Watchkeeper: An age of zero tolerance

Vaughan Pomeroy, whose career began in aviation and whose work in LR has taken in military ships and merchant vessels alike, is a thoughtful lecturer. He reminded his audience of the age they are living in, when public perception and political pressure are very real realities which thrust themselves into our consciousness with their demands for an accident-free industry.

Is this even slightly realistic? And is there anything very wrong with the trend of losses of ships, which has been steadily going downwards despite the age of the world fleet? But course it is not the trend which is remarked upon after a spectacular accident which provide us with a “shock to the system” and precipitates changes. And for all our regulations and science and engineering, we are human beings and make mistakes! Vaughan Pomeroy points out the basics of a “Universal Learning Curve”, identified by Duffey and Saull, who note that the learning rate is a function of a number of errors and accumulated experience, that the human contribution is part of the risk, which dominates as technology advances. They also suggested that we have both a learning curve and a “forgetting” curve, and that it is possible to derive a formula for the minimum error rate.

And the interesting consequence of this is that while technology changes, year on year, the minimum error rate does not change! In fact the MER has not changed in 200 years, producing for the shipping industry about 75 casualties per annum, which is roughly the same for aircraft crashes and other industrial sectors.

 An interesting comparison might be the loss of the Swedish King’s ship Vasa in 1628, with any modern major casualty. This ship, which flooded through her lower gunports and sank in Stockholm, was lost because of a confluence of factors, human element and latent errors. Indeed, if we were to sum up this tragedy in modern terminology, it would be a combination of inadequate training, poor operating and emergency procedures, faulty design, incomplete research and development, insufficient validation, faulty commissioning and non-adherence with procedures which did for the Swedish ship. Does any of this sound familiar?

Do we still need “shocks to the system” to help us improve? Vaughan Pomeroy suggested that we were still very vulnerable, in this age of intolerance, to serious accident. There was, he suggested, too much reliance on complex electronics and systems which were insufficiently reliable and to maintenance failure. We need systems for the average competence, more dependable software, and better automation. We are still reluctant to tell people what happened so that improvements can be made.

We need, he concluded, to gain new skills, to better understand risk and reliability, improve our education and training, and, while there were new lessons to be learned, we need to remain very aware of the lessons of the past! All of which is even more important, in an age of intolerance.

Source: BIMCO