Looking for commonalities to prevent future occurrences. Consider this fictional scenario: On a clear Tuesday evening, an outbound small coastal freight ship collides with an inbound offshore supply vessel while navigating a bend in a waterway, causing moderate damage to both vessels. On a Tuesday two weeks later, an uninspected towing vessel pushing 12 loaded barges collides with a small passenger vessel in the same general location. Both vessels sustain damage. While each incident may seem different at first, upon closer examination we can identify several commonalities. By studying the particulars of incidents within a given area, we can detect similarities such as the time of day, time of year, tidal cycles, vessel types, weather conditions, type of operations, or other factors. Such analysis may show a pattern of factors that could help predict future events, and investigators can proactively implement efforts to curb, control, eliminate, or publicize such contributing factors.
What Are Marine Casualties, and Why Do They Happen? The term “marine casualty” is defined in Title 46 Code of Federal Regulations (CFR) Part 4 as an incident that involves a vessel and includes, among other things:
- Loss of life, injury, or any fall overboard
- Vessel occurrences that result in a grounding, stranding, foundering, flooding, collision, or allision
- Explosions or fres on vessels, reduction or loss of power, or impairments to a vessel’s operation
- Circumstances that affect a vessel’s seaworthiness or incidents that cause significant harm to the environment.
In the simplest terms, marine casualties are accidents, and accidents occur when an undesirable or unfortunate event occurs unintentionally, often resulting in injury, loss, or damage. The captains of the vessels in the scenarios mentioned didn’t plan on colliding, but unexpected events happen every day.
In “Breakfast Club” terms: “Screws fall out all the time — the world’s an imperfect place.” 1 When those screws do fall out, people make mistakes, the weather adversely impacts mariners, or sea conditions unexpectedly change, marine casualties can —and do — occur.
Commonalities or Trends
After studying incident particulars, the next step is to evaluate the events or decisions that led to the accident. An investigator can create an event timeline and identify links between incidents. If there are commonalities between separate incidents, then steps to correct or avert the commonalities
may prevent future incidents.
The two fictional marine casualties mentioned were collisions occurring in the same area of a waterway on the same day of the week. While looking into such incidents, an investigator might identify other interconnecting factors. For example, strong currents could have adversely affected one or more of the involved vessels, the crew might not have made radio calls between the vessels to arrange passing agreements, or fog might have been present. Any number of similarities might become evident during investigations.
Just the Facts
The key in looking for commonalities is to seek events that led to the marine casualty that also occurred on vessels in similar situations. For example, the investigations of our fictional collisions might find that crews of both outbound vessels misinterpreted a radar contact or were unfamiliar with river current patterns in that stretch of the waterway. Such issues would be of note as commonalities between the incidents. The investigator could produce an exhaustive list of similarities linking incidents to each other, but often the most simple interconnecting criteria proves noteworthy. In the first few moments of an incident briefing, start with the basic information passed, then advance to those facets of the investigation that require more probing. Vessels under comparable conditions may exhibit common characteristics that lead to marine casualties. These are the types of occurrences that should lead to trend analysis endeavors, when they’re found to take place with some frequency.
Dr. James Dobbins was an engineering professor at Vanderbilt University when he conducted research analyzing marine casualties. Specifically, his team sought to identify clusters of marine casualties in an effort to pinpoint and chart the most hazardous locations on U.S. waterways. 2 Using information from U.S. Coast Guard databases stretching back as far as 1980, his study identified areas where the historical records were deficient. Dr. Dobbins advised that 60 percent of marine casualty cases used for the study had no property damage amount figures, or they contained a zero in the corresponding data bank. Though this information must be reported to investigators, it was not always available in the public data extracts his studies utilized.
The team also noted problems with incident location information. Dr. Dobbins stated, “It was hoped that the coordinate data would be precise enough to identify a bridge pier or lock wall as commonly involved in allusions, as an example. Ostensibly from manual typos, several coordinates were transposed or incorrect.” 3 Due to some instances of poor data, casualties more than three miles from any waterway were discarded. Dr. Dobbins further noted, “In recent years location accuracy has significantly improved in U.S. Coast Guard marine casualty fles.” 4 With an eye toward continuous improvement, Coast Guard personnel have developed new information quality guidelines, policies, and job aids and stressed the need for improved data entry during marine casualty investigator training at U.S. Coast Guard Training Center Yorktown. Moving Forward It’s impossible to engineer a system that will prevent all marine casualties. As defined, marine casualties are accidents — and accidents happen every day. But through conducting simple trend analysis studies and seeking to identify and eliminate hazardous conditions that lead to marine casualties, we can realize a significant decrease in accidents.
Acknowledgement: Special thanks to Mr. Paul Ledoux, senior investigating officer, Sector Hampton Roads, for his assistance.
About the author: CDR Blake Welborn is a 1993 graduate of the Coast Guard Officer Candidate School. A career prevention officer, his service includes command cadre positions at marine safety units and training tours in vessel inspections, casualty investigations, and incident response management. CDR Welborn holds a master’s degree in quality systems management.
Endnotes: 1. John Bender (performed by Judd Nelson), “The Breakfast Club,” Universal Pictures, 1985. 2. Dr. James Dobbins, personal communication, Mar. 16, 2015.
by CDR BLaKe WeLBoRn Detachment Supervisor U.S. Coast Guard Investigations National Center of Expertise
Proceedings Winter 2016-2016 – Proceedings is published quarterly in the interest of safety at sea under the auspices of the Marine Safety & Security Council.