It Wasn't The Storm
A pirate post-incident review on why your incident commander is doing more than you think.
PROBLEM RECORD — PRB-1743-BLACKSPOT Raised following INC-1743-BLACKSPOT (Total Loss of Vessel, The Black Spot)
Status: Post-Incident Review Complete
Problem Owner: D. Norkin, Harbour Master (recipient of both ravens)
Review Facilitated by: Nobody. This document was written collectively. It took fourteen weeks.
INCIDENT SUMMARY
On the evening of [DATE UNKNOWN - the ship’s log was being used to prop open the powder room door], The Black Spot encountered severe weather conditions in the North Atlantic. The vessel sustained catastrophic and irreversible damage resulting in total loss of ship, cargo, and most of the crew’s confidence in each other.
The position of Incident Commander had been formally eliminated six weeks prior to the incident following an operational efficiency review conducted by Harwick & Sons Maritime Consultants, who noted that the Captain “did not directly contribute to propulsion, navigation, or combat operations” and recommended the role be dissolved with responsibilities distributed across existing crew.
The review was conducted during fair weather. This was considered representative.
The redistributed responsibilities were documented in a two-page appendix. The appendix was filed. No one is able to confirm where.
The storm did not appear to have read the appendix.
INCIDENT DETAILS
Duration: Approximately 64 minutes from initial storm detection to reef contact. The incident is considered ongoing in the sense that the ship has not been recovered as of this writing.
Scope: The entirety of the vessel The Black Spot, inclusive of cargo. Vessel was forcibly relocated in close proximity to a well documented reef in the North Atlantic Ocean.
Crew Impact: Of the original complement of 27, fourteen are confirmed present for this review. Nine are accounted for but declined to participate. The remaining four submitted stew as a mitigating factor and have been asked to resubmit (see below timeline).
Cargo Impact: Total loss. The manifest has not been recovered. This is considered fortuitous given the nature of several listed items.
Reputational Impact: Significant. The Black Spot was previously considered a competent vessel with an experienced crew. This assessment will require revision.
Financial Impact: The Black Spot was valued at approximately £3,400 at time of loss. The efficiency review which precipitated the incident (see summary above) saved the vessel £65 per annum in Incident Commander’s salary. A full return on this saving would have been achieved in approximately 52 years, assuming no further storms.
Recovered by: Several restoration streams were attempted (see below timeline), however none were successful in averting the ship’s erratic movement directly into a reef, resulting in complete loss of service, buoyancy, and stew (again, see below timeline).
Root Cause: Reef.
TIMELINE
02:31 | Storm detected. No single person notified. Everyone notified simultaneously via ship’s bell.
02:33 | Gunner begins firing cannons at the storm. When later questioned, notes that cannon fire successfully deterred a hostile boarding party during a previous storm in 1741. Considered this a comparable situation.
02:35 | Navigator charts course to nearest port. Does not communicate this to the crew. Crew continues bailing toward open ocean.
02:47 | Deckhand J. Pemberton correctly identifies reef ahead. Mentions it to the gunner. Gunner is busy.
02:51 | First Mate assumes command. Calls crew meeting to establish agenda for response.
02:53 | Crew meeting quorum disputed. Three crew members are bailing and cannot attend. Meeting paused pending their availability.
02:58 | Bailing crew members rotate in. Two previous attendees have returned to bailing. Quorum disputed again.
03:00 | Ship's bell commandeered for continuous ringing "to alert nearby vessels." No nearby vessels. Nobody can hear anything anymore.
03:04 | Crew meeting resumes. First agenda item: whether this meeting requires minutes. Debate lasts eleven minutes as the crew is unable to hear each other. Motion eventually passed. No one volunteers to take minutes.
03:15 | Sub-committee formed to determine chain of command. Sub-committee immediately disagrees on its own membership.
03:19 | First Mate declares the storm “appears to be passing” based on a brief reduction in wind. This information travels through the crew instantly.
03:21 | Cook, having heard the storm is passing, begins preparing a restorative meal for the crew. Requests an ETA on full resolution so he can time the stew. Receives four different answers. Begins stew anyway.
03:22 | Storm resumes. Cook does not receive correction. Stew continues.
03:26 | Smell of stew reaches upper deck. Four crew members, independently concluding the storm must be over, secure their stations and make their way below.
03:27 | Bosun identifies mainsail is torn. Goes below to file maintenance request. Awaits approval. Gets distracted by smell of food on his return trip to the upper deck. Does not return.
03:28 | One Crew Member proceeds to set the upper deck on fire, believing that fire will deter water and hence prevent waves from washing remaining crew overboard. Waves unaffected. Upper deck significantly affected. Available crew now managing both storm and fire. Stew unaffected.
03:29 | First Mate notes a significant reduction in available crew on deck. Unable to locate the Bosun, and too occupied to search further, he returns to the helm. The helm is on fire.
03:30 | First Mate sends raven to harbour master with detailed situation report.
03:31 | Raven returns with clarifying questions and a request for additional detail before the harbour master can determine appropriate next steps. First Mate begins drafting response by the warmth of the fire on the upper deck.
03:32 | Crew asks for guidance. First mate is too busy to respond.
03:34 | Deckhand Pemberton raises reef concern again, this time in writing. Information reaches First Mate, who is mid-draft on raven correspondence. Notes it for the agenda.
03:35 | Reef reached.
03:36 | Second raven dispatched. Contents unknown. Raven did not return.
03:37 | Sub-committee adjourns inconclusively.
CONTRIBUTING FACTORS
CF-01: Absence of a single coordinator with authority to direct crew actions. Evidence: Seventeen independent and individually correct decisions were made during the incident window, none of which were aware of the others. Net effect: the ship moved approximately 200 yards in a random direction.
CF-02: Problem identification occurred early but was not actioned. Evidence: Deckhand J. Pemberton correctly identified the reef at 02:47. This information did not reach a decision-maker until 03:34, at which point it was no longer actionable for reasons that will be apparent from the vessel’s current location.
CF-03: Technical response initiated before problem was understood. Evidence: Cannon fire commenced at 02:33. The storm was not a ship. This approach was maintained for eleven minutes.
CF-04: A remediation action created a second, unrelated incident. Evidence: The upper deck fire, intended to deter wave activity, required three crew members to manage for the remainder of the incident window. Those three crew members had previously been bailing. The water level is relevant here.
CF-05: Communications infrastructure repurposed mid-incident. Evidence: The ship’s bell, primary alerting mechanism, was commandeered for continuous ringing at 03:00 and remained unavailable for directed use for the remainder of the incident. Crew reported being “unable to hear anything important, or each other, or themselves think.”
CF-06: Process compliance prioritised over incident response. Evidence: The bosun correctly identified a critical equipment failure at 03:27 and followed established maintenance request procedure. The request remains pending. The ship does not.
CF-07: Uncontrolled communications caused compounding crew misalignment. Evidence: The First Mate’s premature declaration that the storm was passing at 03:19 was not corrected through any official channel. It reached the cook, who began preparing a meal. The smell of the meal reached the upper deck, where four crew members independently concluded the incident was resolved and stood down. Available response capacity reduced by approximately 30% as a direct result of one uncorrected status update.
CF-08: Stakeholder communications consumed disproportionate crew resource. Evidence: Two ravens were dispatched to the harbour master during the active incident window. The harbour master was not in a position to assist. The ravens were.
CF-09: Command structure decided by committee during active incident. Evidence: The crew held a vote on interim command at 02:51. Quorum was disputed twice. A sub-committee was formed at 03:15 to resolve the matter and adjourned inconclusively at 03:37, by which point the matter had resolved itself, albeit poorly.
ROOT CAUSE
The root cause of INC-1743-BLACKSPOT was not the storm.
It is to be noted that both storms and reefs are known environmental hazards. The Black Spot had navigated these previously, under the coordination of a dedicated Incident Commander whose role was to maintain a complete picture of the vessel’s situation, direct crew actions, manage communications, and make decisions with incomplete information under time pressure.
As noted in the summary, that role was eliminated six weeks prior to the incident on the basis that the previous incumbent “wasn’t doing anything visible.”
It is the finding of this review that he was doing something visible. We were it.
RECOMMENDATIONS
REC-01: Reinstate the role of Incident Commander with clearly defined authority during active incidents.
REC-02: Establish a communications protocol that does not involve all crew being notified simultaneously of everything, always, via a bell.
REC-03: Create a defined escalation path for crew observations so that information like “there is a reef” reaches someone who can act on it in under forty-seven minutes.
REC-04: Prohibit the use of fire as a wave mitigation strategy.
REC-05: All status updates during an active incident to be issued by a single designated coordinator. Premature declarations of resolution to be corrected immediately through the same channel they were issued. The cook cannot be expected to know the storm resumed if nobody tells him.
REC-06: The harbour master is a post-incident resource. Ravens are to be dispatched after resolution, not during. This recommendation will not be popular with the First Mate.