Part of an ongoing project looks at the history of maritime accident investigation:”Today, concepts and procedures in maritime accident investigation are changing faster than at any time in the last two and a half thousand years.”
Here’s a draft, feedback welcome.
History Of Maritime Accident Investigation – from ‘who to blame’ to how to Stop Accidents
Today, concepts and procedures in maritime accident investigation are changing faster than at any time in the last two and a half thousand years. Before we look at where it’s going, let’s look at how it began.
Maritime accidents have been happening since humans first learned to float.
Eventually, vessels started carrying goods from one place to be sold in another,
Sometimes they came to grief and the most important question to be asked was: who was going to pay for the damage to the ship and how were they going to be punished?
At first there were unwritten customs and practices, called custom laws, that laid down safety rules and regulations. Later, these were commited to paper and laid the foundations for many of the laws we still use today.
The maritime law of Rhodes, Lex Rhodian, laid down the principle of general average, which determined who pay how much of the losses when a ship cames to grief.
Other laws have vanished into history. In the 13th century if a merchant wanted to pay a ship to carry his goods the ship’s master was required to show the merchant his rigging and cordage. If the merchant accepted them and the ship foundered, then the merchant was responsible for the losses. If the ship’s master did not show the merchant his rigging and cordage then the ship’s master was responsible to pay for the loss.
Under the sea laws of Oleron of 1255, the first written maritime laws in northern Europe, if a pilot was incompetent and the ship or its cargo was damaged, he was required to pay for the damage. If he didn’t have the money, the ship’s master had the right to cut off his head.
Loadlines to ensure that vessels were not overloaded were first introduced by the Venetians and it was the job of the merchant who travelled on the ship to keep an eye on them.
With written and unwritten laws in place someone had to decide who was at fault, who had to pay for damages, who had broken the law.
At first this was the person who usually heard disputes: the local lord, the town mayor, a council of community elders. As trade became more important, it became the job of commercial courts, then, in 321 BC the Admiralty Board, or court appeared in India and spread through China and Egypt and finally to Europe.
The 19th century saw the development of Boards of Enquiry which would summon particpants in accidents and experts as advisers to determine, again, who was to blame, who was liablke, who had to pay. Little had changed in at least 2,500 years but in 1860 the seed for a new approach was sown that would take another century to germinate, the concept of accident investigation for the purposes of safety.
Boards of Inquiry were often formed by the government ministry which was responsible for regulating the maritime industry, or the coast guard, which was responsible for enforcing those laws and regulations. It was rare for a board of enquiry formed by the regulating body to find anything wrong with the regulations and just as rare for an enquiry formed by the coast guard to find anything wrong with enforcement.
As a result, Boards of Enquiry did little to solve the problems of maritime safety. That began to change with a geometric increase in maritime trade from the 18th century and an event which shook the western world: the sinking of the Titanic.
Empires depend on trade so it’s no surprise that the 18th and 19th centuries saw the rise of the maritime industry. Western countries like Britain, France, Belgium, Germany and the Netherlands, and America towards the end of the 19th century, found that like the Chinese trade empire, the Roman empire and the Islamic empires before them, their expatriates want food from home, and their home countries wanted products from elsewhere in their empires.
Britain’s empire was the largest mainly because it led the industrial revolution which created factories and overseas markets were necessary to keep those factories profitable. It’s textile mills flooded the world with cheap cotton and its steel mills provided the world everything from cookware to swords and guns. All of those goods had to be carried in ships. It was a sophisticated global trade and accidents were bad for business.
Studies have shown that maritime accidents increase according to the square of the increase in traffic. If shipping traffic doubles, there will be four times as many accidents. If traffic triples, the number of accidents increases by nine times. It is a merciless mathematical formula that, by the middle of the 19th century, took its toll on the British merchant fleet.
By then, Britain’s merchant navy was losing more than 2,000 ships a year. Not surprisingly, those numbers got the attention of the British bicameral legislature, the House of Commons and the House of Lords.
It was in 1860 thatSir Thomas Farrar told a paliamentary select committee investigating the disturbing level of maritime accidents: the object of the inquiry is not so much to punish anyone who may be at fault, as to prevent wrecks in the future, whether by punishment of and warning against negligence, or remedying anything that is wrong in the way of navigation . . .
For the first time, maritime accident investigation was linked to safety. It was believe that punishment of the guilty as determined by a hearing would enhance safety but, more importantly, it suggested that the findings of an investigation could lead to regulations that enhanced safety.
For the next 52 years not much changed. An accident happened, someone was found liable, and everyone went back to sleep until the next accident. It was enough to find someone guilty.
In 1912, on a calm, starlight night in 1912, that changed.
RMS Titanic was not the safest ship ever built. That honour probably belongs to Isambard Kingdom Brunel’s Great Eastern. Because she was built with a double hull and compartments with full height bulkheads that prevented the ship flooding and floundering, Great Eastern easily survived two accidents of the kind that would doom the Titanic.
Over the 58 years that followed the launching of Great Eastern, her safety lessons were set aside. Double hulls occupied space that could be used for profit so the Titanic was built with only a double bottom. Watertight bulkheads made it difficult for passengers and those who served them to move about the ship, so holes were put in bulkheads. Bulkheads could be made cheaper by not building them high enough.
She didn’t carry enough lifeboats for all onboard because shipowners of the day, unwilling to pay for safety, leveraged their influence over those making the regulations, to base the number of lifeboats required on a ship’s tonnage rather than the number of passengers.
When the Titanic sailed on her maiden voyage, which was her last voyage, she was fully compliant with the regulations. It was a phenomenon that still exists today: compliance and safety are not the same thing.
There was a lack of lifeboat drills so neither passengers nor the crew were prepared or equipped technically or psychologically to make the best use of them in an emergency.
Lookouts in the crowsnet on the last, fateful night of the journey weren’t equipped with binoculars. Binoculars are expensive, someone migh steal them, so they were safely locked up in a box and no-one on watch had a key. They didn’t have the tools for the job.
Then there was the relatively high speed of the Titanic in the ice field at a time following a warning about icebergs.
Finally, since radio was a new invention there were few internationally recognised procedures. Radio warnings about icefields remained in the radio shack and didn’t go to the bridge.
All it now took was a night so calm the sea looked like black glass. There was no tell-tale wash of waves on icebergs that enabled them to be seen at a distance. Without binoculars, the lookouts didn’t see the iceberg until the ship was almost upon it.
Each of these elements were parts of the jigsaw of disaster. There was no single cause for the tragedy of the Titanic, there were many.
Exactly what happened when the Titanic hit the iceberg is still open to question. She may have slid against an outcrop of ice, or grounded on an underwater iceshelf. The result was a series of holes in her hull not much bigger than a domestic refrigerator that let in a tonne of water every five seconds. One by one, forward compartment were filled, dropping the bow, letting water flow over the incomplete bulkheads into compartments further back.
The ship sank, as ships made of iron will, given the right, or wrong, conditions.
Some 1,500 people died not just because there weren’t enough lifeboats but because there was little experience in using them.
The Titanic incident was placed before the traditional board of enquiry system, one in the UK, one in the US. No single person was found to blame, it was just one of those things. No-one living was found to blame.
For maritime investigators the importance of the Titanic disaster is that it lead to the safety of life at sea convention, SOLAS, and the creation of what we know today as the International Maritime Organisation. That process took a half century to gain acceptance, by the time it did, a new concept was coming to the fore, almost the same concept that Sir Thomas Farrar espoused a century before: maritime accident investigation should be about safety, rather than liability.
By the 1960s it was realised that boards of enquiry, with their concentration on liability first and safety second were not leading to greater safety at sea. They also duplicated civil and criminal investigations and investigations by coast guard authorities. it was an inefficient, costly system.
The outcome of that realisation was the creation of a new maritime accident paradigm and the creation of new agencies which were independent of regulatory and of law enforcement bodies and which had full-time investigators. Their objective was to determine how safety could be improved. A good example is the UK’s Maritime Investigation Branch.
Rather than depend on dragging witness and experts into what amounted to a court room atmosphere, this new breed of professional maritime investigator went out into the field using forensics, witness interviews, on-site investigation and root cause analysis techniques to determine what happened, how it happened and how to stop it happening again. To do that, they involve industry stakeholders in enhancing safety.
The one thing they weren’t concerned with was liability, who to blame. How it works in practice we’ll see in a future module.
Most of the world’s major maritime nations have abandoned the board of inquiry approach, although it remains in a number of countries in the developing world. Many of those countries still adhering to the system have accident records that demonstrate well that the system does not work.
The International Maritime Organisation has accepted this new paradigm and on 1st January, 2010, its Code of Practice for the Investigation of Maritime Casualties becomes part of the Standards of Training, Certification and Watchingkeeping Convention, STCW and it will become mandatory for member nations of the IMO. It doesn’t ban boards of enquiry, but it does make them obsolete.
we’ll take a closer look in the next section.