In this article, I will share some thoughts on the Wakashio accident investigation report, a bulk carrier that ran aground in July 2020 off the coast of Mauritius. 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 19:17 when the vessel was proceeding at a constant speed of 9 knots the Master was heard saying “We are very, very close to land. Just one and a half mile” and still it never occurred to anyone on the bridge that the vessel was going aground within the next 10 minutes at 19:27. There was neither any action undertaken by Chief Officer nor orders from the Master to change direction while the vessel was at a distance of 1.5 nm from the coast at 19:23 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 seafarers are combined with a 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 the description of an accident and more like an investigation team that is so far distanced from the reality of global shipping. On two occasions the report reads “we should not lose sight of the fact that …” . But after reading through the report, it appears like the investigation team has lost the sight and the plot of a plausible accident narrative.
I am questioning the underlying methodology of this accident. In so doing, I am keen to share with you the key issues that have been conveniently brushed aside by this methodology.
Let’s get started.
Swiss Cheese Political Analysis (SCPA): the underlying methodology
This is an ideal example of the Swiss Cheese Political Analysis. It is a deliberate selection of Cheese slices and holes in those slices in an attempt to preserve the status quo. The SCPA methodology resists change at all costs.
It is a political analysis. Political because only those slices that are centred on the seafarers’ behaviour are chosen and exclusively those holes that can be used to dehumanise those at the sharp end are amplified by the authorities. And once the slices and 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 owners or the operators of the ship. As always, a balanced view of the accident is missing.
The three main themes of my review:
- The missing context
- The absurdity of absolute goals
- The unrealistic nature of risk controls
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 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 incinerators. 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, these 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 traumatised 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 work 24/7 onboard these 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’ behaviour, and the most dominant influencing factor that shapes their behaviour is silenced in the 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 during the last crew change on 1 March 2020 at Kawasaki, Japan had already completed their tour of duty, and due to 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 changes in foreign ports, low morale, a depressing atmosphere onboard, social isolation, hopelessness, and a suicide that has occurred onboard on 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 contracts 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 go 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.’
Who gets to decide between compelling desires and the essential duties of these precarious labourers?
Of course, the investigation team that has 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.
The absurdity of absolute goals
All absolute (SMART) goals are known to create their own risks. In this case, we should be asking what new risks are being created by introducing Zero 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 Zero Alcohol policy:
- The implementation of Zero Alcohol policy usually rests with the senior management on the ship (captain and 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 onboard? Is there not a conflict of interest?
- It is the senior most officers on the ship who are responsible for implementing Zero 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 mind will question their authority on the ship?
- It is then up to these senior officers (captain and chief engineers) to decide who will get access to unauthorised alcohol on the ship.
- The availability of unauthorised alcohol to the seafarers at lower rank will be at the discretion of their bosses. You learn very quickly not to upset your bosses or else. All this amplifies pre-existing hierarchies.
- Scarcity and uneven distribution of alcohol will invariably create subcultures, jealousy and wrath amongst subcultures and a lack of trust between ranks even with a complement of 12-15 persons on the same ship.
- Why should I trust you when you are enjoying alcohol every evening and I am drinking orange juice or instant 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 finds its way into critical operations on the bride, deck and engine room. Why should I share my concerns with you? There goes the facade of psychological safety out of the window. The very notion of zero alcohol policy to conduct safe operations fall flat on its face.
- On a sidetone, little is understood about how drug 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 ships should or should not navigate in close proximity of navigation 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 quote 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 quote, 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 in investigations and not during audits and inspections? And what are we really checking during audits and inspections?
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 Wakashio accident
Everything that you need to know as a reader is available on page 7 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 from the outset.
The Wakashio investigation report serves to demonstrate how not to conduct accident investigations.
The ritual of accident investigation
I have always maintained that accident investigations are not conducted for the purpose of learning and preventing the accidents. Instead, the ritual of accident investigation is performed to preserve political and social order.
