The First Story is Rarely the Whole Story
- Mike Mason
- Jun 29
- 6 min read
On the evening of 29 December 2024, the towing vessel Patrick J Studdert cast off from a fuel dock on the Lower Mississippi River. It had just completed refuelling and was making the short journey back across the river to reconnect with the barges it had left moored on the opposite bank. There were five crew members on board. The captain was alone in the wheelhouse. Two crew members had just finished letting go the lines and were standing together on the deck outside. Another crew member was in the galley and the vessel’s pilot was asleep in his cabin. It was a routine movement that the crew had completed many times before.
At the same time, the bulk carrier Clara B was making its way upriver in darkness under the control of a river pilot. As the ship approached, the pilot saw the tug getting underway and expected it to wait until the larger vessel had passed before crossing the channel. Instead, the tug continued directly across the river towards its barges.
Recognising that something wasn’t right, the pilot on board the Clara B repeatedly called the tug on the VHF radio. There was no response. He ordered the ship’s whistle sounded and then ordered avoiding action. The warning whistle didn’t sound until just seconds before impact. Moments later, the Clara B struck the starboard quarter of the Patrick J Studdert. The tug sank within minutes, forcing all five crew members into the river before they were rescued by a nearby vessel. Four people suffered minor injuries and the tug became a total loss.
When the NTSB released its report, the probable cause appeared refreshingly simple. Phone records showed the captain had been on a personal mobile phone call from just before the tug got underway until moments after the collision. The report concluded that his distraction resulted in him failing to maintain a proper lookout and navigating directly into the path of the approaching ship. Lesson learned: don’t use your phone while operating a vessel.
I agree this is a lesson. I just don’t think it’s the most interesting lesson.
The First Story
One of the concepts we regularly discuss through On Target and The Human Diver is the difference between the first story and the second story.
The first story is usually neat, simple and satisfying. In context, the first story here is as follows:
The captain was distracted by his phone. He didn’t maintain a proper lookout. He crossed into the path of another vessel with which he collided. Fix the captain. Problem solved.
The attraction of first stories is that they make us feel safe. They reassure us that accidents happen because someone broke a rule, made a poor decision or failed to do what they were supposed to do. Once we’ve identified the mistake and the person who made it, we convince ourselves the problem has been solved.
The second story is rarely so tidy.
The tug wasn’t carrying one person. It had five crew members on board. Two were awake on deck. Another was awake inside the vessel. There was another qualified mariner asleep below. The approaching ship recognised the collision developing almost a minute before impact, attempted to raise the tug several times on the radio and sounded repeated warning signals. Despite all of that, the tug maintained exactly the same course until it was struck.
That doesn’t make the captain any less responsible for his own actions. But it does make me wonder whether we’re asking the right questions...
Humans Become Distracted. Systems Should Expect It.
One of the things that struck me while reading the report was the company’s mobile phone policy. Crew members were permitted to use their personal phones provided they didn’t interfere with the safe navigation of the vessel. On the face of it, that sounds entirely reasonable. After all, nobody is suggesting people can’t ever use a phone while they’re at work.
The problem is that distraction doesn’t announce itself. Nobody consciously decides, “I’m now distracted.” In fact, one of the defining characteristics of distraction is that we usually don’t realise it has happened until afterwards. That’s why so many people insist they can safely use a phone while driving. It’s why experienced professionals often believe they can multitask. It’s why the line between acceptable behaviour and unsafe behaviour gradually shifts over time.
If making a quick phone call becomes routine and nothing bad happens the first ten, fifty or one hundred times, the behaviour slowly becomes normal. Nobody notices the drift because the system continues to work. We call that normalisation of deviance. The phone is almost incidental.
Next time it might be answering a radio call, completing paperwork, speaking to another crew member or looking down to acknowledge an alarm. Human beings become distracted. Distraction isn’t a design flaw. It’s simply part of being human.
A more interesting organisational question could be:
If we know people will occasionally become distracted, why are we still designing systems that rely on them never being so?
Teamwork Is a Risk Control
The previous blog I wrote about the MV Dali explored the idea of barriers. The electrical failure wasn’t the only problem. The bigger issue was that once the failure occurred, there were very few barriers left to stop the ship hitting the bridge.
This accident feels remarkably similar. Once the captain became distracted, what barriers remained? From the report, the answer appears to be very few. Nobody challenged the developing situation. Nobody questioned why the tug was continuing across the channel. Nobody alerted the captain to the approaching ship. Perhaps nobody noticed. Perhaps they assumed the captain had everything under control. Perhaps they didn’t feel it was their place to intervene. We’ll likely never know.
This is where teamwork becomes far more than simply working well together.
Teamwork is a risk control.
High Performance teams go beyond workload division. They will actively monitor one another, cross-check decisions and create opportunities to detect mistakes before they become accidents. Aviation learned this lesson decades ago through Crew Resource Management. One pilot becoming distracted should never be enough to bring down an aircraft because another pilot is expected to notice, challenge and, if necessary, intervene. Why should we expect anything different in any other safety-critical industry?
Psychological Safety Isn’t About Being Nice
Psychological safety is one of those terms that is often misunderstood. It’s frequently associated with being supportive, inclusive or creating a pleasant working environment.
While those things matter, they’re not really the point.
Psychological safety is about creating an environment where somebody feels able to say, “Captain, are you sure you’ve seen that ship?” or “Something doesn’t look right.” Maybe the captain would have ignored them. Maybe he would have looked up and altered course.
We’ll never know.
The important point is that organisations should want people to ask the question. If speaking up feels awkward, disrespectful or likely to result in criticism, people gradually stop doing it. That’s another form of normalisation of deviance. Silence becomes the accepted behaviour until one day everyone discovers it was protecting nobody.
The strongest safety cultures aren’t those where people make the fewest mistakes. They’re the ones where people feel comfortable pointing out someone else’s.
Looking Beyond the Phone
Please don’t misunderstand me. I don’t think the captain should have been on his phone. The report makes a compelling case that it contributed to the collision. My concern is what happens if that’s the only lesson we take away.
The next accident probably won’t involve a mobile phone.
It might involve fatigue.
It might involve somebody programming a GPS.
It might involve completing paperwork.
It might involve answering a radio call.
It might simply involve a momentary lapse of attention.
If our only defence is telling people not to become distracted, we’re relying on something human beings have never been particularly good at. The organisations that consistently outperform others don’t build systems that assume people will never make mistakes. They build systems that assume they eventually will. They invest in teamwork, encourage people to challenge one another respectfully and deliberately create overlapping layers of defence so that one person’s bad minute doesn’t become tomorrow’s accident report.
That’s the second story.
In my experience, it’s almost always the more interesting one.
-----------------------------------------------------------------------------------------------------------------------------------------------------
Mike Mason and Sam Gladman are the co-founders of On Target, a leadership and team development company that brings elite fighter pilot expertise into the corporate world. With decades of combined experience in high-performance aviation, they specialise in translating critical skills such as communication, decision-making, and teamwork into practical tools for business. Through immersive training and cutting-edge simulation, Mike and Sam help teams build trust, improve performance, and thrive under pressure—just like the best flight crews in the world.
If you'd like to learn more about how On Target can help your team, contact Mike and Sam at info@ontargetteaming.com.
Comments