By Ryan Skinner (email)
I stumbled across a curious statement in a report last week. It appeared in a report commissioned by the Norwegian Ministry of Justice and the Police after a fast-ferry accident in 1999, in which 16 people died.
Among the report’s leading conclusions was
a critique of placement of the reserve batteries in the ship (an interim power
source that kicks in if power is lost, and before an emergency aggregate can
kick in). The ferry’s specifications, and drawings, positioned the batteries
above the water-line in the event of an accident, as required by law. In
reality, the batteries were put far lower than that (below the water-line),
thus providing less power, slower, than should have been the case during the
accident.
The commission investigating the accident states that there is reason to criticize the shipyard for this error, naturally. But here’s the curious bit...
The report goes on to say “it must also
be said that neither the Sjøfartdirektoratet (Norwegian Maritime Directorate), the
Norwegian product and electricity review board nor DNV (the classification
company) discovered the error during their inspections.”
That, if you ask me, is more worrisome.
That a welder at a shipyard either misreads, or doesn’t read, a plan and his
supervisor misses it, or simply oversees it, is one thing. That a professional
inspector trained to look for faults misses it, that is something else
entirely. That three inspectors miss it, that begins to look criminal.
Fact is, there were numerous other faults
with the ship – faults by the shipyard, by the operators, by the officers, by
the inspectors, by just about everyone. Further, if you look at practically any
ship casualty report, you will find a laundry list of breaches.
Scary? It depends on how you look at it. It’s
satisfying to think that disasters have had causes. “Of course everything went
wrong. Something was the matter with the ship.” But correlation is not causation. Or, rather,
that something was the matter with the ship did not make it ill-starred. In
most accident investigations, the primary cause cited is – surprise! – human error.
Problems with the ship only exacerbate the disaster.
Rather than seeing an accident as the case
of a defective vessel, it might be more appropriate to see all of the vessels
as full to (almost) overflowing and the accident – a spill, for example – as merely
the result of bumping one of them. By the profusion of rules and regulations
designed to failsafe merchant shipping, every ship is in breach of the law. Not
surprisingly, efforts are underway to failsafe the ships’ officers as well, with
the effect of making them transgressors too.
A comparison to modern psychiatry is apt
here. Critics of psychiatry argue that the field pathologizes everyone; in
essence, your personality is a treatable malady. Result: Quirks become the
focus of study, and the big picture of real, but fuzzy, emotional needs is
neglected.
Modern industrial regulation and
rules-making pathologizes every business, or plant. Result: businesses and
plants (or vessels) become rule-chasing organisations, while the point of the
matter is lost.
If I had to surmise a cause for all of this,
it would be the dissolution of ownership. When owners give way to managers,
business becomes a question of the appearance of the thing, and not the thing
itself.
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