Good article about the term human error. I searched for blunt end sharp end wrt the accident in Fremantle. There’s tendency to put the blame on the person closest in time and place as opposed as taking a broader view.
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nice - and agree. on my quick read of this.
People, especially at the “sharp end” will make mistakes. In a prior life we tried to recognize this, and do as many REAL two man checks as possible and practical. The odds of two people making the same mistake independently gets really small. The absolute key is to make them as independent as possible.
An example. On a chem ship the line up for loading 25-30 grades into 40-45 tanks is complicated, along with all the other systems, and venting and draining - literally thousands of single point failures in the system. After the CM would line up the deck - each mate would independently check the line up - alone. It was rare for the CM to make an error - but it happened, but that error never made it through 3 other mates.
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This, about what standards to use is interesting:
Finally, “error” can be viewed as a process, or more often, as not following the right process. “However, the enduring difficulty is that there are different models of what the process is that should be followed: for example, what standard is applicable, how standards should be described and what it means when deviation from the standards does not result in bad outcomes,” they say.
For example, in the case in Fremantle, what standard applies to the helmsman? Is he expected to catch the pilot’s lapse, apparently forgetting the last helm order?
Don’t want to go off topic here but this and another thread brings to mind the Exxon Valdez. What standard is a third mate held to wrt maneuvering a loaded tanker, at night, outside the normal traffic lanes? Should they be expected to maneuver by eye? What if the helmsman makes a mistake, what standard applies then?
During my training it was drummed into us to give a helm order and observe the rudder indicator. If steering a course in a narrow channel observe both the rudder and course almost constantly.
A not-so-good helmsman can be coped with by close supervision/monitoring. It just seems normal to me that mistakes of a helmsman should be almost instantly spotted and corrected.
Just as an example, some years ago I allowed a totally blind girl to helm the Leeuwin II into harbour at the same berth at the end of a week’s special disability voyage. She couldn’t steer a compass course but she knew the number of turns/spokes of the wheel would result in 5,10 whatever degrees. Obviously she was under the closest supervision with me standing next to her but she did a great job, only needing to be adjusted when back at midships by a degree or two.
Leeuwin nearly always has a learner on the helm because that’s what sail training does. You just direct and correct constantly until they’ve got it. I’m surprised that such basics aren’t standard procedure. In normal running I get 40 brand new helmsmen a week so I have a lot of practice.
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My post was poorly worded, I’ve edited it.
I agree with you that in the case of the helmsman putting the rudder over the wrong way one of the deck officers is most often going to be considered at fault.
Point being who is considered to be at fault depends on what standard is used. Shift the standard and someone else can be blamed.
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A good example of judging using shifting standards is the dive boat Conception disaster.
Before the disaster the captain and crew were judged by dive boat industry standards, after the disaster the actions of captain and crew were judged by the relevant legal standards,
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How about Hebei Spirit, Erika judgements of Masters just to mention those two.?
El Faro?
There’s several posts on this forum related to this topic:
Here’s a short paper https://how.complexsystems.fail/
A search here for “Nancy Leveson” will give some hits.