I bet you have too much chain onboard. Boats can have anchor chain, chain for pennants and stoppers, chain for bridles and chain for a good catenary when you’ve got a long tow on the wire.
But there is one chain that every boat has onboard. That’s the error chain. Each link in the error chain is an event that contributes to an accident. They can be called contributing factors. An investigation after the accident will find them. The error chain can be just a single link where just one mistake can end in disaster or it can be many links where things all have to line up perfectly for the accident to happen.
You may have heard the old saying “For the want of a nail the shoe was lost.” Then the horse and the rider were lost. Finally the battle was lost. The loss of the nail, shoe, horse, and rider all had to line up for the battle to be lost. A break in any one of those links might have prevented losing the war. For mariners, losing the war means causing an accident.
The longer the error chain, the better and safer a boat becomes. As links evolve, error chains get more complex and longer. Thus, the probability of an accident goes down. Also think of each link as an opportunity to catch an accident before it happens by breaking that deadly chain of events. Those are called safeguards. That’s if you know what you’re doing and are paying attention.
Accidents are usually caused by human error with sometimes more than one mistake. Mechanical failures can cause accidents. A combination of both is another good way to have a wreck. Rarely are there acts of God where a lightning bolt from the heavens strikes.
Let’s take a look at some of the links in the error chain locker. None of these should be new to you.
• Lack or loss of situational awareness.
• Distractions. Remember the deadly cellphone distraction when the tug in Philadelphia ran over a tour boat killing two people?
• Bad communications.
• Improper lookout. Rule 5. This goes to situational awareness as most of what I’ve listed affects. Look out the windows and at the scope. I wrote a blog on that.
• Not knowing, understanding, or violating procedures and standards such as those in your Safety Management System.
• “Winging it” which is the same as making it up as you go along.
• Poor teamwork. Teamwork is necessary for checks and balances. Back up each other. That includes proper supervision.
• Fatigue.
• Over tasking.
• Bad attitudes like complacency, impulsiveness, excessive risk taking (“can’t happen to me”) and professional arrogance. Remember the Costa Concordia cruise ship accident caused by the master’s “bad attitude”?
• Not knowing what you’re doing because of lack of training, drills, and/or experience.
• Bad equipment maintenance and repair. Bad QA. Jury rigs are an accident lurking.
• Insufficient or missing equipment.
• Compliance violations.
We hear about near misses and if you’ve been around awhile you’ve had one or two. Look at the error chain that got you to that near miss, especially the last link that prevented the accident. Learn from it. Better yet, look at the possible error chain before you are over a barrel. Review it with your crew.
Turning a near miss into a hit or having the same accident again is an extra bad day.
As they say, “Sometimes you just can’t fix stupid.” Abide the error chain and you might not join that club.
Sail safe.
