From Lloyds List Tuesday 20 January 2009
by Rear Admiral John Lang, former Chief Inspector of Marine AccidentsÂ
AMID the relentlessly gloomy news of recent weeks, the one item that has received widespread acclaim around the world is the supreme display of airmanship by US Airways pilot Chesley Suttenberger, who landed his Airbus in the Hudson River and saved the lives of all 155 souls on board.
I have absolutely no doubt that the aviation community will already by learning from the event. Pilots will be mentally reviewing their own actions in similar circumstances, cabin crew will pay even greater attention to evacuation procedures on water, and I’m pretty sure passengers will listen a bit more carefully to the pre take-off safety drill. And all this happens long before the accident investigators have analysed their findings and produced their report.
By comparison, we in the maritime world still have a long way to go in the wake of any accident. There are still many who possess an obsession with apportioning blame and, even worse, to criminalising those judged responsible. There is still an overwhelming urge to focus on the consequences of an accident — an oil soaked seagull still provokes more anger than a dead sailor.
And we are still not good at looking at the underlying causes why things go wrong and then learning the real, rather than the convenient, factors.
Last week, the Paris-based French Maritime Accident Bureau, BEA-Mer, very thoughtfully sent me a copy of its investigation report into the collision between the France-registered very large crude carrier Samco Europe and the Panamanian container ship MSC Prestige, which occurred at the western end of the Gulf of Aden in December 2007.
By good fortune, the collision resulted in nothing more than two badly damaged bows. There was no pollution and no injury. Relatively few people would even be aware it happened, but the lessons to come out of it are of significant importance to the entire maritime community. I hope I’m proved wrong, but I fear very few people will pay any attention to the invaluable lessons that lie in this near catastrophic collision.
The circumstances of the accident are reasonably straight forward. The two ships were approaching one another in that notoriously challenging situation known as “nearly end on,†a few miles to the east of the Bab el Mandep Strait traffic separation zone.
Both ships were correctly manned by competent masters and crews. There was no suggestion of fatigue. The two officers of the watch had everything they could wish for by way of aids to navigation. Both ships saw each other in good time. The officers on watch communicated by VHF and “agreed†to a passing red to red.
And yet they collided. Why? The accident report rightly identifies a number if shortcomings, especially with the implementation of Rules 16 and 17, but the main lessons only emerge by careful analysis of what happened.
Each OOW was dealing with the same sources of information; radar, AIS, visual and VHF. Each interpreted the information presented but came to different conclusions as to what the “other†ship was doing.
Despite all the training in the world, this does happen from time to time. VHF communication was established but one OOW stated an intention to do something that was not understood by the other. The two ships were at the less than three miles apart and closing at a combined speed of nearly 40 knots.
What does an uncertain OOW do in such circumstances? Argue on VHF, call the master, or take some action and hope for the best? Anyone reading the report will come to their own conclusions about what went wrong and, no doubt, advance an opinion about what should have been done, but they will, I suspect, miss the point. Anyone in such a situation will face what can best be described as a state of stress when the mind starts to converge on a single issue. Rational thinking goes out of the window and even the most normal activity such as calling the master is forgotten.
It is not for me to suggest a text book solution, but what we must all do is learn the lessons from these accidents to make the sea a safer place. Let us not shy away from independent accident investigation, but learn all we can from the subsequent reports. The real lessons don’t come from any recommendations made, but by putting ourselves in the position of those involved at the time and thinking through the actions we would take.
Training takes many forms from talking about it at one level to linked simulation at the other. Far better have an accident in the simulator than on the high seas. We also need to work much harder at developing situation awareness afloat. Above all we must rid ourselves of the blame culture and learn from the mistakes with widely published accident reports.