where was the DPA in all this?
That smacks of a poorly run company considering the weather reports.
where was the DPA in all this?
Complex organizations such as Nuclear facilities, Air Traffic Control Centres, Nuclear Carriers, NASA, some hospitals etc. are run as High Reliability Organisations (HRO’s). Perron and Reason see it as unavoidable that errors in complex systems will always happen, HRO is a tool to avoid as much as possible such errors and the consequences of it.
An example of what can happen to a complex system that was not run as a HRO is the incident with the Costa Concordia which carried about 4000 people. Another example of a very complex system, were however HRO was in place, is the nuclear Aircraft Carrier USS Enterprise with a crew of 5000 which was in service for fifty years with only one incident and that was not a coincidence or just luck.
In a High Reliability Organisation it is recognized that people make mistakes. Everybody should work hard to try to prevent such human errors but knows at the same time that this will not always be possible and that on any moment a fault can be made.
Respect - One should respect the opinions of the other members of an organization or team, from low to high ranks. Others should be encouraged to voice their opinion.
Caution - A cautious approach is a must to avoid errors and create incidents.
Mindfulness - There are five characteristics of HRO’s that have been identified as responsible for the “mindfulness” that keeps them working well when facing unexpected situations:
- Proactive anticipation on incidents
- Reluctance to simplify interpretations
- Sensitivity to operations
- Commitment to resilience
- Deference to expertise
Openness - An open culture is of utmost importance for a safe and high reliability organization or work space.
Reporting - Every incident, never mind how small it might be, should be reported and registered. The results should be analyzed on a regular basis to discover trends and identify problem areas.
If the bridge team of the El Faro had been run as a HRO that accident probably would have never happened, it was so unnecessary. The problem is how to implement HRO in somewhat less complex systems like the El Faro and generally in shipping. A good start would be to teach HRO in the nautical schools and the more posh Academies and to give post-graduate courses on the subject, all with the intention to work towards a better and safer marine environment.
I agree, first step though is to have the “semi-retired” box boat captains that are teaching BRM and similar classes to fully retire.
That would indeed be a good start. Another similar problem here and I suppose almost everywhere is the diehard mentality in shipping, especially in the shore organizations where the grey haired people are mostly in charge and often unwilling to change things except when immediate profits can be gained. Damage by errors on board ships is usually covered by insurance so no sweat. Most of the time there is hardly a long term vision present, only short term same as with governments.
This is the one they don’t like: “Deference to expertise”. Ship’s officers are taught that showing that they don’t know something is a threat to their authority.
Imagine being on a ship where none of the senior officers understand the direction of circulation around a low pressure system AND you can’t tell them anything.
I observed this type of thing all the time when I was AB studying for a license.
And there is also the odd character in my experience that keeps the expertise to himself. He is unwilling to share that because that would undermine his status as the ‘All Important Expert’ who knows it all.
I’ve seen the same thing.
That’s why I thought the way the email up-dates for the BVS weather program were handled was significant.
I was told by a captain that he did it that way because he wanted to “review” them first before the crew saw them. Why? Just have them forwarded to the bridge automatically.
Sounds like control-freakiness. Which I suppose could be an occupational hazard for masters.
Ive sailed with more than one skipper whose arrogance , ignorance ,complacency ,ego and or failure to accept help or advice from his officers in severe weather or other dangerous situations nearly cause a disaster.One time in particular in a bad storm while sailing as C/M the skipper got us in jam because of all of the above traits. He froze when the shit hit the fan .Thankfully with the support of the other officers, we were able avert a catastrophe and make it to port safely. Use your training ,experience, your support staff and every available resource to get through it safely. Working through a storm is no time to play God.
as has been oft said…there is no story still not yet told.
plain and simply, there are some not mentally fit to be master but how to prevent them from being put in the position? who other than an employer can serve as the judge (until there is a disaster and then it is easy!) how can the crew have a say in who they must serve?
The problem is that people like Schettino and Davidson, if not making big mistakes, rise slowly but steadily through the ranks until at last they become a captain. Often these characters know very well there limitations and are masters in hiding their shortcomings on the way up. We call that rising to the surface by lack of weight.
However, once having arrived at the top there incapabilities will show immediately in case of dangerous situations where real leadership is required. They then fall visibly short as they are not equipped to exercise such leadership and take real charge.
I think it’s a mistake to focus on individuals, should look instead at the culture and the bridge environment.
When Veldhuyzen van Zanten flew his plane into another 747 at Tenerife did that start hunt to get rid of experienced, confident pilots like Zanten? No, it started a change in the culture.
This is an example for Peter’s Principle:
“…Thus, employees only stop being promoted once they can no longer perform effectively, and managers rise to the level of their incompetence…"
If the crew had held together Captain Queeg would have gotten through.
Keith: But no matter what, Captain Queeg endangered the ship and the lives of the men.
Greenwald: He didn’t endanger anybody’s life! You did! All of you! You’re a fine bunch of officers.
Greenwald: Tell me, Steve, after the Yellowstain business, Queeg came to you guys for help and you turned him down, didn’t you?
Maryk: Yes, we did.
Greenwald: You didn’t approve of his conduct as an officer. He wasn’t worthy of your loyalty. So you turned on him. You ragged him. You made up songs about him. If you’d given Queeg the loyalty he needed, do you suppose the whole issue would have come up in the typhoon?
I never realized that phenomenon had a name.
To return to the internet and to find this discussion still ongoing is distressing. To base the quantity of lube oil in the sump on the amount entered in the stability programme is nonsense. One ton, two tons the effect on the ships stability is bloody close to zero and I can not apportion blame on the Engineering Staff.
The voyage data recorder tells me that an autocratic action by the master got an old ship into a predicament where a number incidents led to a tragic result.
I did get cross eyed looking at stability data in feet and inches, the last time I did so I was a lot younger with maybe more neurones. Thank god for the metric system.
May I complete that; “Except in Government, where there are no upper limit”
Do Matson still have NCB check the lashings before sailing? Never hurts to have an extra pair of eyes.
After reading Slade’s book I’m more inclined to agree with this.