The Basics of “High Risk” Environments Skipped by OceanGate

(Halifax) The company that owns the submersible that imploded in June during a dive to the titanic ignored basic principles that guide those working in high-risk environments, according to emergency management experts.

Jack Rozdilsky, a professor at York University, Toronto, says OceanGate’s business – ferrying paying passengers to the depths of the North Atlantic – could be compared to the extremely risky work of companies launching spaceflight , drill for offshore oil, fight forest fires or operate nuclear power plants.

“These are so-called ‘high-reliability’ organizations that operate in complex, high-risk industries for long periods of time without serious accidents or catastrophic failures,” the disaster and emergency management professor explained in an interview. OceanGate does not appear to have operated as a “high reliability organization”. »

The professor cited three great qualities shared by these high-reliability organizations:

• They are very reluctant to simplify. They accept that the tasks they are involved in are complex and have the potential to fail unexpectedly;
• They are preoccupied with failure. They do not consider a “near miss” as a “success”;
• They practice resilience. They provide backups for backups – or as Professor Rozdilsky puts it: “braces for braces”.

There is evidence to suggest that OceanGate CEO Stockton Rush – one of five victims when the submersible Titan imposed near the bottom of the ocean on June 18 – emphasized simplicity rather than complexity when it came to the engineering of the small submarine Titan. In an interview last year at CBS NewsMr. Rush gave a tour of the very stripped-down interior of the submersible: essentially a power button, two video screens and a joystick to steer the 6.7-meter submarine.

Mr. Rush boasted at the time of this simplicity – “the Titan is to other submersibles what the iPhone was to the BlackBerry,” he said proudly. Professor Rozdilsky questions Mr. Rush’s decision to simplify to this point a device that visits the great depths, and which should therefore be more complex.

Lessons from Challenger

On another front, Mr. Rozdilsky believes that the lessons learned from the space shuttle disaster Challenger in 1986 – an in-flight explosion that killed all seven astronauts on board – reminds us that organizations operating in high-risk environments can fall victim to risk management errors and an erosion of security protocols.

In the case of Challenger, a presidential commission determined that NASA officials responded to early warnings about design flaws by raising thresholds for “acceptable damage” during shuttle flights. The commission concluded that NASA justified these changes by saying, “We got away with it last time. »

Likewise, the Titan has been the subject of several reports of problems and “near misses”.

“Successful high-reliability organizations see these ‘near misses’ as opportunities for improvement […] There is a preoccupation with failure, not success,” argues Professor Rozdilsky.

As for the commercial enterprise OceanGate, it has become clear in recent weeks that the Titan had experienced many problems over the past three years before and during his 3800 meter dives to the wreck site of the titanic.

Last month, German adventurer Arthur Loibl told The Canadian Press that his 2021 voyage to the “unsinkable ocean liner” had run into worrying trouble. The 60-year-old retired businessman said the submersible had experienced battery and ballast problems which led to 90-minute repair work. But the trip still happened.

YouTube celebrity Jake Koehler also posted a video describing how his trip aboard the Titan had been canceled earlier this year due to ongoing computer issues. “Long story short: let’s say every day they got in trouble,” according to the YouTuber.

Design issues?

Even though the Titan was under construction in Everett, Washington, red flags were already up. In January 2018, then-marine operations manager David Lochridge filed a report identifying serious safety issues, including improper testing of her carbon fiber hull, according to court documents filed in the state of Washington.

Mr Lochridge warned Mr Rush that the submarine would need to be certified by a classification agency, such as the American Bureau of Shipping – which never happened, according to court documents. Mr. Lochridge was fired.

Meanwhile, a search and rescue expert says Mr Rush’s business appeared unprepared for emergencies.

According to Merv Wiseman, a retired search and rescue coordinator, it remains unclear whether OceanGate had filed an emergency preparedness plan with the Regional Maritime Rescue Center in Saint John, Newfoundland and Labrador. Labrador, where he himself worked for 35 years.

“You can’t imagine an area more at risk than that,” he explained in an interview. He reminds that offshore activities such as drilling platforms must produce detailed emergency preparedness manuals, filed with the Canadian Coast Guard.

According to Mr. Wiseman, Transport Canada should also have had jurisdiction over OceanGate’s activities off the coast of Newfoundland. The federal department said last week it would respond to a request for comment, but never did. “I think it may have slipped through the cracks,” Wiseman said.

All the while, deep-diving experts have been issuing warnings about the shoddy construction of the Titan and lack of certification for years. As early as 2018, a group of engineers wrote a letter warning that OceanGate’s “experimental” approach could have catastrophic consequences.

There were also warnings about the lack of rescue systems from the Titan – another worrying trait that contrasts sharply with the practices of “high-reliability organizations.”

“If you send a vehicle [dans les profondeurs de l’océan]you should have a back-up vehicle on hand to help rescue the first one in the event of a breakdown,” Rozdilsky said.

This happened in 1991, when two Russian submersibles, known as Mir I And Mir IIwere used to bring in a film crew to film the wreckage of the titanic. At some point, one of the submarines was trapped by cables on the deck of the doomed liner. But the pilot managed to free the craft with the advice of his colleague on board the other small submersible.

Mr. Wiseman also believes that the Titan should never have dived alone. “It is reasonable to expect that if this type of journey is undertaken, with the lives of human beings at stake, there will be another submersible on the scene. »