Blame & Shame. Letter to Lloyd’s List, Steve Pelecanos

September 7th, 2008 by JCB
Posted in Articles, Incidents & Investigations, Letters | No Comments »

Blame and shame is really just a wasted opportunity

By pure coincidence, at the same time as Dave Williamson wrote his thought provoking article (Pilots under siege?) a letter appeared in Lloyd’s List  written by IMPA Vice President and head of standards and training at the Australian Marine Pilots Association (AMPA), Steve Pelecanos which serves to underline the issues currently being debated by the UKMPA

Cosco Busan Pilot error or pilot support system failure?                  Photo KCBS website

THE United States of America is looked up to by many nations of the world as the epitome of democratic maturity — a nation that embodies the zenith of human evolution. A nation founded on the great ideals of Liberty, Equality and Fraternity and the pursuit of happiness is, after all, where any human being should expect to live and thrive in an environment where fairness permeates all facets of life. This is the stuff of leadership; an aspiration for many.

In the maritime context also, the US has had a great and proud history and has provided the world with leaders such as Nathaniel Bowditch, Thomas Sumner, Matthew Maury and writers of the calibre of Herman Melville and Henry Dana. More recently, Dominic Calicchio won international renown for his investigative work following the sinking of the Marine Electric.

However, on the morning of November 7, 2007, the reputation and image of a great maritime nation collapsed when the world witnessed the knee-jerk response of a bureaucracy to the collision between the MV Cosco Busan and San Francisco’s Bay Bridge.

The process initiated on that morning seemed focused on finding, not the root cause of the accident, but rather, a scapegoat — an individual upon whom to pin the blame; a process that seemed more guided by the philosophy, “if we remove the individual, we remove the problem”, rather than a philosophy of “what lessons can we learn to prevent this type of accident reoccurring?”.

The substantial body of evidence derived from research into accident causation reveals, quite clearly, that individuals are seldom the cause of accidents.

Most organisational accidents occur because proper defences are not put in place to prevent them.

In this, the role of management and the regulator cannot be overlooked and when they fail in their duty, it is normally the hapless individual at the coalface who they’ll pursue to blame and hang out to dry. They will rarely point the finger at their own failure.

And so it was for the pilot on the bridge of the Cosco Busan. Compare what happened to him with what happened to the pilot on the Zim Mexico.

Both accidents occurred in the same country, but the responses could not have been more different. In the former case, the crew of the Cosco Busan were granted total immunity from prosecution to help build the case against the pilot; in the case of the Zim Mexico the pilot carried on working and the ship’s master was arrested. Whatever happened to the presumption of innocence?

In the case of the Cosco Busan, the press has made a meal of the pilot’s medical and pilotage history but has left those who need to be questioned off the hook. Is the press informing the public or protecting the bureaucracy?

Pilotage is a very old profession and the law of pilotage is well established. The pilot is engaged as an adviser to the master. When a pilot arrives on the bridge of the ship, the words “vessel to master’s orders on pilot’s advice” are entered into the ship’s log book. In other words, the master is still responsible for his ship and the presence of the pilot does not relieve him of that responsibility. In San Francisco, the Harbours and Navigation Code expressly reinforces this principle of pilotage law. So why then, was the ship’s crew granted immunity?

In very general terms, the relationship between the ship’s master and the pilot is based on a sharing of knowledge — the pilot has local knowledge of his port’s geography and regulations and the master has knowledge of his ship and its equipment.

From what we read, the event that immediately preceded the accident was a misinterpretation of the information given by the ship’s electronic charts. The pilot relied on the master’s knowledge of the ship’s equipment. Prima facie, it appears that the master provided the pilot with the wrong information and it was this information upon which the pilot made a decision.

But this leads to even more questions. If the master could not provide the pilot with accurate information about the ship’s equipment, had the shipowner ensured, as required by international convention, that the master was properly trained in the use of the equipment?

These questions have not been asked. Nor has anyone asked why, if the pilot’s medical history was of concern, did he still hold a licence? And what standard operating procedures did the Pilot Association have in place regarding pilotage of vessels in fog? Were these procedures robust enough to deal with the circumstances? What measures of oversight did the regulator employ to ensure the Pilot Association had an effective safety management system in place? What measures of oversight did the Pilot Association employ to ensure its pilots adhered to its safety management system?

The old profession of pilotage has been undergoing significant change in recent years. As in all highly operational environments, safety in pilotage is systems based and all of those involved in the regulation, management and execution of pilotage safety sharing a responsibility to ensure the systems are robust and have the rigour to withstand the highest scrutiny.

It is so easy, and so wrong, to blame an individual for an accident of this kind. A proper accident investigation needs to delve deeply to find the root cause. It is only when we understand the root cause of accidents and take measures to address them that we move forward in creating a safer society for the human race. This is something that should be clearly understood and practiced by great democracies.

The way the case of the Cosco Busan is being prosecuted is a throwback to yesteryear where all the benefits that could flow from a modern investigation have been sacrificed in a spirit of vengeance. Blame and shame might provide momentary satisfaction for those with a warped sense of justice but, at the end of the day, it is simply a wasted opportunity.

Captain S. Pelecanos

Brisbane pilot and President, Australian Marine Pilots’ Association (AMPA), vice President IMPA