Let’s go back some 18 years in time. The local time was 03.10. I was standing my watch as a Second Officer on a large container vessel, bound for Irago Pilot Station in Japan in the next 90 minutes. On a container ship bound for a Japanese port, the concept of ‘estimated time of arrival’ actually means
Traffic is usually quite dense in this area. On this occasion the weather was bad, and visibility was down to about 3 miles. We were approximately 20 miles from the pilot boarding grounds with two vessels headed on a parallel course – a car carrier on the port bow and a Taiwanese container vessel on the starboard quarter. Both vessels were on the same course at approximately the same speed of 20 knots, positioned at a distance of about one mile from us. The trouble started at this point.
Without warning, the vessel on the port bow turned on an almost perpendicular course to starboard in an attempt to cross our bows. Turning to port was not a choice, given the shallow waters on the side. Slowing down or stopping the engines never occurred to me, despite bright luminous ‘safety first’ signage, full engine controls on the bridge and the Chief Engineer standing by right behind the bridge panel. My immediate reaction was to call the Captain. The Captain arrived in less than a minute. Dressed in his pyjamas and trying hard to adjust to night vision, he quickly assessed the situation and ordered a hard over helm to starboard.
With the helmsman on the wheel, I immediately switched to hand steering and the helmsman executed the order without further delay. As we were swinging to starboard, the Taiwanese vessel on the starboard quarter adamantly maintained her speed and course. It took us about 45 seconds to swing past the entire length of this ship. Those were the longest 45 seconds of my life. I have no idea how close we came to
The next morning nothing seemed usual. I went up to the bridge to
Perhaps it would be appropriate to say a few words about my past performance here. Arriving on time in port or negotiating heavy
traffic had never been a concern for me. I was in my third year as an independent watch officer. I had never missed arrival time in port nor shown hesitation in a difficult situation. But things changed from here. The ‘Call Master’ position shifted earlier and earlier for every port arrival. Navigating high traffic areas suddenly became a big deal with doubled watches, increased presence on the bridge from the Captain and detailed night orders. I started to lose confidence. In every manoeuvre I performed, my watchman could sense my anxiety no matter how hard I tried to maintain calm.
At the end of my tenure of duty, I knew it wouldn’t be good feedback from the Captain. But I never expected just a dry goodbye. The message was clear – ‘I hope I never get to sail with you again.’
Almost a decade passed by and memories of this unpleasant experience kept recurring. For a long time, I felt responsible for the
entire situation. I should have never allowed my own vessel to become sandwiched between the two vessels. I should have slowed down the vessel or crash-stopped her in the moment. What was the big deal in delaying the vessel? At the most we would have arrived a few minutes late. Why so much hesitation? And why did I not call the Master sooner? Questions such as this kept haunting me for a long time and I went into a negative spiral for a considerable time.
Changing the approach
This is not a unique story of a near failure.
- As professionals, we always have more than one goal. Arriving on time and arriving safely are not compatible goals.
- I genuinely did not know why I did not crash-stop the vessel despite all the instructions and standing orders. We do not know what we do not know. We should therefore not judge ourselves harshly over
split seconddecisions that may seem stupid to others in hindsight.
- When we experience failure, our natural recourse is to search for problems within. It may well be that the system itself is designed to fail us.
- I was a competent officer, and yet I ran into a near collision. Society often views failure as linked with incompetence, but there is no clear linkage.
- Our natural tendency is to treat failures as isolated from everyday work. In fact, the
behaviourthat we exhibit in a failed situation is not far from the behaviourthat we exhibit in everyday work.
More generally, if you ever experience failure – and by this, I mean faced with an undesirable, unexpected situation – stay positive, pay close attention to the situation and share your experiences without guilt, shame, fear or resentment.
Acknowledging failures and sharing our experiences is not a sign of weakness. It is a commitment to learning and development and moreover, an immense source of inner resilience. If we are genuinely striving for a safer future, let’s talk about failures openly and honestly.
“Blink” By Malcolm Gladwell suggests our deliberations to evaluate our decision often results in a worse decision than relying and acting on our immediate thought. Especially when we all ready have expertise in the subject matter.
In my opinion, quickly weighing the consequences of inaction, will require more immediate action.
We have evolved to mitigate risk in real time.
So far in my life, career and personal, I have crossed paths with catastrophe a handful of times and have always been proud of my decisions and actions. However, none of that really convinces me that I will perform as well the next time.
I don’t know if this statement has any value to anyone else – but simply saying it publicly hasn’t lightened a load I never knew I was carrying.
Nice piece Nippin. It is true that the difference between success and failure is the detail, and it is that detail that we are often blinded to with our deeply entrenched doctrines and mental models.
Excellent, honest and illuminating. Valuable contribution to Human Factors understanding; both possible failures and challenge of post-incident learning.
I was delivering an 80′ sailboat to St. Thomas from St. Petersburg, Florida 35 or so years ago when off the coast of Miami a similar situation was occurring at night with a large tanker. I had been tracking this tanker for a passing situation on radar. This was before AIS. I had been attempting to contact the tanker on VHF radio but as typical there was no response even though there is a requirement to have an English speaking person on watch at all times. We were set for a safe crossing when all of a sudden the tanker changed its course directly crossing our bow. I woke up the remainder of the crew getting all on deck. At the last minute I actually reversed the engines and the tanker passed in front of us less than 50 feet. I’ve taken all of my captaining lessons over the years and applied them to safety, human performance, and even Safety-II. I know now and always teach others to plan for failure, not success. It is only when you plan for failures, such as with these events, that you can begin to action effectively when they do occur. Figuring out last minute what is the best course of action, regardless of how smart or experienced you are, may not help you. I use that thinking today for almost everything I do.
An interesting read having been a Bridge Watchkeeping Officer in the Royal Navy. When he got to the bridge the master did not carry out the crash stop procedure either. This suggests to me it wasn’t rehearsed (lack of training/preparation) and/or it wasn’t instinctive as an action that would normally be taken ‘by the ordinary practise of good seamen’ (to quote from IMO rules for prevention of collisions at sea).
What is clear is the master could not contain this reaction to failure. You can’t discipline (goodbye Nippin) and learn at the same time.
Hi I’m a paramedic with 20 years in emergency response. It’s still not taught in our field but there are strong adrenaline based reasons why we do not do in a moment under high stress what In hindsight seems obvious. As the other ship broke the rules and cortisol and Adrenalin spiked, your frontal lobes stepped back and your hind brain shrunk your response to ‘fight flight freeze’. There is no cause for shame here; this is reasonably foreseeable and highly predictable and is why pilots train in simulators. I’ve got through a variety of difficult threatening situations at work with on a few occasions becoming overwhelmed by a situation and finding my awareness shrunk to a narrow focus. There’s a really good albeit totally non academic description of this in a book by an American trainer for military and police called Sharpening the warriors edge which explains this better. I wanted to know why I sometimes froze or got engulfed in trivial actions; I once spent ages getting a police vehicle to move so we could leave scene with a critical patient when we could have just reversed and taken a different route away. If a high reliability organisation doesn’t teach simulation training to help our body memory to respond ‘instinctively’ when pushed into stressful situations then it isn’t down to ‘pilot error’.
We need to talk more about normal human responses to exceptional situations: disbelief; stuck in a groove; fight flight and freeze. Thank you for your honesty ; it’s the only way to get past individual error to ways to prevent it happening again.