Friday, April 16, 2010

Casualty Analysis

It is another beautiful morning in the Atlantic. I can't get over how pleasant the open horizon looks after spending four months channel bound in between Malaysia and Indonesia. The perpetual movement of water down the hull and the lonely expanses of ocean rarely occupied by any vessel besides our own has made for two weeks of low key watches.

The clouds have been particularly spectacular passing through some unsettled weather before entering the Bermuda high. Rainbows, columns of localized rain and towering cumulonimbus have made for great sunrises and sunsets. Yesterday I steered for a pair of humpback whales. Keeping my distance I spent an hour watching them breach and curiously stick only their right fins out of the water to slap them onto the surface over and over again.

I received a preliminary ice bulletin on the Sat-C from the International Ice Patrol today which included a reminder that the 98th anniversary of the RMS Titanic is nearing. This and the more recent grounding of a collier on the Great Barrier Reef got me thinking about how mariners learn about and learn from misfortune at sea.

One of the required courses during my senior year of college was called Casualty Analysis. It consisted of reading National Transportation Safety Board case studies of classic marine disasters. Each episode involved a catastrophic loss of life, cargo, vessels or damage to the environment. Every week for a semester a different collision, grounding or fire was discussed by the class and it was expected that our opinions were to mirror the ageless conclusions of admiralty lawyers as written in the text book.

The class served it's purpose to illustrate why the event's happened and how we could avoid falling into the same traps but the conclusions always felt too black and white and didn't deal with the human factor sufficiently. One time I made the mistake of challenging the consensus and attempted to articulate my own causal factors in a case where a coast guard vessel collided with a tanker in Tampa Bay. This was not a good idea and the instructor informed me that the courts conclusion was the only good explanation as to why the error chain went unbroken.

The other aspect of the class I found disconcerting was the tone of the NTSB's accident investigations. Much like the Coast Guard's marine safety bulletins they reeked of a corner office in Washington where some clerk handled road, rail, aviation and marine accidents as one in the same. The Coast Guard's blend of military and law enforcement interpretation of a bad day in the Merchant Marine has much the same affect on incident reports.

The Australians on the other hand seem to have a master mariner working at their Transport Safety Bureau. The most recent marine casualty in the news being of course the Shen Neng 1 which destroyed a 3 km stretch of coral reef and likely much more due to the resulting fuel spill. The preliminary investigative report reads as if it was written while in the wheelhouse of the ill fated ship rather than a formulated government inquiry.

The investigative team must have had a background in commercial shipping and relayed the events so clearly it read like a journal. Not only that but this preliminary report was issued mere days after the incident rather than months after the fact when the full investigation was in which helps quiet misinformation in the media.

The U.K. does a similar service to marine incidents by publishing a quarterly magazine by the Marine Accident Investigation Branch full of glossy photos and recommended practices to avoid accidents at sea. I would really like to see the U.S. Coast Guard hire a few retired skippers and Chief Engineers to do the same for our marine industry. Right now the Coast Guard's one page bulletins, in house publication Proceedings and Professional Mariner's unprofessional mariner section are about the only printed venues for casualty analysis in the States.

Anyone who enjoys reading about marine accidents knows that there is always more than one contributing factor. Just look at the contemporary findings for the circumstances surrounding the Titanic (Steering compasses not being aligned, communication issues, binocular cabinets being locked).

Marine incidents need to be looked at deeper than which party is at fault for settling insurance and salvage claims. Real people were very tired on the Shen Nang 1 and arresting the Chief Mate and Captain might make the masses happy in Queensland but it's not going to prevent future accidents when cargo officers on undermanned ships end up working another 37 hour day.

1 comment:

  1. Right on the money Deep Water!

    Shame on that instructor; safety investigations are about finding root cause while courts attribute blame. These are very different things. Also - there is NEVER only one causal factor.

    Keep the blog going - great perspective.