Tag Archives: protection

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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SAFETY MANAGEMENT | The dilemma of the 2 Ps

This text is essentially an extract from pages 3-3 to 3-5 of the Safety Management Manual (SMM) of the International Civil Aviation Organization (ICAO).

Although the focus of the text is on aviation, I cannot help thinking that it is absolutely suitable for maritime organizations as well: this is why I am reproducing it here.

The perspective of the management of safety as an organizational process and of safety management as a core business function clearly places ultimate safety accountability and responsibility for such function at the highest level of aviation organizations (without denying the importance of individual safety responsibility for the delivery of services). Nowhere are such accountability and responsibility more evident than in decisions regarding allocation of resources.

The resources available to aviation organizations are finite. There is no aviation organization with infinite resources. Resources are essential to conduct the core business functions of an organization that directly and indirectly support delivery of services. Resource allocation therefore becomes one of the most important, if not the most important, of the organizational processes that senior management must account for.

Unless the perspective of safety management as a core business function is adhered to by the organization, there is the potential for a damaging competition in the allocation of resources to conduct the core business functions that directly and indirectly support delivery of services. Such competition may lead to a management dilemma that has been dubbed the “dilemma of the two Ps”.

Simply put, the “dilemma of the two Ps” can be characterized as the conflict that would develop at the senior management level of the organization because of the perception that resources must be allocated on an either/or basis to what are believed to be conflicting goals: production goals (delivery of services) or protection goals (safety).

Figure 3-1A depicts a balanced allocation of resources to production and protection goals that results from organizational decision-making processes based on safety management as a core business function (i.e. just another core business function). Because the management of safety is considered just another organizational process and safety management just another core business function, safety and efficiency are not in competition, but closely intertwined. This results in a balanced allocation of resources to ensure that the organization is protected while it produces.

In this case, the “dilemma of the two Ps” has been effectively dealt with. If fact, it can be argued that in this case the dilemma does not exist.

Balanced relationship between productivity and protection

Regrettably, the history of aviation shows that effective resolution of the dilemma has not been commonplace. What history shows is a tendency for organizations to drift into an unbalance in the allocation of resources because of the perception of competition between production and protection. In cases when such competition develops, protection is usually the loser, with organizations privileging production objectives (albeit introducing numerous caveats to the contrary). Inevitably, as shown in Figure 3-1B, such partial organizational decision making leads to a catastrophe. It is simply a matter [of] time.

Figure 3-1C shows an alternative to the partial allocation of resources discussed in the two previous paragraphs. In this case, the bias in the allocation of resources is towards the protection side of the balance, thus leading to bankruptcy. Although this alternative is hard to find in the annals of aviation history, it nevertheless alerts one to the importance of sensible organizational decision making regarding allocation of resources. In the final analysis, it is clear that the development of the “dilemma of the two Ps” is denied by an organizational perspective that focuses on safety management as a core business function, at the same level and with the same importance as other core business processes. In this way, safety management becomes part of the fabric of the organization, and an allocation of resources commensurate with the overall resources available to the organization is ensured.

The rationale for safety management as a core business function can be extended into one final argument that bears considerable relevance to the processes underlying hazard identification and safety risk management as the operational activities and functions involved in safety management (discussed in Chapters 4 and 5).

Since aviation organizations have as a primary objective the delivery of services, the timely and efficient delivery of the services may at times come in conflict with operational safety considerations. For example, because of the need to meet a schedule, an airliner needs to land at a particular airport at a particular time, regardless of weather conditions, traffic volume, airport limitations and similar constraints which are absolutely related to the delivery of the service. If the service delivery efficiency considerations (the need to meet a schedule) were removed, operational safety (adverse weather conditions, high traffic volume, airport limitations) would cease to be a factor. The operation would be conducted only when the constraints had disappeared. This, however, is impractical, because it would destroy the viability of the aviation industry. Aviation operations must therefore be conducted under conditions that are dictated not so much by operational safety considerations but rather by service delivery considerations.

The corollary is clear: aviation safety issues are neither inherent to, nor a natural condition of, aviation operations, but a by-product of the need for, and engagement in, activities related to production or delivery of services. This reinforces the need for safety management as a core business function that ensures an analysis of an organization’s resources and goals and allows for a balanced and realistic allocation of resources between protection and production goals, which supports the overall service delivery needs of the organization.

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SAFETY AND ENVIRONMENT | The cost of beancounting

The following article was written by Clay Maitland, one of the most respected voices in the maritime industry.

Im my opinion, it is worth reading, if only to remind us that, at a time when cost management tends to be more important than safety risk management, beancounting can be indeed very expensive.

Here is Mr Maitland’s article:

Robert Dudley is an American oil man who became an employee of British Petroleum, oops, BP, when it absorbed Amoco, the former Standard Oil of Indiana, in 1998.

As of Friday,  Mr Dudley has taken the lead in managing BP’s, er, response to the Gulf oil spill.

Amoco, remember, was the owner of the Amoco Cadiz.

There are similarities between what happened to that vessel in 1979, off the coast of France, and what is happening now; both oil companies had/have rigid cost control systems in place, but no apparent means of minimising risk, or an awareness of the consequences of a failure to control it. In both cases, this failure led to vast financial and environmental loss.

One of many ironies is that the methods by which risk may be analysed and managed began with the Corporation of Lloyd’s, in the coffeehouse kept by Edward Lloyd in Tower and later Lombard Streets, in the City of London, in the reign of Charles II.

To assist shipowners and underwriters who frequented the coffeehouse, a list was maintained of the ships offered for the insurance of hulls and cargo.

These lists became in 1760 a printed volume or register book, and by 1775, the familiar classification of A1 Lloyd’s was used to denote the highest class of ship. The analysis and control of risk of loss became an essential principle, without which ships and cargoes could not be profitably insured, and shipowners avoid ruin.

Today, some of the world’s most knowledgeable and sophisticated experts in containing risks can be found within the ranks of London marine insurers. One hopes that Mr Dudley, who may be the successor to Tony Hayward as BP Chief Executive, will make use, at long last, of this resource.

It is also fervently hoped that he brings with him an institutional memory of the cause of the Amoco Cadiz oil spill.

Many readers will remember that she and her sister ships were ordered and built at the Astilleros yard in Cadiz; that all had a design flaw affecting their steering gear (not good for large tankers to have); that this caused significant loss of hydraulic fluid, which if not remedied, resulted in loss of control.

Amoco was warned to get this problem fixed on all of the Astilleros builds. This would have cost piles of money, so a less expensive solution was found: equip each Amoco tanker with large spare supplies of hydraulic fluid, carried in barrels.

This less expensive solution worked to management’s satisfaction, if not that of Amoco’s crews, until Amoco Cadizwas caught in a storm in the Bay of Biscay.

As part of the Amoco management system of control of all things great and small, each of its masters was required to be in close and frequent contact with company headquarters in Chicago. The effect of the sustained heavy weather encountered by the AMOCO CADIZ, culminating in a particularly severe storm as the vessel approached Ushant, was that most of the spare hydraulic fluid had been used.

Steering control failed, and the master, Capt. Bardari, radioed Chicago for permission (Amoco policy denied him the authority to do this without head office approval) to call for salvage tugs.

At first, and for some time, Chicago declined to grant permission to Capt. Bardari to do so, since this would probably entail his signing a Lloyd’s Open Form of salvage agreement. Surely a less expensive solution could be found.

Eventually, head office in Chicago relented, and allowed Capt. Bardari, poor soul, to call for assistance.

The stormy weather continued,  and his emergency call was answered by only a few salvors, one of which was a famous company called Bugsier.

More time was lost haggling over the potentially costly Open Form. The Bugsier tug, appropriately named Samson, arrived too late, and Amoco Cadiz was driven on the rocks of the Breton coast. The oil that spilled onto the French beaches and oyster beds, among other resources, resulted in very large damages against Amoco. A less expensive solution could not be found.

A noteworthy result of the Amoco Cadiz disaster was an extensive revision of the SOLAS Convention.
What has not, however, been done from 1979 to the present time, either in national or international law, is to deal with the disastrous effect of a business model that, particularly at some large companies, has tended to put cost controllers in policy-making positions.  This was true, at the time, at Amoco.

Such a man was Lord John Browne.

In contrast to the new management of Exxon, after the Exxon Valdez allision, (1989) which adopted pervasive, and effective, quality and safety management policies, John Browne was a ferocious cost-cutter who reined in spending across the board, including safety.

So has his successor and protege, Mr. Hayward. Despite the lash of outrageous circumstances: the Prudhoe Bay pipeline leak, the Texas City explosion, and about 760 safety violations in its refineries, cited by the U. S. Occupational Safety and Health Administration between 2007 and 2010, the corporate culture, despite all the “green” advertising, resisted effective awareness of the extraordinary risks that were being run.

Not so Exxon, now Exxon Mobil. Shortly after the Exxon Valdez spill in Prince William Sound, Alaska, Exxon’s board of directors met, and fired the CEO. It then convened a committee of senior executives, and instructed them to create and institutionalise a pervasive system of safety awareness and management within all of Exxon’s plants and other assets, including ships and rigs. Exxon Mobil now has an outstanding safety record.

This kind of cultural change requires leadership by example. If deepsea drilling is to be resumed, as I think it must, then a way to do it safely and competently will have to be found. All of the oil companies, and their suppliers and contractors must be forced to abandon hardheaded “cowboy” cultural attitudes toward safety and the environment.

There is definitely a need for federal legislation that defines and requires certificated safety management programmes; the Exxon Mobil system would provide an excellent model. A structure of outside audits will be a necessary requirement. The Institute of London Underwriters could provide useful advice.  A safety management and risk control system that delivers value, and is not “bolt-on” window dressing, requires the active engagement of senior officers of the company, and freedom from a “one size fits all” budgetary corset.

Much in the manner of Sarbanes-Oxley, there must be explicit accountability for safety awareness, and the company’s management system, from top to bottom within the company, from the “C” suite to the wellhead.

The key element is of course government enforcement; yes, another layer of bureaucracy is now inevitable! The Exxon Mobils, who will voluntarily change their safety culture, are not universal phenomena; without laws that compel compliance,the cowboys and the beancounters will continue to make their own rules, and life will be risky for those pensioners.

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