Thinking Like a Mariner - Managing the Unexpected

Managing the Unexpected by Karl Weick and Kathleen Sutcliffe is about so called High Reliability Organization..  I mentioned the book when I first purchased it here -US Airway Flight 1549 and High Reliability Organizations I think the book is worth reading and keeping for reference.  It was tough sledding at times, not because the ideas are complex but because  it didn't link the examples to the theory very well.

The book  didn't really change the way I think about ship operations, I think ship's masters generally  already think this way.  It did sharpen my understanding and learning the vocabulary has made it easier to communicate these ideas to other people.

There is a professional written review here.

Rules for Vessel in Fog. Out of Date?

What is a safe speed in restricted visibility?

According to this site - MCA orals the answer is:

(a) A speed that you can stop in half the visible distance you can see, so you can maneuver out of danger in the other half (if the visibility is zero, then minimum speed that you can keep your course.

That's what is known as the half-distance rule. Even my outdated edition of Farwell's acknowledges this rule is out of date. According to my sixth edition (1985) recent court rulings have allowed higher speeds but "not more then a knot or two"

However this article, Safe Speed in a Fog; Ancient Rules in a Modern Age (PDF) says what most mariners know to be true:

We all know that hardly any master will reduce speed in bad visibility nowadays. Instead radars and other electronic equipment are relied upon

and

We have experienced a tremendous technological development during the past 30 – 40 years while the rules have been static, in fact the present rules on speed in restricted visibility are based on the 1897 rules. And they do not recognise radars as a reliable instrument. This is in contradiction to how radars are viewed in other industries i.e. aviation and military and indeed to actual practise by the maritime community as well.

Why are mariners faced with this dilemma, that normal practices would be found in violation of the rules in the event of an incident?

The article argues that the rules need to be updated and quotes from Charles Perrow's Normal Accidents:

The navigation rules have developed to aid the courts in finding fault rather than aiding the ships in avoiding accidents

The author, Tor Lund, argues that:

Instead of taking any proactive efforts, administrations seems to be reactive; merely sending out occasional “notices” telling mariners to strictly follow the rules although they know that these notices will not be followed. This behaviour is contrary to what can be seen in other modes of transportation i.e. road, rail and air where authorities as well as other interested parties are proactive in order to constantly improve their systems and rules.

I agree, my derriere is hanging out too far already, time for an update taking into account such things as radar, AIS, VHF and VTS and other modern aids.

K.C.

US Airway Flight 1549 and High Reliability Organizations

Flight Path of USAIR Flt 1549 from i'm not sayin, i'm just sayin found at Information Dissemination
I was surprised to see HRO in the news this a.m.

Pilot Chesley Sullenberger, Captain of the flight that ditched in the Hudson was an Cockpit Resource Management (CRM) Instructor - a descendant of CRM is the Bridge Resource Management familiar to mariners. He also is a consultant in the field of High Reliability Organization (HRO)- his site Safety Reliability Methods, Inc. here.


Back in April I put up a post "Normal Accidents" - I am getting ready to go back to work and last night I was as Amazon.com buying some books for the trip. One of the books I bought is about HROs - "Managing the Unexpected: Resilient Performance in an Age of Uncertainty" - Review here ,

Some mariners have not yet embraced Bridge Resource Management - I've heard the arguments against it -my answer - go tell Captain Sully.

K.C.

Normal Accidents

ValuJet 592 is the flight that went down in the Everglades in 1996, caused by a fire in the cargo compartment.

In William Langewiesche's article, The Lessons of ValuJet 592, he suggests three type of aircraft accidents. Most common, "procedural" caused by obvious mistakes such a taking off with ice on the wings. The second type is what he calls "engineered" such as the TWA Boeing that suffered an explosion in a near empty fuel tank. The third type, what Langewiesche calls a "system accident" what has also been called by Charles Perrow a "normal accident. The fire that brought down flight 592 was caused by oxygen tanks that ironically are intended to make flying safer. The chain of events that led to them being placed aboard the aircraft was the classic error chain.

There is an good explanation of a normal accident from NASA here (pdf) .
In a system accident the root cause is difficult to determine, there is more then one, the familiar the error chain/ Causes can be complex and interrelated. But...analysis of close calls and mishaps is an effective way to break error chains.

Small mishaps, and daily incidents are clues to possible problems. At the first drill a crewmember doesn't know where to muster. The new mate on watch can't operate the ARPA. A port state control inspector isn't satisfied with your passage plan. Each event should be analyzed, is your familiarization effective? Is you passage plan adequate? Your entire program should be under constant scrutiny for loopholes where an error can slip through.