Human Error - On Ships

Here is something brilliant I read by Jack Devanney :

“human error” is usually a code phrase for “blame the crew”. As we shall see, in many tanker casualties, the crew made one or more mistakes. Most investigations focus on these mistakes. There are a number of reasons for this:

1. Crew errors are usually easy to recognize. Lousy design, lousy maintenance, lousy enforcement of the construction rules, and flaws in the rules themselves tend to be much harder to identify, often requiring specialized technical knowledge. But we are all experts on human nature, especially when it comes to pointing out somebody else’s mistakes.

2. The writ of many investigating organizations is to identify only the most proximate causes. Most of the investigators themselves are or were operators. Operators are conditioned to accept the system as it is and deal with it as best they can. They naturally focus on operational problems.

3. But by far the most important reason to blame the crew is that it is an easy out. A crew screw-up means we don’t have to look into the culpability of the owner that provided the under-sized crew with a lousy, poorly maintained ship. We don’t have to look into the culpability of the yard that built the lousy ship. We don’t have to look into the culpability of the regulatory system which approved the lousy design and overlooked the lousy maintenance. Many of the so-called investigation reports are written by people who have

a big stake in blaming the crew. A Classification Society report will almost always exonerate the Classification Society. A Flag State report will invariably exonerate the Flag State. Neither want to upset their customers: the shipyards and the shipowners. That leaves the crew, who have little means for defending themselves.

One result of all this is that there is no section on “Systemic Factors” in the IMO synopsis. It probably never occurred to the IMO bureaucrats to put one in.