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COSTA CONCORDIA: An organizational accident, after all?

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.


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MARITIME NEWS: Crewman hurt after accidentally releasing a life boat

A Nordic Tankers crewman broke his leg in a fall after unintentionally releasing a faulty life boat, an accident report has revealed.

The incident happened on the 5,800–dwt Nordic Nadja (built 1996) off Rotterdam on 8 October, 2011, as the second engineer entered the free fall boat (FFB) to carry out an inspection.

The Danish Maritime Accident Investigation Board (DMAIB) said the boat was rolling heavily due to waves and swell. It found the crewman “probably lost his balance and reached out for something to hold on to, in the process unintentionally releasing the FFB.” As a consequence of the accident, the second engineer suffered from loss of memory to some degree and could not remember what caused the release.

The inspection revealed that both the security handle and the release handle had been pushed backward, causing the hook holding the life boat to disengage.

A test revealed that it was possible to move both handles simultaneously from the upright position to the position releasing the FFB, which should be impossible.

Investigators were unable to establish the cause of the malfunction.

Nordic has since ensured that all its boats are fastened to lifting hooks before any crew enter.

Source: Tradewinds, Danish Maritime Accident Investigation Board

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INCIDENTS: MAIB releases report on Queen Mary 2 explosion

The UK Marine Accident Investigation Branch (MAIB) has released the result of its investigations into a failure of a capacitor, part of the diesel-electric propulsion system of the cruise ship ‘Queen Mary 2’.

The MAIB feels that there are lessons that the industry should learn from this incident, which resulted in an explosion onboard,so has asked for our help in promulgating the information.

At 0425 on 23 September 2010, as the passenger liner Queen Mary 2 (QM2) was approaching Barcelona, a loud explosion was heard from the direction of the aft main switchboard (MSB) room. Within a few seconds, all four of the podded propulsion motors shut down. A few seconds later, the vessel suffered an electrical blackout. Thick black smoke was seen to be coming from the aft MSB room. Fortunately, the vessel was clear of navigational hazards and no one was injured.

By 0439, the crew had confirmed that the explosion had taken place in the aft harmonic filter (HF) which was situated in a compartment next to the aft MSB room. After establishing with thermal imaging cameras that there were no hot spots, they ventilated the area and isolated the aft HF and MSB from the rest of the 11000 volt electrical network. The crew were able to restore some electrical power supplies and, by 0523,QM2 was underway using two propulsion motors powered from the forward MSB. Subsequent inspection of the aft HF revealed that one of its capacitors had failed catastrophically due to internal over-pressure and another had developed a severe bulge.

The vessel had a history of HF capacitor failures, at an average rate of one per year. Although the exact cause of the capacitor failures could not be determined, it was concluded that capacitor degradation was probably caused by a combination of transient high voltage spikes due to frequent switching operations and occasional network over-voltage fluctuations. The capacitor deterioration had not been detected, and because there were no internal fuses or pressure relief devices, it had continued until the capacitor casing failed catastrophically.

Although the aft HF circuit breaker disconnected the HF from the rest of the electrical network to isolate the electrical fault, the disruption was likely to have caused electrical instability in the electrical network which led to the loss of propulsion and blackout. The vessel’s alarm logs were found to contain early warnings about the impending failure approximately 36 minutes before the accident. However, as the vessel’s alarm systems regularly logged more than one alarm every minute, this information was not seen and could not be acted upon.

The only protection against catastrophic failure of the capacitors was a current imbalance detection system. It consisted of a current transformer which was connected to the capacitor circuit. Under normal conditions, little or no current should have flowed through the transformer. When a capacitor degraded, the current flow across the circuit became unbalanced and induced a current in the transformer’s secondary winding. The system was set to give an alarm when the imbalance reached 400mA and to trip at 800mA.After the accident, the transformer’s windings were found to have failed. There had not been any alarms on this part of the system for several years and it was likely that the imbalance detection system had not worked for some time.

This caused the alarm display to read 0mA giving a false indication that the capacitors were in good condition. Although detection of an unbalanced current was the only protection system for the harmonic filters, it had no backup and did not fail safe. Routine tests of the system were by the secondary current injection method, and by-passed the transformer.

Source: http://www.motorship.com/news101/maib-reports-on-qm2-explosion

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SCIENCE: What is Marine Forensics?

Wikipedia provides: The word forensic comes from the Latin adjective forensis, meaning “of or before the forum.” It roughly means to provide evidence upon which judgement can be made.

Marine Forensics applies this very broad definition to gathering evidence related to causation of incidents and accidents that have occurred on the greater than 70% of the earths surface that is covered with water.

It includes fresh water brooks, rivers and streams, Lakes great and small as well as the oceans.

  • A recent archaeology study on the Island of Crete in the Mediterranean sea proved that humans lived or visited there as far back as 130,000 years ago. Crete is many miles from the mainland and has been separated from it for over 5 million years. This implies that humans had some sort of water craft at least that far back into History. The earliest shipwreck remains ever found go back to several thousand BC.
  • A commercial fishing boat went down with 5 souls off New Jersey in 2009. An ongoing investigation seeks to determine the cause of this sinking. The possibilities range from a broken pipe in the engine room to being run down by a huge containership that passed through the area at that general time.
  • A rented power boat sank in Lake Tahoe a few years ago taking 4 souls to eternal rest. The investigation suggests that the boat was overcome by waves.
  • A 729 foot long iron ore carrier was down bound in Lake Superior on November 10th 1975, when a severe storm arose with hurricane force winds and a significant wave height of 7.9m. The Edmund Fitzgerald broke up and sank taking 29 lives and rests on the bottom in 520 feet of fresh water. The bow is upright, the middle exists as a collection of scattered metal shards, while the stern sits upside down.
  • The largest steamship ever built to that point left Southampton, England, on her maiden voyage on the well traveled route to New York. Of the 53 large steel ships that had struck icebergs in the previous 20 years, all but two had survived to reach port, and those two had time to discharge all their passengers onto other vessels before they went under. The Titanic was not especially concerned with icebergs until she struck one a glancing blow that sliced into or sprung riveted plates in 6 forward compartments. April 15th, 1912 gave us the most famous and enduring shipwreck legend of all time.
  • A ship laden with gold left one country to prop up the government of a friendly country but was lost in a storm at sea. The fall of the receiving government changed the course of history.
  • An earthquake and tsunami struck the largest and most important town in the Americas and destroyed most of it in a single afternoon. Port Royal on the Island of Jamaica went from the most important port in the Americas to a foot note in history in a single afternoon as it sank beneath the seas.
  • An invasion fleet from Kubla Khan reached the coast of Japan not once but twice when a typhoon came up and sank most of the vessels with a death toll that may have exceeded 100,000. In Japan this was seen as the divine wind, known forever after as the Kamikaze. It is no coincidence that the Imperial Japanese Empire chose to name their last ditch suicide mission against the US Navy at the end of World War II, the Kamikaze as it once again represented their last hope.

The list of marine casualties from ancient times to yesterday have shaped the history of individuals, countries and continents is long and varied. It is only since the end of World War II that humans have developed the technology that everyday makes the worlds waters more transparent. This is a new and exciting frontier to be explored by generations of clever and inquisitive minds.

Some Marine Forensic Investigations start with scuba gear, while others start with a newspaper clipping and a fist, head and computer full of equations. There are questions that can only be asked by each method. No amount to diving will ever explain the wave induced forces that caused the Edmund Fitzgerald to break into pieces, but modern computer tools are beginning to have that capability. No amount of computer modeling will ever tell an investigator about the damage to the hull of a sunken ship, but diving by one method or another can survey the damage and report back with evidence that can support the investigation by other means.

When a vessel sinks, there are physical circumstances that caused the sinking that may or may not leave traces. There are forces that can cause extensive damage as the wreck descends through the water column in deep water. The German Battleship DKM Bismarck, left the surface upside down and bow last, but hit the seabed right side up and bow first so complicated things happened in the water column.

There are bottom impact forces and associated damage. How does an investigator separate out which damage happened when? What damage caused the sinking and what happened before or after? These are not easy questions to answer but they are critical to understanding or discovering the truth of the matter.

The study of land based crime forensics has captured the popular imagination in recent years. Many of the techniques that the real experts use in a terrestrial setting will not work at all underwater. How does one take crime scene photos when the optical visibility is 6 inches or done at all? How does one measure off distances and angles when there is no fixed location to orient to?

The analyses desired can still be carried out but the means are forced to be quite different in the marine environment. There are acoustic “cameras” that can take quite good “pictures” using sound waves instead of light. You can’t buy these at any photo shop but there are commercial firms that can do this sort of work for a sizable fee, if you can wait up to several months for them to get under contract and come available.
When a vehicle, train or aircraft wrecks, all of the victims remains are recovered for burial by whatever traditions, beliefs and practices that the victims family, religion and country believe are necessary.

When a ship goes down, it is a very rare occurrence that anyone even tries to recover the bodies for burial on land. This is largely based upon tradition and also the cost and difficulty of doing so. In some cased like the Israeli submarine Dakar, or the Japanese fishing / research vessel Ehime Maru, great expense in what can take many years are expended to return the victims home for burial according to the customs of the group they came from.

The International Marine Forensics Symposium will discuss these and many other issues. We invite you to come listen, learn and help the next generation enter this new and exciting field.

Source: http://www.sname.org/Forensics2012/WhatisMarineForensics/

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SAFETY LAST | Maritime Union Condemns Flag States for ‘Atrocious State’ of Accident Investigation

UK – Last week in London freight and passenger interests witnessed the first ever Marine Accident Prevention & Investigation Conference and the event gave Nautilus International senior national secretary Allan Graveson an opportunity to express, in the strongest possible terms, the lamentable lack of investigation of major maritime accidents despite a well established framework of international regulation.

Nautilus, the trade union and professional organisation which represents 24,000 maritime professionals at sea and ashore, claim there are many shipping accidents where no independent investigation ever takes place, reports are never published, trends never identified, and lessons never learned. Mr Graveson commented:

“What an atrocious state of affairs, and no wonder this is an industry that labours under an image problem. Some flag states will argue that they do not have the resources for adequate investigations. In such cases should states be allowed to register ships? I think not. If you are a flag state you have to discharge the responsibilities that come with the often very attractive income that registration generates. Those that fail to discharge these responsibilities must be named and shamed, and ultimately stripped of their status as a flag state.”

Nautilus feels that the continuing toll of deaths and injuries involving lifeboat drills and enclosed spaces, as well as the large number of fatigue related accidents, indicated that even the best flag states sometimes fall short in delivering accident investigation reports that address long-standing and fundamental safety failings. Mr Graveson continued:

“There is a need for investigations to go beyond the immediate causes of an incident and wide-ranging recommendations that not only prevent the same incident but similar incidents where associated factors have a potential adverse influence. Above all, there should be decisive regulatory action. The latter is difficult to achieve in an international environment where some flag states are dependent upon revenues from shipping and are reluctant to be seen as pressing for what are frequently referred to as ‘burdens’ on the industry for fear of scaring away ship owners from their registry.

“In many countries accident investigation, criminal and regulatory investigations are not independent. This has serious potential adverse effects for the seafarer, but more so for the accident investigator who is less likely to get to truth. As a consequence we all suffer, seafarers without doubt, passengers and cargo owners in not preventing reoccurrence, and the national economy and the environment through possible pollution.

“Despite the sterling efforts of the rapidly developing accident investigation industry, prompted by new regulatory measures, there is still a considerable way to go in an industry that has, and continues to accept, a rate of losses and fatalities that other sectors of industry would find intolerable.”

Source: http://www.handyshippingguide.com/shipping-news/maritime-union-condemns-flag-states-for-atrocious-state-of-accident-investigation_3121


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Maritime accidents: rules for investigative interviews

This was originally post by Maritime Accident Casebook’s Bob Couttie in LinkedIn. According to him, it came to light “when was originally written when the US objected to seafarers being advised of their rights to legal representation and cautioned against self incrimination in the draft of the new investigation code”.

  1. A rubber hose does not make a good investigator.
  2. Waterboarding is not best practice.
  3. Do not play with your sidearm while interviewing witnesses.
  4. Administering pentothal is not recommended practice.
  5. Phrases such as “I know where your children go to school” are best avoided.
  6. Do not ask which finger the interviewee would prefer to have broken.
  7. Ensure that any electrical equipment used on an interviewee is inherently safe, properly grounded and has been verified as safe by a marine electrician.
  8. Do not shout at interviewees unless they are deaf.
  9. Ensure that any dentist present is properly qualified and wearing ear protectors
  10. At the end of the interview count the interviewee’s fingers, toes and limbs and, if appropriate, private parts as you may be held accountable for any subsequently determined discrepancy.

And a special final rule for the U.S.:

11. “Miranda? What freakin’ Miranda” is not appropriate in a maritime accident investigation.

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ACCIDENTS: No interaction between people, destructive interaction between ships

From the British Maritime Accident Investigation Branch’s Safety Digest 2/2011:


A 2,800gt cargo vessel collided with a 58,000gt ro-ro vessel as it was overtaking the larger vessel in the confines of a buoyed channel when they were departing from a major port. Local pilots were embarked on both vessels at the time.

The ro-ro vessel had recently entered the channel from a lock, and was steadily increasing speed as the cargo vessel approached her from the starboard quarter. The cargo vessel’s pilot assumed the ro-ro vessel would quickly increase speed and pull ahead, and initially was not concerned as the distance between the two vessels continued to decrease.

However, the cargo vessel continued to overtake the other vessel, and with shallow water to starboard it reduced speed in an attempt to prevent a collision. Unfortunately this action was ineffective as the cargo vessel was now so close to the ro-ro vessel that hydrodynamic interaction occurred between the two vessels. The cargo vessel took a sheer to port and collided with the ro-ro vessel’s starboard quarter.

The cargo vessel’s engine was stopped, but she remained pinned against the ro-ro vessel for several minutes. The ro-ro vessel’s bridge team had been unaware of the close proximity of the other vessel until the collision occurred as both vessels had been monitoring different VHF channels.

The cargo vessel’s engine was then put astern and she slid aft, along the ro-ro vessel’s hull, until she came clear of the larger vessel. Both vessels suffered minor damage as a result of the collision, but were able to continue on their respective passages.

The Lessons

  1. The cargo vessel was overtaking the ro-ro vessel and was thus the give way vessel. However, the pilot of the cargo vessel assumed that the ro-ro vessel would quickly pull ahead, but by the time it was realised that this was not happening, it was too late to avoid a collision. The pilot of the cargo vessel made an assumption, based on scanty information, that the ro-ro vessel was increasing speed. He should have ensured that this was the case before coming so close to the other vessel that a collision was unavoidable.[REMARK: Something like a “before overtaking checklist” might be useful in helping pilots and bridge teams avoid critical errors in this potentially hazardous situation. It might as well contribute to avoid the dangers of the “control and command” style of navigation in restricted waters. Pilotage is a complex act that requires orchestration rather than one or two bright soloists.]
  2. Hydrodynamic interaction occurred between the two vessels when the cargo vessel drew level with the ro-ro’s starboard quarter. There was a strong attractive force between the two vessels due to the reduced pressure between the underwater portion of the hulls. Mariners should familiarise themselves with MGN 199 (M) Dangers of interactionin order to be alert to the situations when hydrodynamic interaction may occur.[REMARK: A video from the Ilawa Ship Handling Research Training Centre can give you a better idea of how this sort of interaction between ships is about. There is also some relevant footage from the Port Revel Training Centre on the same subject.]
  3. The bridge personnel were not functioning as a team on either vessel. They had been monitoring different VHF channels and those on the ro-ro vessel were not aware of the cargo vessel until after the collision. It is essential that every member of the bridge team remains vigilant and fully involved in monitoring the execution of the passage, and that a good all round lookout is maintained when the vessel is in pilotage waters as well as when she is at sea.[REMARK: It’s about communication and awareness, after all. If overtakings are allowed in pilotage districts, everyone involved in the passage must be aware or made aware of this possibility and prepare for it accordingly.]

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