4 ms·

This accident is actually fairly well understood and is a result of a particular aspect of naval and shipping culture that most of us never experience. It is d

by rsync 9y ago

This accident is actually fairly well understood and is a result of a particular aspect of naval and shipping culture that most of us never experience. It is described in detail, with laugh-out-loud illustrations of boat paths, in an entire chapter devoted to these kind of accidents, in the excellent book _Normal Accidents_ by Charles Perrow.[1] In short, very, very large ships are captained by egomaniacal captains who play chicken with one another - each of whom is certain that they have the right of way (due to ship size, military vs. civilian, etc.) These kind of accidents are nothing more than: "you get out of the way", "No, YOU, get out of the way". A very large cargo ship interacting with a US Navy destroyer is a perfect recipe for this kind of interaction. Again, the illustrations of the boat paths in the book are literally laugh out loud funny as these huge boats slowly point directly at each other and crash or are on-course for near-misses and at the very last second veer into one another as they mistake who is turning where. I highly, highly recommend this book - not just for the funny (but not that fascinating) chapter on the shipping lanes, but for the chapters on nuclear plant accidents and the challenger accident. [1] https://en.wikipedia.org/wiki/Normal_Accidents https://en.wikipedia.org/wiki/Normal_Accidents

valuearb 9y ago
Like everyone else said, captain was asleep. And the cargo ship hit the destroyer obliquely, from behind. The destroyer clearly had right of way and no one was playing chicken because everyone was asleep on the cargo ship.
- nulldev 9y ago
  > no one was playing chicken because everyone was asleep on the cargo ship. Unless everyone on both ships was asleep, this statement doesn't have to be true. If anything, it seems eminently plausible the destroyer's crew was playing chicken with the freighter thinking they were playing against a human opponent, when in fact they were dealing with an automated system.
  - valuearb 9y ago
    This is more realistic. But it begs the question, why didn't the destroyer out-run it? The freighter was approaching from it's back side, and should have given way, but once you realize it's not going to you have 100,000 horsepower to accelerate away with. And standing orders were to wake the captain whenever another ship gets within a minimum distance. So the watch had to not only decide to play chicken with the freighter, but not wake the captain when it breached minimum safe distance.
  - rsync 9y ago
    "Unless everyone on both ships was asleep, this statement doesn't have to be true. If anything, it seems eminently plausible the destroyer's crew was playing chicken with the freighter thinking they were playing against a human opponent, when in fact they were dealing with an automated system." Interesting you should mention this because, IIRC, the book has an aside about ships that (unknowingly) play chicken with lighthouses.
    - nulldev 9y ago
      Is that in any way related to the somewhat apocryphal / mostly untrue anecjoke about the aircraft carrier and the lighthouse? https://en.wikipedia.org/wiki/Lighthouse_and_naval_vessel_urban_legend https://en.wikipedia.org/wiki/Lighthouse_and_naval_vessel_ur...
- barrkel 9y ago
  Everybody's responsible for avoiding an accident. Thinking in terms of right of way is exactly how this kind of accident happens. That's what makes you think you're right to proceed towards what looks like a certain collision. (It's the same on the road; you have to take it as an article of faith that other people will respect your right of way, but at the same time, it makes sense not to go past junctions with waiting cars too quickly, just in case they don't see you. If you get hit, it might not be your fault, but that's little consolation if you're injured or killed.)
  - mpyne 9y ago
    Well, the international regulations that govern maritime traffic do think in terms like right of way. They define for various scenarios of two ships approaching the other which one is the "stand on" vessel, that must maintain course and speed, and which one is the "give way" vessel, which must maneuver around the other. Of course, the rules do also say that both ships are responsible for avoiding collisions with the other, and that both are free to maneuver to avoid collision if they are put in extremis by failure to follow the navigation rules.
- astrodust 9y ago
  Both captains were asleep. The question is why the American one was when, given it's a military vessel, they should be concerned about being approached by other ships. Aren't they held to a higher standard than some random container ship crew?
  - mpyne 9y ago
    Captains have to sleep, which is why warships have a watch team who are awake. They failed here, which is unfathomable, but that is not, per se, the CO's fault. The CO has to sleep sometime -- I've stood many watches as the senior-most officer awake on a nuclear submarine while my CO slept, and I had to avoid collisions just as much as I would have had to do if my CO had been awake. It is true that many COs will try to time their periods of sleep for when the operational tempo is lower as a risk management measure. I can only assume the Fitzgerald's CO had made his risk assessment and figured that it was better to sleep at night than to sleep during the day when the contact density would be even higher. But for a Navy warship being "approached by other ships" is a fact of life for every hour of every day, you can't always plan your sleep schedule for when you're the only boat on the pond.
    - astrodust 9y ago
      Other traffic is no reason to wake the captain, but when you're closing from 4000 yards to 3000 to 2000, well, you might want to give them a poke.
      - mpyne 9y ago
        Yes, and every Captain out there puts the minimum "closest point of approach" for any contact that they're willing to accept into their standing orders, precisely so that they will be woken up by the watch team with enough time to make it to the bridge and assess the situation. But this still relies on the watch team detecting the contact and realizing that it will pass near to the ship, and so again the ship's captain is back to relying on his or her watch team to at least get to that minimal level of competence -- because if they can't rely on the officers on watch to be able to wake them up properly, we're back to captains who can never sleep.
pvg 9y ago
These kind of accidents are nothing more than: "you get out of the way", "No, YOU, get out of the way". That's pure speculation on your part, not an actual account or understanding of what caused this particular accident.
Amezarak 9y ago
The captain of the US ship was asleep. The article suggests the cargo ship was completely computer-controlled at the time of the incident and for a little while afterwards, until the crew realized what happened. I don't think the two-egos-colliding story works here. Additionally, the destroyer was hit around the middle of the right side while the cargo ship hit head-on.
- okket 9y ago
  The egos work also on lower levels, e.g. someone looking at a radar and assuming they have the right of passage b/c they are bigger vs. military. I can not image that no radar alarm was heard and reacted upon on both ships. But it takes a lot of things to wrong for this to happen.
mc32 9y ago
I don't think this was the result of egomania. The destroyer's captain was asleep --it's speculated everyone on the freighter was asleep. The problem was complacency --that may be somewhat forgivable on the freighter's side, but not on the destroyer's side --it's a warship. It should always be on alert and at the ready. They should never be complacent. The captain allowed his sailors to become complacent. I am hopeful the navy will not only examine this crew but will also examine the rest of the navy for laxness and failure to perform/dereliction of duties, etc.
- deusofnull 9y ago
  How is there not some kind of "crew is asleep detecting autopilot" on these ships? If not on the military vessel, then on the cargo transport? Seems like it would be easy enough if they have radar. Just detect when you're on a collision course and adjust 3 degrees to port / starboard if there isn't human input?
  - mc32 9y ago
    That's a good question. I would think that modern ships should scream "collision course ahead" with light, sounds, etc. However, psychologically, maybe it's believed that this would make people even _more_ complacent? I don't know, just speculating. Never the less, the captain should never allow his sailors to think, "we're almost there, we're in friendly waters, we can relax". No, always on alert. It's unforgivable.
  - jessaustin 9y ago
    Of course the cargo ship has BNWAS installed. The captain might have turned it off? If the bridge personnel didn't know about the (no-AIS, running dark, much faster) navy boat, however, their wakefulness wouldn't have prevented the end result.
- rsync 9y ago
  "The destroyer's captain was asleep" I don't think it has to be the actual captain of the ship who could not, of course, be at the helm 24 hours per day. If this was indeed a manifestation of what is described in the book I refer to it could be anyone in command of the ship who has been led to believe that their ships size and/or status gives them universal right of way.
andrewfong 9y ago
Reminds me of the lighthouse joke: https://en.m.wikipedia.org/wiki/Lighthouse_and_naval_vessel_urban_legend https://en.m.wikipedia.org/wiki/Lighthouse_and_naval_vessel_...
rz2k 9y ago
It sounds like an interesting book. Is there a more up to date canonical text on failures of complex systems? The Wikipedia page includes "almost all serious nuclear accidents have occurred with what was at the time the most recent technology". Chernobyl was trying out a new cooling method, but it wasn't a very new reactor. Fukushima wasn't very new either. However, the book was written before both nuclear disasters. I do think there is a social sciences aspect to the risk of nuclear energy. People who know enough to minimize risks are afraid enough of others' over-reactions to transparency about flaws and mistakes that there is an incentive to cover things up when they could be fixed. The other problem is that Chernobyl and Fukushima are talked about as the worst a nuclear disaster can be, when their impact was greatly contained by heroic efforts of individuals
- kevinr 9y ago
  Not the parent who mentioned _Normal Accidents_, but this is one of my hobby-horses, so I'm glad you asked! Prof. Nancy Leveson of MIT has done extensive research over the last forty years on the safety engineering of complex systems, and her 2012 book _Engineering a Safer World_[0] (open-access PDF at that link) is partly a response to Perrow's _Normal Accidents_. [0]: https://mitpress.mit.edu/books/engineering-safer-world https://mitpress.mit.edu/books/engineering-safer-world In particular, and unlike Perrow, she thinks we really can design complex sociotechnical systems which aren't disasters waiting to happen, and her book provides a theoretical framework for doing so, plus a fully-worked design analysis technique and accident investigation technique using that framework. These have been and are being used under real-world conditions in a variety of industries including transportation, the military, and even software. There's a conference every year at MIT which I've been going to every year for about four years now where folks present. Every year there are more industries and disciplines represented, and there have also been presentations of analysis techniques applying the theoretical framework in practical contexts like cybersecurity and privacy. You're also very right that there are huge social and human factors components to safety, and her book talks a lot about getting that right and analyzing what went wrong at various levels of abstraction, including cultural and regulatory. I highly recommend it, if you're interested in this subject. Based on what I know of the US Navy, I'm certain that the accident investigators working on this collision are doing so informed by this methodology.
mjlee 9y ago
As someone with a few years experience at sea, I've never experienced this culture. I have come across ships at sea where the bridge crew were clearly asleep - I think that's a much more likely scenario.
- rsync 9y ago
  "As someone with a few years experience at sea, I've never experienced this culture." I encourage you to read the book - it makes the case that among very large ships there is indeed such a culture. My personal experience as a sailor in the US Navy neither bolsters nor diminishes what is described in the book but I do believe that a culture of machismo and egomania can permeate the ranks. Just because it was the officer in charge and not the actual (sleeping) captain might not make much difference.
  - mjlee 9y ago
    I did read as much as I could from https://books.google.co.uk/books?id=VC5hYoMw4N0C https://books.google.co.uk/books?id=VC5hYoMw4N0C before commenting. I spent years at sea as an Officer of the Watch in the Royal Navy - during that time I spoke to quite a few other watchkeepers from around the world. The attitude I encountered was always one of terror of getting it wrong rather than machismo. I can see how in ambiguous scenarios with large cargo vessels this could lead to a collision. In a relatively nimble destroyer I'm very confident this wasn't a simple case of "I'm the stand on vessel, I won't move."
    - jessaustin 9y ago
      Additionally, it's difficult to imagine how a boat with its AIS transmitter intentionally turned off could ever be a "stand-on" at night.
ChuckMcM 9y ago
Somehow I don't think even the Captain Queeg would lay asleep in his bunk while playing 'chicken' with another large ship. As the article points out, the one explanation that matches the tracks and observations is that everyone was asleep and the two ships were on autopilot. And it is considered "impossible" by many that discipline on a Navy ship would have broken down so much that the entire watch conspired to ignore and not report their fellow sailors dereliction of duty. As a result 'well understood' is not a good description of this event :-)
deleted 9y ago
[deleted]
bmh_ca 9y ago
"I'm a lighthouse. It's your call."

by rsync 9y ago

valuearb 9y ago

Like everyone else said, captain was asleep. And the cargo ship hit the destroyer obliquely, from behind. The destroyer clearly had right of way and no one was playing chicken because everyone was asleep on the cargo ship.

nulldev 9y ago
> no one was playing chicken because everyone was asleep on the cargo ship. Unless everyone on both ships was asleep, this statement doesn't have to be true. If anything, it seems eminently plausible the destroyer's crew was playing chicken with the freighter thinking they were playing against a human opponent, when in fact they were dealing with an automated system.
- valuearb 9y ago
  This is more realistic. But it begs the question, why didn't the destroyer out-run it? The freighter was approaching from it's back side, and should have given way, but once you realize it's not going to you have 100,000 horsepower to accelerate away with. And standing orders were to wake the captain whenever another ship gets within a minimum distance. So the watch had to not only decide to play chicken with the freighter, but not wake the captain when it breached minimum safe distance.
- rsync 9y ago
  "Unless everyone on both ships was asleep, this statement doesn't have to be true. If anything, it seems eminently plausible the destroyer's crew was playing chicken with the freighter thinking they were playing against a human opponent, when in fact they were dealing with an automated system." Interesting you should mention this because, IIRC, the book has an aside about ships that (unknowingly) play chicken with lighthouses.
  - nulldev 9y ago
    Is that in any way related to the somewhat apocryphal / mostly untrue anecjoke about the aircraft carrier and the lighthouse? https://en.wikipedia.org/wiki/Lighthouse_and_naval_vessel_urban_legend https://en.wikipedia.org/wiki/Lighthouse_and_naval_vessel_ur...
barrkel 9y ago
Everybody's responsible for avoiding an accident. Thinking in terms of right of way is exactly how this kind of accident happens. That's what makes you think you're right to proceed towards what looks like a certain collision. (It's the same on the road; you have to take it as an article of faith that other people will respect your right of way, but at the same time, it makes sense not to go past junctions with waiting cars too quickly, just in case they don't see you. If you get hit, it might not be your fault, but that's little consolation if you're injured or killed.)
- mpyne 9y ago
  Well, the international regulations that govern maritime traffic do think in terms like right of way. They define for various scenarios of two ships approaching the other which one is the "stand on" vessel, that must maintain course and speed, and which one is the "give way" vessel, which must maneuver around the other. Of course, the rules do also say that both ships are responsible for avoiding collisions with the other, and that both are free to maneuver to avoid collision if they are put in extremis by failure to follow the navigation rules.
astrodust 9y ago
Both captains were asleep. The question is why the American one was when, given it's a military vessel, they should be concerned about being approached by other ships. Aren't they held to a higher standard than some random container ship crew?
- mpyne 9y ago
  Captains have to sleep, which is why warships have a watch team who are awake. They failed here, which is unfathomable, but that is not, per se, the CO's fault. The CO has to sleep sometime -- I've stood many watches as the senior-most officer awake on a nuclear submarine while my CO slept, and I had to avoid collisions just as much as I would have had to do if my CO had been awake. It is true that many COs will try to time their periods of sleep for when the operational tempo is lower as a risk management measure. I can only assume the Fitzgerald's CO had made his risk assessment and figured that it was better to sleep at night than to sleep during the day when the contact density would be even higher. But for a Navy warship being "approached by other ships" is a fact of life for every hour of every day, you can't always plan your sleep schedule for when you're the only boat on the pond.
  - astrodust 9y ago
    Other traffic is no reason to wake the captain, but when you're closing from 4000 yards to 3000 to 2000, well, you might want to give them a poke.
    - mpyne 9y ago
      Yes, and every Captain out there puts the minimum "closest point of approach" for any contact that they're willing to accept into their standing orders, precisely so that they will be woken up by the watch team with enough time to make it to the bridge and assess the situation. But this still relies on the watch team detecting the contact and realizing that it will pass near to the ship, and so again the ship's captain is back to relying on his or her watch team to at least get to that minimal level of competence -- because if they can't rely on the officers on watch to be able to wake them up properly, we're back to captains who can never sleep.

pvg 9y ago

These kind of accidents are nothing more than: "you get out of the way", "No, YOU, get out of the way". That's pure speculation on your part, not an actual account or understanding of what caused this particular accident.

Amezarak 9y ago

The captain of the US ship was asleep. The article suggests the cargo ship was completely computer-controlled at the time of the incident and for a little while afterwards, until the crew realized what happened. I don't think the two-egos-colliding story works here. Additionally, the destroyer was hit around the middle of the right side while the cargo ship hit head-on.

okket 9y ago
The egos work also on lower levels, e.g. someone looking at a radar and assuming they have the right of passage b/c they are bigger vs. military. I can not image that no radar alarm was heard and reacted upon on both ships. But it takes a lot of things to wrong for this to happen.

mc32 9y ago

I don't think this was the result of egomania. The destroyer's captain was asleep --it's speculated everyone on the freighter was asleep. The problem was complacency --that may be somewhat forgivable on the freighter's side, but not on the destroyer's side --it's a warship. It should always be on alert and at the ready. They should never be complacent. The captain allowed his sailors to become complacent. I am hopeful the navy will not only examine this crew but will also examine the rest of the navy for laxness and failure to perform/dereliction of duties, etc.

deusofnull 9y ago
How is there not some kind of "crew is asleep detecting autopilot" on these ships? If not on the military vessel, then on the cargo transport? Seems like it would be easy enough if they have radar. Just detect when you're on a collision course and adjust 3 degrees to port / starboard if there isn't human input?
- mc32 9y ago
  That's a good question. I would think that modern ships should scream "collision course ahead" with light, sounds, etc. However, psychologically, maybe it's believed that this would make people even _more_ complacent? I don't know, just speculating. Never the less, the captain should never allow his sailors to think, "we're almost there, we're in friendly waters, we can relax". No, always on alert. It's unforgivable.
- jessaustin 9y ago
  Of course the cargo ship has BNWAS installed. The captain might have turned it off? If the bridge personnel didn't know about the (no-AIS, running dark, much faster) navy boat, however, their wakefulness wouldn't have prevented the end result.
rsync 9y ago
"The destroyer's captain was asleep" I don't think it has to be the actual captain of the ship who could not, of course, be at the helm 24 hours per day. If this was indeed a manifestation of what is described in the book I refer to it could be anyone in command of the ship who has been led to believe that their ships size and/or status gives them universal right of way.

andrewfong 9y ago

Reminds me of the lighthouse joke: https://en.m.wikipedia.org/wiki/Lighthouse_and_naval_vessel_urban_legend https://en.m.wikipedia.org/wiki/Lighthouse_and_naval_vessel_...

rz2k 9y ago

It sounds like an interesting book. Is there a more up to date canonical text on failures of complex systems? The Wikipedia page includes "almost all serious nuclear accidents have occurred with what was at the time the most recent technology". Chernobyl was trying out a new cooling method, but it wasn't a very new reactor. Fukushima wasn't very new either. However, the book was written before both nuclear disasters. I do think there is a social sciences aspect to the risk of nuclear energy. People who know enough to minimize risks are afraid enough of others' over-reactions to transparency about flaws and mistakes that there is an incentive to cover things up when they could be fixed. The other problem is that Chernobyl and Fukushima are talked about as the worst a nuclear disaster can be, when their impact was greatly contained by heroic efforts of individuals

kevinr 9y ago
Not the parent who mentioned _Normal Accidents_, but this is one of my hobby-horses, so I'm glad you asked! Prof. Nancy Leveson of MIT has done extensive research over the last forty years on the safety engineering of complex systems, and her 2012 book _Engineering a Safer World_[0] (open-access PDF at that link) is partly a response to Perrow's _Normal Accidents_. [0]: https://mitpress.mit.edu/books/engineering-safer-world https://mitpress.mit.edu/books/engineering-safer-world In particular, and unlike Perrow, she thinks we really can design complex sociotechnical systems which aren't disasters waiting to happen, and her book provides a theoretical framework for doing so, plus a fully-worked design analysis technique and accident investigation technique using that framework. These have been and are being used under real-world conditions in a variety of industries including transportation, the military, and even software. There's a conference every year at MIT which I've been going to every year for about four years now where folks present. Every year there are more industries and disciplines represented, and there have also been presentations of analysis techniques applying the theoretical framework in practical contexts like cybersecurity and privacy. You're also very right that there are huge social and human factors components to safety, and her book talks a lot about getting that right and analyzing what went wrong at various levels of abstraction, including cultural and regulatory. I highly recommend it, if you're interested in this subject. Based on what I know of the US Navy, I'm certain that the accident investigators working on this collision are doing so informed by this methodology.

mjlee 9y ago

As someone with a few years experience at sea, I've never experienced this culture. I have come across ships at sea where the bridge crew were clearly asleep - I think that's a much more likely scenario.

rsync 9y ago
"As someone with a few years experience at sea, I've never experienced this culture." I encourage you to read the book - it makes the case that among very large ships there is indeed such a culture. My personal experience as a sailor in the US Navy neither bolsters nor diminishes what is described in the book but I do believe that a culture of machismo and egomania can permeate the ranks. Just because it was the officer in charge and not the actual (sleeping) captain might not make much difference.
- mjlee 9y ago
  I did read as much as I could from https://books.google.co.uk/books?id=VC5hYoMw4N0C https://books.google.co.uk/books?id=VC5hYoMw4N0C before commenting. I spent years at sea as an Officer of the Watch in the Royal Navy - during that time I spoke to quite a few other watchkeepers from around the world. The attitude I encountered was always one of terror of getting it wrong rather than machismo. I can see how in ambiguous scenarios with large cargo vessels this could lead to a collision. In a relatively nimble destroyer I'm very confident this wasn't a simple case of "I'm the stand on vessel, I won't move."
  - jessaustin 9y ago
    Additionally, it's difficult to imagine how a boat with its AIS transmitter intentionally turned off could ever be a "stand-on" at night.

ChuckMcM 9y ago

Somehow I don't think even the Captain Queeg would lay asleep in his bunk while playing 'chicken' with another large ship. As the article points out, the one explanation that matches the tracks and observations is that everyone was asleep and the two ships were on autopilot. And it is considered "impossible" by many that discipline on a Navy ship would have broken down so much that the entire watch conspired to ignore and not report their fellow sailors dereliction of duty. As a result 'well understood' is not a good description of this event :-)

deleted 9y ago

[deleted]

bmh_ca 9y ago

"I'm a lighthouse. It's your call."