MANAGING SAFETY PERFORMANCE NEWS

Effect – And Cause

“Tell it like it is.”

~Howard Cosell

The sky was dark, the moon was relatively bright, the weather was pleasant with unlimited visibility and calm seas. As thirty-five sailors rested in their racks in Berthing Unit 2, their destroyer was on a collision course with the ACX CRYSTAL, a container ship three times its size.

The collision was felt throughout the ship.

Watchstanders on the bridge were jolted from their stations, thrown off their feet.  Some thought the ship had run aground, while others were concerned that they had been attacked. Sailors in parts of the ship away from the impact point compared it to an earthquake. Those nearest the impact point described it as like an explosion.

Seconds after impact, sailors in Berthing 2, located below the ship’s water line, started yelling, “Water on deck!” and, “Get out!” One Sailor saw another knocked out of his rack by water. Others began waking up shipmates who had slept through the initial impact. At least one Sailor had to be pulled from his rack and into the water before he woke up. Senior Sailors checked for others that might still be in their racks.

The occupants of Berthing 2 described a rapidly flooding space, estimating later that the space was nearly flooded within a span of 30 to 60 seconds. By the time the third Sailor to leave arrived at the ladder, the water was already waist deep. Debris, including mattresses, furniture, an exercise bicycle, and wall lockers, floated into the aisles between racks, impeding Sailors’ ability to get down from their racks to exit the space. The ship’s 5 to 7 degree list to starboard increased the difficulty for Sailors crossing the space from the starboard side to the port side.

One Sailor escaped via the starboard side. This Sailor tried to leave his rack, the top rack in the row nearest to the starboard access trunk, but inadvertently kicked someone, so he crawled back into his rack and waited until he thought everyone else would be out. When he jumped out of his rack a few seconds later, the water was chest high and rising, reaching near the top of his bunk.

The Sailor struggled to reach the starboard egress point, struggling through lounge furniture and against the incoming sea. Someone said, “go, go, go, it’s blocked,” but he was already underwater. He was losing his breath, but found a small pocket of air. After a few breaths in the small air pocket, he eventually took one final breath and swam.

He lost consciousness and did not remember how he escaped, but he ultimately emerged from the flooding into Berthing 1, where he could stand to his feet and breathe. He climbed Berthing 1’s egress ladder, through an open watertight scuttle and collapsed on the Main Deck. He was the only Sailor to escape through the starboard egress point.

The last Sailor to be pulled from Berthing 2 was in the bathroom at the time of the collision: a flood of water knocked him to the floor. Lockers were floating past him and he scrambled across them towards the main berthing area. At one point he was pinned between the lockers and the ceiling, but was able to reach for a pipe in the ceiling to pull himself free. He made his way to the only light he could see, coming from the portside watertight scuttle. Swimming towards the watertight scuttle, he was pulled from the water, red-faced and with bloodshot eyes. He reported that when taking his final breath before being saved, he was already submerged and breathed in water.

……..

Prose from some Tom Clancy thriller? The screenplay from a World War 2 action movie? Nope. Every single one of those words was lifted directly from an investigation report: the US Navy’s investigation into two separate collisions, between its destroyers and commercial vessels. Both happened in the middle of the night in the Pacific, weeks apart. Each characterized as a “preventable collision”—the two costing seventeen lives.

That was the effect.

As to its cause, in the words of the investigation report, it was “leadership’s failure” to “plan” “adhere” “execute” and “respond.”

Reading Reports

In my line of work, I read a lot of reports about events—negative—that happen in operations the world over. A few make headlines; most are events that would never show up on the CEO’s radar screen.  Too bad: if more of those minor, even non-event, events had made their way up to the big boss’s desk, I will guarantee that most of those headline making events would never have happened.

Case in point: those collisions. Among the twenty-one investigation findings was this gem: “The leadership command did not foster a culture of critical self-assessment. Following a near-collision in mid-May, leadership made no effort to determine the root causes and take corrective actions in order to improve the ship’s performance.”

As a practical matter, effect determines the degree of interest in finding out about cause. Have a big event, a big investigation will predictably follow, but not so for a near-miss. Too bad, because that leaves a lot of significant causes undiscovered…. until it’s too late.

So, in addition to those other leadership failures—plan, adhere, execute and respond—add this one to the list: leadership’s failure to understand that, for events and non-events, their difference is found in effect—not their cause.

It really is that simple.

Effect and Cause: A Different Looking World

If leaders the world over—from captains of ships to captains of industry—understood that simple truth about cause and effect, the world of investigating problems would look a lot different. Near-miss reports wouldn’t be seen as a leading indicator so much as they would be valued as a great way to understand and prevent bigger problems. Investigation would become a leadership core competency: if you aren’t good at figuring out what went wrong, you probably don’t have a bright future in management. Supervisors and managers would love hearing about problems from their followers—every bit as much as they like hearing about the good stuff.

And the reports themselves—whether about a hit or a miss—would make for good reading. Anyone in the outfit could pick up a report, understand what went wrong, and appreciate what should be done to prevent that from happening again. Here—or anywhere else in the outfit, anywhere in the world.

That, indeed, would be a better world. And ultimately a safer one.

Telling It Like It Is

On the important matter of conducting effective investigations, the Navy’s investigation report should be required reading. In over forty years of reading investigation reports, this one is the best. The Navy’s account of the two events were written so that an ordinary civilian—you and me, for example—can understand perfectly. No jargon, no acronyms; all relevant terms defined. Pictures and drawings provided a perfect—but not pretty—picture of what went wrong.

When it came to finding cause, absent were any popular terms of management art—process, system, culture—to deflect responsibility away from individuals. No clever behavioral science terms—“expectancy of safety” being but the latest—that confuse rather than clarify. Nor did the Navy hide behind “classified” or “privileged and confidential.” They live in the same litigious world you do, and could have done just that.

Instead the Navy decided to “Tell it like it is.”  At the bottom line, this investigation lays out all of the failings of those whose fingerprints were found on the causes of two tragic events: those standing watch, and their leaders.

In my book, that’s not placing blame; it’s being honest about the facts—and the failures.  If those Sailors were your kids, siblings, parents, or friends, you would want nothing less than that truth.

Finally, in the spirit of telling it like it is, we might as well put out the other inescapable truth about the causes of those safety effects you have to deal with, from near-misses to tragedies.  There are only two causes to choose from: acts of God—or humans.

When it comes to cause and effect, it really is that simple.

Paul Balmert

November 2017

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