Copied from GCaptain 19 February 2020
By Captain George Livingstone –
There has been a lot of work in the last few decades directed toward
accident prevention in marine transportation. We know most accidents are
caused by human error, importantly, a series of errors. The much talked about
error chain comes to mind, and eliminating single person errors. The
theory is that reducing single person errors will reduce accidents overall.
So how is it working? Long term accident studies indicate there has been
a reduction in high frequency, low consequence accidents, the low hanging fruit
so to speak. Credit is well deserved there.
What about low frequency, high consequence accidents? Not good results,
and therein lies a problem. How do we go about preventing something that has
very significant consequences but rarely occurs? Aviation struggled with the
same problem for decades, what did they do?
Two years ago, John Konrad introduced my brother, Grant Livingstone, and
me to some works that a Col John Boyd (USAF) had completed in the late
1960’s. Col Boyd, a decorated combat flyer in three wars, developed a
theory he identified as the OODA Loop, explained in a piece
published by John Konrad, Grant Livingstone and John Merrigan in October of
last year in gCaptain. All of us were very interested by Col Boyd’s theory, as
it seemed to hit the mark regarding problems in modern-day marine
transportation accident prevention.
US Military Fighter Doctrine
Col Boyd felt that US military fighter pilots in Korea and later Vietnam
had lost critical combat skills. As early jet technology advanced and became
very complicated, pilots became more ‘check box’ flyers resulting in the
erosion of critical thinking. Col Boyd felt this was proven by the serious
losses in actual combat. Aftermuch research and self-searching,
Col Boyd came up with the OODA Loop theory, the idea of
continuous observation, orientation, decision and action(observe-orient-decide-act)
when in combat. He emphasized that the loop is actually a set of
interacting thoughts that should be kept in continuous operation while engaged
in combat (or any other critical operation, including ship
movement). Anyone that can process this cycle quickly, observing and
reacting to unfolding events more rapidly will win the outcome of events. This
neatly folds into marine transportation operations, especially when things are
beginning to unravel.
With the best intentions, is modern day marine transportation facing the
same dilemma as U.S. military fighter doctrine faced in the late 50’s and 60’s?
Have we drifted off course?
The International Maritime Organization (IMO) is responsible for
developing and maintaining a comprehensive regulatory framework for shipping
including safety, environment, legal matters, technical cooperation, maritime
security and efficiency of shipping. There are over 60 IMO legal
instruments guiding regulatory development to improve safety at sea. Some of
the more well-known:
Code of Signals
Regulations for Preventing Collisions at Sea
Ballast Water Management Convention
The IMO enacted Port State Control (PSC) Authority to allow domestic
maritime authorities such as coast guards to inspect foreign shipping at the
ports of many port states.
The working professional mariner may have reached a point of saturation
over the myriad of maritime regulations, statutes and codes meant to improve
safety at sea. The average master, chief engineer and senior shipboard
staff are being forced to address constant inspections and check lists through
Port State Control to the detriment of the safe evolution of the
vessel. Even the likes of Bridge Resource Management (BRM) training
becomes just another box to check rather than a critical learning event. Are
officers so over saturated that they have lost focus on the primary metric, the
safe movement of the vessel and its cargo?
Check List Culture
And therein may lie the crux of the matter, has the effort toward
accident prevention in marine transportation created a check list culture? What
if we all got off track? Has the well-intended focus through ISO/ISM in
preventing accidents led us to a place of putting critical thinking at risk? It
is one thing to discuss theory and diligently follow check lists, and quite
another to successfully manage developing crisis situations in real time. Have
we become more about documenting than operational excellence?
Continuous Loops and Recurring Cycles
Col Boyd felt that the OODA Loop theory served to explain the
nature of surprise and shaping operations in a way that unifies Gestalt
psychology and cognitive science in a comprehensive way. In other words, he
believed that using a continuous loop, in a recurring cycle by all involved
will create a winning situation.
One of the critical points raised is that all involved in an evolution
should be using the OODA Loop, specifically trained to use critical,
out-of-the-box thinking skills, in a continuous and recurring cycle. On ships
that means everyone, not just the captain and pilot, including tugs, all in the
game, all aware, and not afraid to ask questions. The fact is, it may be a
dereliction to remain silent, there is too much at stake.
Has the effort generated toward preventing one person error
morphed into all person errors?
Captain George Livingstone is a San Francisco
Bar Pilot, co-author of ‘Tug Use Offshore’, contributing author of ‘IMPA On Pilotage’ and a
regular contributor to gCaptain.