It is a disturbing report, not so much because of what has happened, but how it is presented in the public domain.The report reads superficial at times, and at other times it reads like a comical narrative.

Below is just one example from the report.At 1917, while the vessel was proceeding at a constant speed at 9 knots, the master was heard saying we’re very, very close to land, just 1 1/2 miles.

And still it never occurred to anyone on the bridge that the vessel was going aground within the next 20, next 10 minutes.At 1927, there was neither any action undertaken by chief officer nor orders from the masters to change direction while the vessel was at a distance of 1.5 nautical miles from the coast at 1923, but instead the master was heard saying how close we are.

We are very close.We are very close.My heart is beating shit.Notice how the emotions of the seafarers are ridiculed to make a persuasive point.Notice also how selective excerpts from the chief office from the seafarers are combined with the judgmental tone of the investigation team to amplify the problem in an attempt to gain the credibility of the reader.

It is a style of writing that appeals to the uncritical masses.Sections of the report read less like description of an accident and more like an investigation team that is so far distanced from the reality of global shipping.On 2 occasion, the report reads we should not lose sight of the fact that, but after reading the report, it appears like the investigation team has lost the sight and the plot of a plausible accident narrative.

I’m questioning the underlying methodology of this accident.In so doing, I’m keen to share with you the key issues that have been conveniently brushed aside by this methodology.So let’s get started.I call it a Swiss cheese political analysis, which I believe is the underlying methodology here.

It’s a classic example of Swiss cheese political analysis.A deliberate attempt to select cheese slices and holes in those slices and attempt to prevent in an attempt to preserve the status quo.The Swiss cheese political analysis methodology resists change at all costs.

It is a political analysis, political because only those slices that are centered on the seafarers behaviour are chosen and exclusively those holes that can be used to dehumanize those at the sharp end are amplified by the authorities.

And once the slices in the holes are decided upon, a desperate attempt is made to align between those holes and ignore others to create a one sided narrative of blaming and shaming the seafarers.Both the Captain and the Chief Officer are charged with gross misconduct and culpable negligence.

The Investigation Authority has made a recommendation to the administration in charge to withdraw the captain’s certificate.By contrast, no concerns have been raised against the owner of the OP or the operator of the ship.As always, a balanced view of the accident is missing.

These are the three main themes of my review.One, the missing context, 2, The absurdity of absolute goals, and three, the unrealistic nature of risk controls that the investigation has highlighted.

The missing context At the time when the accident took place, the entire world was in the middle of a global pandemic.This was a time when many of us would not dare to step step out of our homes, even for buying essential supplies.

Ships were known to carry dead bodies of seafarers in plastic bags.Seafarers did not know if those bodies of their shipmates would ever reach the shore, be sunk at sea or burnt to ashes in the incinerator.It is a traumatic situation on land.

How much more distressing it would feel in the middle of an ocean with little to no support.Think in this background.The seafarers were transporting goods from all over the world to help ensure guaranteed deliveries at our doorsteps.

Global shipping did not stop for a day because these seafarers were doing their best to run the show.But the social resilience of the supply chains during the pandemic and the trauma and distress of the seafarers who worked 24/7 on board those floating factories is nowhere to be seen in the accident report.

I’m asking myself here.We are trying to make sense of the seafarers behaviours and the most dominant influencing factor that shapes their behaviour is silenced in this report.In establishing a narrative of gross negligence and culpability, guess who is being negligent and complacent?

Surprisingly, the report picks a hole in the cheese that would have shed so much light on this missing context.It reads most of the crew except for a very few who joined the last crew change.Who joined during the last crew change on 1st March 2020 at Kawasaki, Japan had already completed their tour of duty and due to the COVID-19, their contracts of employment were extended until arrangements could be made by the company for disembarkation at a convenient port.

The extended service was in no way an impediment to most of the crew except for the former bosun who jumped off the ship with his life jacket on near the coast on the previous voyage from Australia to China in May June 2020.Unfortunately though, the investigators never really dare to engage with this vital piece of information longer than usual.

Contracts during the pandemic.The logistical hurdles of crew change in foreign ports, low morale, depressing atmosphere on board, social isolation, hopelessness and a suicide that has occurred on board in the previous voyage.None of this makes up to the report.

On the contrary, the report makes an attempt to downplay all of this.Why On what basis?The investigation team concludes that extending the contract was not a problem for the crew.And then where was the support and assurance from the company for the crew members to connect with their families in such difficult times?

The question is not how the ship managed to get so close to the land, but why it did so.Why did the crew really need to get so close to the land in search for cheaper phone calls and accessible Internet?But we are not asking those questions.

Instead, the report states, although laws and rules were being violated, there was a compelling desire to get telephone signal and that took precedence over anything else to the extent that those in charge became oblivious to their primary essential duties.

My question is who gets to decide between compelling desires and the essential duties of these precarious labourers?Of course, the investigation team that is unlimited access to Internet and the privilege of permanent employment that allows them the luxury to work from home during the pandemic and perhaps even beyond.

My next theme is the absurdity of absolute goals.All absolute or SMART goals are known to create their own risk.In this case, we should be asking what new risks are being created by introducing 0 alcohol policy?

Did we think of these risks during or after implementing the policy?Here are some common themes that I have noticed in global shipping as a result of 0.Alcohol policy. 1.The implementation of 0 alcohol policy usually rests with the senior management on the ship, that is, captain or chief engineer from the outset.

Such an intervention creates grounds for abuse of power and authority.Scarcity of alcohol combined with an autocratic structure on the ship raises a whole range of ethical issues.Who is given the charge to prevent access and supply of alcohol on board?

Is there not a conflict of interest?It is the senior most officers on the ship who are responsible for implementing 0 alcohol policy.Who is controlling the controller?Power is often abusive and corrupt.

In many instances, these senior officers will find ways to procure alcohol from foreign ports.Who in their right minds will question their authority on the ship.It is then up to senior officers, that is captain and chief engineers to decide who will get access to unauthorized alcohol on the ship.

The availability of unauthorized alcohol to the seafarers at local at lower rank will be at the discretion of their bosses.You learn very quickly not to upset your bosses or else.And all this amplifies pre-existing hierarchies.

Scarcity and uneven distribution of alcohol will in invariably create subcultures.Jealousy and wrath among subcultures and a lack of trust between ranks even with a complement of 12 to 15 people on the same ship.Why should I trust you when you are enjoying alcohol every evening and I’m drinking orange juice or coffee?

The envy that comes from watching self indulgence of a powerful few sitting in their cabins, mess rooms and smoke rooms enjoying alcohol slowly find its way into critical operations on the bridge deck and engine room.Why should I share my concerns with you?There goes the facade of psychological safety out of window.

The very notion of 0 alcohol policy to conduct safe operations falls flat on its face.On a side note, little is understood about how drugs and alcohol addiction really works and why bad habits cannot be controlled through such absolute interventions, if at all.

It makes the situation worse for everyone, including those who do not consume alcohol.The unrealistic nature of risk controls.Ships invariably navigate close to land.

The question is not whether ship should or should not navigate in close proximity of navigational hazards, but what control measures are available to the seafarers to allow safe navigation.On this particular ship, the captain had requested for large scale charts to navigate close to the land.

A court is found in the investigation.The captain is heard saying if they want to supply, they will supply.Not now.We don’t know how far we are going.Following this vague court, the investigation team makes a cold remark.

It would appear that they were talking about ordering a large scale chart.No further attempt is made to delve deeper because all this does not fit with the Swiss cheese political analysis.One wonders why these issues are picked up investigations and not during audits and inspections.

And what are we really checking during audits and inspections?Equally, what are we doing in the name of risk assessments?In most instances we will find a mindless remark in the passage plan stating be careful when navigating close to the land or call master when in doubt.

As long as we can move the risk from red through amber to green on the paper, who really cares about the controls?Lessons learned from the Waukesha accident Everything that you need to know as a reader is available on page seven of the official report.

What is the point in conducting an Accident Investigation and compiling a 223 page report when both the crime and the culprit have been established, have been established from the outset, Have been established from the outset?

The Bakashio Investigation report serves to demonstrate how not to conduct accident investigations.The ritual of accident investigations.I’ve always maintained that accident investigations are not conducted for the purpose of learning and preventing accidents.

Instead, the ritual of accident investigations is performed to preserve political and social order.That’s all from me.My name is Nippin and I’m the founder of, CEO, and CEO.That’s all from me.My name is Nippin and I’m the founder and CEO of That’s all from me.

That’s all from me.My name is Nippin and I’m the founder of and that’s all from me.My name is Nippin and I’m the founder and CEO of Novella Solutions Consultancy, specializing in human centered approaches to learning, risk and social decision making.

I’m a former Master Mariner with an MSC in Economics and a PhD in Social Sciences and Anthropology.I bring the transdisciplinary lens to the challenges of work and organizing, which includes humanities, social psychology, mythology, semiotics, anthropology, and philosophy.

You can know more about my work by visiting my website, Novelist dot Solutions.You can also follow me on my podcast, Embracing Differences, which is available both on YouTube as well as Spotify, Apple Podcast, and other famous platforms.

Thank you for listening and I hope you have enjoyed listening to this podcast and given you enough to think about.If that’s the case, my job is done.