Tag: forensic analysis
Martin & Ottaway has been involved in dozens of capsize failures. Capsizes are strange events because the cause of a capsize can be difficult to determine.
There are clear incidents of negligence with regard to capsizes, but, in our experience, about half of the world's capsizes strike like lightning on a clear day, and are totally unexpected. Then the analysis and cause determination becomes quite complex and often tracks back far in time.
Often there is fingerpointing, but it often loses track of the actual cause of the incident. One such incident that we worked on was the Ethan Allen in 2005.
The vessel capsized in mostly normal operating conditions with passengers aboard and loss of life. The analysis indicated that there were a number of factors at work which, together, interlinked to result in the subject incident and there was a red herring.
Causal analysis is a surprisingly complex process that over the years has been subject to push and pulls from a wide variety of professional influences. When determining the actual cause of an accident or an incident, any number of stake holders would like to address the issue that “caused” the accident, whether to prevent a reoccurrence or, on the other side of the remedial spectrum, to punish the causal party.
In theory, there must be a cause for everything, but, in practice, finding the cause often involves a high level of judgment, and judgment is complicated and often deeply flawed. If judgment were to reside in one professional community, there is a possibility that some type of convergence on the determination of the cause of an incident could be developed. And once the cause is established, we can give that cause a name. It apparently is too simple to simply call it “the cause” of an incident, and that makes sense, since all too often there are multiple causes of an incident. And because there can be multiple causes, different terms for causes have started to emerge.
Ignorance is very pervasive and fighting ignorant behavior can be very exhausting. Jonathan Swift is believed to have said that you cannot reason someone out of something they were not first reasoned into. If that statement is true, and it certainly contains a lot of truth as far as I can see, it means that opinions and judgments need to be based on reasoning before they are made.
It also should not be forgotten that reasoning should be based on correct data. I have previously mentioned Hans Rosling as an example of a clear thinking based on good data and mentioned his excellent TED lectures. (After this blog, if I have the energy, I plan to discuss a TED lecture by Boyan Slat that is nothing short of incredibly awful)
Hans Rosling continues to provide interesting and amusing TED lectures and he deals with devastating ignorance in “How not to be ignorant”. Hans and his son Ola provide some very direct guidance as to how one can make more accurate judgments on world events and developments even with limited data. The lecture is a delight, but, after looking at world trends, the lecture concludes with four very simple guidelines that almost automatically allow any person to make much more accurate world judgments without access to data on the subject.
This story will makes two important points about technical reasoning that in the heat of combat, disasters, disputes, commerce, parenting or politics often get overlooked.
1.If your starting data is flawed, the rest of your argument becomes inherently flawed
2.Just because one thing looks like the other, it does not mean that they are comparable.
The problem is that it is so easy to hide these issues in clever packaging. Only when somebody carefully analyzes the argument and looks at the underlying data, will it become apparent that it is fatally flawed.
The example I will use is a TED lecture by Malcolm Gladwell. Malcolm Gladwell is the author of "Blink, the Power of Thinking without Thinking" and other popular observational works and TED is an organization that organizes symposia where smart people listen to other smart people who discuss unusual discoveries or insights. A TED lecture is about 15 minutes and there are some truly incredibly useful lectures such as the Hans Rosling lectures, but not all TED lectures rise to that level.
So that is the setting; here is the story..... read more »
The actual slogan is “Trenton Makes, the World Takes”, and even in that form it is still a pretty weird slogan. The slogan originated very early in the 20th century when Trenton, NJ just about made anything, and it is supposed to mean: “Trenton makes the stuff that the rest of the world buys”. I suppose at the time there was no budget for that many letters and it didn’t rhyme and therefore the shorter slogan was fitted in neon on the Lower Delaware River Bridge.
Still it was true, not just Trenton, but all of New Jersey was an incredible manufacturing hot bed starting with the country’s first industrial park at Paterson Falls, NJ in 1791. Towns such as Perth Amboy and many others in New Jersey were just as capable, but is New Jersey's manufacturing prowess gone forever?
Accident analysis is a strange and complex task. Often blame is considered to be the motivator for an accident analysis, but the most interesting and useful purpose of an accident analysis is to tease the universally useful gems out of the huge pile of information that tends to get generated during an accident analysis.
I recently read the accident report on the January 2013 grounding of the USS Guardian, a US Navy minesweeper that ran aground and was ultimately lost on a reef that was mislocated on an ECDIS type chart.
The report makes interesting reading, mostly because it is a US Navy version of the work Martin & Ottaway engages in on an almost daily basis. It is interesting to compare the Navy approach to the civilian approach and learn from it. read more »
The weak English translation of the MIT Costa Concordia report made me wonder about the use of English as a more universal communication system. While driving to a project, I was listening to National Public Radio, and there was a bit about Voice of America broadcasts. I never realized that Voice of America programs cannot be broadcast within the United States, since, in essence, they are government propaganda. However, if there is a specific request for VOA information, a recent law change has now made it possible to broadcast VOA segments in the United States.
Oddly, the factual quality of VOA is not bad, and probably much better than some of the commercial networks we all are subjected to. Actually, VOA’s efforts at truth during WWII had a major beneficial impact on the whole scope of the war. Regardless, the most interesting point in the NPR broadcast was their reference to Special English, which may be a path to better communications in international shipping.
Our first blog on "Women and Children First" elicited a fair amount of comment on various discussion sites.
A major part of the discussion centered on the Birkenhead disaster. The Birkenhead disaster is considered to be the first application, or even the invention, of the "Women and Children First" concept.
Mikael Elinder and Oscar Erixson of Uppsala University recently performed an interesting analysis of survival rates in a large number of major ship disasters ranging over a period of over 150 years. They were interested in determining whether the old adage "Woman and Children First" actually occurred in such disasters.
While many of their conclusions are statistically very dubious, their data indicates that women and children survival rates actually are substantially lower than men and crew in major shipping disasters.
The most significant exception is the Titanic where a much higher percentage of women and children did survive. This study was a statistical analysis, and while the numbers do support their findings, each disaster is unique and there may have been factors that would have resulted in lower women and children survival rates even if there was an intent to allow the women and children to enter the life boat first. Some of these disasters may have been so confusing that the order was never heard, others may have developed too quickly for any type of abandonment order to have taken place. And when panic develops, "Woman and Children First" (or any other type of group objective) is simply abandoned in the quest for individual survival.
However, quite possibly, Messrs. Elinder and Erixson's analysis just sheds light read more »