(First published 30 Mar 2021)
How hard is it to sail straight? With only 8 major bends in the journey through the Suez Canal, one might expect Ever Given to be stuck at one of these turns. Yet, for almost a week, she was stranded right in the middle of a straightaway.
News Agency USA Today has a wonderful illustration of Ever Given's voyage up until it was dead in the water, and given ships should know and expect the occasional heavy winds and sandstorms in that region, it's no wonder the Suez Canal Authority looked beyond the initial excuses and hinted at "technical or human error".
Since then, the final safety report by the Panama Maritime Authority identified the root causes as "both the physical aspects of the canal and poor communications between the pilots and the bridge". Notably, communication difficulties between the Indian crew and the Arabic speaking pilots were a major cause of the accident. The investigations also revealed how the two pilots were disputing among themselves in Arabic, which further delayed any corrective response Ever Given and their Indian crew could have benefited from.
Incidentally, this is a great example of what an organization's root cause analysis should be. Maine safety investigations aim to improve safety and prevent future incidents, away from any litigation influences or purposes.
But wait, there's more.
Ever Given is one of less than a hundred giants that can carry the heavyweight title of "Ultra Large Container Ship" (ULCS). In today's world where ~90% of everything you own came by the sea, ULCS demonstrates what it means to have economies of scale, energy efficiency, and environmental considerations. To qualify, your ship needs to transport more than 20,000 twenty-foot equivalent unit (TEU) "standardized" shipping containers.
As a reference, a 20ft container can hold 200 mattresses, or 48000 bananas, or 18000 iPads.
With ULCS, ports need larger container gantry cranes (which will need to reach further too), a larger storage yard, and better inland distribution. ULCS go deeper into water (known as draught) and are taller (air draught), which means ports, rivers, and canals need to be dredged deeper. Insurance companies like Allianz constantly highlight the risk of fires on ULCS and the challenges of cargo misdeclaration and fire-fighting. It is almost like ULCS is regressing all the safety advancement the maritime industry has made over the years.
Bigger is better, when everything is smooth sailing. Yet the bigger they are, so too the harder if and when they do fall. In our healthcare quest to "do more with less", to push the envelop and blaze new trails, we adopt technology in piecemeal, rushing for bigger ships in an environment that's not ready for big ships.
We make outpatient payment paperless, cashless, and counter-less, only to have patients struggle over days trying to find someone in our system to correct the subsidy claims and generate a payment receipt (true story).
We embrace huge machines to churn out higher volumes while slowly reducing manpower, further making sudden down-times a nightmare to recover. Like the distance between Ever Given to the canal banks, the margin for error becomes narrower, and the burden on human performance becomes ever more heavier (so too the ease of blaming human error).
Just like bigger ships, it is easy to just focus on improving bits and parts of our healthcare operation (e.g. apps). But if we want to significantly reduce harm in our care delivery, we need to address the larger system and all its multiple moving parts (e.g. patient volume, IT ecosystem, information quality), in tandem.
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