Accident Defense - The Costa Corcordia

Costa Concordia lays on the rocks Isola del Giglio

The Costa Concordia sank about a year ago, there have been numerous reports and commentaries  I thought the his one:   Costa Concordia   Anatomy of an organizational accident was interesting.

The report listed 6 errors which lead to the grounding. The errors were referred to as breaches of a defense. Defenses against incidents can be compared to a defense in a game such as soccer  against the opposing team scoring a goal.

In the case of a soccer team the defense is also in layers.

The first layer  is a good offense. If your team has possession of the ball and is in scoring position there is little chance the opposing team can score.

The second layer is keeping the opposition out of scoring position. The last layer of defense is the goalie.  If at all possible the goal of the defense is to avoid allowing shots on goal.

Looking at the 6 errors;

 This was where the captain allowed the opposition to have possession of the ball.

 The first error was made by the Captain, when he decided to change his original voyage plan without the agreement of the Company and local authorities

On the second and third errors  the opposition is moving the ball down the field.

The second error was a shortfall in voyage planning. According to the Safety Officer8 - who arrived on the bridge just after the impact with the rock – only the original route was drawn on the paper chart, a few miles off the island.

The third error relates to route monitoring, a specific task of the Officer Of the Watch (OOW). The bridge team was composed of a Senior OOW, a Junior OOW, a deck cadet, and a seaman with either lookout or helmsman functions. The SOOW was in charge of the conduct of navigation, with regards to conning orders, collision avoidance and route monitoring on the INS. The JOOW was assisting him fixing the ship’s position on paper charts, which has to be considered with priority over the INS route monitoring. The JOOW could not correctly monitor the approach to Giglio Island, firstly because there were no routes drawn on larger scale charts than 1:100.000, and secondly because she left the chart table to assist the helmsman when the Captain took the command of navigation

Now the opposition is moving the ball into scoring position

The fourth error also relates to route monitoring. In contrast to the third error, this involved the INS, to be officially used only as an aid to navigation. The equipment was operated by the SOOW, who used the radar distances and the electronic chart overlay to monitor the approach to the island. The error consisted in assessing the distance from the furthermost radar echo of Le Scole rocks, and not from the limit of the no-go area, that is the 10 meters bathymetric line.

 The fifth error is in the area of Bridge Resource Management (BRM), and it can be attributed to the Captain, as team leader. Indeed the effectiveness of BRM practices - essentially aiming at optimizing team work – depends heavily on the leadership skills of the Captain. That night, since the Captain arrived on the bridge at about 5 miles from Giglio Island, a series of erroneous BRM practices can be extracted from the depositions. These shortfalls are of a non-technical nature, involving mainly lack of team briefing, and lack of formal handover. In short, the Captain did not share intentions and expected outcomes of the decisions made, both before and during the manoeuvre.

 On the sixth and last error nothing stands between the opposition and a goal except the goalie.

 The sixth error is of a shiphandling nature. It was the one breaching the last available defence: the human expertise. The error consisted in failing to maintain the newly established safety margin of about 0.25 nautical miles.

The captain worked himself into a position where he had only his shiphandling skills to prevent disaster.

A good defense in sports reduces the number of shots on goal rather then depending upon the goalie to make saves. Careful voyage planning and good bridge team management likewise reduces the number of "saves", situations which in which the crew has little room for error.

K.C.

Iceberg 1 crew freed

gcaptain is reporting that the crew of the Iceberg 1 has been freed.

The Iceberg 1 was hijacked 29 March, 2010.

A report from Garowe on line is here, it reports that the crew is recieveing nutrition and medical care.

K.C.

The Crew of the Iceberg 1 is in Distress and Requires Assistance

Photo from IndiaSite.com

"some members of the shipping community feel the industry has failed the crew of the Iceberg" 1
That quote is from Two scars on the conscience of the shipping industry.

The shipping industry and governments have chosen to ignore the plight of the crew of the Iceberg 1.

Its time for mariners to step up and come to the aid of the crew.  I understand that mariners feel powerless, mariners are easy targets when a scapegoat is needed  and easy to ignore when  they  are held by Somali pirates.  Mariners are, in fact, almost powerless to act in this case. No one cares what mariners  have to say. In this case the shipping industry and governments evidently consider the crew not worthy of attention.

I believe mariners can bring needed attention to the case of the Iceberg 1, but not as individuals. That's the idea behind the Mariners Action Group.

 You can now join Iceberg 1 Mariners Action Group here. 


The propose of the group is  "to bring international attention to their plight, and pressure to bear for their release". 

  The Facebook page, which has gotten over 2000 "likes" is here  M/V Iceberg 1 Mariners Action Group, 


The Pear Link post is here 

Time To Act!  The MV Iceberg 1 Mariners Action Group Website

 I know these web sites and so forth are not a lot but it's something, and the crew of the Iceberg 1 deserve more help then they are getting.

K.C

M/V Iceberg 1 Mariners Action Group Forming.

Photo from IndiaSite.com

 UPDATE: Iceberg 1 Mariners Action Group web site here.
 

 UPDATE:  You can now join Iceberg 1 Mariners Action Group here. 

 Looking for mariners and one who would like to add their name to the effort to assist the crew of the Iceberg1.

The M/V Iceberg 1,  has been held by  Somali - based pirates since March 29, 2010 and has been abandoned by it's owners, Azal Shipping & Cargo, UAE and, as far as I know, no one is working for it's release except the families of the crew who have little leverage

As individuals we also have little leverage to assist the crew. To gain leverage, a  group of mariners,  the M/V Iceberg 1 Mariners Action Group  is being formed to:  "to bring international attention to their plight, and pressure to bear for their release". 
  
The group has started the  M/V Iceberg 1 Mariners Action Group, Facebook page. At this point we've not established a way to join the group except to leave a comment  but:  "please help by Liking, linking, tweeting;  spreading the word!"

The M/V Iceberg 1 Mariners Action Group currently is supported by myself and Reid Sprague of Pear Link and we are seeking more support. - Reid's post about the MAG is here:  Reid is planning a petition. I'll post  more when we've got more, meanwhile go "like"  M/V Iceberg 1 Mariners Action Group, Facebook page.

K.C

Susan Clark, Ship Captain, Pilot, Crosses Final Bar.

Capt. Susan Clark (Bangor  Daily News Photo)

Capt. Susan J. Clark, Portland Harbor pilot passed away 6 Sept.  Susan was born and raised in Skowhegan Maine, a mill town on the Kennebec River.

Susan finished first in her class at Skowhegan High School, and first at Maine Maritime. She was Exxon's first women ship captain. She Obtained her law degree and became a Portland Harbor Pilot.

Condolences to her family and friends.

Bangor Daily News obituary here.

 

Kennebec River at Skowhegan


K.C.

Debby - When Forecasts are not Accurate

Possible paths for Debby (from The Original Weather Blog)

After I posted "How Accurate are Weather Forecasts?" I encountered Tropical Storm Debby this past June  as it formed  in the Gulf of Mexico.  We didn't experience much besides some rain and 25 kts or so of wind. 

The interesting thing about Debby was the  large error in the forecast which seems to contradict my post in which I linked to the post  Extraordinary Skill for Extended Weather Forecasts  from Cliff Mass Weather Blog

This was an early  forecast from the NWS:

(from The Original Weather Blog)

This is a latter  forecast which is much closer to the actual track.

(from The Original Weather Blog)

In fact forecasters were well aware of the uncertainty in the forecast, here is a chart showing what the various models were showing:

(from The Original Weather Blog)

 The question is; how does the mariner at sea know when forecasters are not confident in the forecast?

 If access to the internet available mariners can dig down deeper by reading the discussion of the forecast which is available on weather web sites including the NWS.

Without internet access it's a little more difficult. The key is to use more then one source when available, in addition to national weather service forecasts  I use a weather routing service if I am going to be in the vicinity of heavy weather. The operations department also sends additional weather if  I request it.  A couple of times I've had my wife email me weather info.

Don't bet too heavy using a single source. As before, with the weather forecast, trust, but verify.

K.C.

A good discussion of Debby at The Original Weather Blog here
Tropical Storm Debby Forms in the Gulf... Now What?

Stowage of Arms Put the Ocean Atlas at Risk

Mossberg 12 gauge Shotgun (Photo by K.C.)

The U.S. flagged  M/V Ocean Atlas was delayed in the port of Maracaibo, Venezuela for 12 days for issues related to arms carried aboard for anti-piracy.

Weapons are used by security teams in  areas that are at high risk for piracy. These weapons  are left on board the ship after transit of high risk waters even after the security teams disembarks  to avoid the expense and hassles related to the transfer of weapons to and from the vessel.

The problem with using the ship for storage for weapons outside piracy waters is apparent in the case of the Ocean Atlas. On-board stowage of  weapons puts the captain, crew and vessel at risk and  places  the vessel and crew at  mercy of  port authorities  and government officials.

Aside from the risk of delay, having to clear weapons though customs  port authorities  of various ports  is a hassle. Port officials require documents, inventories etc  and frequently demand  to see and count weapons upon arrival and again upon departure.

In my last post I suggested that it would be better to remove weapons and ammunition at the same key points where the teams are picked up and dropped off now, Port Suez, Fujairah, Galle and Durban.

Governments involved should  set up convenient armories  at key points and eliminate costly bureaucratic obstacle to the transfer of weapons ashore so ships are not unnecessarily put  at risk by  port officials in ports of call outside high risk areas where weapons are not needed.

K.C.

Board and Disembark Security like Ship Pilots

 

Armed security teams should be able to board and disembark from vessels as routinely as do ship pilots.  If vessels were stationed at key points, the same places where security teams are dropped off and picked up now - Port Suez, Fujairah, Galle and Durban, then teams, and their weapons could easily board and disembark and it would avoid hassles associated with carrying weapons aboard ship.

The case is laid out here: Anarchy on the High Seas (pdf)  (via Maritime Security Review)

 A few other interesting comments as well


K.C.

EDIT: Make clear that weapons should be removed with the security team.

Running the Route with the St. Louis

Loading at Dundalk Terminal Baltimore the ship in front of us pulled out first, I snapped a couple  photos as she slid by.

American flagged Alliance Saint Louis

Here she is sliding past using two tugs.

Sliding by

Here is the same same ship a few days later as we are both southbound in  the Gulf of Suez after leaving the canal.

It's common to see the same ship during a voyage. Often the same ships will be ahead or behind you for the entire voyage. It's like driving a bus on a bus route.



K.C.

Risk Managment - Failure to Rescue

One of the concepts in the book Managing the Unexpected is "Weak Signals of Failure". There is a lot to this, in operations small things are always going wrong, this is the "Unexpected" in the title. Risk management is not just about reducing or avoiding risk but also having a plan for coping when things go wrong.

In medicine when poor outcomes result from the failure to recognize and  properly deal with weak signals of failure a term used is "failure to rescue"

From this  post at The Epicurean Dealmaker - 50 Ways to Leave Your Lover.

The point of risk management is not to prevent failure, for that is impossible. The point is to have a plan ready to manage and control failure when it inevitably comes.

The  post links to a commencement speech by Atul Gawande . The speech uses a medical example of a women who had surgery for one problem but had a second hidden, unexpected problem which was discovered by investigation of a weak signal of failure.

From the speech -

This may in fact be the real story of human and societal improvement. We talk a lot about “risk management”—a nice hygienic phrase. But in the end, risk is necessary. Things can and will go wrong. Yet some have a better capacity to prepare for the possibility, to limit the damage, and to sometimes even retrieve success from failure. 

When things go wrong, there seem to be three main pitfalls to avoid, three ways to fail to rescue. You could choose a wrong plan, an inadequate plan, or no plan at all. Say you’re cooking and you inadvertently set a grease pan on fire. Throwing gasoline on the fire would be a completely wrong plan. Trying to blow the fire out would be inadequate. And ignoring it—“Fire? What fire?”—would be no plan at all.

Also mentioned however was the Deepwater Horizon disaster. -

In the BP oil disaster in the Gulf of Mexico two years ago, all of these elements came into play, leading to the death of eleven men and the spillage of five million barrels of oil over three months. According to the official investigation, there had been early signs that the drill pipe was having problems and was improperly designed, but the companies involved did nothing. Then, on the evening of April 20, 2010, during a routine test of the well, the rig crew detected a serious abnormality in the pressure in the drill pipe. They watched it and took more measurements, which revealed a number of other abnormalities that signal a “kick”—an undetected pressure buildup. But it was two hours before they recognized the seriousness of the situation—two hours without a plan of action. Then, when they did recognize the trouble, they sent the flow through a piece of equipment that can’t handle such pressures. The kick escalated to a blowout, and the mud-gas mix exploded. At that point, emergency crews went into action. But for twelve minutes, no one sounded a general alarm to abandon the rig, leading directly to the loss of eleven lives in a second explosion.

Failure to Rescue - Weak Signals of Failure, same concepts.

 I highly recommend Managing the Unexpected, it's a good solid book. I like being able to recognize these concepts when I run into them elsewhere.

K.C.

I posted about Managing the Unexpected Thinking Like a Mariner - Managing the Unexpected

and here At Sea

A good review from Harvard Business Review here.

For terminology this is a good site (pdf) Normal Accident Theory from NASA

How Accurate are Weather Forecasts?

GOES Eastern US SECTOR Infrared Image

How much trust can a mariner place in a weather forecast?

Aboard ship this question is sometimes a matter of considerable importance.

 I've run across a couple items recently that address this question.

The first is from Cliff Mass Weather Blog -  the post is Extraordinary Skill for Extended Weather Forecasts

(found via Channel 14, Seattle Traffic)

 In the early days of forecasting, when our forecast models were crude and our observational resources were few, weather prediction could not get close to the theoretical limits.  But during the last decade or so, with the availability of satellite data, fast computers, and far better computer models, prediction skill has extended further and further out in time.   In the 60s-80s we were lucky to skillfully forecast out 2-3 days.  In the 90s 3-4 days.  And in the 2000s, 4-5 day forecasts were often quite skillful.  But recently, we have seen highly skillful forecasts consistently at 5-7 days, and occasionally approaching two weeks.

Here is the bottom line

So when people ask you how far into the future meteorologists can predict the weather, a good answer is:

2-3 days with excellent skill

3-4 days with moderate, but useful skill

5-6 days with marginal skill

..and occasionally skill extending out 7-10 days.

Yes...sometimes forecasts go wrong in less than a day...but is considerably less frequent than a decade ago.

The second post is from gcaptain - What is the Mariner’s 1-2-3 Rule and Should it Be Updated? - By Fred Pickhardt,

I'm not going to get into details here as I've posted on the 1-2-3 Rule before here: Guidelines For Avoiding Hurricanes At Sea

 Basically the argument is that the accuracy of hurricane track forecasting has improved and the safety margins used in the old 1-2-3 rules can, in certain circumstance, be reduced. Better to get the info  from the horse's mouth - Fred Pickhardt's post is here 


Aboard ship it is important to  monitor the accuracy of the forecasts, We don't dispose of the weather until the voyage is completed without incident. If you check  the 96hr, the 48 hr and the 24 hr forecasts against the actual  weather you can develop a sense of how accurate they are.

My experience is  that the NWS  (National Weather Service) forecasts and some other agencies  are much better then many people believe but  also it is  easy to fall into the trap of accepting them uncritically out of habit. Much like monitoring the position  of the ship to ensure it stays in safe water you should check from time to time to ensure the forecast is "on track".  How often you check depends upon the situation.

Most mariners are aware that the longer the range the forecast is the less accurate it is. The 24 hr forecast can be relied  upon more then the 48 hr and so on.  Beyond that  my rule of thumb  regarding the trustworthiness of  the forecast is it depends on the issuing agency and how complex the weather situation is. Another important considerations is how much is at stake if the forecast is inaccurate.

 I have higher trust in forecasts from the United States, Japan and Europe then some other places. I've had  the most experience in those areas and have had many opportunities to verify the forecasts. I have more trust in simple situations then complex ones, for example if there are lots of low pressure areas about I am more wary then the simpler case of a single big high pressure system.


An important question  is how much is at stake? If you lose the bet will it result in a  delay in operations or are you risking the safety of ship and crew?  In cases where you have lots of sea room it may matter little if the forecast is inaccurate as you can adjust your track as needed.  On the other hand if you are coastwise or in port your options are likely far fewer. You need to think what is the worse case scenario  and is a plan B practical?

 Plan B developed for unfavorable weather is a subject in and of  itself.

The bottom line is trust but verify - make sure you monitor the weather on a continuous basis, keep the latest forecast posted - the watch mates  should know when the next forecast is due in. Keep the old forecasts and compare them to the actual weather.

Finally, keep an eye on the barometer and the sky. - Look not to leeward for fine weather.

K.C.

UPDATE: I've tinkered with this post a couple of time and reserve the right to continue editing it in the future.

My Post Capt McWhirr on Weather Routing.

 Here is a somewhat  inane post from Freakonomics How Valid Are T.V. Weather Forecasts? The conclusion is the NWS does better then the TV weather man and that short term forecasts are more accurate then long term (no surprise there)

Lee Chesneau's Marine Weather is here - A few years back Lee wouldn't leave me alone until he was sure I understood a critical element of the 500 mb chart

Was the Maersk Texas Incident a Pirate Attack?

Maersk Texas

gcaptain has reported an attack by pirates on the Maersk Texas. According to the report the attacking  pirates were either driven off by the embarked security team or by the Iranian Navy.

There a a few oddities about this incident - this is one:

vessel’s master reported to authorities that assailants’ observed physical features resembled those of Somali pirates.

What?

A couple trips back we were transiting the  GOA/HOA area and I asked the second mate what he thought was meant by the term "suspicious vessel".  His reply was,  according to our embarked security  team, a suspicious craft is a white skiff with skinny black men in it - it was meant as a joke, at the expense of the security team.

Some security teams are not as experienced at sea as you'd think and some team members do not have a sophisticated world view. For example I've noticed that some  have a very simple method of determining if a skiff is a threat of not. Skiffs in sight of land are fisherman, skiffs out of sight of land are pirates.

Waters that are high risk for piracy also often  have a large number fisherman using the same type skiffs  as pirates. Most of the skiffs have skinny black men in them. It's not the way to determine if a skiff is a threat or not.

Neither is distance offshore a good guide. Somalia fisherman take skiffs well offshore to fish. For some reason this idea is sometimes difficult to communicate. A previous post -Identifying Pirate Skiffs in the Gulf of Aden is here.

One trick to making an incident-free passage  is to avoid getting close to any vessel during the  transit. When carrying an embarked security team the minimum   passing distance from  skiffs should be about twice the effective range of a AR-15. If your team has weapons with greater range the passing distance should be increased accordingly.  The master has final say with regards to use of deadly force but a boat out of range can neither harm or be harmed.

Another oddity is the location.

The position of the attack was given as "position 25:29 N – 057:16 E, approximately 28 nm west-southwest of Bandar-e-Jask" (my convenient chart of the Straits of Hormuz includes this position -  here)

As far as I know no other attacks have been reported that close to the Straits of Hormuz although there have been reports of suspicious craft. This area has a lot of small craft activity, including small fishing vessels, smugglers are also frequently seen in the area as well using high speed skiffs.

That's not to say it wasn't a pirate attack  However  according to Bloomberg the EU anti-piracy force the EU NAVFOR is not buying it:

The European Union’s counter-piracy force said it had reviewed the incident and determined there was “no case of piracy and it’s a false alarm,”

Obviously I don't know what occurred during the Maersk Texas incident but based on what I've seen so far my money is on EU NAVFOR - looks to me that there is a high probability this  is a  false alarm.

K.C.