persisting in a position, defending against fact free or evidence free assertions and giving opinions backed by substantial experience is unwelcome when not conforming to the in-group preferred world-view, ok, done.
I notice that you didn’t tell us about your small commercial vessel sailing experience. So it’s obvious that you are just talking through your hat.
To the OP………absolutely spot on. Well said.
I feel like my next safety drill is just going to be a long ramble about cheese.
Homer Simpson is the Plant’s safety manager.
Responsibility should be divided up in a way that’s similar to the percentage method used by courts in collision cases but it’s the nature of the job that the captain faces the most legal risk.
I agree that the captain in this case is not the only party that has contributed to the accident but wouldn’t venture a guess as to what the actual percentages are.
Logging truck drivers are under the same pressures internationally it seems.
the risk is the industry governed buy the USCG, how to mitigate that in the USA?
If managing risks is thought of as a hierarchy than the captain is at one level and regulators at another, higher level.
The captain makes a lot of decisions at the boat level but not, for example, whether to carry sufficient PFDs (lifejackets). That decision is made at the federal level and the CG comes down once a year and checks for compliance.
The CG also requires a roving patrol but by default the CG and company let individual boat captains assign crew tasks according to each captain’s personal perception of the risk
Clearly, this is an ideal opportunity to give the higher level a boot in the arse. The CG should be brought to account.
Gcaptain thread here.
My point exactly. The USCG sets standards that are far too low but then they don’t want to be the fall guy with politicians who get blasted by the companies. The guy in the company corner office is at least just as guilty as the Captain, probably far more so. When I was sailing commercial the ships I was Master of for the greater part of my career went from 28 crew to 21 and now they are even at couple less, with NO major change in the equipment save for an Engine Room fire detection system. Yes we made it work, but we always pushed the work hour limits and we were well qualified to fight a small METAL trash can paper fire if it hadn’t spread. The Captain and Chief routinely had more than 12 hour days but that was “balanced” by a day of NO REQUIRED duties as we transited open water. But then I will never be convinced that the “talk” the office guy reportedly had with the Captain of the El Faro about job performance was not a major, if not a primary factor, in that ship’s loss.
2 posts were split to a new topic: In Conception fire, divers trapped below deck sought way out