Karl Weick - An Analysis of the Tenerife Air Disaster

The Vulnerable System An Analysis of the Tenerife Air Disaster (pdf)

Mariners that have called to Honolulu recall that at the entrance to the port there is a sea buoy and then three sets of buoys (IIRC). Once the ship gets through the buoys it is inside the breakwater. Next there is a short straight section and then a 90 degree turn.

The connection between the Weick article and Honolulu Port entrance is that a pilot there explained there was possibility of starting the 90 degree turn late. The reason was because after the difficulty of getting through the buoys (sometimes strong set to the west with wind and current) the pilot and the bridge crew would stop concentrating on the task because little attention was required on the straight section.

The error of the late turn would come because crews would slip into an almost daydream state.

Weick mentions the same phenomena with the KLM crew as they had to turn the 747 around on the narrow runway.

I was reminded of this article when I was reading about the Fitzgerald, the crew had also just completed some difficult tasks (exercises and then heavy traffic) and might have had a brief respite.


The article talks a lot about stress and I think that is an important factor in the soporific situations you suggest.

Your brain consumes more energy than any muscle in your body and the levels of energy consumption are greatly increased during times of stress because the typical stress response is a release of chemicals (e.g. adrenaline) which can help sharpen your focus but at the expense of greatly increased amounts of energy consumption. It is for this reason - along with the fact that the release of too many chemicals can push you over the threshold of focus - that it is so important to stay calm and emotionally detached during highly stressful events.

Basically your brain is running a sprint as you enter the breakwater and can not sustain the level of energy consumption just as a runner can not continue sprinting at maximum effort more than a 100 yards or so.

The best way to prevent stress is mindfulness training which is basically just actively cheching in with your self and accepting the uncertainty you face coupled by a solid understanding of what causes stress. I don’t think may mariners practice mindfullness or even understand what stress is.

This article defines stress academically but basical all stress is is knowing what you want (e.g. the give way vessel to move, the helmsman to listen, the weather not to worsen, your wife not to call and undload family problems on you…) but not being fully confident that you will get it.

How this pertains to the el faro is that a very effective but highly dangerous stress relief mechanism is to ignore or actively understate the potential for trouble. Ignorance is bliss because if you refuse to understand the full extent of the problems ahead of you then you will not discover what you want… and if you don’t know what you want you will not get stressed.

So I think some aboard the el faro avoided really engaging with the weather problem because they already had a high level of stress and did not (mostly unconsciously) want any more.

The stresses of delivering the new builds on time and on budget might have also resulted in the office ignoring the hurricane the el faro because they did not have the ability to take on more stress.

This is a problem I have seen a lot with Chief Engineers. They will refuse to understand the broader picture because “hey Captain, I gotta stop you there because I got enough problems of my own to deal with!”


Is there a book you would recommend for Mariners about learning and dealing with stress?

There are a great many books on mindfulness, it’s something my wife actively teaches the use of in her line of work. I’ll ask her for some recommendations.

Oh wait, it’s Deep Sea Diver…yeah…never mind.


In the UK the MCA and industry majors, including the Nautical Institute, commissioned a study into the Human Element in Shipping.

The USN would do well to read it:


I’d like her recommendations.


Excellent report on an incredible accident. Not sure about the connection with Honolulu harbor. If it was a state pilot he should have made that approach several hundred or even thousands of times. It’s not that harrowing. Not like taking a large jet to an alternate smaller airport because of a bomb, with distressed passengers and fog setting in. That pilot is either really full of himself, or maybe he was on maui wowee when he put those two ideas together.

But thanks for the link very interesting indeed.

It sounded to me like @Kennebec_Captain made the association between the Karl Weick and the story the pilot told him.

Then that would be my bad. Still, there are many situations in shipping that could lead to what he is describing. Just getting a ship loaded and out of port can be extremely stressful and hard to control at times. The Poet comes to mind

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The Honolulu pilot was discussing the nature of human attention.

In the article the KLM pilot had the task of turning the 747 around 180 degrees. The aircraft requires 142 feet to make turn and the runway was 150 feet wide. After making this turn, because of the nature of our brains, the pilot would have relaxed a bit.

This is not to say that turning a 747 around 180 degrees is “harrowing” for an experienced pilot. But it is a task that would require his attention.

The Honolulu harbor pilot told me that as he approaches the turn he will engage the captain in some way, for example, asking what was his last port. Not that he cares but this is because by nature, there is a tendency between the breakwater and the turn for captains to lessen their attention to the task at hand.

I’ve found this knowledge to be useful.

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I would think asking the captain questions that have nothing to do with the task at hand would distract him rather than help him concentrate.

Presumably the captain is already distracted because when the ship is in the wider, straight section with little set the mind will, by nature, wander off task.

Also, the other thing he told me was short-term memory can track six to seven “things” For example when mooring the status of each tug, the status of the engine, the bow thruster, the mooring lines, ship’s position, clearance fore and aft, speed etc.

These things are held in short-term memory and if there is an interruption and attention is needed elsewhere, for example answering the VHF, it will take about 30 seconds to reload short-term memory, that is to say 30 seconds to regain the picture.

That is true. As a Towmaster I used to be able to keep in my short term memory the last orders (engine power in % and heading) for up to 5 tugs.
Anything more then that would require a whiteboard and someone to keep it up to date.

Computer records are no good as it require more direct concentration to see what’s on the screen, thus loss of concentration for other tasks.
Too many sources of data is also contributing to loss of concentration. (Data overload)

I must admit that in later years anything over three tugs would be a struggle. Having to ask the tug what settings they were on, especially if it had been a while since last change, became a more frequent occurrence. The introduction of Barge Management System help, however.

That’s a much better document than I expected. Good information and very readable.

So you want to make it worse by providing more distraction? I don’t get it. I agree 100 percent on the short term memory numbers depending on the demands and complexity of each unit providing information. I don’t get how distracting someone from the task(s) at hand is going to help them focus on the task(s) at hand. In what universe does that work?

I think the point is that after the higher stress event the mind resorts to a somewhat altered state conducting some other business than the real task just ahead that should be the focus. It sounds like the “distraction” of the pilot is meant to serve as a splash of cold water on the face. As in “Huh, what? Oh yeah something else coming up.”

I’m pretty sure I’ve seen some people react this way before. But it was not like that behavior was their standard reaction either. Time, place, circumstance. Awareness of the possibility of this reaction and some this here mindfulness stuff might go a long way to warding it off if you’re someone who is susceptible to it.

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Asking him about his last port is not going to elicit a response of “Huh, what? Oh yeah something is else is coming up” as much as it is to going to make him think of his last port and begin formulate an answer. Sure, some people might respond to a polite cough or a question about a last port. I guess I’m not very sophisticated because if I had to break someone’s reverie under these circumstances, I’d just cut the crap and say “there’s a tricky bit up ahead”.

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