Wednesday, December 02, 2015

Vessel agrouding incident at Elephanta Island

      Recently a 300mtr container vessel being piloted inward by JNPT pilot had run aground at the south west corner of Elephanta Island.
    As a consequence of this incident the port management has decided to reduce the tonnage of the Pilot involved in it.
     Whereas the defendant pilot maintained that the leading cause of the incident was incessant working of 22hours in the 24hour watch schedule, during which he had piloted 8  large size vessels in and out, the port management apparently has chosen the pick fault in complacency of the pilot.
     These material facts in the aftermath of this incident are causing concerns to me about non-conformity to the principles of natural justice during an investigation and employing an irrational root cause analysis technique.
      I have growing feeling that port managements have not yet geared themselves to take the fatigue factor in  vessel piloting job with as much seriousness as is the prevailing industrial standards.
   In this case, since fatigue was also an accused causation of the incident, then the port management itself becomes a suspect for abetting the incident and therefore not an appropriate authroity to be trusted away a fair investigation. I wonder how, within the principles of Natural Justice, they should be allowed to be a judge of their own accused misdoings.
       But the agony in this case is that not only did the matter settle through an in-house investigation, they have even proceeded to impose a "corrective action" of reducing the tonnage licence of the unfortunate pilot which will bear long term adverse impacts on his career.
    It has often been said that during an incident investigation, the companies (the port management in our case) often adopt wrong set of questionnaire and reach to certain root causes which stand to deny any share of blame on themselves. Accident investigations are conducted with untrained and unscientific principles and often times the layman-spoken accident causes are arrived at in conclusion which have no positive way of resolving out in preventive terms, but only by of imposing a punishment on certain human being as a deterrent and corrective measure. Two of the such very commonly  and abusively defined root causes are Complacency and Over-confidence.
    It must be realised that there are no scientifically defined method of  measuring out if a person was suffering from any such thing as Complacency. One needs to question himself as to who should be burdened to eradicate the human weakness of Complacency, or rather if Complacency should be seen as a problem at all? Many people have expressed difficulty to differ between Complacency and Satisfaction and they question if complacency is a bad behavior at all. In accident investigation theories, the state of complacency is understood to be that stage of learning where a driver has reached of fulfillment where his driving actions are involuntarily controlled by his habits than by active portions of the mind. The learning is now supposedly gone into his muscle memory such as to free his brain of much of the active participation.
   Therefore, Complacency is understood as a natural human tendency much in the same way as we know what Drudgery is to office clerical jobs. Can the solutions be searched in punitive measures? This would be same as demanding a work-horse not to feel hungry or not to feel tired BUT not by way of feeding him food, or by providing him rest; instead, by feeding him a warning that since hunger causes distraction, and tiredness accidents hence he should not let his mind and body be subjected to these ills !
  Which sensible person should agree to this viewpoint and a way of resolving problems which originate from natural human behaviour limitations ?
  Problems which arise due to tiredness cannot be resolved by warning a horse not to get tired (as tiredness causes accidents) and then on a black day, proceeding onto punishing the horse for getting tired.
    Complacency therefore is a human limitation and therefore a challenge to the management to be resolved; it is not a human sin, to be corrected by way of punishment and setting a deterring example. But the unfortunate story is that ordinarily it gets viewed as personal weakness and then the individual gets targeted.
     Many of the thinkers and the academicians working in casualty investigation field suggest that the better and more humane solutions to the challenge of Complacency are by creating positive habits in the people. Thus, often times operational rules are created, such a drawing a line where any person having overstepped the line is said to have acquired wrong habit and put for a habit correction. This is a stage of preventive measure which is put in place much earlier than when accidents happen. 'Safe work practices' is a detailed set of those habits which are meant to overcome the challenges which Complacency may create. It should be noted that Safe Work Practise is not aimed to eradicate the Complacency itself, but only to avoid the possibility of accidents which Complacency can lead a human being into.
    A famous shipboard, computer based training company for seafarers, Videotel Inc , has actively advocated the above view on Complacency. It proceeds to train the sea farers of Behavior-based safety, therefore.
   Over-confidence, too, cannot have a retributive solution. Over confidence is sought to be resolved by way of filling up worksheets of Risk Assessment, whereby a person may pause up and think within himself the probability and the consequences of the risky job he is about to undertake.
     Unfortunately, the sea piloting group is far removed from these widely taught views and works rather arbitrarily to solve those causes which it has chosen at its whims to call as a problem.
     Elephanta Island is a world renowned tourism destination and it is sheer good luck this time that the incident of agrounding did not blow into an accident by having a follow through of devastating impacts.
   I hold it that rest-deprivation was the leading cause of the incident. But the unfair investigation principles seem to arrive at some other conclusion and the follow-up corrective action is more worrisome.