When Near Misses Become Casualties – or not…
Fostering a culture of blame at sea.
My good friend, Captain Tom Hudson, an Operations Superintendent with Mitsui O.S.K. Bulk Shipping (USA) Inc. gave me a call the other day to discuss something that had been bothering him for quite some time. He referred me to a “near-miss” situation that occurred on one his tankers over the summer; one which has now taken on heightened meaning for all ships traveling in U.S. waters because of how the event has been interpreted by local Coast Guard officials. Almost three months later, Hudson has been on a one-man campaign to make right what he believes goes much deeper than a single (near) mishap. From where I sit, it is a cause worth fighting for. Here’s why:
- Near Miss – Another Day at Sea…
On 10 July in the Bayport Channel, one of Hudson’s ships experienced what he characterized as “a bank sheer.” Also according to Hudson, the ship was successful in regaining control and there was no damage, injury or potential to damage the environment. The “near miss” was recognized and the vessel gathered all available information from the incident for a review by the office. Hudson learned about the event approximately two hours after it happened. Although MOL routinely looks at all “near misses” internally to make sure that they do not happen again, Hudson saw no reason to notify the Coast Guard, but did so anyway, primarily to cover all the bases.
A few hours after the agent's call, the local Coast Guard Sector's Investigation Department visited the ship. They picked up the information from the ship, took statements and assisted the Captain with the 2692. At that time there was no mention of any need for further material from the ship – indeed, ten weeks later, also according to Hudson - there still has been no effort to obtain further information from the ship, pilot or tugs.) Prior to vessel’s departure, Hudson visited the ship and obtained copies of all information related to the event, primarily to prepare a presentation to use the value of the near miss as a tool to understand the event.
Later, however, when the ship left the dock, the Coast Guard Investigator notified the ship to go to anchor and await clearance. After several hours at anchor, Hudson learned that the ship was delayed for a "needed" Class report. The internal inspection done by the Chief Officer was not sufficient proof of the vessel’s safety for the purposes of the Coast Guard. Beyond this, Hudson was incredulous to discover that the ship had been fined $250 for running aground and had been further fined $5,000 for late notice. The vessel lost a half day's hire (> $10,000) and the charterer probably a good deal more. A Class report did not provide any additional information. And, after incurring the cost of divers and an extensive internal investigation, there has yet to be any indication that the vessel ever touched bottom.
- Casualty Reporting
Plans to expand what can be interpreted to be a “marine Casualty” are said to be underway, with that enhanced reporting requirement to come as early as January of 2012. Reportedly, any event listed in 46CFR4.03-1 (as examples of what might cause a casualty) must be reported. Where it is apparently heading is that every tripped circuit breaker and/or false alarm bell must now be reported promptly to the Coast Guard. Hudson told MarPro on Tuesday, however, “I am in complete agreement that near misses must be studied by the ship (and management) to prevent casualties in the future. However, I do not think the intent of Congress enacting 46 U.S.C. 6101 to devote the resources needed to record all possible events that might lead to a casualty. I believe that an incident must first be a casualty, before one decides if it is a ‘marine’ casualty. And if it is not a casualty (so not a marine casualty), there is no requirement for a report.” But, in this case, the rapidly festering problem goes much deeper than that.
- The Culture of Blame
In the second quarter print edition of Maritime Professional magazine, the value of Quality Audits is discussed in depth, with the ultimate message that “Quality Audits Matter,” and an explanation of why you should care. In the article, it is explained that “…management welcomes the audit findings. They encourage internal and external auditors to provide findings which could be useful for improving company processes. Such managers do not discourage staff when non-conformities are reported, as those findings are considered tools for improvement or opportunities for growth.” That’s well said and good advice.
Looking back at our “near miss” on the Houston Ship Channel, and using the above logic, this was certainly an opportunity for improvement and/or growth. Instead, it has been turned into an event which shipboard personnel and office workers alike will long remember: even if nothing tangible happens, we’re still in trouble. And, in that scenario, the likelihood of future “near misses” being reported to the authorities or even internal supervisors is reduced to two possibilities: slim and none. Quality Audit professionals call this deadly cycle the “Culture of Blame.” That’s because it goes counter to virtually every principle of good ship safety management.
Piloting a ship on the Houston Ship Channel isn’t an easy task. Like the old saying goes, “If it were easy, everyone would do it.” And, back at my maritime academy in 1976, one of the first things they told incoming first year cadets was, “Going to sea entails hours and hours of boredom, interrupted by fleeting moments of terror.” During my relatively short career at sea, I found that adage to be very true.
So, on July 10, two appropriately credentialed and experienced marine professionals – the harbor pilot and the ship’s Master – teamed up to move a large, deep draft tanker up the channel to safely moor it alongside the intended berth. Eventually, that’s exactly what happened. Along the way, the job got a little harder when the ship apparently did not handle as intended, but the folks charged with driving the boat adjusted their methods and because they were skilled mariners, the end result was a good one. That’s the way it is supposed to be and that’s why they get paid the big bucks.
- When a Near-Miss Becomes a Casualty
A look back is a good thing. Did this, as the quality auditor might say, involve a non-conformity? I don’t think so. What it did entail is an event in which a potentially destructive result was averted and the methods employed to do that ought to be widely disseminated for all to see. At the same time, the events leading up to the point where this situation manifested itself need to be similarly examined to determine what and if happened to put the vessel into an “iffy” situation. That shouldn’t involve fines and penalties.
How this event got the point of becoming a punitive police action by the nation’s top marine watchdogs is beyond me. But, it brings us back to the realization that the U.S. Coast Guard, as much as five years ago realized that it had lost its edge in terms of marine inspection and technical skills. A concerted effort is underway to right that ship and bring the Coast Guard’s marine safety mission back up to a reasonable standard. This includes, among other things, enhanced training at so-called “centers of excellence” and the active recruitment of experienced commercial mariners and other civilian marine professionals into the Coast Guard to shore up a mission that had lost its way. That said; events like the one described by Captain Hudson in July do not necessarily provide any measure of comfort that improvements are happening.
The same organization that routinely sub-contracts important inspection duties to certain, appropriately qualified classification societies also should be able to take those same folks at their word when they say that a vessel is in compliance with no apparent damages or evidence that anything untoward has occurred. And, that’s just what has happened. In the wake of all that, no fines have ever been collected by the Coast Guard and the initial penalties – according to Hudson – have since been reduced to letters of warning. Still, the delays and expenses incurred by the vessel, its operator and charterers were needless. Could this happen to you? You bet.
On July 10 of this year, no damage to any ship or facility occurred in the port of Houston or Bayport. No oil was spilled and no one was injured. No hulls got dented and no anti-fouling paint got scraped against a murky bottom. Nevertheless, a responsible operator and its technical personnel are examining an anomaly that occurred during a channel passage with the ultimate goal of making an already safe vessel – and fleet – even better. They even let the local authorities know of their efforts in a reasonably timely manner. And, that’s the way it should be. Period. – MarPro
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Joseph Keefe is the lead commentator of MaritimeProfessional.com. Additionally, he is Editor of both Maritime Professional and MarineNews print magazines. He can be reached at firstname.lastname@example.org or at Keefe@marinelink.com. MaritimeProfessional.com is the largest business networking site devoted to the marine industry. Each day thousands of industry professionals around the world log on to network, connect, and communicate.