The Ritual of Accident Investigations

This article – an extract from a longer chapter – is an enquiry into the rituals of accident investigations. We will begin with an understanding of rituals and a framework to understand the hidden power and meaning in rituals. This framework will then be applied to the rituals of risk and safety, with a specific focus on accident investigations to question if we are really learning from accidents.

Can accident investigations be seen as rituals of learning? This will be the guiding question.

The first rule of anthropology is that everything is significant. What was the significance of this ritual to the community? How well did the ritual fulfil its purpose? Once we understand how to question the meaning and purpose in a ritual, our next step is to find out if and how the rituals of accident investigations serve their purpose.

Rituals

A ritual is the enactment of a culture. In other words, a ritual is how culture is performed. The first image of a Ritual (with big R) that usually comes to mind is of major life events. But even listening to a podcast in the train, washing the car at the weekend, going to the gym or out for a morning walk and putting kids to bed are examples of rituals (with small r) in our everyday lives.

You may think that these are chores and routines of everyday life. Why should we call them rituals? For this, we must draw a distinction between a routine and a ritual. Our daily lives are full of routines, from how we get out of the bed to how we shower, put on our clothes, comb our hair, prepare breakfast, leave home for the office, return home, share a meal with our family, and go back to bed. How do we know which of these routines qualify as a ritual?

Routines are a cluster of habits that can be organized in a sequence; and they lighten our cognitive load. Unless something unusual happens, nature has given us the capacity to accomplish almost all routines through our habits in a pre-programmed mode.

Rituals give a cultural meaning to our routines. Even a routine as simple as cleaning teeth can be turned into a ritual if it extends beyond just personal hygiene to include looking and smelling good. The marketing and advertising agencies know so well how to turn routines into rituals: elevate your life when you drink coffee with your wife, or bring a smile to your face with a certain brand of toothpaste. Whereas a routine serves a function or a practical need, a ritual extends to give symbolic meaning to the routine. A ritual is a routine with soul and spirit.

Take the example of an informal memorial that I saw in Hamburg, erected following a road accident. The sudden death of a young cyclist is a tragedy for the family. A ritual is evoked, and the girl’s bicycle is erected in the spot where she died. The decision to create a makeshift memorial in a public space with a personalized message means that beyond the family of the deceased, the wider community, the general public and public bodies participated in the ritual.

The text on the placard by the top of the bike, translated into English, went:

On 30.01.2023, our daughter died here on this crossing. She was on her way to the KITA to pick up her son. She was run over by a truck. She died at the scene of the accident. On that day, our grandson waited in vain for his mum. For us, the world has stood still since then. We miss her very much, we will never hear her voice, her laughter again and miss our conversations together. We will no longer be able to hug her and feel her warmth. It is so infinitely difficult to continue living without them.

We would like to thank from the bottom of our hearts all the first responders who were on site at the accident site and supported our daughter!

We miss you very much, in gratitude your mum and dad!

The ritual sought to share the family’s pain and grief with passers-by. On the family’s message there were no details about how the girl was killed except that she was hit by a truck. Even though a passer-by told me that a policy had been mandated to prevent future accidents, it was clearly not considered necessary to include this news in the message on the bicycle. Rather, the ritual was about grieving and expressing gratitude to the community for their support.

When misfortune hits us, and the world comes to a standstill, such rituals become a source of coping, healing and inner resilience.

Does the makeshift ritual fulfil its purpose?

Every culture creates its own rituals to give meaning to the mysteries of the universe: nature becomes Mother Nature, sky is where heaven belongs, a deadly disease is the spell of an evil being, a goat carries with it the sins of an entire society, a bicycle gives us the strength to move forward, gargoyles and griffins become symbols of protection – and identifying the ‘root cause’ brings closure to an investigation. We seek moral reasoning in random phenomena, we feel a sense of control when we can name a problem, and we find solace in putting a face to the faceless. We humans find it easier to deal with the mysteries of the universe by turning towards rituals.

The table below provides the components of different kinds of rituals. Each of these components will help us to observe the visual and audible performance of the accident investigation ritual.

Table

Ritual components based on the Social Psychology of Risk.

A ritual of ‘lessons learned from accidents’

I present the example of a maritime investigation agency performing the ritual of ‘lessons learned’ following an accident. The purpose of this exercise is to observe the ritual and find out if we are learning from accidents. The accident involves the capsize of the PCTC (car carrier) Hoegh Osaka when the ship was departing from Southampton on 3 January 2015. The official investigation report, published on

17 March 2017 by the Maritime Accident Investigation Branch (MAIB) of the UK, highlighted a combination of human and organisational factors that led to the accident. I invite you to view the video link published by the investigation branch as we work our way through this ritual.

We begin by observing how the MAIB shares the lessons following the accident investigation. The chief inspector of the MAIB is formally dressed. He begins by thanking all the stakeholders involved in the accident investigation for their cooperation and assistance. He states: ‘It has required the branch to draw upon a broad range of expertise to establish what happened, why it happened and identify lessons for future safety.’

The video shows an aerial view of the Hoegh Osaka being salvaged during the night, with the chief inspector’s voice in the background explaining the sequence of events shortly before the accident. The rescue of the crew and the successful salvage of the ship is perceived as a fortunate outcome. It is also acknowledged by the chief inspector that in a slightly different situation, the outcome of the accident would have been far worse.

The video then changes from night to daytime, with the capsized ship in focus. The chief inspector is heard in the background explaining that once the ship had settled into a stable condition, the MAIB inspectors boarded it to collect evidence, including the ship’s loading computer. A team of inspectors can be seen boarding the ship via a rope ladder. The video then shows investigators gathering evidence from the ship, but this time there is no audio. A team of investigators can be seen holding torches and pulling ropes to guide them through unlit machinery spaces to access the logbooks and electronic logs situated at the bottom of the ship’s engine room.

Another investigation team can be seen walking on the main deck of the heeled ship to access the bridge. Inside the bridge, a lot of equipment, files, furniture, tools and rubbish is scattered on the floor. After unscrewing the data logger, the investigator is seen extracting the evidence from it, placing it in an ‘evidence bag’, sealing the bag and writing the ship’s details on its label.

In the next section of the video, the chief inspector presents the main causal factors of the accident:

• The stability conditions did not meet the international stability requirements for ships proceeding to sea.
• The calculations also demonstrated that while the ship was able to safely execute a similar turn at Calshot at a minimum speed of 10 knots about seven minutes before the accident, it had insufficient residual stability to survive the Bramble Bank turn when proceeding at 12 knots (accompanied by the visuals of a nautical map).
• Hoegh Osaka’s cargo loading plan had not been adjusted to account for the ship’s usual European port rotation, which resulted in the ship leaving the port of Southampton with a higher centre of gravity than normal.
• The number of vehicles which were designated to be loaded in the pre-stowage plan was significantly different from the final cargo tally, and the tally’s estimated weight of the many items of cargo was less than the actual weight (accompanied by pictures of cargo holds).
• A key causal factor in the accident was the routine practice onboard of adjusting the ballast tank quantities entered into the ship’s loading computer so that its output reflected the observed draft readings taken at the end of loading.
• Additionally, the ship’s automatic ballast gauging systems had been largely inoperative for some time, and the ship’s staff were not keeping a proper log of the distribution of ballast.
• The actual distribution of ballast onboard when Hoegh Osaka commenced its voyage had a near-adverse impact on the vessel’s stability, and had no resemblance to the distribution of ballast used by the crew to calculate the ship’s departure condition.
• Had the ship’s staff adhered to a more robust regime of ballast control so that the actual distribution of the ballast had been entered into the ship’s loading computer, Hoegh Osaka’s inadequate stability could have been identified, and it would have been entirely possible to resolve the situation by taking on additional ballast.
• While the chief inspector presents the learnings from the accident, the visuals of the damaged and toppled cars can be seen on deck. In one photograph, a steel plate with a measuring tape can be seen.
• In the concluding section of the video, the focus is back to the chief inspector. Standing outside his office, he ends with the following message: ‘The Master is ultimately responsible for ensuring that his or her ship has the adequate stability for its intended voyage on the completion of cargo operations and before it sails. A loading computer can be an effective tool for that purpose but only if accurate information is entered into it. It is therefore imperative that the working practices adopted by the PCTC ashore and afloat ensure that there is always a sufficient time and accurate cargo data provided on completion of cargo operation to enable the stability of PCTC vessels to be properly calculated before departure.’
• At the end of the video, the front cover of the accident report can be seen, with a photo of the ship aground. Then there’s a brief message of thanks to the National Police Air Service for providing the aerial footage of the accident.

Observing the ritual components in practice

Let us observe what we hear and see in the video within the framework of ritual:

1. Place: The video appears as a formal event in a public office. It is not clear who else is participating in this event, but since this is a public video (on YouTube), it would be a fair assumption that the video is meant to communicate the ‘lessons’ to a wide audience.
2. Code: The use of maritime jargon means that the video is specifically produced for the maritime community.
3. Apparel: The attire of the chief inspector is formal, and the message is conveyed in a formal manner.
4. Metaphor: The expression ‘stakeholders’ at the beginning of the video is an indication of the extent to which business language has gained penetration in public discourse; in this case in a formal accident investigation report. The report ends with the reminder that ‘commercial pressures do not result in an erosion of the basic operational safety standards’. But the language of the investigation in itself is influenced by commercial metaphors. If you think Iam being overanalytical or pedantic, consider the use of the term ‘community’ instead of ‘stakeholders’, and observe the difference. Words matter, and when we choose our words consciously, it influences our decisions and actions (Lakoff, 2014) (Long, 2012)
5. Discourse: Without setting out the context of the situation, the chief inspector begins by saying, ‘What happened, why it happened and identify lessons for future safety.’ Shortly afterwards, he can be heard saying, ‘In a slightly different situation, the outcome of the accident would have been far worse’. Is it possible to imagine a slightly different situation without knowing the actual context of the accident?
6. Discourse: The rescue effort and salvage are perceived as the fortunate outcome of the accident. The term ‘fortunate’ means that the rescue effort must have been seen as a matter of chance. The desire to understand ‘what went right’ and how the ship was refloated does not form part of the discussion. There is no mention of co-ordination, communication, heuristics, skills, situated experience and resilience of the rescue personnel in the successful handling and co-ordination of an emergency operation in the middle of the night.
7. Symbols: The visual representation of a team of inspectors gathering evidence in the dark and carefully preserving the evidence in a plastic bag is meant to show that truth is objective, and that accurate truth can be established so long as the data is not contaminated by human bias.
8. Repetition: In the backdrop of point 7 above, the report reflects the subjectivities, biases and political constraints of a government agency. Within the 83-page investigation report, the term ‘chief officer’ appears 132 times, and ‘Master’ 89 times. By contrast, the organisation responsible for the safety management system appears in the report on only 60 occasions. Of the 24 conclusions drawn from the report, 16 are centred on the vessel and the behaviour of the ship’s crew. (MAIB, 2016)
9. Discourse: The causal factors of the accident are presented in a prescriptive manner by establishing breaches of rule compliance. A descriptive view of why those breaches would have occurred is not presented in the accident report.
10. Metaphor: The metaphor of ‘ultimate responsibility’ of the ship master is situated in obedience and conformance with rules and procedures, leaving aside the empowerment and autonomy essential to exercising the authority of a ship captain.
11. Repetition: The use of the terms ‘normal’, ‘practice’, ‘routine practice’, ‘working practices’, ‘adjusted’ and ‘short cuts’ can be observed on several occasions both in the video and as part of the formal investigation report. There is no attempt to engage with what is considered normal and routine practice from the crew’s perspective.
12. Discourse: The narrative is framed as a mechanistic problem. The representation of mechanistic problems can be observed in several visuals such as computers, control panels, stability calculations, the cargo loading manual and the measurement of steel plates.
13. Metaphors: The chief investigator acknowledges the problem with the design of equipment and systems. At the same time, the expectation is that the operator should have done more to avoid the accident. The term ‘adjusted’ means that the operators are expected to adjust their behaviour to accommodate the expectations of the organisation, and the physical and social context.
14. Symbols: At 2.10s, a ‘Safety First’ sign can be observed in the video. What meaning would such a signage trigger to those watching a capsized ship because of the ‘commercial pressure’?
15. Symbols: The video shows various photos of machinery breakdown and damage to cars in cargo holds, symbolizing destruction and chaos.
16. Dissent: Since the YouTube comment feature is turned off, there is no opportunity for community engagement. But this could also be a feature of technology.
17. Sequence: The video begins by thanking all the ‘stakeholders’, and ends with thanking ‘the National Police Air Service for providing the aerial footage’ of the accident. No gratitude is expressed to the emergency response team, the pilot or to the seafarers.
18. Discourse: Neither the report nor the presentation brings to the surface the seafarers perspective. There is no recognition of the fallible humans in an accident.

Can this example serve as a ritual of learning?

For learning to take place, you would expect an appreciation of: the social context; space for discussion; an acknowledgement of limitations and assumptions of the investigation process; dissent; engagement; critical thinking; questioning; humility; diversity of perspectives; and sharing of experiences. But in this ritual, we do not see any of that.

What we see instead is formality, belief in objective truth (measuring tapes, log records, and plastic bags to seal the evidence), and an expectation for the crew to conform with rules. The ritual is framed as a monologue of obedience, control and fallibility, and a visual display of damage, destruction and disorder. There is neither dissent nor any attempt to engage with the seafarers’ perspectives (in both the video and the accident report). As the comments in the YouTube video were turned off, the opportunity to engage with the questions, comments and feedback from the community is clearly not considered important. The purpose of this ritual cannot, then, be one of learning and sharing, but instead one of providing comfort and certainty to society in the wake of misfortune.

The makeshift ritual in the bicycle accident was meant to mediate transition when a family was confronted by the sudden death of a young girl. As we observed, the ritual drew support from the community and served as an interim solution for the family to come to terms with a sudden tragedy. By contrast, if we think of accident investigations and ‘lessons learned’ to be seen as rituals of learning, we do not observe the key components of learning in the performance of the ritual. Instead, what we see is a tendency to seek comfort, certainty and order in the ritual by denying fallibility and dissent. We also notice in the ritual of accident investigations a propensity to find someone to blame under the pretext of ‘science’ and ‘scientific methods’.

How is the ritual of accident investigation any different from how our ancestors gave meaning to misfortune? In my view, our ancestors were more aware of the meaning and purpose of their rituals.

This is an edited version of a longer chapter from the book ‘Are we learning from accidents? – A quandary, a question, and a way forward’ first published in the Seaways Journal of The Nautical Institute.