errata and a look inside the mind of a ship’s captain.

On a recent story I confused the Norwegian Dawn with the Norwegian Dream. The error itself is small but the implications are large and the reason for the error gives me the opportunity to shed light on the cause of so many maritime incidents. A short explanation might give you a look into the mind of a ship’s captain, so here it is;

Some articles are the result of hours spent researching, writing and editing while other posts are simply excerpts of stories found elsewhere on the web. My Norwegian Dream post was part of a general interest series we run called “Incident Photo of the Week“. These posts are designed to be short, interesting and easy to write and only require one line of explanation but, sufficient to say, I did not put much time into the “easy” job of posting the article.

Aboard ship 90% of the navigational jobs are easy. Some jobs, like departing Valdez Alaska, seem difficult to an outsider but are simple tasks for an experienced mate. This is the very reason Capt. Hazelwood of the Exxon Valdez left the 3rd mate in charge of the watch. These simple tasks, however, can result in tragedy caused by an even simpler mistake.

Moving large ships is not the only profession requiring complicated mathematical calculations, little room for error and disastrous consequences but marine navigation differs from professions like structural engineering because we have no brakes. The time is ticking on a large ship and errors are often not seen until after the danger has passed. During the incident you can not stop the job and spend hours reassessing the hazards, Newton‘s law of motion doesn’t allow it. This is why my error in reporting the story is significant and had it been made aboard ship would be cause for alarm.

So how does a captain prevent the simplest mistakes from becoming catastrophic incidents?

The first is training. While a brilliant structural engineer could be given the top spot at a young age this is not the case with ship captains. At the minimum regulations require 10 years of sea time in addition to hundreds of hours of course work and multiple levels of testing prior to being allowed by the Coast Guard to sit for the Master Unlimited exam. This method of advancement prevents a shining star from rising quickly but not for his lack of knowledge, rather from his lack of experience. This is required to give an officer the time not only to learn the theory and application of job specific tasks or even to give the time required to actually witness the full gamut of possible situations, although both are important. The primary reason is to a mate the time needed to feel the ship and understand/compensate for his limitations. The ability to master this is the mark of good captain and one reason companies prefer promoting older chief mates and rarely hire someone based solely on his qualifications (note: this is changing).

The best captains can identify instability by the feeling the roll of a ship, correlate the simplest annoyance with a larger problem (e.g. a sticky door caused by hogging) or recognize the tone of an officers voice that masks concern. They not only can identify but also have developed processes for solving problems. Last they know their own shortcomings and have built a system to identify and manage them.

In my case I have the occasional tenancy to correlate similar information so in this case my mind failed to separate the Norwegian Dream from the Norwegian Dawn. Aboard ship I would combat the problem by writing down each name on opposing sides of a yellow note pad and keeping relevant notes separated by space.

Second I am careful to listen for the voice in the back of my head that whispers “Something Is Wrong”. I have found this voice to be present 90% of the time prior to identifying a problem. It is important to note that incidents are not caused by single failures they are always the result of what our industry refers to as an error chain. The clearest example of this chain would be a catastrophic cylinder failure in the main engine. To most this type of failure would be classified as bad luck but mariners are trained to realize this is not the case. I use the following example because I recently read an incident report on a cylinder failure that was ten pages long and took 6 months to complete. The findings were nothing spectacular, rather they described many small problems dating back decades. The findings included an overworked engineering officer in charge of lubrication (days before the incident), the supplier substituting lubricants not ideal for that particular lube oil pump (the previous year) and even the designers failure to relate this seemingly small problem to the manufacturer 15 years prior to the failure. In this case all seemed well but I would bet heavily on the presence of a voice in back of the Chief Engineer’s mind calling out “I can’t identify it but we have a problem” his daily routine simply drowned it out. If he had identified just one of the links (minor causes identified in the report) in the error chain and removed it the incident would not have occurred.

Last I always step back and take a “time out”. This simple and effective technique taught in Major Emergency Management, an optional class in managing nightmare situations, closely resembles something we learn at a young age; step back, take a deep breath and ask yourself “what doesn’t make sense here?”

So putting it all together I could have avoided the mistake by first writing the key points down on a note pad and separating similarities (the ship names). Then I could have actively listened for the voice whispering (or in this case shouting) “something is wrong” and finally, if I had failed to identify the difference in the first step, I should have called a personal time out, stepped back and asked myself “does this make sense.” If I had done this I would have quickly realized the obvious fact that containers do not belong on a cruise ship.

Why didn’t I? …well this is just a blog, right?

Many thanks to our loyal readers for finding the error, especially Perry. Despite my initial annoyance from his repeated corrections a good captain must always smile when a concern is related (even when woken at 0400) and hopes all of his makes are just as diligent and persistent. It’s the “easy” posts, after all, that often results in longest incident reports.

Stay Safe,

John

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John A. Konrad, Master Mariner

John Konrad is a USCG licensed Master Mariner of Unlimited Tonnage and the editor in chief of gCaptain.com. Since graduating from SUNY Maritime College he has sailed 4 of the world’s oceans and reports from his ship via satellite.

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