Human error, boats and tigers.

In the Man Booker Prize-winning "Life of Pi", Yann Martel tells the story of a boy who survives a shipwreck to find himself sharing a boat with the only other survivor, a tiger. This blog is not about that book.

However it is about a boat, a tiger and... human factors.

When the Costa Concordia  ran aground on the 13th January 2012 off the coast of Italy 32 people died. The waters were well-charted and calm. The weather was clear. One had to wonder how this cruiseship with over 4000 passengers and crew managed to hit rocks and become partially submerged. The company which owned the cruise ship issued this statement on the 15th January:

"It seems that the commander made errors of judgement that had serious consequences: the route followed by the ship turned out to be too close to the coast, and it seems that his decision in handling the emergency didn't follow Costa Cruises' procedures which are in line, and in some cases, go beyond, international standards."

The CEO of Costa Cruises on the 16th January told the world media that the captain made an "unapproved, unauthorised" deviation in course. Lloyd's List published an illustration, widely distributed, which showed how far off the "correct" course the ship had been.

The facts seem very clear: The captain of the Costa Concordia deviated from company protocol and somehow managed to ram his ship into rocks. However a later illustration, also from Lloyd's List, starts to raise more questions. This illustration shows that on a previous voyage the Costa Concordia actually deviated further from its route than on the day it sank.

According to this BBC review of the incident, the captain committed a number of errors. However there are other factors to consider:

• Why did the helmsman not question the captain's decision to come so close to shore? What are the power gradients on board large cruise ships? Can any member of the team voice a concern and expect it to be listened to?
• What are the cruise owner's protocols for dealing with violations? According to Richard Meade, the editor of Lloyd's List, the owner would have known about the route taken in August.

Leaving the boat behind we turn to the tiger and the tragic case of Sarah McClay. Ms McClay was a zoo keeper who died on the 24th May this year after being mauled by a tiger. A statement on the zoo's Facebook page on the 25th May explained:

"...from the investigations that have taken place it is clear that this tragedy was caused by a sad error of judgement and breach of protocols, in essence keeper error. This is not blame, it is not anything but defining the facts as they appear. This does not mean Sarah killed herself on purpose it means simply she died from her own tragic mistake."

The BBC on the 25th May reported the zoo owner, David Gill, as saying:

"We have very strict protocols and procedures for working with big cats, but it seems she failed to follow correct procedures. For inexplicable reasons she opened a door and walked into the enclosure. We will never know why she entered without telling anyone. There was no reason for her to go in there."

And on the same webpage Mr Gill is quoted as saying: "It would not do any good to close the park as there is no safety issue."

However, the most recent news report now suggests that Sarah McClay did not walk into the enclosure. The tiger dragged her into it from a staff area, to which the tigers are not supposed to be able to gain access.

The parallels with the Costa Concordia incident are clear. From an initial blaming of the individual the widening investigation starts to show up human and technical errors. As part of an error chain these incidents lead to a sequence of events which result in the loss of life. In the end, whether it's boats, tigers, or healthcare, we need to move beyond the scapegoating of individuals. In a complex system, we need to focus instead on the series of mishaps which culminate in a catastrophic error.

Updates:

On the 11th February 2015 Costa Concordia captain Francesco Schettino was sentenced to 16 years in jail for multiple manslaughter. According to the maritime trade union Nautilus "There has been an absence of meaningful action to improve safety in response to the Costa Concordia accident, and this trial has simply served as a distraction from the important underlying issues." The ship's operator, Costa Cruises, paid a 1-million euro fine in April 2013 to settle potential criminal charges and in the February 2015 court case the company and Schettino were jointly ordered to pay £22,000 to each passenger.

On the 18th September 2014 an inquest into Sarah McClay's death concluded that the tiger was able to reach her through a door which should have been locked with the possibility that the door was faulty.