HUMAN AND ORGANISATIONAL ERROR AS A FACTOR IN MARITIME CASUALTIES

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SHIPBOARD VIOLATION OF PRACTICES, PROCEDURES,
RULES AND REGULATIONS
eNavigation 2009, Seattle, Washington November
17 GEOFFREY W. GILL Of Counsel Law Offices of
Countryman McDaniel Los Angeles
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Causes Of Groundings
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Causes Of Collisions
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• VIOLATIONS Aviation 65 crew error component
• (1) Routine - fairly notorious but no one seems
  to care.
• Excessive speed in fog.
• Easily rationalized through radar.
• (2) Optimizing personality.
• Extraverts-expect closer CPA.
• 20 pilots are Drongos.
• (3) Situational - its the only way...
• Work area too confined for life jacket.
• OOW tells lookout- do not report lights in
  channel.

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• VIOLATIONS
• (4) Exceptional - situation calls for training,
  experience and judgment.
• CHERRY VALLEYs master... immediately altered
  course to rendezvous
• with the tug. In so doing, he took his relatively
  unmaneuverable craft into
• perilous shoal waters in direct violation of his
  companys standing orders.
• - Margate Shipping Co. v. JA
  ORGERON, 143 F3rd 976 (5th Cir. 1998)

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BEHAVIORAL CAUSE MODEL

• 62 of violations within one or more of 4 basic
  PREDICTORS
• Expectation rule must be violated
• Violation a better solution
• Faulty initial planning
• Empowerment / personality

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Procedural Intentional Non-Compliance (PiNC)

• High reward
• Low probability of detection / high probability
  of success
• No / minimal adverse peer reaction

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Procedural Intentional Non-Compliance (PiNC)

• 3 Aspects of PiNC
• Assumes others follow rules
• Removes at least one error barrier
• 25 greater likelihood of other errors.

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CP VALOUR
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• ... the ISM systems appeared good and in order,
  and the crew were reasonably well qualified and
  trained. There is no benefit to be gained from
  good training and qualifications unless they are
  used as the basis for good practice when the crew
  return to their ship. This raises the question of
  how employers and others can be sure that bridge
  teams are actually following instructions and
  guidelines, and performing well on board their
  vessels.
• There is thus a need for ship owners and
  managers to ensure that their orders and training
  are being put into practice by those operating
  their ships.
• - MAIB Investigation Report, CP
  VALOUR, 28-29

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Monarch Of The Seas
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• ... The primary reason for the master and crew's
  decision not to adhere to SMS procedures centered
  on the master's disregard for and lack of by
  sic in to the formalized requirements of the
  ISM Code SMS. He voiced his displeasure for the
  sort of company oversight, bureaucracy and
  micro-management that the SMS procedures
  represented. Without the master's expressed
  support of the ISM procedures the crew
  unsurprisingly failed to embrace the newly
  established SMS and disregarded the established
  procedures, guidelines and job aides made easily
  accessible to them on the vessel's bridge. -
  Joint Report of Investigation Surrounding
  Grounding of MONARCH
• OF THE SEAS,
  Proselyte Reef, St. Maarten, December 15, 1998.

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• At the ship level, the master can exacerbate or
  mitigate the adverse effects of high level
  decisions, but the master can also introduce
  other failures into the system.
• A conning officer's perception of importance
  will be directly influenced by the Master and the
  prevailing attitudes of the experienced personnel
  on board.
• - A. Brown M. Amrozowicz, Tanker
  Environmental Risk -
• Putting the Pieces Together, 4
  and 8 (1996)

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DESTRUCTIVE OBEDIENCE
Eihme Maru
USS Greenville
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• Heres a man with much more experience than I
  have, much more schooling than I have, who can
  much more rapidly assess and evaluate
  information.
• - OOD USS GREENVILLE

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PROCEDURE INTENTIONAL NON-COMPLIANCE

• Staff Commander and flag lieutenant realized
  danger of the order but the Vice Admiral "was not
  a person who was agreeable on being asked
  questions or cross-examined." They were reduced
  to "dropping clumsy hints and talking loudly
  about the distance" between the lead ships, and
  assumed the Admiral had an undisclosed purpose.
  Camperdown rammed Victoria, which sank with 358
  fatalities.
• Gordon, A. The Rules of The Game Jutland and
  British Naval Command, 246 (1996)

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AVIATIONS PACE CHALLENGING PROCEDURE

• Probing for better understanding
• I need to understand
• Alert to anomalies
• It appears to me that the result will be
• Challenge appropriateness of strategy
• This course places the ship in immediate danger
  from describe.
• Emergency response to immediate danger
• Captain, if you do not immediately , my duty
  and responsibility is to take command.

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Closing Thoughts

• you here you all had something out of life
  money, love whatever one gets on shore and,
  tell me, wasnt that the best time, that time
  when we were young at sea
• Conrad, J. Youth.

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• THANK YOU!
• GEOFFREY W. GILL
• Of Counsel
• Countryman McDaniel
• 5933 West Century Blvd., Suite 1111
• Los Angeles, California
• T [phone]
• F [phone]
• E gwg_at_cargolaw.com
• www.cargolaw.com