On my first Coast Guard cutter we got the ship lost. True story. It was before GPS, but there was a new Navy satellite receiver on board called SatNav. Because there wasn't as many satellites up as there are now, you had to wait for them to rise and set to get a good fix. We thought it automatically updated our position whenever a good fix came in, but that was not always true. If it went a long time without a good fix we were supposed to do a, "Code 51, Enter." No one knew that. No one really studied the user manual. We could have wrecked the ship. Luckily we figured out our error before we got close to land. It was certainly a "near miss" in today's terminology. It was my first year in the Coast Guard, and I was only an E-2, but I could have read the manual too. That lesson did not escape me.

In reading Rachel Slade's book, Into the Raging Sea, on the sinking of the U.S. flag ship El Faro, I was shocked to find that not knowing the ship's equipment also played a role in that disaster. According to the book, the captain made his decision to continue on his track based upon the private weather service forecasts, which he may not have known, were based a data which was twelve hours old. They also had the NWS forecasts available on board, which are based upon data only four hours old, but the captain preferred the private weather service forecasts. He may not have read the user manual.

I highly recommend this excellent book to anyone interested in continuous improvement in the maritime industry. The lessons to be learned are many, and apply to vessel personnel, shoreside staff, ocean going vessels, inland vessels, regulators, and their agents (TPOs). We talk a lot about lessons learned, and learning from our mistakes. This book provides an excellent opportunity to learn from others' tragic mistakes. If we don't learn from mistakes, such as not "knowing your equipment," we are bound to repeat them.