Accident analysis is a strange and complex task. Often blame is considered to be the motivator for an accident analysis, but the most interesting and useful purpose of an accident analysis is to tease the universally useful gems out of the huge pile of information that tends to get generated during an accident analysis.
I recently read the accident report on the January 2013 grounding of the USS Guardian, a US Navy minesweeper that ran aground and was ultimately lost on a reef that was mislocated on an ECDIS type chart.
The report makes interesting reading, mostly because it is a US Navy version of the work Martin & Ottaway engages in on an almost daily basis. It is interesting to compare the Navy approach to the civilian approach and learn from it.
The Navy report quite clearly concludes that there were major flaws in the navigation of the vessel by its crew (the senior officers in particular), and names hundreds of routines, standards and regulations that were violated.
It appears to indicate that many of the crew members were not properly trained on the many navigational aids and procedures aboard the vessel and, if equipment and procedures had been properly used, it would have caused the crew to realize that the reef was improperly located on the ECDIS chart that the crew relied on.
The Navy acknowledged that the reef was not properly located on the digital chart that was used aboard the vessel, but stressed that the navigational system and other navigational procedures aboard the vessel would have revealed this error. In other words, if the crew would have done one of the many extra things they should have done, the accident would not have happened because they would have realized the chart had an error.
This might be true from an altitude of 30,000 feet, but how does that truth feel in the wheelhouse of this vessel on a dark night at sea? Undoubtedly the crew could have done more work with electronic equipment and other wheelhouse references. But with all that (paper and digital) information cross checking, they might have never noticed the lighthouse that appeared on the horizon in an odd location before the grounding. The anomalous light on the horizon was actually discussed in the wheelhouse, but nobody drew the obvious conclusion that something was wrong. (If the proper conclusion had been drawn, there would have been only one response: We are totally lost, stop the ship and let’s figure out what is going on. Since that action is uncommon in the middle of the ocean, people will not readily choose that option either)
Actually, the issue is not deeply related to errors in charts. Errors in ECDIS charts will become progressively less common, and therefore our level of faith in them should require less cross checking of charts instead of more cross checking. But even with ever more capable navigation equipment, we can still get lost.
Being lost is not necessarily related to running a ship aground. Being lost happens all the time, but we only hear about it when things go seriously wrong. Meanwhile, all of us have received directions and followed them and at a certain stage realized we are lost.
But where did we get lost? Did we get lost at the point that we are no longer sure where we are going (seeing a lighthouse in an odd location) or did we get lost when we could no longer find our way home (grounding the ship)?
Seeing a lighthouse in an odd location is where the gem in this accident can be found. Instead of bogging down in ever more detailed searches for abstract postmortem errors, we should learn to recognize the anomalies that are provided to us in real time. These are often subtle anomalies, but training to recognize those anomalies is where we learn to discover we are lost before we cannot find our way home.
Instead of grafting another procedure on top of other marginally useful procedures, we should develop a culture where the chain of command learns to listen to, and address, the concerns of junior personnel.
“Sir, why is ……..?”, on a moving ship should not be answered with: “Hold on son, let me first finish filling out this paperwork.”
Recognizing that one is lost, is a wheelhouse chain of command issue, but it is also a personal internal chain of command issue. It is difficult to teach ourselves to do it, but when you are going somewhere and your directions no longer make sense, you should stop and do an OODA loop. Not think: “Well, if a keep going for a while longer, maybe I’ll figure out where I am.”
This is difficult to teach oneself to do, but it is essential to survival.
Very strangely, the concept applies just as well to large organizations. When large organizations get lost, they tend to ignore being lost by moving more paper instead of stopping and figuring out where they are. Looking at it from that angle, was the Guardian crew lost, or are all of us just as lost?
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