Blame does not prevent accidents.
Accidents almost always have a human involved who did or didn’t do something at some point.
The vast majority of these are errors or mistakes rather than wilful acts.
On very rare occasions the action or lack of action was the result of a wilful decision to act or not act in a manner which contributed to an accident.
In a just world, accountability still exists. For those rare occasions.
This particular case, involves a specific rule which was not complied with. The roving patrol.
Regular drills was also reported to be a problem.
The law was not followed, the requirement was written. Appears at first glance to be easy open and shut case.
March the guilty bugger in, try him fair and square, find him guilty and hang him from the nearest yard arm.
Problem solved.
In reality. It’s not that simple. In order to prevent incidents like this, or duck boats sinking.
We still have to determine, why
Not just why did this particular skipper not comply with requirement.
Why was it a common practice for the dive boat industry not to comply? Throughout this company and others.
Why was this requirement not monitored by the regulatory body?
There are plenty of people to blame.
Would the skipper have been fired if he chosen to follow this rule? I doubt the question ever occurred to him or his employer. There is no suggestion it did.
Anecdotal opinions of the regulatory body. This was one of the better run small passenger vessels companies in the area. With a good reputation for safety.
It is quite possible even probably, if this had ever been brought up or pointed out to the company they may have made the appropriate change.
The truth is they had 2 more Crew than the manning certificate required.
Indeed they appeared to have thought having one of the crew sleeping in the bunk area somehow met the requirement.
It would not have been a big cost to change this to someone being on watch.
No additional crew required, just rearranging how the existing crew worked.
It would have been a significant change in understanding what was required. Resulting in a significant change to “the way we do things”. Which might not have been popular or easily understood before this incident.
If only someone at sometime had said a a roving patrol means someone has to be on watch.
Particularly if this had been an inspector.
It would most likely have been complied with.
A common theme for accidents. Sometimes some of the best humans make some of the worst mistakes.
This incident and unfortunately several previous incidents highlight a ongoing problem with small passenger vessel operations. Which requires better regulatory oversight and education.
All of which have been recommended by the NTSB and not implemented by the regulatory body.