Wavelength #34

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Volume 4, Issue 34, July 2009

avelength The CENTROFIN Newsletter

Building “Error Tolerance” Into Maritime Industry By Captain Timothy Crowch (Reproduced with Author's kind permission) www.assm.biz

1. Introduction Increasingly over recent years, a growing number of organisations, particularly those operating within complex industries, have been turning toward civil aviation for assistance in establishing modern, effective safety strategies. The reason for this is well known, namely, that since the early 1960s, the world of commercial aviation has invested heavily in safety management and associated training programmes and is proud to admit that the results are now testimony to the return on that investment. However, it was not always this way and we have had our share of "wrong turnings" and failures along the way. The main benefit, though, from these negative experiences is that we have learned from our past mistakes and turned them into positive success stories. In our world, the 1960s witnessed the introduction of the jet age, which brought new technologies and demanded new flying skills from our aircrews. It also brought the beginning of the recording devices that have now become

In this issue synonymous with flight safety. With the invention of the first Flight Data Recorder (FDR) in 1957 by the Australian, Dr. David Warren, followed a few years later by the Cockpit Voice Recorder (CVR), we now had the means of recording, at least then in a rudimentary fashion, some of the aircraft's behaviour and a little of that of the crew. Ten years later, two airlines started to analyse sporadically some of this data to ascertain how their aircraft were indeed being operated away from base. With time and with the advent of the digital age, these devices became much more sophisticated and progressed from measuring tens of parameters per minute to over 1500 per second. The analysis of the acquired data also matched the sophistication but we were, on the whole, only measuring technical performance and the crews' technical skills. Then on a Sunday afternoon in March 1977, in Tenerife, our worst nightmare became reality when two Boeing 747s collided on ground in poor visibility caused by cloud rolling in off the Atlantic and shrouding this high altitude airfield. That afternoon, our industry killed 583 people to this day the industry's worst disaster. There were a number of contributory causes to this accident but what broke through the final defence barriers was a misunderstanding in communication (between the air traffic controller and the crew as well as within the crew) exacerbated by a very steep authority gradient on the flight deck of the departing aircraft.

pg 1-2

<Error Tolerance> pg 4

The Most Famous Ships That Never Were pg 6

Thirty-Six Stratagems pg 8-9

Safety First !! pg 10

Early World History pg 14

UTOPIA

cont'd on pg 2

A Common Maritime Language - Cross cultural issues “Why do competent seafarers have accidents?” This editor could not hide his joy while perusing through the above 'wise' and realistic feature article. It comes from an aviation expert of 35 years, who additionally is having a 'Risk and Safety Management' 'obsession' under his concern. Fully subscribing to the articles' contents, I got an even larger pleasure when I received the author's permission to have reproduced it, unaltered. For the last two years, as an independent freelancer I have focused my premium time to investigating, researching and exploring the question that seems to be in every person's mind, of our shipping industry:

So far the findings are guiding to the direction of lack of communication influenced by the impact of language and culture differences, among the large seafarers' family whose English is not their mother language, and of course, not only. I have had an extensive exposure living, working and sailing - with a vast assemble of seafarers from this earth's four cardinals, as well, as extensive discussions with academics, scholars, maritime English teachers and shipping managers. I have come to realise how important is the existence of a common working language for communication at sea, coupled though with a 'uniform maritime attitude and mentality'. Is this feasible? The following text is an attempt and a small contribution. The case for a common maritime language (English); the need for effective communication (onboard communication and this of watchkeepers); the evidence of communication problems at sea and ports; and the examples on non-communication at sea has been in the 'gutters' for many years.

cont'd on pg 12

TO THE MASTER: Please circulate copies of this Bulletin to the CREW.

To reach our Seafarers


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