To Blame or not To Blame.
7 young seamen serving their country, lost their lives in a tragic accident. It must be someone fault? Somebody is to blame? Somebody should be held accountable? Somebody should be punished?
All very natural questions. Usually the public reaction to any accident. Particularly when injury or fatalities are involved.
While I suppose its natural to want to blame someone or a ship or even several people on both ships. Its not a very good way of finding out what went wrong and how to help prevent it happening gain.
Was the Captain to blame? Apparently he was seriously injured in his quarters at 0130 in the morning, quite probably in his bunk.
For some very good reasons the NTSB does not find or apportion blame. People who are accused of doing something wrong particularly something they might be blamed for. Tend not to be entirely open about what happened. Particularly if they might face some form of charge. According to US and Most western law. The accused has a right to remain silent. Its up to the prosecution to prove beyond a reasonable doubt someone is guilty. If not they are deemed not guilty. Which is not the same as innocent.
I do not know how the US Navy investigates accidents. My knowledge comes entirely from watch JAG. On TV. I hope they start with a NTSB like philosophy.
Were the officer of the watch or the officer of the deck to blame? I would suggest it doesn’t really matter. At least not until after we find out what happened. How it happened, why it happened, And what can we change to prevent it happening again.
Why? If we leave the question of who is to blame out of the equation. They are much more likely to speak openly about what happened.
Two ships had a collision. In order for a collision to happen two different bridge teams have to have made some significant errors.
Why both bridge teams? One ship was stand on one ship was give way. Which was which we do not know yet. Part of the normal every day practice of good seamen. Is to take whatever action is required to avoid a collisions. Somehow both got it wrong.
The most important action now is to figure out why. Finding out why is much more important than finding out who to blame.
I suspect an investigation which is not intending to find out who to blame, will find several different reasons why this happened.
If after finding out why. You figure out someone, or several people, intentionally chose, not to do what they were supposed to do. Then you can start thinking about blame and consequence.
For this discussion I like this quote.
After the outcome is clear, any attribution of error is a social and psychological judgment process, not a narrow, purely technical or objective analysis.
•Richard Cook and David Woods
Evidently for many people the line between objective analysis and blaming is too blurry to understand.
If we are willing to accept that the NTSB is very skilled at providing an objective analysis we must also accept that the phrase “Probable cause is the captain’s failure to …”
If there is another more convenient term than “blame” to describe that very objective finding then please post it.
By way of example say a driver gets a ticket for rolling through a stop sign. By law the driver is responsible. The driver however might blame his wife or his kids for distracting him. He might blame the police for arbitrary enforcement of the law, or he may have been distressed at being laid off and blame the president and so forth.
If there was an accident the probable cause is the driver’s failure to stop. The distractions created by his passengers are a contributing cause as might be the personal issues related to his being laid off. His blaming the president is irrelevant but it does bring his emotional state into question.
At this point it probably is not too difficult to write the probable cause for the Fitz crash, it was a failure of the bridge team to follow proper procedures in the performance of their duties, most likely creating a breakdown of communications and crew coordination. The litany of contributing factors will include a whole boatload of stuff that the Navy guys probably won’t be too happy to read …but that is just speculation isn’t it?
Words of Wisdom:
“Blame is the enemy of safety.”
“Human error is a symptom, not a cause.”
– Prof Nancy Leveson
“For [a crew] to fail, someone else has to fail too.”
– Kevin Lacy, drilling expert.
FWIW, IMHO, YMMV and all that.
Cheers,
Earl
A comparison between what occurred against some standard would be objective. In the case of getting a ticket for a rolling stop, by law the standard is a full stop. However in practice the percentage of rolling stops would vary, presumably by location, time of day and other factors such as the presence of law enforcement.
Which standard to use is often the basis for discussion at this forum. Take the MSV Fennica for example, the discussion was which standard to apply to Alaskan pilots, should they have local knowledge of depths or is using the charted depths the standard?
Or the El Faro, what is the standard for tropical cyclone avoidance?
The area where the incidence took place , early in the morning, it reminds me lot with few factors that contributed the accident…Haze condition during the Northern Summer period -starts fm May,dense traffic with crossing situation within normal traffic lane from Uraga Suido( Tokyo bay ports) to Irago Suido ( Nagoya or adjacents ports), speedy vessels with PCC/Container coupled with Japan coaster-Kinkai vessels , intend to pick up pilots early in the morning.Wondering how the USS navy ship following the normal Commercial busy lane where no VTIS coverage similar to Singapore strait…they shud be slightly out of lane to avoid such incidence. Regret to say, Navy personnel are poor in Navigation in all nationality with factors that compiled by Captain Conrad are very legitimate based on my 30 yrs sailing exp with at least 20 yrs of exp within the waters where incidence took place
I think the standard is to avoid. Not avoiding can be found to be the probable cause or a contributing factor in the event of a storm related casualty.
I don’t see a great deal of maneuvering room in these things, we have all gotten away with bad choices or knowingly taken risks for any number of reasons that we knew might be difficult to defend if the outcome was not what we were confident would follow. When we take a risk or an action that is contrary to defined procedures or policy and results in a negative outcome we shouldn’t be surprised or dismayed when we are blamed for our acts or omissions.
I don’t think many people are surprised, it’s fully expected.
What to you think Prof Nancy Leveson means by “Blame is the enemy of safety.” ?
Many moons ago I worked with a guy in the oilfield, a wise man from the FL panhandle, who had a great understanding of this principle and an equally great way of explaining it: “When you start out getting ready to do something you’ve got to imagine it all going to shit on you somehow, then start with the lawsuit and work your way backwards. If at any time while you’re explaining what you did and why you did it you start to feel stupid, or you have to make excuses, then you definitely need a different plan.”
Notwithstanding the usual outside pressures to do stupid stuff, that’s a pretty good way of keeping yourself honest and preventing self-inflicted wounds, if you have enough discipline to always do it.
It’s a good quote. simple and to the point.
She followed it with.
Human error is a symptom, not a cause.
Human factors
She probably wrote a whole book on the subject and teaches an entire course.
All humans make errors. Usually quite frequently. Blaming the human who made the error. Doesn’t usually prevent another human making a similar error later.
I usually ask myself
So Mr Uricane. Tell me just exactly WTF were you thinking when? If I can answer its ok, if not? its probably a good indication its a bad idea.
That’s a good way of putting it.
There is a difference between blame and understanding an incident.
In the case of the Fitz there was a flurry of posts based on the location of damage on the stbd side of the Fitz and the port bow of the Crystal. That’s driven by an intense desire to know which ship is at fault. Several post saying both ships are at fault etc.
If you are more interested in a good understanding of what happened the COLREGS are just the bare bone basics. The good info comes from mariners familiar with the area or the procedures aboard ships. To the blame crowd this information is going to look like making excuses when it just trying to find the reasons behind the collision beyond basic COLREGS.
Just like what occurred during the Washington State Ferry discussion.
During the discussion on the El Faro the subject of the NWS forecast and how they may have shaped perception of the weather situation, a legitimate topic in my view. One member however posted that we shouldn’t blame the NWS. Didn’t occur to me to “blame” the NWS. If they have some responsibility it would be a matter of checking to see if they meet NWS standards. Beyond that perhaps the standards need to be changed which the NTSB recently recommended.
Here is an example of what should be an objective an analysis being seen as an attempt to shift the blame. An article in Palm Beach Post about the NTSB report. From that article:
The report notes that investigators have yet to determine the probable cause of, or contributing factors in, El Faro’s sinking, but says “factual data on the official forecasts for Hurricane Joaquin and other recent tropical cyclones suggest that a new emphasis on improving hurricane forecasts is warranted.”
Here is the comment left at that site:
Hmmmm… They didn’t have top notch navigational systems… And the idea of keeping a better eye on the forcast. No one will ever be able to tell 100% where and when storms will be… Thats. I think someone dropped the their responsibility on the ship and putting blame elsewhere. So they dont get in trouble . thats just my opinion. I dont think NOAA should get blame.
From technical standpoint improving TC forecasts and communications to ships independent of what happened on the El Faro seems like a good recommendation. That the NTSB would want to improve safety at sea seems reasonable. That the NTSB is attempting to shift the blame to NOAA seems like nonsense.
It looks like the Navy has finally assigned some blame:
The removal of those three people is almost a given.
I’m certain you will see Article 15 (i.e. Admiral’s Mast) and/or Courts Martial punishment for other watchstanders directly involved in this incident.