Apr 142010
 
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Hugues Cauvier

Reporting near-misses and unsafe conditions has proven to help reduce serious accidents. In the case of pilots, legal issues get in the way of reporting close calls says St-Lawrence River Pilot Hugues Cauvier, of pivot point fame, calls for greater transparency.

Says Hugues: “I would like to share some thoughts with you gentlemen whom I feel may be concerned by the title subject. It might be naive to hope that the regulations can be changed but stirring the idea may be better than doing nothing at all.

I will be delighted to read your reactions if any of you feel like sharing them (Use the MAC contact from, or the ConReps form).

“Near misses experienced by navigators are rarely publicly discussed. They have to be reported by regulation, at least here in Canada, but few individuals are masochist enough to incriminate themselves in the face of the world if they are not forced by some authority. The result is that lessons that could be learned from these errors are lost forever.

“For the last couple years I have been conducting a non-official inquiry among my colleagues in order to gather various shiphandling experiences at the different docks of our districts. The goal of the process was to “augment” the experience of the trainees and the newly certified pilots.

Surprisingly, many pilots have been willing to bring their input, not only their good tricks but also some inglorious ones, which includes here any manoeuvre that did not evolve like it should have done.

I will teach nothing to some of you who are professional inquirers that there is at least as much to learn from the bad experiences than the ones performed “by the book”. Having been coaching apprentice pilots on a few occasions, I can report that the ear-and-eye opening effect that these stories have on the listener is tremendous and all candidates are happy to store them in their “virtual experience” brain file.

As my story research went on, some colleagues made me realize fully what it was legally implying. It resulted, to my enormous disappointment, in censorship of an important part of the collected data.

Near misses just happen. According to a former TSB investigator I was discussing with recently, statistics say that for one actual accident involving loss of life, there can be as many as 600 near misses (I couldn’t believe it!). But near misses are not always due to incompetence. In an environment subject to so many uncontrollable factors as maritime pilotage, an individual, regardless of his years of experience, cannot be expected to foresee all possible conditions and foremost have the instantaneous best solution as the situation arises. To benefit from the cumulative experience of others in such situations would be a powerful preventive tool.

The legal frame is unfortunately depriving the pilots from an effective and open sharing system of near miss reports. Having a parallel record of such events would simply just make us guilty of not declaring the mishaps to government authorities in the first place.

Result: Apart from a few confidant colleagues we trust to confess our sins (like the surgeon who admits to his peer having forgotten his cell phone in someone’s belly), the valuable lessons we learn from a near miss situation remain completely useless for the vast majority of fellow pilots, which is, let’s admit it, an even greater sin.