How things in life can go wrong

Dear Bloggers,

As we all could see and hear on the news that a modern Cruise liner went of it’s normal position and sank close to the Italian island Giglio on Friday the 13th is a strange combination of human error and bad luck. Or are the supersticious people right about this special day, question is why did the captain go overboard or is he just another asshole that is only thinking about himself? It must be a drama if you were part of it as your life will never be the same again. Eventhough It is this year a quarter of a century ago that I had to take part in military support actions during the disaster with the roro ferry Herald of Free Enterprise. A picture that is never gone out of my memory.

Herald of Free Enterprise
My thoughts go out to the families and friends of the ones that passed away or have gone missing during this disaster. It will take many years to pick up your life and see the sun shining again. At least that is my experience as being only a helper on the side not doing anything else then my job at that time.
Costa Concordia in better days
Following the tragic Costa Concordia accident, Carnival Corporation & plc, parent company of Costa Cruises and nine leading cruise lines around the world, today announced a comprehensive audit and review of all safety and emergency response procedures across all of the company’s cruise lines.Carnival Corporation & plc and the cruise industry as a whole have maintained an excellent safety record over the years. “However, this tragedy has called into question our company’s safety and emergency response procedures and practices,” said Micky Arison, chairman and CEO of Carnival Corporation & plc. “While I have every confidence in the safety of our vessels and the professionalism of our crews, this review will evaluate all practices and procedures to make sure that this kind of accident doesn’t happen again.”


Initial timeline and track of the Costa Concordia grounding.

Friday 13 January 2012.

Times and positions approximate.

2116 = 9:16 pm local time.

1900. Costa Concordia departs Civitavecchia.

2116. Costa Concordia turns left toward Isola del Giglio in order to pass close to the island. This deviation will add a short distance to this overnight leg and require a slightly higher overall speed. This ship is doing 15.5 kts.

2133. Costa Concordia is on course 276 (almost due West) at 15.5 kts approaching Isola del Giglio. The island is about 2000 yards directly in front of Costa Concordia. The plan is to turn right, toward the north, and leave the island to the port side.

2136. Costa Concordia commences turn to the right late, maintaining speed of 15.5 kts. Due to advance and transfer, the momentum of the vessel will carry it closer to the island before the turn to the new course is completed. It looks like the new course was planned to be something like 320.

2138. Costa Concordia strikes charted rocks off Isola del Giglio on her port side. Power is lost to the electrical plant and propulsion. The ship starts to slow. The crew announces there is a power outage and reports to Isola del Giglio that they need no assistance. Many news report are quoting “9:30″ or 2130 as the time of the impact. That time isn’t supported by the AIS data below.

2145. First alarm is sounded.

2145-2150. Ship begins to list.

2200. Bow thruster is used to turn bow to the right. The ships is moving slowly toward Giglio, likely the result of current.

2242. Accident is reported to port authorities.

2250. Abandon ship order is given.

0100. Schettino reports only 40 people remain on board. In fact there are hundreds.

0146. Italian Coast Guard orders Schettino to return to Costa Concordia.

source of AIS data:

AIS data for Costa Concordia night of 13 January 2012. Times are GMT, one hour different than that on the ship.

At present it appears that Carnival Cruise Lines (and their subsidiary Costa Crociere) are treating this as a special cause event, the actions of a rogue sea master. Costa Crociere’’s statement already indicates this is the direction they are headed. What needs to be investigated are issues of command and leadership. To what degree are tenets such as “forceful backup” and “a questioning attitude” prevalent. Further, the system surrounding selection, training, and routine monitoring of masters needs to be scrutinized sufficienty in order to understand whether Mr. Schettino was indeed a rogue captain operating outside the system, or whether there were systemic contributors to this tragedy.

If the investigation focuses solely on the actions on board Costa Concordia the evening of Friday 13 January, then the probability of recurrence is 100%.

A stricken Costa Concordia.

The statement Micky Arison, CEO of Carnival Cruise Lines should issue.

It is with sadness and regret that I report the latest on the Costa Concordia tragedy. As of 0700 this morning xx bodies have been recovered and xx people remain unaccounted for. Our search efforts continue.

Our subsidiary and operator of the Costa Concordia, Costa Crociere issued a statement that identified significant human error on the part of the ship’s master as the likely immediate cause of this accident. While that appears thus far to be true, I don’t believe the statement goes far enough in describing my responsibility for safe cruising and the actions we are taking.

I have directed for following.

We have provided all cruise ship captains with all available information about the Costa Concordia accident and aftermath. As more information becomes available, I will pass that to them. Cruise ships at sea will continue their itineraries. All captains of cruise ships in port will recertify to me personally that they understand their responsibilities to operate within the procedures, ensure their crews are operating within procedures and the paramount importance of passenger safety, prior to getting underway.

I have directed full compliance with the investigating body and commissioned an independent company investigation that will report directly to the Board.



This investigation will proceed in 2 phases.

In the first phase, the immediate causes of the grounding, capsizing, and incomplete evacuation will be investigated. The intent is not only to understand why the ship was so far off course, and how it’s navigational safety equipment malfunctioned, but how the damage control efforts to control the flooding failed to prevent the ship from capsizing.

When complete, I will recommend a public release of our findings and actions.

In the second phase, which will likely take several months, the investigation will look into the distant causes of the accident. We will understand how ship design, manufacture, crew training, and leadership structures all affected this event.



It would be too easy to identify this accident as the rogue action of a single irresponsible master and I am not going to take that route. I have charged the investigators with understanding and identifying the role that fundamental questions of company culture toward safety, the willingness of subordinates to question the direction of superiors, and the ability of watchstanding teams to respond with resilience to unanticipated events.

In this investigation, no decision will be off limits no matter who made them or how removed they may seem from the immediate event.

Leadership lessons from the Costa Concordia tragedy.

In the evening of 13 January 2012 the modern cruise ship Costa Concordia with about 4300 souls aboard grounded and capsized off the Italian Isola del Giglio. The death toll is likekly to run into the 20s.

It now appears that the captain, Francesco Schettino directed the ship alter course to take it very close to the island as a sort of nautical fly-by as a tribute to one of ship’s company who was from that island. From the photos, it is apparent that the ship was passing very close to the shore. These waters have been plied since before the Romans and the chance that any rocks were uncharted is unthinkable.

Don’t we wish that one of the other crewmen spoke up against this reckless, dangerous, and ultimately lethal stunt? As captain of a nuclear powered submarine I strove to give a few orders as possible in order to maintain a detached perspective on the actions of the ship, balancing safety and operational tasking dispassionately. In a strong leader-follower culture, the leader gives orders and the others follow. Asking questions is discouraged. It would appear that this is another case of leader-follower in action.

A bigger question lies for the cruise ship company: Costa lines and the parent company Carnival Cruise lines.

How is such a leadership structure tolerated on board their cruise ships? This is a throwback to the 18th century “Master and Commander” style leadership: top-down, autocratic, imperious, and wrong.


Did someone challenge the Captain's ill-thought out orders?

I only can see this as a bad decission of one captain it is no needed to be scared to go on a cruise but it is something to think about. If you might go cruising just realize that you might need to rescue yourself one day and you are happy if you have read the safety instructions.


The Old Sailor,

Comments

  1. Dat laatste stukje gaat me wat boven de pet, maar alles wijst er, van wat ik erover heb gevolgd, wel op, dat de kapitein niet echt bekwaam heeft gehandeld. Dat hij per ongeluk, toen hij wilde assisteren, in de paniekerige menigte van dek was geduwd en toevallig in een reddingsbootje terecht kwam,klonk ook wel heel ongeloofwaardig.
    Een vreselijke ramp.
    Ik had net een hele reactie geschreven, maar die was, toen ik het hier zou 'publiceren' weer verdwenen. En je weet zelf waarschijnlijk wel, dat het een tweede keer toch altijd weer minder wordt.
    groetnis...

    ReplyDelete
  2. Geachte Vrouwe Babbel,
    Het is in mijn ogen ook een laffe daad dat deze kapitein gevlucht is voor zijn verantwoordelijkheid. Maar waar was de rest van de officieren ook deze mannen waren niet in staat om de operatie te leiden. En waarom heeft niemand op de brug deze navigatiefout gezien? Dat vraag ik me af er zijn altijd een man of vier op de brug aanwezig als men zo dicht langs de kust vaart. En dan wordt alleen de kapitein gearresteerd. Ik heb het idee dat men een reddingsboot heeft laten zakken om te kijken hoe erg de schade was. Toen ze ontdekten dat er geen redden meer aan was lag het schip al op een oor en konden ze niet meer terug aan boord worden gehaald. Dit is mijn idee over het gebeurde en is de kapitein niet echt slim geweest om zo lang te wachten met evacuatie maar ze hebben waarschijnlijk getracht om het schip aan de grond te zetten en dat is zoals we weten maar gedeeltelijk gelukt.

    ReplyDelete
  3. Anonymous23/3/12 19:39

    Do not believe that Thrusters are used anymore after the grounding and Black out. No power is available, only emergency lighting and essential instruments from emergency generator. Only luck prevented a much bigger catastrohy. Had the current been different, had the wind blown the CC further from shore, then thousands would have been lost, given the emergency organisation, or lack of same.....
    The Engineer

    ReplyDelete

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