It is increasingly clear to me that what took place off Giglio last January was an organizational rather than an individual accident. Have a look at the text below, from http://www.canadianbusiness.com/article/98536–court-experts-fault-captain-crew-owner-for-deadly-ship-grounding-off-tuscany, and have your say:
ROME – Court-appointed experts have squarely blamed the captain of a cruise ship that ran aground off Italy for the wreckage and deaths of 32 people, but they also faulted the crew and ship owner for a series of blunders, delays and safety breaches that contributed to the disaster.
The Costa Concordia ran aground and capsized off the Tuscan island of Giglio on Jan. 13 after Capt. Francesco Schettino took it off course and brought it close to the island as part of a stunt. He is accused of manslaughter, causing the shipwreck and abandoning the ship before all passengers were evacuated.
Eight other people, among them crew members and Costa’s crisis co-ordinator, are also under investigation. The court in Grosseto ordered the expert investigation to help it determine who, if anyone, should be put on trial. A hearing is scheduled for next month.
In a 270-page analysis, the four experts described in second-by-second detail the unfolding disaster as Schettino slowly came to realize the gravity of the situation. Using data and voice recorders to reconstruct the drama on the bridge, the report showed how Schettino failed to grasp for a good 45 minutes repeated reports from his crew that his ship was flooding and its motors dead.
The analysis came out Wednesday and was placed online Thursday by the Rome daily La Repubblica.
The experts contrasted what went wrong on board with maritime rules and procedures and determined that Schettino should have given the “abandon ship” order at 10 p.m. that night, 15 minutes after the 9:45 p.m. grounding against the rocks off Giglio.
Instead, the evacuation order only went out at 10:43 p.m. — and Schettino himself didn’t give it but another officer, in violation of maritime rules. By that time, passengers on their own had already reported to their muster stations with life jackets on, despite a decision from a crew member at one point that they should go back to the dining room.
“Madonna, what a mess I’ve made,” Schettino muttered soon after the collision, according to the transcript.
Beyond Schettino’s faults, the experts said a series of problems hobbled the execution of his initial manoeuvre and efforts to fix it, and contributed to the botched evacuation. Bridge crew members bungled directions and didn’t his understand orders because of language barriers. Other crew members weren’t trained or certified in security and emergency drills, the report found.
In all, the experts said, Schettino and his bridge crew showed “scarce professional seriousness” before and during the disaster, with Schettino joking just before the crash, after his helmsman again misunderstood an order, that he needed to do it right “otherwise we go on the rocks.”
And the experts said ship owner Costa Crociere bore blame, too, by delaying alerting coastal authorities about the emergency — a charge Costa denied Thursday.
In a statement, Costa said by law it was Schettino who was supposed to have alerted authorities about the accident, and that the captain assured the Costa crew on land that he had done so. And regardless, Costa said, Schettino’s reports to Costa’s headquarters were so delayed, “partial and confused” that the company couldn’t discern how serious the emergency was.
Yet the expert report said Schettino had “clearly explained the situation” to Costa’s fleet crisis co-ordinator in his initial call. Schettino was far less forthcoming when the Livorno port authorities called him after hearing word the ship was in trouble: in that conversation, Schettino only told the port that there was a blackout on board.
And Costa firmly rejected the experts’ claims that the crew was unprepared for emergencies, saying the “alleged defects in the certifications of some of the crew” didn’t affect the evacuation.
From the start, passengers described a confused and delayed evacuation, with many of the lifeboats unable to be lowered because the boat was listing too far to one side. Some of the 4,200 people aboard jumped into the Mediterranean and swam to Giglio, while others had to be plucked from the vessel by rescue helicopters hours after the collision.
Some passengers said they were shocked to see Schettino already ashore when they were being evacuated. Schettino claims he helped direct the evacuation from the island after leaving the ship. The report demonstrates how he refused several demands by port authorities to return to the ship to oversee the evacuation.
Schettino has insisted that by guiding the stricken ship to shallower waters near Giglio’s port instead of immediately ordering an evacuation he potentially saved lives. He has claimed that another official, and not he, was at the helm when the ship struck.
But the timeline in the expert report makes clear that he had assumed control with a verbal order at 9:39 p.m., after being called back up to the bridge to oversee the stunt, which he had planned as a favour to friends from Giglio.
Work has begun to remove the tons of rocky reef embedded into the Concordia’s hull, a first step in plans to eventually tow the wreck away from the island.
The whole removal process is expected to take as long as a year.
To learn more about organizational accidents, an interesting starting point might be Organizational Accidents: A Systemic Model of Production versus Protection, a paper written by Yang Miang Goh, Peter E. D. Love, Helen Brown and Jeffery Spickett of Curtin University of Technology, Australia. I quote the abstract below:
Production pressure is often cited as an underlying contributory factor of organizational accidents. The relationship, however, between production and safety protection is complex and has not been adequately addressed by current theories regarding organizational accident. In addressing this gap, this paper uses the methodology of system dynamics to develop a causal model to address the dynamic interaction between management of production and protection, which can accumulate in an organizational accident. A case study of a fatal rock fall accident in Tasmania, Australia was conducted based on the developed model and is used to uncover the intricate dynamics linking production pressure, risk tolerability, perception of safety margin, and protection efforts. In particular, the study demonstrates how a strong production focus can trigger a vicious cycle of deteriorating risk perception and how increased protection effort can, ironically, lead to deterioration of protection.