by Scott Wilson on 07/10/13 at 3:28 pm
That’s the only adequate word I can come up with to describe Mario Vittone’s presentation at the Museum of History and Industry on the 2012 sinking of the HMS Bounty replica off the coast of North Carolina. The title of the presentation was “The Illusion of Experience” and it is that illusion, for any thinking sailor, that is so sobering: ultimately, Vittone is talking less about the Bounty than about us, and the difficulty of seeing through the veil of what we call experience into the reality of the dangers that any day on the water may entail.
“Nobody on the crew is terribly unlike you or me,” Vittone said. The failures aboard Bounty, in his view, were failures inherent to human nature, not to intentional neglect or outright indifference. To Vittone, the mechanisms of the actual sinking had become beside the point (although he clearly had explored them in as much detail as anyone who cannot visit Bounty’s cold grave at 2400 fathoms ever can); instead, the tragedy encompassed every other problem, every other tragedy at sea that he had heard or read about in his 22 years of experience as a highly decorated Coast Guard rescue swimmer.
It’s Vittone’s assertion that all tragedies at sea (with the exception of some medical evacuations) begin with decisions made on the dock, before a line is ever let go. On the Bounty, it was the cumulative impact of a host of decisions, some made years previously, that culminated in what might have been the one last fatal one of slipping the hawsers and heading out at all with a Category 2 hurricane on the horizon.
His talk explored the roots of those decisions more than the consequences. In both his presentation and his series of articles on gcaptain covering the joint NTSB/Coast Guard hearings on the incident, he focused on the thinking behind those decisions and explored the rationalizations that the decision-makers used at each stage to convince themselves that what to all objective appearances was a dangerously rash voyage was, in fact, business as usual.
Vittone originally used the phrase “illusion of experience” as a reference to someone who knew a very little bit about hull maintenance teaching someone who knew absolutely nothing; in relative terms, that little bit of knowledge must have looked like a lot of experience to someone completely new to the business. But he has taken the concept further, suggesting that even someone who had a great depth of experience (such as Captain Robin Walbridge) but who came by it only narrowly (e.g., aboard a small handful of vessels; or primarily one, such as was the case with Walbridge) might undergo the same illusion.
This scenario should ring a loud bell for many small-craft sailors.
Vittone’s insights mesh with those of other authors who have explored this mystery in detail, including Laurence Gonzales (“Deep Survival”) and Atul Gawande (“The Checklist Manifesto”). Gawande’s characterizations of the condition that Vittone describes might be to call those in its grip “inept.” In Gawande’s world, ineptitude is a failure to apply existing knowledge to prevent catastrophe. Captain Walbridge had all the knowledge at hand to make a decision to stay in port or seek other shelter; he simply failed to apply it to the conditions he was facing.
But Vittone’s take is more insidious; he might argue that Walbridge did apply his knowledge to the situation; and, unfortunately, among those things which he thought he knew was that he had been in difficult, marginal conditions with Bounty previously and successfully sailed her through them. That knowledge may have helped inform his decision to put out in conditions, and in a vessel, that objectively were an extraordinary risk.
In this, Vittone seems to join Gonzales in suggesting that, in fact, experience can be one of the most hazardous contributors to tragedy… something that Gonzales calls “The Sandpile Effect,” in which positive experiences in marginal conditions sublimate the risks so that they appear, subjectively, acceptable, even normal. After each such experience, the margins become stretched further and further.
In fact, Vittone said, what scared him the most about the Bounty incident was that they had almost made it… if the pumps had been working, there was a good chance the ship might have made port. And, having succeeded once more at one further extension of his storm experience, Walbridge might have stretched his luck even further the next time, and more people might have died.
If this has a familiar feeling to it, it’s because it’s just an extension of what most of us are pleased to call simply “experience.” We learn we can do things successfully by having done them; we expand the horizon of the possible by measuring what we have succeeded at and extending our ambitions out a bit further. This “crawl, walk, run” model is the basis for training programs of every sort, from day-sailing instruction to master’s endorsements. The thought that it can, itself, become a dangerously subversive pattern of thought is profoundly disturbing. “Experience is being fooled by someone who’s gotten away with the same mistake longer than you have,” said Vittone.
Vittone makes it clear that none of these revelations are new, and indeed, that they are nearly universal. He spent some time explicitly relating the phenomena that Walbridge underwent with that of NASA administrators responsible for the decisions to launch Challenger and, later, Columbia in the face of objective data that suggested caution. (Anyone interested in the Challenger disaster and in the sort of rationalization and normalization of risk that Vittone is highlighting here owes it to themselves to read Richard Feynman’s appendix to the Rogers Commission Report on the accident.)
If this is in fact simply human nature at work, then none of us are, by definition, immune to it. In fact, those who believe that they are (“that could never happen to me; I would never make such bad decisions”) may be the most susceptible. If it can happen to genuine rocket scientists, what hope do the rest of us have for avoiding it?
Vittone’s suggestion is that we all stay a little bit afraid… to provide “a fair estimation of the account of peril” in our decision-making process. And he says that one of the best ways of achieving that is to entertain doubts; your own, and those of your crew. Or, as Gonzales advises more succinctly, “Be humble.”
At the end of the day, you’ll have to make a decision, and it may be right or wrong. But it is likely to be better if it is informed by not just experience, but a diversity of experience.
And this is where Gawande’s prescriptions can be useful; they provide a systematized method for objectively assessing decisions even in the face of extreme emotion or pressure… a method that can be designed and evaluated at leisure in the safety and with the resources of the experience of others easily at hand.
Again, these recommendations are not new. But they are not broadly encouraged in the sailing community today either. Our experiences have been that they are unnecessary to our successful return. But that experience may be just another illusion.