June 27, 2008

Inhuman Error

Twenty ports a month in the North Sea, English Channel, Mediterranean and off the Bosphorous. Thick fog almost all the time off Northern Europe. Master living on the bridge at sea. A small short manned ship. No pilotage except when compulsory. High winds in almost all Mediterranean ports. Pressure to meet schedules. Inexperienced third mate, fourth engineer and two AB’s. Not enough competent crew to steer the ship even while under pilotage. Specialised ship, so almost the entire deck officers and crew involved in cargo, including unlashing and lashing alongside, during approaches and in rivers and locks. Almost weekly inspections or statutory surveys, port inspections and others, the ship having been just taken over from a previous management who let it run down as usual. Company refusing Master's urgent requests for an additional experienced navigator. Charterers used to running their own ships where the European crew works on a two week rotation and permanent wages and expect similar initiative from the crew. Our crew on board working on a nine month contract, officers 4/6 months. Cold as a witches unmentionables in winter. High seas in the Bristol Channel, some Mediterranean ports and in the North Sea, resulting in some ports being occasionally closed, and ships steaming at slow speed for a day or two in heavy weather just off port. No sleep. No rest for the wicked.

This has happened to many of us, including me.

And this relentless stress, fatigue and constant multitasking is, I firmly believe, one of the main causes of human error.

Recent insurance and P&I statistics highlight the increase in casualty rates and, since money is involved, ring alarm bells. Insurance companies are tightening up, statistics are being compiled and premia and calls recalculated. The complex financial structure that makes for insurance at sea is worried.
Human error is usually cited as the biggest cause of casualties; and though fatigue, stress and other such factors may be sometimes mentioned in passing or obliquely, this is not really dwelled upon. It literally rocks the boat, asks uncomfortable questions and is best left swept under the carpet. It also costs shipowners money to fix this problem. It is almost as if human error is taken in isolation; it seems like a well rested and not overstressed seafarer has made a blunder because of his innate stupidity, contributory factors not being mentioned too loudly.

Some factors impacting safety of navigation are well chronicled because they are easier to highlight. Drunkenness or inebriation. Poor seamanship, and here, the ‘ordinary practices of seamen’ is a catch all phrase, nothing being ordinary these days with seamen being relegated to administrative roles for much of their 'free' time. Other reasons sound good too: Poor navigation. Command breakdown.

Here are some others which I hope some of the braver casualty investigators have highlighted at some point in time: I believe these are major factors in declining safety standards at sea today.

· Lower professional standards of seamanship and navigation. Very limited use of doubling watches, since two times zero is still zero. Result, Master spending an absurd amount of time on the bridge on short sea trades.

· Poor training standards. The industry’s penchant for adding fancy course titles with poor content and delivery must be stopped at once.

· Navigating officers’ over-reliance on electronic gizmos and under reliance on common sense and basic navigation. The VHF and, increasingly the AIS, being used as a collision avoidance tool, basic navigational rules and common sense is being ignored too often.

· Masters and navigating officers’ incomplete understanding of the Rules of the Road

· Administrative overload. Enough has been written about this, ad nauseum. Maybe all feel that by ignoring the problem it will go away. It won’t; it will bite back.

· Management passing the buck to the ship, effectively daring the Master to use his prerogative to stop the ship with all the resultant fallout. In this respect, the catch all ‘Master’s overriding authority’ is being used by all shore personnel, whether in insurance, operations, ship management, Class, Flag States or the IMO, to simply pass the buck. At the same time, countries are backtracking from traditional maritime commitments, criminalising seafarers, adding ponderous, arbitrary and unilateral laws to their arsenal, and making the IMO partly redundant. This is a recipe for disaster.

· Shortmanning or inappropriate manning for the ship and run. Manning certificates are a joke, and one can short man ships to dangerous levels and still exceed the requirements by about twenty five percent. No allowance is made for the trade or mandated rest periods on a hectic run. The blind are leading the blind on this one.

· Poor communication and language difficulties with multinational crews. Poor ability to multitask in such an environment, which is essential in any emergency.

· Poor maintenance of machinery. In these booming days it is not the cost of repair which is a factor, but the time for repair. Ships are surreptitiously drifting just off busy sea lanes in areas of quickly changing weather catching up on machinery maintenance in fits and starts. There is no time in port. And, while there is no time at sea either, one can perhaps steal a couple of hours on charter to quickly do some maintenance. And hang safety for awhile.

· Commercial pressures resulting in ships reaching open seas in all kinds of weather before they are battened down and therefore seaworthy.

· Lack of dissemination of critical information, often intentionally by operations or charterers. I have been asked to call a small port in South America when everybody and his mother in law knew that there was no water in the channel. Except me, the Master. Also, nobody told me that the NAABSA clause had been added to the charter party, and it was customary for ships to sit on the mud at the berth. The agent was surprised, then bemused, that I did not know. The Chief Engineer was not, at least the first time I told him, in a hurry, to prepare for shutdown.

· Substandard or unsafe ports/berths. These days, anybody builds a finger into the sea and calls it a terminal. I could write a book on this one. How each call, every two weeks to a port, used to be a harrowing affair, with strong weather and incompetent pilots at a borderline unsafe terminal, the office communicating every ten minutes with me expecting immediate answers and applying commercial pressure. In actual fact, any sensible person would have agreed with me that that terminal was unsafe at that time of the year. We often talk about substandard seafarers. Perhaps we should talk of substandard charterers, management and terminals more often.

· Incompetent or inexperienced pilots.

Unfortunately, Safety is a culture and not a checklist. Besides, a concerted approach is required to address this, with at least Management working in tandem with the Master, and not second guessing him in real time.
The fact that communications is easier is a handicap; I have lost count of the number of times I have had to indicate to managers that I was too busy handling an emergency to be communicating. Sometimes I seem to be giving an almost ball by ball commentary to them by phone, email and fax.

As to making a ‘quick’ report in writing as per some elaborate reporting format which has been designed without practical thought, I once had to tell a gentleman that if I made that report now as he wanted I would be making a longer one later since we were still in a pretty hairy situation, and I needed to concentrate there.
That seemed to strike a chord, or ring a bell, or whatever, but I did not get any more calls.

I have a term for this kind of communication which is detrimental to basic safety: Paralysis by communication.

Meanwhile, we prefer to pay higher premia and justify it on the bottom line. We prefer to ignore some of the root causes (a term we otherwise love with gay managementspeak abandon) of casualties. We prefer to jail seafarers for being on the wrong junk at the wrong time.

Maybe I need to remind us that, along with Human Error, there is a term in Maritime and Admiralty Law called 'Error in Management' too. And, as far as I can recall, limitations on liability are traditionally low or nonexistent with that one.

Maybe we should just call this one the 'Error of the Untouchables'. That should set the cat among the seagulls.



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