Greed, Fatigue, Complacency and Other “Holes in the Swiss Cheese”

Gordon Graham here! Madame Editor has been very patient with me on this article. I had it prepared several weeks ago, but then I thought of something else to enhance the reading—and then again and then again. Then Mrs. G and I went out in the Pacific on our boat to watch the Pacific Airshow from the water and my head was swimming (note the clever play on words) as I watched a lot of very stupid people avoid serious injury or death only because “all the holes in the Swiss cheese did not line up.” So here are some more thoughts on maritime disasters.

In my last article, I wrapped up with a promise that my next article would include a summary of the NTSB investigation of the fatal wreck of the Taki-Tooo. First, a quick word about the work of the National Transportation Safety Board. When there is any major event involving transportation—plane crash, ship sinking, pipeline rupture (yes, they are transporting fluids)—the NTSB does an INVESTIGATION.

If you have been to any of my live programs over the decades, I am critical of many of the “after action reports” prepared by public safety agencies when they are involved in some tragedy. While a few are excellent, most are not really investigations but rather reports that focus on “proximate cause” vs. the real “problems lying in wait” that led to the tragedy. I have a feeling too many are written at the direction of lawyers who are trying to protect the involved organization from a lawsuit. We do not learn the lessons that should be learned from past tragedies in our profession.

We cannot rely on luck—we must rely on proven systems to prevent tragedies from occurring.

There are very, very few (if any) Black Swans (unknown unknowns) in the world of police work. Most of our tragedies are “Gray Rhinos” (massive beasts running right at us and we can see them coming)—yet we refuse to get out of the way. I am currently working on a massive project with a working title of “Your Black Swan is someone else’s Gray Rhino.” Just because it has not happened in your agency does not mean it has not happened in our profession—yet we are not learning. Part of my goal in this project is improving the quality of investigations when we have a line-of-duty death or a death of a person caused by public safety personnel.

But back to the closing comments in my last writing. Here is a summary of the final NTSB report on Taki-Tooo.

On June 14, 2003, the small passenger vessel Taki-Tooo, a U.S. charter fishing vessel with 2 crewmen and 17 passengers on board, was enroute from the marina at Garibaldi, Oregon, to the Pacific Ocean for a day of fishing. A small craft advisory was in effect for the northern Oregon and southern Washington coasts, and personnel at U.S. Coast Guard Station Tillamook Bay had activated the rough bar warning signs based on their assessments of existing hazardous conditions. At the Tillamook Bay inlet, the Taki-Tooo operator waited in the channel for an opening in the ocean swells so that he could cross the bar. After the Taki-Tooo exited the inlet and turned northward around the north jetty, a wave struck and capsized the vessel. As a result of this accident, the master and 10 passengers died; the deckhand and 7 passengers sustained minor injuries….

The National Transportation Safety Board determines that the probable cause of the capsizing of the Taki-Tooo was the decision of the master to attempt to cross Tillamook Bay bar despite the hazardous sea state that existed at the time. Contributing to the severity of the accident was the failure of the Taki-Tooo master to ensure that he, the deckhand, and the passengers donned lifejackets before crossing the bar. Also contributing to the severity of the accident was the failure of the U.S. Coast Guard to enforce the regulatory requirement at 46 Code of Federal Regulations 185.508, which stipulates that vessel masters shall require passengers to wear lifejackets when transiting a hazardous bar.” (NTSB. MAR. Capsizing of U.S. Small Passenger Vessel Taki-TOOO, Tillamook Bay Inlet, Oregon, June 14, 2003. 2005, p. vi.)

A full read of the final report—or the summary you can read in the various newspapers that covered this tragedy—is valuable for every boater. But the point of this article is that the story of the Taki-Tooo can be of value to everyone one in public safety, too. Of particular note was the failure by most of the people on this boat to wear personal flotation devices (PFDs). How many cops have died because of a failure to wear seatbelts, protective vests and high-visibility vests while out of their vehicle on or near a roadway? How may firefighters have died because of a failure to wear personal protective equipment while fighting fires and during post-fire salvage operations?

The story of the Taki-Tooo can be of value to everyone one in public safety, too.

A full read of this final report (and the news articles) will show you “the money factor” involved. The captain did not want to turn around and return to dock because of the payments he had already received from the people on this charter—money he did not want to return. How many big-rig tragedies involve sole operators trying to make ends meet?

In future articles I plan on covering vehicle tragedies but let me give you a primer on that issue. In upstate New York in 2018 there was a massive tragedy (20 deaths ) involving a limousine. I have not looked at the NTSB report on this event in a while, but my recollection is there were many “problems lying in wait” with respect to the involved vehicle, the driver and the company. A lot of people knew about these problems—and yet they failed to act. My guess is there was a “money factor” involved in this tragedy also.

In my last article I talked about the “Titanic of the Mississippi”—the Sultana. If you want to read a quick piece on this, you can go to Wikipedia; the article prepared there is accurate. What will you learn is that the Sultana was designed to carry 376 passengers, but the captain decided to load it up with over 2,100 passengers—again “the money factor” is at play. And again there is a lesson for public safety: Many personnel are heavily dependent on overtime to make ends meet; they will work every available overtime shift for the money. They are grossly fatigued most of the time – and their fatigue likely plays a prominent role in many situations that end up in tragedy.

Also in my last article, I made reference to the USS Fitzgerald tragedy in 2017 southwest of Tokyo, where seven U.S. Sailors died. What should be learned from this final report? There was a lack of knowledge by those driving the ship regarding rules of navigation. Again, many people knew about this, but no one did anything about it. There was a close call shortly before the fatal collision that was not properly reported, crew members refused to talk to each other because of bad interpersonal relationships, many pieces of electronic equipment were not functioning correctly—and again fatigue is part of this story.

Last year, the New York Times published a detailed account of the Joola maritime tragedy along the coast of Senegal in 2002. A passenger ferry with over 1,900 people on board hit a predicted storm, the ferry capsized and only 64 people survived. As you have probably guessed, the Joola was overloaded; it was designed to carry 580 people. Of note were the actions of the Sengalese military prior to the tragedy. They ran the ferry operations, and they had tied the boat’s life jackets together so they could not be taken by “skittish passengers” who would grab them over “small incidents.” The life jackets were found during the recovery portion of the tragedy—still tied together 39 feet under the water.

This brings my thinking up to the other day, when Mrs. G and I sat off the coast of Huntington Beach watching the Airshow with literally hundreds of other boats. Many were overloaded. We observed lots of drinking, loud music, small kids swimming without parents paying attention, boat propellers spinning near swimmers, speeding jet skis and lots of distracted boaters looking at the planes above. Somehow no one got killed. The lesson for all of us: Just because things end up without tragedy does not mean we do not have problems lying in wait. We cannot rely on luck—we must rely on proven systems to prevent tragedies from occurring.

In my next article I want to move to aviation tragedies. If you want to get a jumpstart, pick up the great book Darker Shades of Blue by Dr. Tony Kern. He is the go-to guy on aviation safety—and you will find the book fascinating.

Until then, thanks for your work, please be safe—and try to learn from past tragedies. The errors you are going to make can be predicted from the errors already made.

Gordon Graham

GORDON GRAHAM is a 33-year veteran of law enforcement and the co-founder of Lexipol, where he serves on the current board of directors. Graham is a risk management expert and a practicing attorney who has presented a commonsense risk management approach to hundreds of thousands of public safety professionals around the world. Graham holds a master’s degree in Safety and Systems Management from University of Southern California and a Juris Doctorate from Western State University.

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