Posted: 28th March 2014 | Written by: Simon Harvey
“From an early age, we’re taught to break apart problems in order to make complex tasks and subjects easier to deal with. “ - Peter Senge. But as Peter Senge continues in his book The Fifth Discipline: “this creates a bigger problem… we lose the ability to see the consequences of our actions, and we lose a sense of connection to a larger whole.”
The investigation of the Milly RIB tragedy is one such example, where a simple explanation of events fails to deliver a complete understanding of why the accident happened.
Today, kill cords are a solution to a problem of a helmsman falling overboard (or inboard), and leaving an out of control vessel. The kill cord (when attached correctly), is connected to a kill switch to the engine, avoiding an out of control vessel should the driver fall, or be incapacitated.
The idea and theory seems to tick the right boxes, and use of kill cords is taught in RYA level 1 & 2 powerboat handling training courses.
Yet over the last decade we have continued to see accidents related to out of control vessels and kill cords in the media, and documented by RYA, RNLI, MCA and MAIB. So what’ going wrong?
A kill cord may solve one problem, ‘an out of control boat’ but does it look at the bigger picture? Let’s take a look at two things, behavior and environment. Both are inter-related, non-linear, and affect the final outcome.
In a recent MAIB report on the investigation of the ejection of six people from the RIB ‘Milly’ (with two fatalities), there are several clues to behavior and environment.
Mr and Mrs M were the adults in the RIB ‘Milly’. Both Mr & Mrs M had taken an RYA level 2 powerboat handling training course. The report offers this:
“Mr M was described as a keen, confident and responsible boat handler”, while “Mrs M was described as a very attentive student with a good level of risk awareness.”
Standard operating procedure (SOP) for changing drivers while a boat is underway is to stop the engine and attach the kill cord to the new driver before restarting the engine. This was covered during the RYA course, yet this SOP was not followed when Mr & Mrs M changed driver of their RIB. The engine was not stopped (although the report notes that the boat was stopped), and Mrs M did not attach the kill cord to herself after Mr M took the kill cord off himself.
Standard operating procedure was not followed and tragedy resulted. This may be the end of the search for an answer for many, but there is a lot more that we need to understand.
Sidney Dekker, a professor of human factors and systems safety at Lund University Sweden, writes in ‘The Field Guide to Understanding Human Error’:
“Without understanding and addressing the deeper and more subtle vulnerabilities that surround failure, we leave opportunities for recurrence open.”
It is difficult to understand the vulnerabilities that surround failure based on hindsight alone. However, we must try to understand why things happened the way they did, and to accept that what people did must have made sense to them at the time (no one wants to have an accident).
Behaviour and environment can offer clues. The report notes that between the time Mrs M takes the helm, and Mr M leaves the helm, Mrs M : “moved to stand in front of the wheel to ensure no one inadvertently knocked the throttle.”
There are suggestions here of priorities of concern and support, and as Mrs M is asked to do another turn again, we see evidence of this:
“Mrs M was reluctant to do so as she did not consider there was sufficient space between the boat and the beach. However, due to encouragement from the children and Mr M, she began a slow wide turn. “
Mr M’s style was quite the opposite, showing a tendency towards results and action:
“Mr M then reached across, in front of his wife, took the helm in his right hand and the throttle in his left, and then increased the engine throttle setting to full as he turned the helm to starboard.”
What we do, why we do it, how we do it, is all behaviour. Culture, relationships, environment, mental models, and individuals can all affect behaviour. Interestingly a group of leading North-eastern university network scientists recently found that human behaviour is 93 % predictable.
There are tools available that can help us understand the behaviour of other people, as well as our own natural styles. And since behaviour is an expression of the way people are feeling or thinking, this is a good place to start.
What we pulled from the report are two very different styles of behavior.
The first was a dominant and driving style from Mr M, tending towards results and action - even challenging the status quo. The second, from Mrs M, had a more steady and supporting style, towards maintaining stability and collaboration.
However, from different perspectives these can look very different.
Take a look at the second from the perspective of the first style. This could appear indecisive, over accommodating, with little sense of urgency. In contrast, the first style seen from the perspective of the second can appear intimidating, blunt, even insensitive.
These different perspectives offer insight into our own vulnerabilities, but also explain how easy it is to misinterpret others.
Even with a little knowledge about other’s styles of behavior, we are far better placed in training, at work and in life to see the subtle vulnerabilities that surround us and be better placed to make changes.
The RYA instructor made observations of behavior: “keen, confident and responsible boat handler” and “attentive student with a good level of risk awareness” but, without an understanding of these styles, this is just an observation.
Whether crews get RYA training or training elsewhere, accidents involving kill cords and tenders are a fact within the industry and not wearing kill cords continues. Over a period around the Monaco Yacht Show last year, I took photos of tenders going in and out of Monaco and Antibes. I did not see one kill cord being worn in all the pictures I took.
Opportunities for improvement come from a better understanding of both others and ourselves, in training, in everyday life onboard, and from accident reports. It can also increase the effectiveness of working relationships, improve trust, reduce conflict, and lead to better communication and decision making.
Today there are tools that can help improve your powers of observation and help you recognize important behavioural clues.
DISC is a tool used across many industries, and at all levels, to enhance personal and team development, performance and communication. It offers a common language to help us understand people’s behavioural styles and interpersonal issues. It is simple without being simplistic, measuring tendencies and priorities rather than skills or ability. Learning the language of DISC encourages an appreciation of individual differences, which in turn can lead to improved individual and team performance.
In order to learn from the more subtle vulnerabilities that surround failure, we must try to understand the connections to a larger whole. If we can start with learning more about ourselves then we are half way there.
Human error is not the cause of trouble but a symptom of trouble deeper inside a system.
*About the author:
After working on superyachts for nine years, Simon moved ashore and applied his captain skills in the corporate world. Working in management and leadership positions, and heading a real estate development company for this owner, Simon's interest in people skills development widened.
From both sides of the yachting industry, Simon noticed a gap in the skills required, and the training being offered. Tools for recruitment and selection, career advancement, management, leadership, and team development were standard ashore, yet few of these were available to owners or captains aboard. With crew size and accidents growing, the time was right to offer these. Today, with N2 People Skills, Simon brings the science behind building great teams to the superyacht industry by offering a range of tools to improve recruitment and selection, management, team development and leadership.
Simon is published in ALERT!, A Nautical Institute project, sponsored by ‘The Lloyd’s Register Educational Trust’, is a licensed MBTI facilitator, is trained in DISC, and he is a 2013 ISS board member.
Use the 'Contact Author' button below to contact Simon directly.