- Reaction score
- 6,504
- Points
- 1,040
Underway said:Yah you can find it on the DWAN. The engineering community is all over it, especially at DC School and Sea Training.
Nope, there have been bits and pieces fed out about what happened, but there was never anything comprehensive to come out of the BOI that would be useful for lessons learned and also for fixing the underlying habits that led to the fire. The videos that they have pumped out are useful in understanding what the crew was dealing with, but totally different from what you would get out of a proper BOI result. For a good example, see the Westralia BOI below. You can find similar public reports for a lot of the USN incidents where they break down timelines and try to understand what people knew when they made the decisions, and that's the useful and important bits. You need the full context of what they knew and what they were thinking at the time to understand the decision; generally 'mistakes' make perfect sense after the fact when you understand that, and can help you correct it to prevent it happening in the future. There are still a huge amount of misinformation of fitted systems that prevent them from being used in a timely manner, and things that we know have led to fires still happen.
One thing I found working with the det was that, even when someone does something stupid, it's looked at as a learning opportunity and no one is blamed. Because of that underlying culture, they take the opportunity to learn from it and widely distribute the report. Also, part of their routine was to review every air safety report and make sure they didn't repeat the same mistakes.
Aside from the PRO fire, there were also BOIs for the PRO/ALG collision, when PRE allided into the Irving floating drydock, and a few other fires. AFAIK, none of those have an unclass summary of events available, and unless you know a guy, you'll never see the actual reports, as they are still treated as a 'need to know'. Tech Investigations are even worse; they get done, filed away (in a number of unlinked, limited access databases) with folks very rarely seeing the actual results. I had the full engine room halon bank fire off on me without warning that was on Environment Canada's radar due to the amount (which can result in massive fines directly to crew members if they are found to be negligent) and didn't see anything about it until nearly two years later when it was finally finished, and the author forwarded me the results as a courtesy (faulty PGA on the main cylinder). If I hadn't known him would never have seen a copy, and wouldn't be able to see where it was logged.
Westralia BOI: https://s0.whitepages.com.au/d73ef9ce-8c9c-4d2b-becb-975402164fac/collaery-lawyers-document.pdf