Statement of Rear Admiral John Lang, British MAIB

ADMIRAL LANG: Mr. Chairman, ladies and gentlemen, good afternoon. It's a very great pleasure to be back here in Washington and to have this opportunity to tell you something about the United Kingdom's experience with data recorders in marine accident investigation.

I hope you have no difficulty in understanding a British accent for the second time today, and that you all forgive me if I lapse into an excess of nautical jargon. It's a habit of sailors when they get carried away, but I promise to stay with you, if I possibly can.

I have with me a friend and colleague, Captain Nick Beer, whose primary role is to answer all the difficult questions afterwards.

Allow me to start by setting you a very small mental task, albeit one with a very high-risk factor. I want you to shut your eyes for a moment and think what image springs to mind if I say the single word "transport". The risk involved is that so soon after lunch, you may feel this is an outstanding opportunity to nod off. So, perhaps you should perhaps open your eyes and consider the word again.

Most of us here today will have arrived by car or perhaps by Metro. Others will have flown into Washington, and there isn't one of us, I suspect, who isn't aware that there's a very busy airport less than one mile away.

The chance is that most people will associate the word "transport" with planes, cars, trucks or trains, and these are the modes that each one of us sees or uses every day. It's a curious fact of life then when asked this question, very few people ever pause to think that 95 percent of the world's trade in weight is actually carried in ships, and the sea is still the busiest highway of all.

Every day, millions of tons of gas, oil, bulk freight, manufactured goods and people are being transported across the oceans, through coastal waters, and along inland waterways. In many countries, rivers and canals are the main arteries of trade, and in some places, boats are the only form of transport.

The sea continues to be a prime source of food stuff, and fishing is a key industry for many, many countries. It is also increasingly a place of recreation. Many of us take holidays on floating cruise liners, and places like Miami are home to ships that can carry several thousand passengers.

On a more modest scale, in vessel size, if not in bank balance, some people could enjoy pleasure craft at this level, while others, many more, enjoy sailing and boating on a more modest scale on rivers, estuaries, lakes and on the open sea.

So, if I was to ask you once again what vision the word "transport" conjures up, I'll place a very small bet that perhaps one or two of you are now thinking of ships and the sea.

Now, let me try a second word, "safety". What image springs to mind? Life boats? Life jackets? Storms? Air-sea rescue helicopters? Or those poignant letters SOS or does it conjure up the name of a single ship? Titanic?

It's a curious feature of maritime life that the first thing that many people associate with the sea is disaster. This particular one remains amongst the worst of all times, and the story continues to grip people's imagination. No doubt, many of you have seen the Oscar-winning film, and if you can find a new angle on the disaster and have the gift of writing, you, too, can probably earn yourself a dollar or two.

But it is even more curious to reflect, and I hope you can read this slide, that if I was to mention the name "Donna Paz", the chances are that very few of you would know what I was talking about. It was the name of a Philippine Islands ferry that collided with a small tanker carrying petroleum in 1987 in what was one of the most awful transport disasters of all time.

The fire that broke out after the collision killed nearly 4,400 people or, to put it another way, about the same number of people that are carried in 10 jumbo jets, all who lost their life at the same moment.

The point of mentioning these horrific examples of past marine accidents is that although sea transport is relatively safe, accidents can and do happen.

Now, of all the things that can go wrong at sea, few manage to excite quite as much attention as a large oil tanker landing up in somebody's backyard. At one end of the scale, the master may get no more than a parking ticket, but at the other, we are talking about massive pollution damage, such as we have seen in Torey Canyon, as is seen here, Amoco Cadiz, Braer, and, of course, Exxon Valdez.

Safety at sea is foremost in many people's minds. The only United Nations body in the United Kingdom, the International Maritime Organization or IMO, is dedicated to improving safety, and many flag states spend much time and effort trying to raise standards in an industry where shortcomings are often all too evident.

But just like the air transport industry, one of the most effective catalysts for improving safety at sea has been the careful analysis of accidents. When properly carried out, they lead to effective recommendations and appropriate measures to prevent them happening again.

I can say with a degree of confidence that despite some awful tragedies, such as TWA 800 and SwissAir 111, aircraft safety has benefited immensely from the careful analysis of air accidents in the past. Much of this has been due to the widespread fitting of flight deck recorders and cockpit voice recorders and what they have revealed after the event.

I have to say I wish I could say the same about sea transport. I will make the bold assumption that most of us here are in no doubt about the value of having data recorders, but I have to say that such a view would not be shared by many ship owners and flag states around the world.

Many of them would argue strongly against them on commercial, financial or even, surprisingly, safety grounds. They see no commercial advantages to having them, and there is no doubt they are expensive to install.

They would also say that it is rare for there to be no witnesses to a marine accident, and those present are likely to be well placed to give a perfectly-good account of what occurred.

Although few would admit it, there is at least a suspicion, the one reason for this resistance is that many will be greatly embarrassed if marine accidents were probed too carefully. An element of doubt is a useful tool to employ in the law courts when resolving liability.

This failure to fit any form of data recorder in ships means that even when an investigation is carried out, those conducting it have to rely extensively on what people remember or by forensic means.

As this slide shows, there are many limitations to the existing methods of investigating accidents at sea, and it is perhaps worth reflecting that even when an accident investigation takes place, very often no report is ever published. So, none of us can ever learn from the experiences of others.

The problem with having to rely on witness evidence is that even the most gifted among us tend to forget things. How many of us remember where we put the car keys last night or what we were doing at 3:30 yesterday afternoon?

Until relatively recently, the main objective of marine accident investigation was to apportion blame or establish where liability lay. Many marine lawyers still focus on this for perfectly legitimate reasons. So far as the press is concerned, this is still the only thing worth reporting, but it is in my view an unhelpful approach when the principal objective is to find out what caused whatever the accident was and to make recommendations to prevent the same thing happening again, and this is a view shared by the growing number of independent marine accident investigation organizations around the world, many of whom are represented here today.

This enlightened approach has also led to greater interest in the human factor side of marine operations. Unlike the air transport industry, where much emphasis has been placed on this in recent years, it remains a little understood or perhaps even ignored part of sea-faring.

It is often said that over 80 percent of marine accidents are caused by human error. Interestingly, nobody really knows why, and surprisingly, little research has been conducted to find out how this appallingly-high figure can be lowered.

One of the problems faced by those who seek to make ships as safe as possible is that accidents can rarely be investigated with quite the same thoroughness as we see in air accident investigation, and the main reason for this is that with one or two exceptions, we still do not have the means of recording exactly what happened when the accident occurred.

But all is not lost. Some ship owners realize the great benefits of fitting data recorders and a handful of vessels are now sailing with a voyage data recorder fitted, and this is what one looks like on a bulk carrier. This particular one is carrying many thousands of tons of iron ore up the English Channel.

In my opinion, the sooner these are widely fitted, the better, and we can start to find out why things do go wrong at sea, and why so many accidents occur.

Although voyage data recorders are not widely fitted at sea, there are in practice many electronic instruments with memories. Some are obvious, such as shore radars, on-board closed-circuit tv, course recorders, private video cameras, and the automatic monitoring of radio transmissions.

At the same time, nearly every ship carries a range of computers that can be accessed for information if done correctly. This particular slide shows what the inside of a relatively small British fishing vessel wheelhouse looks like. Every one of these various displays has some form of memory with a potential to reveal valuable information, and I sometimes wonder how the officer of watch ever has time to look out of the window.

United Kingdom's Marine Accident Investigation Branch or the MAIB has been slowly accumulating experience in the use of a wide range of data recorders. These have varied from the simplest private video camera to a fully-integrated VDR on board a large cruise liner.

The information that we have managed to extract has frankly been quite a revelation. Not only have these various devices played a valuable and often crucial role in establishing the cause of an accident, they have also shown up the limitations of traditional methods of accident investigation, and they have also revealed much about human factors at sea.

Let me give you some examples. About three years ago, in this not particularly good slide I'm afraid, a security camera on a harbor jetty filmed a fishing vessel capsize in 16 seconds flat. This slide shows the unfortunate craft some six seconds into its embarrassing claim to instant fame. Not only did the film help identify the serious shortcomings of one fisherman's stability calculations, but recordings of the event made a major impact on other fishermen.

More recently, a vessel was in-bound up the River Thames when it ran aground and resulted in this picture. The master was absolutely sure he was in the deep water channel at the time, and the nature of the damage tended to support his view. But the evidence and the radar tapes recorded by the local port authority showed without any doubt whatsoever that he had been steering outside the channel for several minutes before he grounded.

Without such evidence, we would have been unable to make a firm judgment on what had happened or make several far-reaching recommendations about navigation competence in piloted waters.

About two years ago, a cruise liner was leaving a British port when she struck a rock and severely damaged herself as this picture of her bottom shows. Now, time doesn't permit me to go into any details, but suffice to say much of the event was recorded on video by someone standing next to the pilot, and while the video pictures greatly helped us reconstruct what actually happened, its most revealing feature was that it recorded what the pilot was saying, and we know from this that the pilot had absolutely no idea that the ship was just about to run aground.

But perhaps the most interesting investigation we have carried out was in a vessel which suffered a complete power failure one night in rough weather and started to drift towards a lee shore, and what made this incident so revealing is the vessel was equipped with a fully-integrated VDR, and to give you an idea of what it looks like inside the bridge, the recorder in this ship is situated in the gray box on the deck below the left-hand window.

The events in this incident, however, took place on this bridge at night. The most obvious advantage to arise from the VDR on this occasion is that we were able to reconstruct what happened against a common time standard, but of equal interest is it allowed us to identify many human factor issues that for all we know might have gone totally unnoticed in an investigation without the data recorder.

It was also interesting to note the surprise of some extremely reliable witnesses when they discovered that their recollection of what had happened was so different to what had actually occurred, and what made the whole episode particularly interesting is this was a well-run ship with an experienced and fully-qualified staff handling what was in effect a totally unfamiliar situation, and yet many inadvertent mistakes and errors were made.

Had it not been for the VDR, we would never have known precisely how things unfolded that night, and nothing would have been learned for the next time.

Let me take you through some examples of what actually did happen. The incident was investigated initially in a conventional manner. The crew were interviewed. Documentary evidence was examined, and the causes of the initial black-out were identified, and a picture emerged about what had happened.

But as so often happens in investigations, certain things were just not tieing up, and the deeper the investigation probed, it became clearer the events had not happened in the way described by witnesses. But the difference with this investigation is, as I said, we had access to a VDR that was, most importantly, functioning at the time.

It recorded all the significant features that underpinned the decisions taken and indeed the actions that followed. For the first time, we were able to find out not only what happened but why. We were able to listen to what people were actually saying to each other on the bridge, and this more than anything enabled the investigators to work out how the various discrepancies arose and to focus attention on matters that would almost certainly have been forgotten or ignored had it happened somewhere else.

In this particular incident, the master recalled keeping the Coast Guard informed about his vessel's movements towards the shore. He was very comfident he had done so. The Coast Guard, on the other hand, said that they had indeed been kept informed, but the reports from the vessel clearly stated that it was drifting away from the land, and using this information, the local emergency plan was never activated.

The actual exchange was recorded on both a radio transcription and the VDR. Faced with the evidence, the master was incredulous. His recollections about some of the things he had said during the emergency were very different to what the recorder revealed when it was replayed for him later.

But more revealing was that the VDR provided the information as to why the master had passed the wrong information. The bridge microphones had picked up what the officer at the chart table had reported to the master. The positional information on the VDR revealed that the officer concerned had in fact made several mistakes when plotting the ship's position on the chart and incorrectly calculating the drift direction and rate.

The VDR provided invaluable information about a vessel that was normally well run, but as it clearly revealed, even the most experienced people failed to remember things afterwards, and it also demonstrated that even in the best-run ship, things can go wrong when the pressures start to mount.

To the accident investigators, such discoveries focused attention on why the mistakes were made rather than apportioning blame or disciplining the poor person who got it wrong.

Very few merchant ships ever have the opportunity to exercise real-life crises, and when they do occur, they have to rely extensively on established but modified routines to manage whatever the new situation is. It is up to the investigator to make recommendations to explore how things might be handled differently in an emergency given the realities of life at sea today.

The catalyst for any such innovative thinking is the VDR. Without it, the chances are that precisely the same errors will be made again and again, not only in the ship in question but in others. So far as I'm aware, no in-depth study has ever been made to identify how a passenger liner captain should handle the command and control aspects of a major emergency, and this is because nobody really knows what they do at present, but the chances are that in the next major incident, the master will, I predict, probably try and do too much himself.

Careful accident analysis using VDRs may show there are better ways of doing things. Perhaps I should be bolder and say that VDR will show there are better ways. The reality of the data recorder is that it can expose the things that do go wrong, and as we have seen, things can go badly wrong at sea.

In many ships, such exposure could be acutely embarrassing if the raw material gets into the wrong hands. It is therefore understandable that such considerations might influence people's judgments when deciding whether to fit VDRs or not, but without such devices, we will never really get to the bottom of why some things do go wrong.

The important thing is not so much to point the finger at people who make the mistakes, the favorite ploy of many in the past, but to identify the problems and do something to overcome them.

Our experience to date demonstrates the very real differences between traditional ways of investigating an accident and what can be achieved with data recorders, both on board and ashore.

Despite some encouraging progress by the IMO, things will not really improve until VDRs are cheaper to fit, have proved to be effective in improving safety at sea, and mariners have confidence that the data on them is only made available to the accident investigators.

In my opinion, and it is only my opinion, the wide fitting in VDRs in every sea-going vessel, both big and small, would do more to improve safety at sea than almost any other measure. The problem is how does one encourage the ship owners to fit them.

According to some, regulating the international marine industry is comparable to King Canute telling the tide to "hold it". There is one thing a ship owner will always find attractive, the reduction in operating costs.

If some form of financial incentive can be provided to the vessels fitted with a functioning VDR, then we may start to see a much greater willingness to fit them and a commensurate reduction in installation costs.

If the incentives can be made large enough, then what could start as a trickle could land up as a flood. I hasten to assure you I use the word "flood" metaphorically.

And, finally, a personal observation. Although my evidence is still slightly tenuous, there are signs that a VDR-fitted vessel tends to have crews who are more safety conscious than those in vessels without. After all, those on board a VDR-fitted vessel will know that their poor performance can be monitored, and if they are involved in an accident, their actions will be closely scrutinized, and this thought tends to concentrate the mind a bit.

If this is true, it could just become a factor when charterers or potential passengers come to choose which vessel to use or sail in. Can you imagine what the impact would be if they were to ask whether the ship they were interested in had a voyage data recorder because they thought it was safer? It is an interesting thought, and those who travel or use ships to transport goods around the world should ask about safety because safety at sea and ways of improving it is why so many of us are here today, and in my opinion, having VDRs widely fitted at sea is one of the ways of achieving it.

Thank you.