Thoughts on Casualty Investigations by NTSB Member Robert L. Sumwalt III
On May 14, 2007, the passenger vessel Empress of the North grounded at the intersection of Lynn Canal and Icy Strait in Southeast Alaska. “The U.S. Coast Guard and several good Samaritan vessels assisted in evacuating the passengers and nonessential crewmembers and safely transporting them back to Juneau. No injuries or pollution resulted from the accident, but the vessel sustained significant damage to its starboard underside and propulsion system.
The National Transportation Safety Board determines that the probable cause of the grounding of the Empress of the North was the failure of the officer of the watch and the helmsman to navigate the turn at Rocky Island, which resulted from the master’s decision to assign to the midnight-to-0400 watch an inexperienced, newly licensed deck officer who was not familiar with the route, the vessel’s handling characteristics, or the equipment on the vessel’s bridge.” – NTSB
The Safety Board’s investigation of the accident identified the following safety issues:
- Master’s decision to put an inexperienced third mate on watch without supervision or guidance.
- Junior third mate’s actions.
- Watchkeeping procedures.
- Documentation deficiencies.
- Malfunctioning lifesaving devices.
Of particular note were comments in the report by then-Member of the NTSB, Robert L. Sumwalt III :
Member Sumwalt, Concurring:
The written report of this accident does a fine job of describing the crew errors that led to the accident. However, as Dr. James Reason has established, an examination of human error should assess the actions and decisions of the managers and designers at least as much, if not more, than the actions of the system operators.
As I read the errors of those on board the ship, I could not help wondering how (or if) their inappropriate actions may have been influenced by organizational factors. I believe the draft report, even as revised by staff, did not fully address these issues.
As discussed during the board meeting, Majestic America Line did not have in place several components associated with a healthy safety culture. For example, the company did not employ adequate controls to ensure that the Empress of the North was seaworthy when it sailed. This lack of oversight enabled the Empress of the North to be out of compliance with its annual verification for almost an entire year. As a result, the vessel’s document of compliance was invalid, along with its safety management certificate and thus, its Safety Management System (SMS). The company also failed to ensure that the vessel received internal and external audits and did not adequately perform risk assessments, which are all requirements of SMS.
During the board meeting, a member of staff acknowledged that the company did have shortcomings in its safety processes, but staff was unable to establish a definitive link between the company’s poor safety performance and the crew’s performance. I accept their findings but wish to comment on the direction of the investigation and reporting process. Although the linkage between the company’s and the crew’s performance could not be determined in this accident, I believe the quality of the report could have been strengthened by documenting these factors as part of our investigation. The Safety Board has the reputation for doing thorough investigations. In order to maintain that reputation we must not only consider and investigate these factors; we must document our work as well.
My hope is that this important part of the investigation be fully discussed in future reports brought to the board and that documentation of organizational factors will become the norm. Such discussions should not be delayed until a board meeting. It is critical that we investigate these factors, even if we end up ruling them out.
Most accidents have organizational roots; if we don’t at least look for these underlying causes, it is likely we will not find them. As stated in the Columbia Space Shuttle Accident Investigation Report:
Many accident investigations make the same mistake in defining causes. They identify the widget that broke or malfunctioned, then locate the person most closely connected with the technical failure: the engineer who miscalculated an analysis, the operator who missed signals or pulled the wrong switches, the supervisor who failed to listen, or the manager who made bad decisions. When causal chains are limited to technical flaws and individual failures, the ensuing responses aimed at preventing a similar event in the future are equally limited: they aim to fix the technical problem and replace or retrain the individual responsible. Such corrections lead to a misguided and potentially disastrous belief that the underlying problem has been solved.
In other words, if we focus our investigation on those individuals who committed the active error that led to the accident, we may be overlooking other systemic factors that caused the accident. In doing so, we miss valuable prevention opportunities which directly impacts our mission—preventing accidents.
Robert L. Sumwalt, III
July 29, 2008
Of particular interest in the IMO Casualty Investigation Code is section 16.5, which states,
16.5 Scope of a marine safety investigation: Proper identification of causal factors requires timely and methodical investigation, going far beyond the immediate evidence and looking for underlying conditions, which may be remote from the site of the marine casualty or marine incident, and which may cause other future marine casualties and marine incidents. Marine safety investigations should therefore be seen as a means of identifying not only immediate causal factors but also failures that may be present in the whole chain of responsibility.
This section seem in line with the thinking of now-retired former NTSB Chairman Sumwalt in the Empress of the North report. It’s unfortunate that many maritime accident investigation findings continue to focus on the immediate rather than root causes. While human error may exist in these immediate causes, we must consider the brittle system that allows those errors to become a casualty. A resilient system may have the capacity to withstand, capture or otherwise mitigate these same errors. If we don’t consider the potential systemic issues, those opportunities for increasing resilience will be lost.
Our thanks to Captain Clarke Sheehan for bringing this section of the NTSB report to our attention.
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