Is there any connection between the VS and HI incidents as regards people following process but failing to see what is happening?
The myth here is the the “good seaman” does not need a step-by-step process but will instead be able to immediately size up the situation and unerringly make the the right move.
This was the point of this thread: The Difference Between Amateurs and Professionals
The terms amateur and professorial meaning a mindset, not paid vs unpaid;
Amateurs focus on being right. Professionals focus on getting the best outcome
Amateurs have a goal. Professionals have a process.
With regards to the Viking Sky my regular chief used to tell the assistant engineers with regards to answering alarms to follow this process: Don’t recall the exact words but something like this:
- Acknowledge and confirm direct cause of the alarm
- Correct the direct cause of the alarm.
- Ask what indirectly caused alarm condition and correct.
So for example a high tank level alarm. The cause is high tank level, cure is pump down the tank. But also what caused the high level and correct that as well or likely find yourself back in the E/R with the same alarm.
In passenger ships the engine room is always manned regardless of the sophistication of the automation. In other ships under UMS an experienced duty engineer would set tank levels and other parameters up so for six to seven hours he would get no alarms and some sleep. Less experienced engineers would get alarms throughout the night because they didn’t follow the steps above.
The exception was a Chief Engineer with a third world crew who found that the cards were being pulled on persistent alarms. He remedied this by making bars that locked the cards in.
I see some differences. The Helge Ingstad accident unfolded in a relatively short amount of time, and had a lot of moving parts. Through some evil quirk of attention channeling, several key players dropped the ball at the same time, and the holes in the cheese lined up. They very much failed to follow established process, the watch officer by failing to cross check sources when it was called for, the VTS operator by failing to track the radar target.
I don’t quite know what to make of the Viking Sky. I think @camjournal has a good point here:
It’s also going to be about this:
It’s clear that they somehow failed to see, and I’ll be interested to read more about that when the report comes out.
I asked the question because I am interested in organisational culture. On the face of it, the bridge of a warship and engine room of a passenger ship have little in common. But as Kenebeck says, amateurs have a goal, professionals have a process. But I wonder what happens if the process becomes the goal?
Some folks across the pond may have heard of Grenfell Tower.. Last week the report was published. That report criticised the London Fire Brigade for sticking to policy and process beyond the time when Policy worked.
Is this a feature of modern organisations?
With all that’s been revealed about the Grenfell Tower someone’s going to talk about the “policy and process” of the fire brigade? How about the policy and process of putting flammable cladding on a residential building? How about the policy and process of the “professionals” who thought it was ok to cram all those people into that dive boat off California?
Rant off, back on subject - I don’t see any similarity with the VS & HI. The VS crew I believe understood what was happening, followed process and got her back (freaking barely) - the HI crew clearly didn’t understand what was happening and may or may not have followed process, I don’t have an informed opinion about whether they followed a process or not.
But I’m kinda interested in the actions of the HI OOW who apparently after realizing very late the collision danger, ordered “hard to port” and very shortly countered with “hard to stbd” (or something like that) and whether that may have avoided a direct T-bone situation with much more loss of life. If that’s what s/he was thinking in that agonizing moment was s/he doing process or amateur goal-striving? It seems to me that the goal here was more important by a long shot than the process.
Ha Ha. This just the kind of BS I used to tell my captains all the time. It helped them think they understood WTH was going on…
My point was not about the technical side. I likely would not discuss with the chief the minutia of the E/R routine. Rather the idea of repeating to the crew a consistent message about solving routine problems with a routine process.
The common feature of the two incidents would be the presence of humans and thier amazing ability to F up.
Not really able to comment to much about the Viking Sky. It’s not my area of expertise. Yet I suspect somewhere near the root of the problem there was one or more humans making errors.
The HI clearly lots of Humans making errors. And while those humans on the HI made the most spectacular errors. There were humans on the TS Sola and in The VTS home made significant errors. Any one of which if avoided may have changed this from an incident to a near hit.
Clearly VTS, the pilotage, Authority’s the tanker company and the Norwegian Navy all had lots of policies which if followed should have prevented this incident.
Even though it’s not my area. I would suspect not following OEM recommendations or requirements would be a bit of an engineering faux pas.
The alarms? Crying wolf? Turns out one day there a f ing wolf. Who would have thunk?
To much I don know to say?
A cruise ship full of little old ladies and little old men, Cruising the Northern coast of Norway in the winter? Mostly sheltered water. Some bits not so much. What was 6 to 8 m seas.
What could possibly go wrong?
Yes, I see an interesting difference in the two incidents. -Disclosure- I’m not a nautical guy, I’m in the basement, nonetheless I like to look at these events to see what can be learned. What interests me now about the VK incident is that it doesn’t really fit the usual “chain of events” where if one link in the chain is broken the incident is avoided, or call it the swiss cheese model if you prefer. These guys were screwed long before they left the dock, this incident was inevitable, it just had to wait until they hit some kind of rough water. I am in no way trying to let engineering off here, this was clearly a failure of the engineering dept even before the VK poked out into the exposed seaway. I really hope we get some in-depth insight into how this could have happened, I’m sure you all do too.
But remembering my disclaimer - this does show the danger of sailing along an ugly lee shore in a stiff breeze right? Boy, one minute you’re sailing along with those stabilizers doing their thing and suddenly you and all those little old ladies and men are in a heap of danger.
Another thing about the HI which others on here know much more about - someone previously mentioned that it was the quartermaster who first thought that the TS Sola was not actually stationary? The QM is on the ship’s centreline maybe with a foremast to work with and most of the others had parallax (correct nautical term?) to deal with. I’ve seen how that can make it more difficult to keep that all-important “situational awareness”.