Our recent post Was the titanic sunk by a small key? elicited some great response from our readers. Surprisingly, the best ones had little to do with the titanic itself and more to do with the cause of all maritime incidents… the error chain. First a recap from the original post:

While some point to the ship’s excessive speed, the vessel’s design or the positioning of the ship’s compass as the cause of the incident the facts clearly show the titanic sunk as a direct result of the accident chain>. In other words the titanic sunk, not due to one large error but a combination of small errors that linked together caused the tragic circumstances. Remove one small link in the chain and the incident is avoided.

It is interesting to note that a string of small errors caused by human error is the cause of most large maritime incidents. The lesson to be learned….. next time you make a mistake aboard ship listen for the voice in the back of your mind and quickly ask yourself; is this an isolated incident or indication of larger problems?

Shrivan states; “Now I understand how important keys can be in ships” to which Fred Fry replies; “Keys are important. Keys are power!”

This comment reminded Jim of a quote from his Captain: “Give a man key with a clipboard and you’ll find out what kind of person he is. Give them in the morning and you’ll know by lunch.”

Things start to get serious around comment number 20 where Bob Couttie writes:

In the past I’ve used ‘error chain’ and ‘domino effect when discussing accidents but, at the risk of getting too theoretical I think both are inadequate since they are basically descriptions of single-point failure (A chain fails when a single link fails, a domino falls over when its neighbour hits it).

The best physical description I think is the wooden tower game, “Jenga” or “Topple” in which players take turns removing blocks from a stack. The first few extractions don’t do much harm but as the process continues the stack becomes more and more unstable until one reaches a point where removing any block at all will cause the stack to fall over.

If you think of the tower as ’safety’ and the individual blocks as the elements, precautions, procedures that make up safety, you’ve got a fairly good visual model for how accidents happen.

Kennebec Captain replies in agreement and points us to this post on his blog:

A more helpful model is the Swiss Cheese Model first proposed by British psychologist James T. Reason (nice name!).

This site (Dukes.edu) has a nice graphic of the S.C. model.

The Swiss Cheese Model provide a positive method of reducing risk, rather then seeking to break some invisible chain, one simply adds layers, or increases the effectiveness of the existing layers (making the holes smaller). As an example, one could add a layer of crew training, or seek ways to improve the effectiveness of existing training, or use additional care during passage planning.

On a well run ship you can observe the Swiss Cheese Model in action Each near miss, representing a hole in one layer, is evaluated and if needed procedures are modified. Near misses, lessons learned, Bridge Resource Management, careful passage planning can all be seen as adding layers of cheese. Of course it may not be called that. Another name for the application of the Swiss Cheese model is – good seamanship.

So from the Titanic to Swiss Cheese I enjoyed the comments… thanks to all who participated!

Cosco Busan – Questions,Questions,Questions

By Bob Couttie

Once the US National Transportation Safety Board has produced the transcripts of the voyage data recorder from the Cosco Busan (Formerly the Hanjin Cairo, the Hanjin name remains on the ship side) we’ll have a better idea of who said what to whom and when. Currently only the pilot’s version of events is available and it is raising a number of questions.

A malfunctioning radar appears to have been an element, though not the cause, of the incident and so far there has been no indication regarding the second radar on the ship’s bridge. Given that there was poor visibility, was the speed of the vessel excessive? Should departure have been delayed until the fog cleared.

The pilot was not familiar with the ECDIS equipment onboard, which does not appear to have malfunctioned. When the pilot asked the Captain to point out the centre of the bridge span the captain allegedly pointed to the bridge support and the pilot navigated accordingly.

With an apparently malfunctioning radar and a lack of familiarity with the primary method of navigation, did the pilot seek to confirm the vessels position with the VTS and/or the accompanying tug?

VTS informed the pilot that the ship was off course, which the Pilot disputed and shortly afterwards a lookout shouted a warning that there was a bridge support ahead and the vessel went hard right and allided with the Delta bridge support.

There also appears to have been a lack of detail in the master/pilot exchange when the latter took conduct of the vessel, as the pilot’s lawyer admits. Would the missing information have been enought to prevent the incident?

There may also have been communications problems between the American pilot and the bridge team who were Chinese. Of there were, to what extent did they reduce the pilot and the bridge team’s situational awareness?

It is not uncommon for pilots to ‘go it alone’ rather than work with a bridge team with whom communication is problematic. This increases the workload on the pilot and reduces his situational awareness. Had the pilot and the bridge team undergone bridge team/bridge resource management training?

Incidents such as this rarely have a single cause, or a single responsible individual. They are usually the result of systemic problems with Bridge Team Management, leadership, culture and navigational practices.

It will be a while before we know the full story of the Cosco Busan, but we’ll hit that bridge when we get to it.

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Bob Couttie has written for a number of maritime industry publications, including the prestigious Lloyd’s List International daily newspaper and Lloyd’s Ship Manager magazine. His reportage on problems with ship’s officer certification examinations in the Philippines in the late 1990s influenced the adoption of computerized examinations for ship officers by the country’s Professional Regulatory Commission.

Bob currently writes and produces podcasts for The Maritime Accident Casebook

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The San Francisco Chronicle has published the Pilot’s Report on the Cosco Busan Incident. Here are the parts of interest to mariners;

Meadows said problems also cropped up in “bridge management,” the communication between the pilot, who had years of experience on the bay, and the ship’s officers, who had never navigated the bay in the Cosco Busan. All were supposed to work together and exchange information on how to successfully navigate the harbor.
“While some information was exchanged, perhaps it could be said it wasn’t a full transfer of information. It was enough for the pilot to work with the master and get the ship ready for sea,” Meadows said.

We have previously reported on bridge management also know as Bridge Team Management or BRM.

gCaptain’s BRM related articles;

• Cosco Busan – Bridge Resource Management
• Environmental Catastrophe Possible Averted – M/V Pasha Bulker
  
• Pasha Bulker Incident Report – Nearly Unbelievable
• What Went Wrong Aboard the MV Pasha Bulker? (Telstar Logistics)

The article continues;

The Cosco Busan’s radar “conked out” twice – first before departure and again as the ship was near the lighthouse on Yerba Buena Island.

Cota was forced to rely on an electronic chart display, showing the track of the vessel and its speed, plus charts of San Francisco Bay. Meadows said the pilot told him he was “not familiar” with the electronic system on the Cosco Busan. “They are all different,” Meadows said.

Cota asked Mao Cai Sun, the captain of the Cosco Busan, to point on the display to the center of the bridge span between the Delta and Echo towers on the western side of the Bay Bridge.

“The master pointed that out,” Meadows said. “In fact, several times during the trip. That’s what the pilot was heading for.”

…

“The pilot had to go along with what the master indicated on the electronic chart display was the center of the span,” Meadows said. “That turned out to be the tower instead.”

We have received email asking; Should the vessel have left without a working radar? and Did the second radar work? …unfortunately those are questions we can’t answer. You will have to wait until the NTSB investigation report is complete.

Read the full SF Chronicle article HERE.

Related Maritime Blog Posts;

Pilot Terror by Bob Couttie

First a note… I am publishing this short clip ahead of my next article because of its importance!

While preparing our upcoming “questions for investigators” article on the Cosco Busan incident we were asked by more than one party a question along this line; with communications failure being a leading cause of incidents and the crew of the Cosco Busan being Chinese of limited english skills (they required translators during the investigation) why do incidents of this type not happen more often?

The answer is Bridge Team Management.

Ok… so what is BRM? Simply because it’s an increase focus of incident investigation and watchkeeping.

Revisiting a previous post I state:

• Bridge Team (or resource) Management (called BRM in the industry) is a process to use all of your available resources during critical operations. It came from the airline industry which found an alarming number of accidents happened despite prior warning from the equipment or crew…. mostly by captains with military backgrounds and a “I can do this” attitude who did not fully use critical information from either the equipment or junior personnel.Boiled down it’s a class all officers must take in both teamwork and processing the large amounts of data (lookout reports, radar, radio comms, gps charting, weather information….) that pours into the bridge.
• Here’s a more official answer:The Bridge Team Management course introduces the concept of a navigation team to ship masters and watch officers and frames their decision making process toward establishing watch conditions during the course of the voyage. Bridge Team Management techniques will emphasize decision making based upon conditions related to workload and potential threat to the vessel. The intent of the program is to define the individual task and responsibilities of the various team members while developing a situational awareness to prevent individual errors.

In stating the importance of this post I am looking at the media reaction to the incident. In reporting disasters the public is often not satisfied until a single individual is blamed…. quickly. This was the case in the Exxon Valdez oil spill, Tampa Skyway Bridge Disaster and even in the early reports on the Empress of the North grounding where fault was placed on the Jr. Officer on watch who was only weeks out of the Maritime Academy. In the Empress of the North incident gCaptain broke from traditional media and laid the blame on management techniques rather than the “green” officer and we are happy to report he was recently clear of all charges (as was Capt. Hazelwood of the Exxon Valdez).

It is clear to us the Cosco Busan allided with the Bay Bridge because of a breakdown in Bridge Team Management. For example while VTS contacted the ship questing its course did the mate on watch, captain, helmsman or assist tug captain also voice concern? Was the equipment operational and set up properly? As the primary fault for the Exxon Valdez incident was not with Captain Hazelwood (he was cleared of charges and his license was reinstated) John Cota, Pilot aboard the Cosco Busan is not solely at fault for this incident.

The team failed the Cosco Busan not the ship’s Chinese Captain or American Pilot alone. Lets just hope the court of public opinion does not convict either person before the long and thorough investigation is completed. Otherwise they might stand the fate of Captain Hazelwood, cleared of charges and fully licensed to pilot a ship but unable to find a company willing to hire him.

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Asking yourself how a ship 131 wide could have such trouble in a channel 737 metres wide? Read a more unbelievable story HERE then watch the amazing slideshow HERE.

UPDATE: Bob Couttie of the Maritime Accident Casebook has a very interesting article along similar lines. You can find it HERE.

UPDATE 2:
Criminal probe opened in Bay oil spill

The entire crew of the cargo ship that sideswiped a bridge, causing San Francisco Bay’s worst oil spill in nearly two decades, has been detained as part of a criminal investigation, a Coast Guard official said Sunday.

Capt. William Uberti said he notified the U.S. attorney’s office on Saturday about issues involving management and communication among members of the bridge crew: the helmsman, the watch officer, the ship’s master and the pilot.