Human error

I think we are all pretty familiar with the chain of events that led to the Titanic disaster. Most of them were human errors.
: A telegrams warning of icebergs was not sent on to the bridge.
: The owner insisting on full speed.
: A nearby ship thinking that the distress flares and rockets were some kind of celebration. And so on.

A recent grounding of a large bulk carrier (M.V. Wakashio) in Mauritius seems to have been the result of a similar chain of human error events.
: At 2:00 am 16th July 2020 the Wakashio changed course 2 degrees to starboard which put her on a collision course.
: The captain believed he was on the correct course which would miss Mauritius by 10 miles.
: For an hour on the evening of the 25th the Mauritian Coast Guard tried to contact the Wakashio to warn them that their course looked dangerous.
:When finally coast guard officials got through to the master, the captain insisted the planned route was safe. A few minutes later, however, the ship radioed local authorities to say the vessel had grounded on a reef.
: That part of the island is especially well lit with the airport quite near the spot where they grounded.
: The crew were celebrating someone birthday and there is a speculation that the ship was diverted close to Mauritius to pick up mobile phone reception. That is unproven at this stage.

As sailors we can shake our heads in disbelief or think, "Cripes, I am capable of some or all of those mistakes."

Source: www.nakedcapitalism.com/2020/08/mauritius-oil-spill-tragedy-how-why-the-mv-wakashio-ran-aground-and-aftermath.html

Gary

The topic of Human Error is a very long and complicated topic and you need to avoid at all costs, regardless of the environmental impact the oils spill is causing, to call in the lynch mob.

I don't know if the maritime industry has the equivalent to the aviation industry, but aviation has been focusing on human factors for decades. It was once known as CRM or Cockpit Resource Management and later changed to Crew Resource Management to encompass the entire crew. It has now developed even further into what we call HFNTS -Human Factors Non Technical Skills and now encompasses an entire operation and organisation. Because although the buck still stops with the Skipper, you'd be amazed at how far back down the system a decision or action can go to cause a devastating result. Even in Gary's example of the Titanic, the failures started way back when the boat was still just a drawing (bulkheads not full height, a 3 screw arrangement too close to the centreline of the vessel reducing asymmetric thrust moment in the turn). That boat should not of sunk by design, regardless of the failures of the crew on the night.

To a lot of us with skin in the game, CRM seemed like nothing more than a touchy feely, feel good how to talk to your copilot nicely waste of time, especially captains who felt they were a scape goat for 80% of incidents and accidents. It was even referred to at the time as Pilot error and later changed to Human Error. It still accounts for approx 80% off all incidents, but the shift is now away from blaming.

So let's just assume for a moment the captain did agree to sail closer to Mauritius to enable a mobile phone call (not even necessary these days), no Captain would deliberately or negligently run an oil tanker onto a reef. We as humans are not as rational as we like to think we are. We largely still operate as 'info input, info output', and many outside factors will dictate the level rationalisation we place on that output information at that present time. You need to look at ALL the factors (firmware, software and liveware) that lead not only to the decision to alter course, but why or how it lead to the grounding.

Was the steering mechanisms functioning correctly (not as far fetched as it may sound)
When was the last time the compass was swung (we all know how some hate the use of GPS. Was the skipper one of these)
Was the fluxgate compass for the GPS appropriately shielded (or even shifted - mine shifted by 180 degrees once)
Was there a company directive to sail close to the reef, either as a one off or as an SOP (shorter route, better current save fuel)
Was there a time restrain into the next port and they were behind
Did the company provide up to date charts, both paper and updated GPS data cards.
Did the Captain feel pressured to go with out of date information.

A two degree change at 10nm does not amount much of a lateral change. A two degree change at 100nm does. What information was being inputed. Did all the crew on the bridge receive the same information? If not why did they not say something?

Was it his first time on that route
Was the crew fatigued. What was the weather and sea state like leading up to the accident (lack of adequate sleep) were they short handed
Was the Captain the dominant old style military type (this is my ship and I will do it my way)
Why did they need to sail so close to the reef
Was the Captain emotionally distressed. Maybe it was his wedding anniversary and as he was at sea for the last 10 of them his partner
threatened him with divorce if he missed this one and he really needed to get a call out (purely example only)
Maybe he had just become divorced and he needed to get a call out.

So many factors.

The Captain was adamant he plotted a safe course. The need to sail closer to the reef in order to make a phone call is only speculation. An investigation at this point has probably not even begun.

If the maritime industry does not have a similar initiative as the aviation industry does to prevent or better understand the above, maybe it is time it does.

I havnt read all the article but will do.
Ships like his have a navigation unit. I have forgotten the exact name. Everything is built into it. GPS,compass,plotters etc. It is duplicated onboard incase of failure or problems. Very rare from what I understand. Gyro compasses and gps are not affected by magnetic fields. They must also have AIS A. Someone watching the marine traffic app could have seen they were going to run aground!
At the least the captain has failed to maintain a proper watch as the coast guard tried calling on the VHF and they didn't respond. When they finally did they were told they were on a collision course and they carried on and ran aground a few minutes later! There should be the equivalent of black box onboard. So they should no exactly what happened.
So he should be put on trial and if found guilty of not maintaining a safe watch or ignoring the coast guard put in jail. The company's should then be held responsible for the clean up if he is found guilty.

Quick google found this from the merchant shipping act.
I guess 1 (b).
The captain interfered which endangered the safe navigation of the ship.
Was it actually the captain that changed course to go closer? Not clear in the article.

The thick plotens..............

Hi Strachan.

"Avoid further pollution"? Out of sight, out of mind. Good to see that old traditions such as treating the ocean as a garbage dump haven't changed.

The full quote is.

On Wednesday, the government said the ship's sinking would be done in a way that would avoid further pollution or interfere with maritime routes.

This is now in the hands of professional salvagers. These people know the rules and the risks.
They will do everything they can to avoid further pollution because that is what they are contracted to do.
I have worked with Dutch (Herrema ) hmc.heerema.com/fleet/ and Spanish Serema salvage operations out of Singapore.
These guys are big time.

Hi Ilenart
You are correct about the tow. The section that they are towing is unballested and extremely unstable and could roll over in a heavy sea in a moment.
Capetown, Mumbai and Singapore would pose a risk as they got closer to those places.

I have seen a ship sink. It happens much faster than you would expect.
Tell you about it over a beer one day.

gary