Accident reports do not always directly attribute blame. In most instances, blame is allocated unconsciously through the investigators to the readers.

If we cannot think critically, we will end up implicating someone even if it was not our intent.

Let us examine a recent investigation on a sailboat where a skipper had died after being entangled in a powered winch.

The sailboat Mollie departed from New Zealand and arrived in Solent, United Kingdom. Apart from the skipper who lived permanently on the boat, there were three temporary crew members on the boat. Two had joined on the day before the accident and one had been on and off the boat for about 5 months.

On the day of the accident, the skipper informed the crew that they needed to raise the storm jib sail to improve the upwind progress of the vessel.

‘As the skipper started to clear the hoist rope from the inboard winch it started to turn, and the skipper’s right hand became caught in the rope around it. As the winch continued to turn the skipper was progressively pulled tighter onto the winch drum, causing severe injuries to his arm and hand, trauma to his head and chest, and pinning him around the winch. The crew tried to stop the winch using the control switch. After a number of attempts the winch stopped turning and the crew assessed the skipper for signs of life. The skipper was unresponsive and tightly wound over and around the winch …’

Despite the best efforts of the rescue operation teams, the skipper unfortunately died within the hour.

There are several loose ends in the preliminary report, for instance:
➡️ A 74-year-old skipper
➡️ How the winches were normally operated by pressing the control switches fitted to the pedestal with the user’s knee
➡️ How the storm jib sail was usually hoisted using a powered winch
➡️ Unpaid crew
➡️ And a known intermittent defect to the control switch which sometimes caused the winch to continue to operate after the control switch had been released.

As I read the report, I am questioning:

❓ What is the relevance of stating the age of the skipper in a preliminary report?
❓ On a ship with 3 temporary crew and a deceased skipper, how do we know what is usual and normal and by whose standards?
❓ What is the relevance of including ‘unpaid crew’ in the report?
❓ And finally, who really knew about the intermittent defect on the control winch (let alone what ‘knowing’ even means)?

Can you see how incomplete information and dubious language is used in a report?

Do you notice how blame is attributed to a dead person?

Do you see the parallels with the Air India Flight 171 preliminary report?

The problem is not that a public body can write such a narrative. The problem arises when we accept such a narrative as the preliminary report.

If you really want to learn from accidents and life, start thinking critically.