File under “can happen to anyone” I guess.
Written standing orders in place but this “OOD” didn’t feel, what, “empowered” to speak up that he was impaired or not fit to stand the watch? (What would have been the consequences of doing the right thing in this case anyway? Worse than what happened?)
This kind of process interests me because there is a ‘moment of truth’ in the sequence of events when one should just know better. Whether fatigue, complacency, rushing, frustration, making poor assumptions or some other faulty thought / decision making process is at work, at the end of the day a competent person must take action. Why didn’t this guy know better? Because he didn’t have enough written procedures?
Revising / tweaking the written procedures (in this case standing orders) should always be considered but I’m starting to feel like that is becoming the go to solution. And instead of providing true, consise and valuable guidance these documents are becoming encyclopedic, disjointed and I fear little referred to and ultimately of declining usefulness. Except for after the fact, CYA or however you would like to phrase it.
This was not a merchant vessel / crew but one would expect the leadership/management skills onboard to be be top notch no? So if a crew member has the technical and administrative skills and knowledge why is that not enough? Where / when / how does good judgement and decision making skills come in to it?
One has to exercise one’s judgment, discretion, whatever to get better at it but that means making mistakes on the way to good judgement. Do we do enough to establish the climate for this development?
These are some of the things I think about when I read reports like this. How do I react to small mistakes? Big ones? Do I have the resources to get everyone enough rest? How do I react to someone “stopping the job”? What does the office do or say about it after the fact.
I came out of ERM and LMS courses with a good bibliography of references to add to my library and some good ideas but no silver bullets with regard to changing “culture”. Of course not, there are none. One thing I notice is that the talent pool responds better to graduated development of technical skills than to judgement skills. I have a feeling that this judgement thing starts long before a guy / gal steps on to a ship. It’s not tested for and it’s not taught per se. I do think increased technical skills builds confidence and that seems to have a beneficial effect on judgement.