The local TV stations are all up at arms, why did "three officers" (sic) (really one 4th officer and one quartermaster) on the bridge not make a course change. We want heads! Give us blood !
I had a chance to read the report almost fully, hard to do with a crying baby, but it was for the most part a typical TSB report, I found. Good reading of the facts as they are known. Perhaps not juicy enough for some but not to my surprise.
We all knew that you had to be very busy with something you should not be doing while on watch, to make that kind of mistake. It happens, most time they don't result in such catastrophic consequences, but as I learn from reading many of these reports, my own experience and my training such as Engine Room Management (similar to Bridge resource management) rarely does one mistake, or one person hold the absolute responsibility.
I believe BC Ferries has allowed a culture of egos to develop rather than a culture based exclusively on procedures born of sound risk assessments. Because of the experience and stature of some, I believe they have been able to tweak company procedures effectively to their advantage.
Ultimately, it feels like a more humane way to work, but really makes the system dependent on the the style and abilities of the watchkeeper. People are different, some are trained differently (if at all), have experience or confident levels enough to handle certain levels of distraction that other might not. Then there are those other distractions not really measurable, that kick in, expectations, home stress, union grievances over promotions, and the likes, all have impacts, and obviously personal drama which take away the concentration needed for the task at hand.
It is not the first time that BC Ferries has been involved in accidents because of lack of attention, most accidents always boils down to a long series of errors in judgment. No matter how many rules, SMS, ISM procedures you put in, or VDR you installed, it won't really make the fleet safer until they tackle a fundamental attitude within the company.
And they better not rely on government to lead them, as the report illustrated, Transport Canada was unable to clamp down its own mind on the watertight doors as well. That subject is a thread of its own, but I don't think it would have made one iota of difference. But the fact there was wishy washiness regarding the enforcement of the rules regarding watertight doors, points to my previous assumptions that people are not taking a stand on regulations. Regulations and protocol should be made for a reason and not reinterpretated by individuals because of their pleasant, or not so, demeanor at the time.
I have never worked for BC Ferries but in my observations I feel that the personal relation between the company and its employee are not very good, a corporate culture that is lacking some teamwork qualities. Why exactly, I am not sure, but everyone needs to realize they are in the same boat and quit fighting every one. There always will be the usual us versus them vis a vis ships and office, but they really need to put their people first, and the crew (union) must support them, for the benefit of all.
Like I said above, I believe dominant personalities have emerged over the years and have shaped the workplace; but now they are starting to retire and the status quo that has develop for at least the last decade if not two, is in transition, not just at BC Ferries, but throughout the industry. The training and confidence of the younger guys to take over was not invested in, due, I believe, by severe lack of vision.
Now you have people working in situation they may not be comfortable in trying to have a relaxing atmosphere even though they need more structure. But they learned from the senior guys rather than formal training protocols and therefor are unable to "error trap" and voila, you have accidents.
I think we will see many more accident in the coming years until the system changes, and it will over time, unfortunately at a very high price for some.
BTW, I am not sure what the mood was at the press conference, but from what I saw, the TSB people seemed defensive and combative. I though in the past they seemed to hold themselves with better composure, anybody know if this is normal for them?
My two cents.
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