Safety Committee Article: Standing the Watch

Just after midnight on March 24, 1989, the supertanker Exxon Valdez grounded on Bligh Reef, and over ten million gallons of crude oil were released into Prince William Sound, Alaska.

This event was immediately devastating to the environment, and its effects are still being felt in 2025.  Multiple human factors were identified as contributing to this event.

• The third mate had the watch on the bridge when the grounding occurred, and fatigue has been cited as a factor. He had decided to let his relief sleep and carried the watch longer than scheduled.
  
  
• The Captain is ultimately responsible for the crew, cargo, and ship. It was reported that he had been seen drinking in a bar in Valdez, AK, the evening before the vessel left port. The captain was in his cabin, sleeping and not at the controls, when the vessel struck the reef. He was charged (and ultimately cleared) with criminal mischief and reckless endangerment.
  
  
• Critical equipment: The Raytheon Collision Avoidance System had not been properly maintained and was not functional.
  
  
• Corporate oversight failed to provide the ship’s captain with a well-rested crew and properly maintained equipment.
  
  
• Coast Guard regulations, the Valdez was operating outside of the normal shipping lane, and the emergency response was delayed.

There are other factors that I will not go into, as this commentary is not about the Exxon Valdez Oil spill. We can see comparisons in the factors between the Exxon Valdez disaster and accidents and mishaps that have occurred in the practice of hyperbaric medicine. 

Shortly after the Exxon Valdez disaster, I remember reading an article in a marine trade journal titled “Standing the Watch (1999).” The article has had a long-lasting impact on my life. Standing the Watch has a deep meaning for many of us, especially if we have military or maritime experience. To “Stand the Watch,” you are responsible for a specific function, and to remain alert until relieved by a qualified person or until the purpose of the watch is completed. The author, who was a Captain of a large vessel, urged us to remember the origins of the phrase “Standing the Watch” and wondered if the event would have occurred if the mate had been physically standing and alert. In older times, we did not have the convenience of radar, weather, computerized navigation, comfortable control rooms, and so on. You physically stood the watch, think of the Sentinels that guard the Tomb of the Unknown Soldier. When you have the watch, stay alert and do not become complacent.

Another factor of “Standing the Watch” is qualification. For hyperbaric facilities, NFPA 99 2024 edition, 3.3.162 defines Qualified Person as “A person who, by possession of a recognized degree, certificate, professional standing, or skill, and who, by knowledge, training, and experience has demonstrated the ability to perform the work.”

Not only do we need to remain vigilant in our various roles and responsibilities, but we also have an obligation to ensure we are qualified.

When we look at accidents and mishaps in hyperbaric medicine, many can be linked to human factors such as complacency, the normalization of deviance, and a lack of qualifications. Oversight by management may be lacking, and Authorities Having Jurisdiction (AHJ) may not be aware of your facility or be unable to respond to an emergency efficiently. In my personal experience, many of the mistakes I have made in my personal and professional life have been related to not paying attention (complacency) or doing something I was not qualified to do (but thought I was).

Other contributing factors to accidents and mishaps include a lack of maintenance, limited or delayed emergency drills due to financial concerns, and practices outside norms and code. I suggest that “Standing the Watch” includes ensuring that the equipment you use is well maintained, that the governing body supports a culture of safety, and that the local AHJ is aware of your facility.

There have been two adverse events in 2025 that have impacted those of us involved with the provision of hyperbaric therapy.  Both had fatal outcomes. A 5-year-old child and an adult male have died this year in separate events involving the practice of hyperbaric medicine. In my opinion, both events may have been avoided or mitigated if the concept of “Standing the Watch” had been in play. I challenge us to be constantly aware. While we have an excellent safety record, the outcome(s) of an adverse event can be devastating.

Regardless of your role(s) in our practice, i.e., administration, medical oversight, Safety Officer, RN, RT, chamber operator, inside attendant, maintenance technician…consider adopting the concept of “Standing the Watch” into your personal practice. Find ways to maintain vigilance and avoid complacency. Maintain your qualifications and be honest with yourself and others.  Follow through on proper equipment maintenance and department administration.  Know your local AHJ and communicate with them.