This requires the design of appropriate procedures for knowledge capture, its restructuring, and its dissemination to those who need it. Ergonomists have a big part to play in this. The main message that comes from this story is that disasters are due to a number of events, none too serious on their own, that come together in an unfortunate combination. Then there is usually a final, triggering event that sets the whole accident in motion. The slow response of the ship means that when you get into coastal waters, basically you have to hope that everything else gets out of your way, including the land.
Company issues Operational scheduling of ships.
Time pressure always increases the probability of errors and bad decisions. Equipping ships for schedules. If you wait to tell the ship where to go, you must ensure that someone puts all the right charts on board before it leaves port. The link between scheduling and resourcing doesn't seem to have worked well in this case. Responsibilities for competence.