A look at how faulty thinking can bring on disaster
The skipper’s dream ketch arrived from Taiwan, 40 feet of fresh and sparkling beauty. He was going to take his family out for the first sail with dreams of world cruising to follow. On a clear morning they sailed north from California’s Marina del Rey towards the Santa Monica pier. Basic commissioning had been completed, but who could wait for the details on such a fine day. A celebration dinner had been reserved at a marina restaurant when they would return that afternoon.
The fog rolled in when they reached the pier and a medium swell was running. One of the children felt seasick and wanted to go home. The depth sounder was not hooked up; the compass had not been corrected, etc. The skipper plotted a compass course from the pier to the marina north jetty. They started back to the south in poor visibility. He ran aground 100 yards from the entrance.
We heard the radio squawk “MAYDAY.” We raced to a car and sped to the beach. The ketch was rolling in the swell, grounded by the bow and starting to swing broadside. The portholes and hatches were all open and the family was jumping off the bowsprit into the surf. The skipper was frantically trying to unbolt the radio.
“Get a line out to one of the boats farther out!” “Drop the dinghy, we’ll row out an anchor!” “Close your hatches and portholes!” To each piece of advice the panicked man shouted, “I’ve got to get this radio free!”
Finally he clambered down clutching the radio and splashed ashore. The boat was now beam to, taking water and sand in through the open hatches.
Two days later we watched as a bulldozer hooked up to cable that had been passed around the boat and padded at the stern. As the bulldozer took the strain, the cable cut right through the stern all the way to the main mast. The end of a dream.
Only a few months later, I was soloing south from San Diego off the Mexican coast on a clear moonless night. The lovely Herreshoff 28 ketch was my first boat of any size, and she glided along to a light breeze. Surmising that wind would be better farther offshore I tacked and headed out. Approaching from the south was a melange of lights. Quick reference to Chapman Piloting identified a tug towing a barge more than 600 feet astern. But weren’t there a few extra lights scattered around? No matter. Lots of time to cross the path of the oncoming tug.
No sooner had I cleared the course of the first tug, when to my complete and utter horror saw a second tug to seaward of the first, undeniably hooked up to the same enormous barge by its own cable, as a breasted tow. We were caught right in the jaws of a deadly V and were going to be run down with no chance to clear the seaward tug.
I crash gybed and reached for the starter switch of the balky Atomic Four gasoline engine. It started immediately as we spun to starboard right in front of the onrushing first tug. We were lifted by the bow wave, shouldered aside, and saved as the tug rushed past entirely unaware.
Even after 40 years these incidents illuminate the causes of bad judgment and accidents at sea. There is an enormous literature of the theory of accident causation. There is an even greater literature about the psychology of human decision making. This information, however, has largely eluded the recreational mariner and boating literature.
There is a legitimate objection to using the word “accident,” something that occurs unexpectedly or unintentionally, because it implies an event over which there is little or no control. Professional investigators use the word “incident,” an occurrence or event that interrupts normal procedure or precipitates a crisis. However common usage makes it impossible to avoid “accident.”
The father of accident causation theory, H.W. Heinrich, estimated that 88 percent of all accidents were caused by unsafe acts, 10 percent by unsafe conditions, and only 2 percent by unavoidable “acts of God.” His 1928 paper “The Origin of Accidents” suggested that negative events rarely stem from a single decision. Rather an incident begins with a person’s social environment and habits. These predispose a method of thinking that gives rise to bad judgment that interacts with a physical hazard. This was known as the domino effect. It is widely used in the investigation of airplane accidents.
In the 1970s, a Canadian commission investigated accidents in the uranium mining industry. They added a concept that negative outcomes begin in the very culture of the organization involved, whether uranium mine, the U.S. Navy, or the owner of a single boat. Amongst many other constructs, we should mention the Swiss cheese theory. Picture five or six slices of Swiss cheese standing on their side with a gap between each piece. The holes represent various weaknesses in the particular element of a system. So the first piece might be the personality of the skipper; the second, his physical condition on that day; the third, social pressures; the fourth, equipment on the boat; the fifth, environmental conditions; the sixth, some precipitating event. These weaknesses are inherent in the system whether structural or temporary. A skipper may have an impatient temperament, but the day will not always be foggy. The crew might be uncomfortable, or a piece of gear could break down. However, a negative event or outcome only occurs when all of the weaknesses align. Picture a rod being passed from the holes in the first slice and traversing holes in all of the slices to emerge through the final piece of cheese, representing occurrence of an accident. Our task is to shrink the sizes of those Swiss cheese holes.
To these accident theories we can add a concept from psychology, heuristic thinking, and the trap it sets. Every medical student learns, “When you hear hoof beats in the barn, think of horses, not zebras.” This epitomizes heuristic thinking, learning from experience and categorizing inputs into specific boxes or pigeonholes. This is a necessity for human functioning. We are bombarded by so much information, that we have to have a method for dealing with it in order to navigate daily life.
By the time medical students become residents, they learn, “Rare things are rare, but there are enough rare things that rarities are common.” The emergency room may see 10 cases of fever an hour from the flu epidemic, so the doctor is wired to think, “Little kid, his sister has the flu, listless, fever, therefore he has the flu.” But the eleventh patient through the door could have meningitis. Anyone in a position of making critical judgment MUST take into account his or her hard-wired tendency to making decisions based on heuristic thinking.
That night off the Mexican coast, my perception of the lights was reinforced by looking at a book, comparing it to what was in front of me, and ignoring faint glimmers that didn’t fit into the pattern that I expected. I saw what I wanted to see.
Every vessel would benefit from having written emergency management plans. Every guest aboard needs a safety briefing. Involvement in the process creates the culture that will make us safer. The acronym KASA stands for the four elements of seamanship: knowledge, attitude, skills and awareness. Knowledge of the causes of negative incidents; an Attitude toward a culture of safety aboard; the Skills of analyzing a chain of events underway, and Awareness of our thought processes will make us safer at sea.
Joshua J. Tofield, MD, FACS, is an experienced Pacific voyager.