Consequences of complacency – A study on maritime disasters

Capt [Link], Dean – Department of Nautical Science, AMET deemed to be Univeristy

Abstract

This paper is an attempt to explain the consequences of complacency which can be categorized as one of the
significant type of human error among various others detected in the domain of ship accidents. The term
Complacency is present as an influential social and psychological factor which has similar cause in shipping and
port commercial operations. Complacency on the part of any member of crew who forms an essential part of any
shipboard operations can be a triggering point for a series of undetected chain of events which can result in an
accident with different scales of consequences. Over confidence in carrying out a routine operation has the
potential to set in a blind sector in the perception of mind to remain alert, stay focussed and carry out a task with
the same level of alertness as it was done at very first time. The paper attempts to review a sample of maritime
accident in the past 100 years to haul out the human error component and identify the extent of complacency
factor that led to the accident and offer recommendations to stay alert while performing a routine, emergency or
critical operation.

1.0 Introduction

Complacency is defined as self-satisfaction especially when accompanied by unawareness of actual dangers or

deficiencies. ―When it comes to safety, complacency can be dangerous‖ (Merriam Webster, since 1828).
Synonyms to complacency are smugness, self-satisfaction, self-approval, self-approbation, self-admiration, self-
congratulation, self-regard. ‖ Complacency might be rooted in what psychologists refer to as ―confirmation
bias‖ — the tendency to look for or interpret information in a way that confirms currently held beliefs. It is
likely that King Phillip II only listened to ideas that supported his confidence in his Armada, and rejected any
contrary views. ―Complacency can strike any person in any occupation, where a person feels his skill,
knowledge and his experience are called into question by superiors. And the result will most likely be changed
attitudes caused by gradually hampered creativity. The tankers Torrey Canyon, Amoco Cadiz, Erica, Exxon
Valdez and collision between Scot Isles and Wadi Halfa are clear examples of the effect of Complacency.

2.0 Complacency– Basic concept and operational influences

A recent approach to the analysis of maritime accidents accentuates some basic prerequisites for the occurrence
of human error in the form of spotted lack of free communication and cooperation not only within ship
organisation but also in its relation to external factors, especially shipping companies. It is the inappropriate
communication along with deficient cooperation both on board and in the relation of ship to external factors that
represents one of the basic causes of reaching improper decisions and taking inefficient actions. (Maxwell 1976;
Curtis 1991; Fukuda 1992;Emmott 2003)

3.0 Complacency – Natural tendency of the human brain

The human brain constantly and unconsciously scans the environment for signs of danger. We notice and
respond to what is unique, unusual or threatening. However repeated exposure to situations, even if they are
potentially dangerous dulls our defence mechanism and our awareness. Human beings seem to have a
psychological predisposition towards believing matters will eventually turn out well. The phrase 'optimism bias'
is sometime used to describe this phenomenon. Humans expect positive events in the future even when there is
no evidence to support such expectations. A moderate amount of optimistic illusion has been related to mental
health, and the general idea is that it is adaptive because it motivates us towards future goals. Complacency is a
natural function of the brain. The brain is designed to automate repetitive behaviour. Complacency is not the
result of apathy, carelessness, or a flaw in your personality; it is the way the brain functions. Most of our day-to-
day behaviour is automated; it happens without conscious or deliberate thought. The brain can handle routine
actions without conscious guidance. Repetitive tasks become automated to free up our attention for things that
are new, unusual, or threatening. If it were not that way, we would be overwhelmed by the simplest of tasks.
3.1 Complacency Trend

It is the natural tendency of the human brain to become excessively alert after an incident or accident, brood
over it for a passage of time and during the period of normalcy the levels of alertness erodes as the work
becomes more of routine thus setting the conditions for the next cycle of complacency trend. For example if an
accident occurs at work place there usually exist a level of complacency prior to the accident. The safety level
suddenly soars up with awareness program and other instructional mechanisms to register the root cause for the
accident and to enforce preventive measures to prevent reoccurrence. However with consciousness towards
safety awareness begins to decline and attains a low seeking to reach the moderate behaviour of pre-accident
era.

Major Maritime Disaster

2050
2000 2012 2014
1978 1987 1989 1994
1967 1976
1950
1900 1912
1850

Figure 1

Figure 1 is a graph which shows the year of occurrences of major maritime disasters in the last 100 years.
Although after each one of the disaster major changes to the maritime regulatory frame work had taken place, it
is apparent that there is either a 2 year or 10 year cycle in which the accidents have been taking place. While
machinery failure happens to be the reason for these accidents, human error had been the most important
contributing factor for all these accidents.

3.2 R M S ‘ T i t a n i c ’ ( 1 4 A p r i l 1 9 1 2 )

In response to the sinking of the RMS ‗Titanic‘ the first version of the International Convention for the Safety of
Life at Sea (SOLAS) was agreed in 1914. The 1914 treaty never entered into force due to the outbreak of the
First World War. Further versions were adopted in 1929, 1948 1960 and 1974. They represented considerable
steps forward in modernising regulations and keeping them up with technical developments in the shipping
industry. In 1974 a completely new Convention was adopted to allow SOLAS to be amended and implemented

3.3 SS ‘ T o r r e y C a n y o n ’ ( 1 8 M a r c h 1 9 6 7 )

Crude oil tanker ‗Torrey Canyon‘ was sailing with 119 000 tons of crude oil from Mena Al Ahmadi in Kuwait
to Milford Haven in Great Britain. Ship‘s captain, under pressure to meet the narrow tidal window in the port of
destination, decided to proceed between Land‘s End and Scilly Isles. The tanker did not have a scheduled route
and as such lacked a complement of full scale charts of the Scilly Islands. To navigate the region, the vessel
used LORAN system, but not the more accurate Decca Navigator. During this passage on 18 March 1967,
following a navigational error, ship struck Pollard‘s Rock on Seven Stones reef between the Cornish mainland
and the Isles of Scilly causing spillage of cargo. It was the world‘s worst oil spill at the time. About 80 km of
French and 190 km of Cornish coast were contaminated. Around 15 000 sea birds were killed, along with huge
numbers of marine organisms, before the 700 km2 slick dispersed.

The disaster led to many changes in international regulations. Inter-governmental Maritime Consultative
Organisation (IMCO) adopted the International Convention on Civil Liability for Oil Pollution Damage (CLC)
of 1969, which imposed strict liability on ship owners without the need to prove negligence, and the 1973
International Convention for the Prevention of Pollution from Ships (MARPOL).

3.4 M T ‘ A m o c o C a d i z ’ ( 1 6 M a r c h 1 9 7 8 )

‗Amoco Cadiz‘ was a VLCC (334 m long, 51.1 m wide) launched in 1973, owned by Amoco International Oil
Company and exploited under the Liberian flag. In March 1978, on route from the Persian Gulf to Rotterdam
with 219 797 tons of light crude oil the ship encountered in English Channel stormy weather with gale
conditions and high seas. On 16 March a heavy wave hit the ship‘s rudder causing a loss of steering possibility.
Attempts to repair the damage were made but proved unsuccessful. The German tug Pacific responded to the
call for tug assistance and offered assistance under a Lloyd‘s Open Form. Due to the stormy sea several attempts
were made to establish tow line and ‗Amoco Cadiz‘ dropped its anchor trying to halt its drift. The ship ran
aground the first time on Portsall Rocks, 5 km from the coast of Brittany, flooding its engines, and after half
hour second time, breaking the hull and starting the oil spill. ‗Amoco Cadiz‘ disaster resulted in amendments to
the MARPOL and CLC Conventions.

The total extent of oiling one month after the spill included approximately 320 km of coastline. In 1978, it was
estimated to have caused US$ 250 million in damage to fisheries and tourist amenities.

3.5 M F ‘ H e r a l d o f F r e e E n t e r p r i s e ’ ( 6 M a r c h 1 9 8 7 )

MF ‗Herald of Free Enterprise‘ owned by Townsend Thoresen (1980–1987) and Compania Naviera S.A. (1987–
1988), operated by Townsend Thoresen and hoisted flag of Saint Vincent was a RORO car and passenger ferry
built in 1980 and designed for rapid loading and unloading on the competitive cross-channel route between
Dover and Calais. It had not watertight compartments. It capsized moments after leaving the Belgian port of
Zeebrugge on the routine way to Dover on the night of 6 March 1987, when the ship left harbour with her bow-
door open. The sea immediately flooded the decks, and within minutes vessel was lying on its side in shallow
water. Before dropping mooring lines, it was normal practice for the assistant boatswain to close the hull doors.
However, this time the assistant boatswain had returned to his cabin for a short break after cleaning the car deck
upon arrival, and was still asleep when the harbour-stations call sounded and the ship dropped her moorings.
The first officer, was required to stay on the car deck to make sure the doors were closed but being under
pressure to get to his harbour station on the bridge, he had left car deck with the bow doors open in the
expectation that assistant boatswain would arrive shortly. Ship‘s captain assumed that the doors had been closed
since he could not see them from the wheelhouse owing to the ship‘s design and had no indicator lights in the
wheelhouse, and begun manoeuvres to leave the port. 193 passengers and crew members lost their lives in this
accident. Although the immediate cause of the sinking was found to be negligence by the assistant boatswain,
asleep in his cabin when he should have been closing the bow-door, the official inquiry placed more blame on
his supervisors and poor communication and ship‘s management in Townsend Thoresen. After the accident
IMO begun works on the International Management Code for the Safe Operation of Ships and Pollution
Prevention and several improvements to the design of the RORO car and passenger ferry boats were introduced.
These included changes in SOLAS regulations [11]:  to require 125 cm of freeboard for all new RORO vessel,
instead of the previous value of 76 cm and to prohibit an undivided deck of this length on a passenger RORO
vessel;  introducing indicators that display the state of the bow doors on the bridge, watertight ramps being
fitted to the bow sections of the front of the ship, and ‗freeing flaps‘ to allow water to escape from a vehicle
deck in the event of flooding

3.5 M T ‘ E x x o n V a l d e z ’ ( 2 4 M a r c h 1 9 8 9 )

‗Exxon Valdez‘ was a single-hull tanker 301 m long, 51 m wide, with the draft in fully loaded condition 26 m,
built by National Steel and Shipbuilding Company in San Diego and delivered to Exxon Shipping Company in
December 1986. On 24 March 1989, ‗Exxon Valdez‘ carrying about 201.000 m³ of oil, after departure from the
oil terminal in Valdez, passing the Valdez Narrows and leaving the ship by pilot, encountered icebergs in the
shipping lanes. Ship‘s captain ordered the helmsman to take the vessel out of the shipping lanes to go around the
icebergs. He then handed over control of the ship to the watchkeeping officer (third mate) with precise
instructions to turn back into the shipping lanes when the tanker reached a certain point. For some reason the
OOW and helmsman failed to make the turn back into the shipping lanes and the ship ran aground on Bligh
Reef causing a spillage of approximately 38.000 to 42.000 m3 of crude oil. Ship‘s Captain was in his quarters at
the time.

The US National Transportation Safety Board investigated the accident and determined that the probable causes
of the grounding were:

 the failure of the third mate to properly manoeuvre the vessel, possibly due to fatigue and excessive workload;

 the failure of the master to provide a proper navigation watch, possibly due to impairment from alcohol;

 the failure of Exxon Shipping Company to supervise the master and provide a rested and sufficient crew for
the ‗Exxon Valdez‘;

the failure of the U.S. Coast Guard to provide an effective vessel traffic system;  the lack of effective pilot and
escort services;

 the failure of Exxon Shipping Company to properly maintain the Raytheon Collision Avoidance System
(RAYCAS) radar, which, if functional, would indicate to the third mate an impending collision with the Bligh
Reef by detecting the radar reflector, placed on the next rock inland from Bligh Reef (this cause is not present in
the official accident report). This disaster resulted in introducing by IMO comprehensive marine pollution
prevention rules through various conventions.

3.6 M F ‘ E s t o n i a ’ ( 2 8 S e p t e m b e r 1 9 9 4 )

MS ‗Estonia‘, previously Viking Sally (1980–1990), Silja Star (1990–1991) and Wasa King (1991–1993) was a
ferry boat with bow visor and stern ramps built in 1979/80 in the Germany. It sunk on 28 September 1994 on
route from Tallinn to Stockholm. The ship was fully loaded and listing slightly to the port side due to poor cargo
distribution. The weather was rough, with a wind of 15 to 20 m/s, force 7–8 on the Beaufort scale and a
significant wave height of 4 to 6 m. The strokes of the waves failed the locks of the bow door which had
separated from the rest of the vessel, pulling ajar the ramp behind it. The subsequent failure of the bow ramp
allowed water into the car deck and resulted in the capsizing and sinking of the ship.

Drawing conclusions from the accident IMO introduced [9, 10]:  recommendations for modifications to be
applied to similar ships included separation of the condition sensors from the latch and hinge mechanisms of the
bow visor and ramp;  special training requirements in crowd and crisis management and human behaviour for
crew on all passenger ships (in 1999);

4.0 Influence of Human factor in safety of navigation and environment protection.

Marine accident statistics show that the cause of more than 80% of them is the human factor. According to
information provided by Dr. A. M. Rothblum from the U.S. Coast Guard Research & Development Centre,
human error was the reason of:

 84–88% of tanker accidents;

 79% of towing vessel groundings;

 89–96% of ships‘ collisions;

 75% of ships‘ allusions;

 75% of onboard fires and explosions.

5.0 Human and Organisational Errors

Human errors can be described as actions taken by individuals that can lead an activity (design, construction,
and operation) to realise a quality lower than intended. Human errors also include actions not taken, as these
also may lead an activity to realise a quality lower than intended. Many people typically think of human error as
―operator error‖ or ―cockpit error‖, in which the operator makes a slip or mistake due to misperception, faulty
reasoning, inattention, or debilitating attributes such as sickness, drugs, or fatigue.

However, there are many other important sources of human error. These includes factors such as management
policies which pressure shipmasters to stay on schedule at all costs, poor equipment design which impedes the
operator‘s ability to perform a task, improper or lack of maintenance, improper or lack of training, and
inadequate number of crew to perform a task.

The human error factors range from those of judgement to ignorance, folly, and mischief. Inadequate training is
the primary contributor to many of the past failures in marine structures. Also boredom has played a major role
in many accidents. Based on a study by Bea [1] of human error factors in marine engineering the following
primary factors were identified as in Table 1:

Table 1

Organisation errors are a departure from acceptable or desirable practice on the part of a group of individuals
that results in unacceptable or undesirable results. Primary organisational error includes the factors indicated in
Table 2
 Table 2

For example, the goals set by the organisation may lead rational individuals to conduct certain operations in
manner that the corporate management would not approve if they were aware of their reliability implications.
Similarly, corporate management, under pressures to reduce costs and maintain schedules, may not provide the
necessary resources required allowing adequately safe operations.

Other types of organisation and management procedure that affect the system reliability include, for example,
parallel processing such as developing design criteria at the same time as the structure is being designed – a
procedure that may not be appropriate in economic terms according to the costs and uncertainties.

6.0 Procedures to overcome complacency

Complacency exists on board all vessel types and with all crews. It is endemic and contagious and will not go
away of its own accord. Its symptoms are injuries, groundings, collisions and mooring accidents and it need
treatment. Therefore, we must encourage an approach where each task is approached with the same caution as if
it were the first times it was being undertaken. Effective teamwork is essential for optimizing safety on board
vessels. Productive interactions among crew members can preclude accidents caused by deficiencies in
technology design, inadequate familiarity with systems and overreliance on technology.

Complacency continues to be a recurring safety issue in accidents investigated by the MAIB. Shipowners should
recognise the risks posed by complacency and ensure that their vessels operate with effective bridge teams at all
times.
• Masters should make best use of standing/night orders to set operational benchmarks and heighten bridge
watch keepers‘ awareness of risk when appropriate.
• Masters must lead by example. Ships‘ crews are unlikely to apply the high professional standards demanded if
these are not observed by the officer in overall command.
• The use of designated lookouts is an essential requirement for safe navigation, but continues to be regarded as
a low priority on some vessels.
• The use of navigational aids is not a substitute for maintaining a visual lookout

7.0 Conclusion

Despite the efforts of a global maritime community, maritime accidents caused by human error still occur. In
order to reduce their number, it is vital to understand which human and organizational factors determine how the
work on board a ship is carried out. Our analysis of the accident reports confirms that ineffective relationship
between human and technology remains one of the factors that contribute to the development of human error.
Inadequately designed, baffling and insufficiently understood technology created error pathways that lead to
accidents. On the other hand, perception of technology as fully reliable resulted in an inadequate crew members‘
performance. To decrease the likelihood of an occurrence of human error related to technology, several actions
are necessary. Because bridge standardization is a huge challenge and it will probably not happen in the near
future, it is important to conduct trainings using same or very similar systems to those installed on board ships.
Furthermore, a favourable learning environment should be created and all trainees should be encouraged to
participate in confirming understanding and to be sure that training was effective. During delivering training
courses, it is essential to accentuate that human operator should use technological aid critically and obtain
information from as many sources as possible. All crew members should provide safety-related information. To
establish and maintain an effective safety culture, it is necessary to abandon old-established methods of ship
organization and regard crew as a team with the master as a leader.

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