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The real cause of the collision was poor seamanship and failure to follow the COLREGS on the part of the bridge crew of the destroyer. Most specifically they we
by jordanb 9y ago
The real cause of the collision was poor seamanship and failure to follow the COLREGS on the part of the bridge crew of the destroyer. Most specifically they were seriously in violation of Rule 6: the Safe Speed Rule
http://navruleshandbook.com/Rule6.html http://navruleshandbook.com/Rule6.html
Every vessel shall at all times proceed at a safe speed so
that she can take proper and effective action to avoid
collision and be stopped within a distance appropriate to
the prevailing circumstances and conditions.
The USS McCain was traveling at over 20 knots at the time of the collision, through a very crowded area at the entrance of a traffic separation scheme. If they hadn't been traveling at this obviously excessive speed they would have had the time to think, and to work through little UI issues like the one described here.
- csours 9y agoThe path to a disaster has been compared to a tunnel [0]. You can escape from the tunnel at many points, but you may not realize it. Trying to find the 'real cause' is a fool's errand, because there are many places and ways to avoid the outcome. I do take your meaning, reducing speed and following well established rules would have almost certainly have saved them. 0. PDF: http://www.leonardo-in-flight.nl/PDF/FieldGuide%20to%20Human%20Error.PDF http://www.leonardo-in-flight.nl/PDF/FieldGuide%20to%20Human... Amazon: https://www.amazon.com/Field-Guide-Understanding-Human-Error/dp/0754648257 https://www.amazon.com/Field-Guide-Understanding-Human-Error...
- JshWright 9y agoI've never heard the tunnel analogy. Seems odd, since tunnels generally only have one entrance and one exit... In a lot of fields where the stakes are high and mistakes are costly (aviation and emergency services are the two I'm most familiar with) the analogy used is a chain. Break any link in the chain and you prevent the event. https://www.aopa.org/asf/publications/inst_reports2.cfm?article=4401 https://www.aopa.org/asf/publications/inst_reports2.cfm?arti...
- csours 9y agoIt's the perception tunnel. There are many branches, but only one route is followed. In hindsight, you can see all the branches and call out everything that went wrong.
- tantalor 9y agoNormally that is called "tunnel vision". https://en.wiktionary.org/wiki/tunnel_vision https://en.wiktionary.org/wiki/tunnel_vision (figuratively) The tendency to focus one's attention on one specific idea or viewpoint, to the exclusion of everything else; a one-track mind.
- mustacheemperor 9y agoI think the idea is that if you are stuck in a dark train tunnel and there's a train coming towards you, there may be doorways, recesses, etc in the walls that are invisible without the proper tools (flashlight, etc).
- deleted 9y ago[deleted]
- blattimwind 9y ago> I've never heard the tunnel analogy. Seems odd, since tunnels generally only have one entrance and one exit... Road and train tunnels have many emergency exits...
- JshWright 9y agoGenerally they have a parallel tunnel (either for traffic in the other direction, or specifically for emergency egress), and connections between them. They still take you to the same general place.
- Piskvorrr 9y agoUrban tunnels have many regular entries and exits, as well as emergency exits, not to speak of emergency crossovers.
- mostlyskeptical 9y agoAs we say when teaching new riders to ride a motorcycle, a crash is often an intersection of factors. If you remove even one of those issues it likely would have prevented it.
- pbhjpbhj 9y agoI've noticed a lot of learners (eg in YouTube videos) crash because they grab at the handlebars, grabbing the throttle and inadvertently accelerating. Is there a reason the throttle can't be reversed so that grabbing would reduce throttle and slow the bike? (FWIW, I'm a fully licensed motorcyclist, don't currently ride.)
- mjlee 9y agoI prefer the swiss cheese model. https://en.wikipedia.org/wiki/Swiss_cheese_model https://en.wikipedia.org/wiki/Swiss_cheese_model "In the Swiss Cheese model, an organisation's defenses against failure are modeled as a series of barriers, represented as slices of cheese. The holes in the slices represent weaknesses in individual parts of the system and are continually varying in size and position across the slices. The system produces failures when a hole in each slice momentarily aligns, permitting (in Reason's words) "a trajectory of accident opportunity", so that a hazard passes through holes in all of the slices, leading to a failure." A series of minor failures that combine for a serious crisis seems very relatable.
- civilian 9y agoYup! My cousin & cousin-in-law work to maintain human health at some nuclear power plants in Canada. They use the swiss-cheese model, and whenever they notice that one layer missed something, they do a re-evaulation of that safety layer.
- jabl 9y agoAha! I sense an opportunity for an enterprising statistical physicist to model this with https://en.wikipedia.org/wiki/Percolation_theory https://en.wikipedia.org/wiki/Percolation_theory :)
- drdrey 9y agoAre you recommending the 2nd edition specifically? There is a 3rd edition available: https://www.amazon.com/Field-Guide-Understanding-Human-Error/dp/1472439058 https://www.amazon.com/Field-Guide-Understanding-Human-Error...
- csours 9y agoNo, I just didn't notice (speaking of confusing UI, Amazon seems to do everything possible to move UI elements small and large on a basis so arbitrary as to seem completely random)
- drsopp 9y agoI’m sorry for bringing this up here, but why do I need to scroll sideways in Safari on iphone on Hacker News every time there is a quote written in an unproportional font? Just, why?
- wtallis 9y agoBecause the markup for those blocks isn't intended for general-purpose quotations; it's <code> blocks. You don't word-wrap code.
- throwaway613834 9y agoPretty sure merely not wrapping doesn't imply quite as horrible a UI as we have there.
- monocasa 9y agoBecause he used block quote syntax. It's designed for code on HN's implementation, so it preserves newlines, instead making you scroll. It's a poor choice for quoting non computer languages.
- Jtsummers 9y agoMore importantly, in mobile the code block's width is only 200 pixels.
- ju-st 9y agoDoes anyone know a HN web interface (like hckrnews.com) that prettifies such quirks on the comment page for mobile phones?
- d_k_f 9y agohttps://app.hackerwebapp.com https://app.hackerwebapp.com is rather nice, although read-only. Tapping a link if you want to comment is acceptable to me, though I'd love to have voting on there.
- acdx 9y agoLeave it to HN to uncover the real cause.
- kpil 9y agoA number of the worlds largest ferries - 50% longer than USS McCain - are routinely navigating in very restricted and crowded waters in the archipelagos of Stockholm and Helsinki with a clearing under the keel of just a few meters. They seem to manage avoid colliding with both commercial traffic and the numerous sailing yachts while doing 18-20 kn. Accidents have happened, but it's not recurring events. One exception in the Baltic see is the Polish M/S Jan Heweliusz, that was involved in a number of of accidents, until it finally capsized in hard weather.
- eternalban 9y ago> The USS McCain was traveling at over 20 knots at the time of the collision http://cdn.cnn.com/cnnnext/dam/assets/170821080742-04-uss-john-s-mccain-collision-0821-exlarge-169.jpg http://cdn.cnn.com/cnnnext/dam/assets/170821080742-04-uss-jo... Sorry. That does not compute. Based on that visual, the ship was dead in the water.
- deleted 9y ago[deleted]
- jordanb 9y agohttp://s3.amazonaws.com/CHINFO/USS+Fitzgerald+and+USS+John+S+McCain+Collision+Reports.pdf http://s3.amazonaws.com/CHINFO/USS+Fitzgerald+and+USS+John+S... The McCain entered the TSS at 20 knots and varied between 20 and 18 knots until the steering problem began. The OOD ordered the vessel slowed to 5 knots but due to confusion on the bridge the orders weren't carried out properly and the vessel was still making 11.8 knots and turning to port at the moment of impact. The Fitzgerald was also traveling through traffic at 20 knots and narrowly passed three vessels at that speed before finally being struck by the Crystal.
- zaroth 9y agoThis to me is the under reported fact. Realizing how fast these ships were moving up to and through the moment of impact, while the crew responded hopelessly is extraordinary. Absolutely tragic.
- jabl 9y agoSounds like some kind of cowboy culture. "Hey, we have this fast and maneuverable ship moving along these lumbering civilians. We can handle it, we're the best of the best!". A bit like those organ donors, err.. motorcycle drivers, that swerve among the traffic at high speed.
- eternalban 9y agoSure, don't believe your lying eyes. Point out a single scratch that indicates anything other thana 90 degree impact with a stationary vessel.
- jasonkostempski 9y agoThat rule seems to apply to female ships only.
- zaroth 9y agoI completely agree, it seems like the speed was entirely excessive, and they literally lost control of their boat. Shameful. This sounds like pandemonium and panic. Sounds like the bridge was totally out of control. They didn't even follow basic procedure to warn nearby ships of danger, they just plowed right in front of one.
- frik 9y agoWhen will the first ship crash because of a BSOD? You think I am joking? No, unfortunately several types run on general purpose OS, and the possibility is there. http://www.popularmechanics.com/military/navy-ships/news/a27108/hms-queen-elizabeth-windows-xp/ http://www.popularmechanics.com/military/navy-ships/news/a27...
- Buge 9y agoThe article says they fairly quickly tried to reduce speed once they noticed something was wrong. But due to a (UI?) mistake they only reduced speed for 1 engine. It wasn't until 3 minutes later they finally fixed that mistake but by then it was too late. So they were unable to understand their own speed controls.