On December 28, 1978, a DC-8 aircraft crash-landed in a Portland, Oregon, neighborhood when it ran out of fuel. During the hour preceding the crash, the captain had been consumed with diagnosing a landing gear issue and had not been monitoring the fuel. The two other flight crew on deck were either also unaware of the fuel situation or did not communicate the issue clearly enough to the captain.
This was a year after history’s deadliest aviation incident when two planes collided on a runway in Tenerife, one taking off, the other attempting to locate a taxiway in thick fog. The captain of the 747 taking off was convinced he was cleared to go while his first officer questioned their clearance and the flight engineer expressed concern that the runway was not clear — but neither vehemently enough to dissuade the captain.
The maritime world has been slower to catch on, perhaps due to a lack of urgency to change; after all, when mistakes are made in the air, people die a lot faster than at sea.
Both incidents were caused by human error. From these and similar deadly accidents in the 1970s, Crew Resource Management (CRM) was born, ushering in a new safety culture paradigm that improved crew coordination and — while respecting the chain of command — emphasized team decision making, ending the reign of the captain as authoritarian in the cockpit. United Airlines was the first to institute the training in 1981; by the 90s it was international standard.
CRM develops seven critical skills: active communication, leadership, situational awareness, adaptability/flexibility, decision-making, assertiveness, and mission analysis. With leadership that fluctuates from autocratic to democratic to laissez-faire, depending on the situation, the workload is better shared between all flight crew with the underlying logic being one person can only see a few things at a time, while two can see five to six things. Using all the resources of the crew produces better solutions than an autocratic approach. This is non-technical skill training that encourages an environment where all flight crew are responsible and not afraid to speak up. Note that when Capt. “Sully” Sullenberger was forced to ditch US Airways flight 1549 in the Hudson River in 2009, one of the last things he is recorded saying to his first officer is “Got any ideas?”
The maritime world has been slower to catch on, perhaps due to a lack of urgency to change; after all, when mistakes are made in the air, people die a lot faster than at sea. Run out of fuel on the water and no one is injured; hit another boat and there may be fatalities, but not likely in numbers reaching the 583 that perished in Tenerife. Based on CRM, the first Bridge Resource Management courses (BRM) began more than a decade following the aviation industry, but it wasn’t until the STCW 2010 Manila Amendments that training focusing on the human element was mandated — to be completed by January 1, 2017.
So, has it made any inroads into the yachting sector?
“The short answer is no,” says Brian Luke, president of bluewater Management & Crew Training in the U.S. for the last seven years and holder of a USCG Master 3,000-ton license. But it’s his other gig that gives him true perspective here: he’s also a captain with JetBlue Airways. “If you’re on a boat with ISM or mini-ISM, there is supposed to be CRM in it, but in my estimation, it’s something that is glossed over, (i.e.) ‘We’ll check this box’…but it’s not really happening. I can tell you that because I know what it’s like to be and work in an environment where it really does happen.”
Ted Morley, principal of Maritime Professional Training (MPT) in Fort Lauderdale, where they teach BRM and its follow-on course HELM (Human Element, Leadership, and Management), and also both a USCG unlimited tonnage master and a commercial fixed-wing pilot, says that on yachts below the 500-ton mark it’s rarely seen beyond some basic concepts. BRM is required for all USCG operational-level deck officers, but it’s not included in training for yacht-restricted MCA licenses. On the other end of the size spectrum though, he has noticed an increased influence of BRM and other commercial type courses on the new generation of gigayachts.
Even in the commercial maritime world, there is room for improvement, notes Jarle Gimmestad, a retired airline captain and now senior partner with Gimmestad AS, a safety management consultancy in Norway. “Their bridge team management regimes are too captain-centered: The captain does the work, the crew assists if needed, which it is not. The captains are technically skilled persons, but it is still severely immature and vulnerable in a system safety perspective.”
“We all want to learn from each other’s mistakes. The only way we can do that is to communicate and talk about them in an open forum….”
In his article for maritime insurance company Gard, “Crew resource management — silly small talk or crucial dialogue?” Gimmestad notes the difference in communication styles in a cockpit and a bridge. Between pilots, there is a continuous exchange of information, “Never leaving a thought, an observation, a reflection, a selection, a decision, or an execution unspoken.” It’s not small talk, he observes; it serves to keep the lines of communication open, thus the threshold to speak up is low. In contrast, on a ship, “when approaching the berth or narrows, the bridge will turn silent in individual concentration,” he writes. “This is done with the best intention, but it is vulnerable: the longer the silence, the higher the threshold for giving corrective inputs.”
When Gimmestad discussed this point with the bridge crew of a high-speed passenger catamaran, the first officer took affront and claimed that of course he would speak up if the captain were making a mistake. Days later, the captain tested this by deliberately not making a planned course change at a buoy. “At first, the officer felt uneasy, looked across to his captain, out of the window to the passing buoy, and into his radar screen,” Gimmestad describes. “He then started making noises, kicking the wall with his shoe, and knocking the screen with his hand. Nothing happened. The captain kept her steady, with a blank expression on his face. The officer’s final reaction? He left his chair for the toilet! To question his superior was impossible…for every second beyond the buoy, it became more impossible to speak up.”
Another key difference between the maritime and aviation industries is the variance in Standard Operating Procedure between boats compared to the continuity in aviation — a natural dissimilarity considering the thousands of individually owned vessels in yachting compared to airlines with hundreds of aircrafts each. “At JetBlue, we have two hundred airplanes and four thousand pilots so we all have to operate exactly the same way,” says Luke. “If I went from JetBlue to American Airlines, even though we have slightly different CRM programs, things are going to be really close, there won’t be any big surprises. I find in the yachting industry, it’s still very loose in terms of the way a captain wants to run his ship; he’ll run it the way he wants. The captain wants things done the right way — but what is the right way? The right way is his way.”
Gimmestad gives the example of two friends who rotate as master on the same vessel in Norway. “One of them always moors with a single bow spring line on short port calls, adding a little forward power to hold her alongside. The other does the same but with a single stern line,” he writes. “Both argue offensively that the other’s technique is dangerous.”
With this lack of consistency, it is difficult to fully incorporate the tenets of CRM. How do crew know to question a discrepancy if the standard is ambiguous? Aviation operations are centered on checklists — not so in yachting, yet having a checklist or job description puts everyone on the same page, with all working to ensure the job is done properly. The ultimate goal of CRM or BRM is error trapping — as Morley describes it, “identifying a failure or a fault before it results in an accident. That’s where BRM really shines because you have got that redundancy,” he says. “You’ve got people checking things, you’ve got double equipment, you’ve got checks and balances there. A lot of accidents have been avoided because someone caught the error early on.”
Error mitigation is also achieved through post-mission analysis. Aviation encourages conversation as a means of education, says Morley. “We all want to learn from each other’s mistakes. The only way we can do that is to communicate and talk about them in an open forum. That’s really tough in the yachting industry because we all want to appear to be infallible when in fact no one is.” Big mistakes can’t be avoided, he says, but small mistakes can easily be hidden, and it’s from these small mistakes that most learning can occur.
Luke concurs: “If we do something wrong in the yachting industry, we shut our mouths and never tell a living soul. We just don’t have good systems in place that will help us do that.”
On the contrary, the U.S. Federal Aviation Administration has a reporting system where non-criminal, non-intentional mistakes are exonerated; flight companies also have their own systems in place; they want their pilots to report anything that went wrong during a flight so no one will do it again, explains Luke. The yachting parallel would be management companies, but within some, a blame culture exists that works against the goal of error mitigation.
“If we do something wrong in the yachting industry, we shut our mouths and never tell a living soul. We just don’t have good systems in place that will help us do that.”
A captain of very large superyachts praises his current management company, Burgess, for its progressive attitude in this respect. “They are one of the few companies I’ve worked with who I feel is actually working with me and not against me. I have worked with management companies before where if I reported something, it was like, ‘Oh, why did you screw up?’ rather than ‘Okay, we made a mistake, what was the root cause, let’s move forward, let’s fix it and make sure it doesn’t happen again,’” he says.
His background in the commercial world means he was brought up on BRM as opposed to a captain coming up from 30-meter boats who may not have been exposed to it. “I make an environment on the boat where nobody is afraid to speak up,” he says. “I am extremely approachable and transparent. The last thing you want is someone afraid to speak up and an accident happens. That’s a crazy way to run a boat.”
Yet on some yachts, a fearful environment still prevails where crew learn to keep their mouths shut. “That culture is what needs to change, and that’s what is slowly changing across the board,” says Morley. It’s only been four years since HELM training has been required by STCW 2010. “HELM gets into the psychology of human interactions, the psychology of chain of command, and how to be an effective, communicative leader and not create this environment where no one wants to talk to you, no one wants to share, and no one wants to be blamed,” Morley explains. “The concept of resource management is a little behind the curve in the maritime industry as opposed to the aviation industry,” Morley acknowledges, “but it’s gaining traction.”
Comparing the two industries, it’s clear that the risk is much less in yachting, and that the practicality of adhering to a single standard is questionable at best, but when it comes to the safety culture on board perhaps it’s better to focus on what binds these industries: the fact that most maritime accidents are caused by human error — just like in aviation.
This article originally ran in the October 2020 issue of Dockwalk.