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Nearly All Vessel Navigation Errors Have the Same Cause

Imagine the following scenario:

Two ships with plenty of space are approaching each other. It’s a clear night, and they see each other fine—both with radar instruments and visually. Equipment for both ships is functioning fine, and multiple officers onboard are on watch (or just observing). Yet, despite all this, the captain of one of the vessels decides to make a turn that puts him in the direct path of the other ship. His crew, knowing what’s about to occur, say nothing as the two ships inevitably collide.

It sounds ridiculous to people who weren’t there, but this is a description of what happened between the M/V Santa Cruz II and the USCGC Cuyahoga. No one intended to collide with the other ship, no equipment was malfunctioning, and there was nothing affecting visibility. There was virtually nothing that could have led to the collision.

Except one thing:

The Cuyahoga’s captain misinterpreted the running lights of the Santa Cruz, and so misjudged the size of the ship. He believed his order to turn put him well out of the way of the other vessel’s path. However, though his crew knew exactly how big the Santa Cruz was (and that the turn would put them in harm’s way), they presumed that the captain knew as much as they did—so they said nothing.

The collision caused the death of 11 Coast Guardsmen that night.

Navigation Errors Are Ultimately Human Errors

According to the U.S. Coast Guard Research & Development Center, 89-96% of vessel collisions are caused by human errors—notably, usually by a sequence of human errors occurring at once or in quick succession. A Dutch study cited in the report researched 100 maritime casualties and found that in 93 of them, 2 or more individuals each committed at least 2 errors that led to the injury or death of a crew member.

Here’s the worst part:

According to the report, in these 93 cases, “every human error that was made was determined to be a necessary condition for the accident.” In other words, the situation could have been prevented if one mistake had been corrected. Just one.

In a presentation from a forensic engineering firm in partnership with the California Maritime Academy, experts highlighted that most navigation errors have nothing to do with the technology involved—and in fact, overreliance on navigation technology makes vessels less safe, not more. So human error is the ultimate cause of most vessel navigation problems, and is the root cause of virtually all casualties at sea. That much is obvious—but how can navigation systems account for human mistakes? What do vessel navigation errors specifically have in common?

The National Safety Council published a report that highlighted the most common error causes:

  • Failing to adhere to established procedure, or “winging it”
  • Distraction from the navigational tasks at hand
  • Ambiguity or disagreement between multiple instruments or sources of information
  • The bridge staff failing to remain vigilant, or “not minding the store”

In August 1999, a cruise ship collided with a container vessel in the English Channel because the staff committed nearly all of these mistakes. Only 1 officer was on watch during a period of high traffic in the Channel (while procedure required 2 officers to be on watch). Moreover, he was engaged with clerical tasks that took his attention from the 10 other vessels near the cruise liner.

In addition, he was relying entirely on his radar instruments (which were not calibrated correctly and should have been spotted) and he neglected to simply look around. The officer’s negligence caused a collision, despite having ample time to correct and prevent it.  

However, the NSC report highlighted the most vital thing that stands between a vessel’s safety and navigation disasters: situational awareness.

Situational Awareness: Humanity’s Secret Weapon Against Collisions

In the report from the National Safety Council, they found that navigation errors all involved a failure of “situational awareness.” Situational awareness is defined as the ability to comprehend the conditions that affect a vessel during a high-risk situation. It’s the ability to remain mentally present, to pay attention to the relevant data, and act accordingly to the right factors.

Situational awareness can fail from a number of factors, including:

  • Overwork or fatigue
  • Distraction (e.g. poor weather, personal issues)
  • Lack of staffing
  • Lack of constant communication
  • Insufficient knowledge of the ship itself

Adequate situational awareness can help steer a ship through the worst of conditions, including disastrous weather or malfunctioning navigation equipment. However, poor situational awareness can lead to a disaster under the most ideal circumstances—that’s why you’ll hear about captains running aground or colliding with other vessels in broad daylight, with clear skies, on wide-open water.

Situational awareness failure includes:

  • The inability to keep track of events
  • Failure to assess the significance of events
  • Failure to take corrective action

Good navigation only requires a few things: redundancy, cross-checking, and the use of bodily senses (along with training and experience). That’s it. Ship managers and navigation staff simply need to exercise the simple caution of using their common sense, remain vigilant, and save secondary tasks for another time. When they don’t, innocent people can pay a steep price for their mistakes.

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