Comments on the Costa Concordia Grounding 13 January 2012. Part 3: Repercussions for Passenger Ship Safety – written by Prof Ed Galea, 20 January 2012 18:15

Posted on 20/01/2012 by Prof Ed Galea

As in most disasters of this type, so soon after the incident, information concerning the nature of this incident is far too sketchy to draw any firm conclusions.  Indeed, at the time of writing there are more questions than answers.  In my next few blogs I would like to make a few general comments related to issues associated with ship evacuation, and based on media accounts, attempt to put together a picture of what we currently know.  Finally, I would like to make some tentative comments about the incident and its repercussions for passenger ship safety.  

In the third and final blog in this series I want to raise some questions about the Costa Concordia incident and discuss the repercussions for passenger ship safety.

1) This incident shows that a disaster can happen hours after a ship leaves port. So should the mandatory assembly drill be completed prior to leaving port rather than having the option of doing it within 24 hours of embarkation? 

The Costa Concordia disaster couldn’t have happened at a worse time.  Most if not all of the passengers who boarded at Civitavecchia would have been new to the ship.  It takes passengers some time to get accustomed to the layout of a large cruise ship.  It may take days before the passengers know their way around.  Even figuring out if you are walking forward (towards the front) or aft (towards the rear) of the ship when in one of the long corridors can be difficult.  On top of this, not having experienced the emergency assembly drill means that new passengers (especially those new to cruise ships) would not know what the process was to abandon ship and that there was an assembly phase, what the signal was to commence the assembly phase, where their assembly station was located, where their lifejacket was kept and how to don their lifejacket.  All of this will add to the confusion associated with the assembly process.  Not having conducted the assembly drill prior to leaving port is likely to have contributed to the reported confusion during the evacuation of the Costa Concordia.  

In my opinion, the drill must be undertaken prior to leaving port.  IMO should review this requirement as soon as possible.

2) Given that there would have been other officers on the bridge of the Costa Concordia, why didn’t anyone stop the Captain from taking the ship off course and dangerously close to the Island of Gigilo? 

Is there an issue with the culture onboard ships that makes it impossible for junior officers to question the Captain’s decisions regarding the safety of the passengers and vessel?  A similar situation existed in aviation where first officers felt it was not appropriate to highlight potential problems with decisions made by the Captain which may impact the safety of the passengers and the aircraft.  This is believed to have contributed to several accidents in the past but the aviation industry, on the whole, has now addressed this problem.  Is there a problem with bridge culture on large passenger ships?  IMO should review the situation.

3) Assuming that the Channel 4 timeline is correct and there was 90 minutes between hitting the rocks and heeling over (see blog 2), could the Costa Concordia have been safely evacuated?  

With the ship upright, a calm and orderly assembly may have required 40 to 60 minutes.  With the abandonment process requiring 30 minutes in ideal conditions, all the passengers and crew could have abandoned the ship in 60 to 75 minutes.  This assumes that the call to abandon the ship is made at 30 to 45 minutes into the assembly process.  With 60 to 75 minutes estimated to be required to abandon the ship, the Captain had a 15 to 30 minute window in which to decide to start the assembly process. 

Taking the lower limit of these time estimations, the evacuation could have followed the following timeline:

  0 min – ship hits rock, Captain starts assembly phase

30 min – Captain starts abandonment phase

40 min – Assembly phase completed, 40 min after ship hits the rocks

60 min – Abandonment completed 30 min after the start of the abandonment phase.

This minimum timeline requires the Captain to start the assembly process immediately the ship struck the rocks and assumes that the assembly process is completed in the minimum practical time.

Taking the upper limit of these time estimations, the evacuation could have followed the following timeline:

 0 min – ship hits rock

15 min – Captain starts assembly phase

60 min – Captain starts abandonment phase

75 min – Assembly phase completed, 60 min after start of assembly phase

90 min – Abandonment completed, 30 min after the start of the abandonment phase.

On this basis it is conceivable that the ship could have been safely evacuated prior to it healing over.  But it would have required the Captain to have started the assembly process within 15 minutes of hitting the rocks and the abandonment phase within 60 minutes of hitting the rocks. 

4) It appears that it may have been possible to complete the evacuation before the ship started to heel over, so given the severity of the situation:

Why didn’t the Captain start the assembly phase earlier then he did?

While there is a lot going on in the initial minutes of such an incident, it would have been prudent for the Captain to have commenced a precautionary assembly as early as possible.  In general, there are many reasons why a Captain may hesitate in starting an assembly.  This is not an easy call; the last thing that a Captain and a ship owner wants is to ruin the first night and the first dinner of the cruise with a false alarm.  Imagine how upset the passengers and the ship owners would be if it turned out to be a false alarm or not as serious a situation as first thought!  What type of satisfaction ratings would the passengers give the Captain and crew if it were a false alarm?  What if a passenger was injured during a needless assembly?  Not an easy call, but with the safety of everyone on board at stake, it is a call that has to be made without fear of repercussions if wrong.  The safety culture of an organisation must reflect this type of approach.

5) As it appears to have been possible to complete the evacuation before the ship started to heel over, so given the severity of the situation:

Why didn’t the Captain start the abandonment phase earlier then he did?

It is noted that at this stage it is not even clear if the Captain did give the order to start the abandonment phase.  Nevertheless, according to the Channel 4 timeline, 73 minutes elapse between hitting the rocks and the command to abandon ship. From the media accounts, passengers who had assembled with their lifejackets were waiting to board the lifeboats.  Clearly, passengers were ready to board the lifeboats much earlier in the evacuation sequence. Doubtless, this delay contributed to the unrest reported by some passengers in the assembly area.  The delay in issuing the order to abandon ship will have made the job of the crew in the assembly areas significantly more difficult then it needed to be.  It also possibly contributed to the reported criticism of the crew in the assembly areas, by passengers who blamed the crew for delaying the abandonment process.  

6) The crew on the Costa Concordia had a tough job managing the assembly and abandonment process, a job made all the tougher by the delay in starting the evacuation process.  How can crew be better trained in handling the assembly process?

The crew undergo training in the assembly process usually without passengers present.  This is to ensure that they know where to go and what their duties are.  In addition, crew take part in the mandatory assembly drill for passengers, usually prior to departure.  While this is primarily a training event for the passengers, the crew also get to interact with passengers during a mass assembly process and so they get to experience what it may be like in an ideal evacuation.  However, the process could be made more realistic by having an unannounced drill – where the passengers and crew do not know when the drill will take place. 

As mentioned in blog 1 of this series, FSEG, my research group, are involved in an EU FP7 project called SAFEGUARD (see paper 252 at http://fseg.gre.ac.uk/fire/pub.asp).  As part of project SAFEGUARD we have performed five semi-unannounced ship assemblies at sea.  We wanted the assembly drill to be a surprise to the passengers and crew so that it would more closely resemble a real situation.  While the passengers knew that they would participate in an unannounced assembly drill after they had left port, they did not know when this would occur.  We had a lot of opposition from the industry at first.  The main issue that was raised was that the trial we proposed would be no different from what they normally do i.e. the announced drill along side and so would not produce anything that was not already well known.  They essentially wanted us to base our analysis on the normal assembly trials.  This is clearly nonsense since in the normal assembly drill, passengers are warned in advance of the exact timing of the assembly drill.  The passengers are even reminded 10 minutes before the drill takes place that the drill will start soon. As a result, many passengers pre-empt the drill and collect lifejackets and head off to the assembly stations prior to the commencement of the drill.  Anyone who has experienced a cruise will know precisely what I mean.  

As a result, many of the people are either already in the assembly station or in their cabins waiting for the drill to start.  While the passengers still have to find the assembly station, they do not experience an assembly with all the passengers trying to find their cabins and their assembly station at the same time.  So they do not experience the levels of congestion and organised chaos this produces – an experience not too dissimilar to what may occur in a real emergency assembly in ideal conditions.  Perhaps of more importance, the crew do not experience these conditions.  I am happy to say that we did eventually find three ship companies that were prepared to get involved and run the unannounced drills.  Without exception, the assembly process took considerably longer than is usually experienced when done alongside.  In most cases the assembly times produced by the unannounced drills at sea took about twice as long as the announced alongside drills.  Also, the ships officers and crew were particularly appreciative of the experience as they had never experienced anything like it before, in particular the numbers of passengers all moving at the same time, not knowing where to go, requiring guidance, it really put their training and their procedures to the test.  Without exception, everyone involved learnt some valuable lessons about the assembly process and what they may face in a real emergency assembly. 

It would not be practical or desirable for a cruise ship to run all their standard assembly drills as unannounced drills.   However, given the added training value it offers, it may be useful to require cruise ships to run some of their drills using this approach.  I suggest that IMO should consider making running a limited number of unannounced drills mandatory for cruise ship operators.

7) Should the IMO MSC Circ 1238 evacuation benchmark scenarios be more demanding?

Project SAFEGUARD (see item 6) is aimed at improving the current evacuation analysis process used to certify large passenger ships.  As part of this process it is conducting unannounced assembly trials at sea to collect more realistic data to utilise in the certification analysis such as the response times of passengers i.e. how long it takes passengers to react to the call to assemble.  In addition, SAFEGUARD is also collecting full assembly time data which will be used to validate and test the software tools used to simulate ship evacuation.  Perhaps of greater interest, SAFEGUARD is developing additional challenging benchmark scenarios to be investigated as part of the evacuation certification process.  These include a fire scenario and a scenario involving heel. Both fire and heel are serious hazards during ship evacuation and are currently excluded from the certification evacuation analysis.  By the time project SAFEGUARD is due to be completed (December 2012) it is hoped that several position papers will be produced and submitted to IMO for their consideration.

8) Why did the Costa Concordia heel over to the starboard side revealing the gash on the port side of the vessel?

I am not a naval architect but I am somewhat puzzled as to how the Costa Concordia has ended up.  The gash to her side is on the port side of the vessel.  So she would have been taking on water on her port side causing the ship to heel to the port side and eventually overturn onto her port side.  However she has overturned onto the starboard side revealing the gash on the port side.  How did this happen?  Was it the result of actions of the crew who tried to flood the starboard side to keep the ship in balance, was it the action of beaching, or was she holed again during the beaching, this time on her starboard side?  

Hopefully the inquiry into this incident will reveal what happened and why it happened.  It’s a little too easy to simply heap the blame on one individual.  It is hoped that from this tragic incident lessons will be learned that will lead to the improved safety of those who take to the sea.

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Comments on the Costa Concordia Grounding 13 January 2012. Part 2: What do we currently know about the Costa Concordia Incident – written by Prof Ed Galea, 19 January 2012 11:40

Posted on 20/01/2012 by Prof Ed Galea

As in most disasters of this type, so soon after the incident, information concerning the nature of this incident is far too sketchy to draw any firm conclusions.  Indeed, at the time of writing there are more questions than answers.  In my next few blogs I would like to make a few general comments related to issues associated with ship evacuation, and based on media accounts, attempt to put together a picture of what we currently know.  Finally, I would like to make some tentative comments about the incident and its repercussions for passenger ship safety.   In the second blog I want to discuss what we currently know about the Costa Concordia incident based on media accounts.

The world’s media has been flooded with accounts concerning the Costa Concordia. 

We know that the Costa Concordia left the port of Civitavecchia (just north of Rome) at 19:00.  The assembly drill had not been done and was planed for 17:00 the following day – within SOLAS requirements.  Also, the ship already had an undisclosed number of passengers onboard who were continuing on the cruise when she came into Civitavecchia and so these passengers would have already had the assembly drill.  In total it has been reported that there were 3206 passengers on board and 1023 crew, making a total of 4229 people on board.  We also know that the ship did not follow its pre-programmed route but was diverted to pass close by the Island of Giglio.  At this point in time it is not clear why the ship was diverted, but it appears to have been at the command of the Captain who wanted to “salute” a retired colleague on the Island.

From here on, things get confused.  According to one account:

“……Mr Ebbage, also 68, added: “Suddenly, around 9.30 pm, there was an almighty bang. Our table went flying, everything crashed to the floor and the lights went out…..”

From: Italy cruise ship disaster: survivors describe ‘pure chaos’, The Telegraph, 15 January 2012

http://www.telegraph.co.uk/news/worldnews/europe/italy/9016776/Italy-cruise-ship-disaster-survivors-describe-pure-chaos.html

There are many similar survivor accounts in the media.  As we all know, the Costa Concordia hits an outcrop of rocks which cuts a 50m gash into her side.  However, it is not clear at what time this occurred.  This account suggests it was 21:30.   However, the severity of the impact is unmistakable from this account and other similar accounts.  What is clear is that at around 21:30 everyone onboard was plainly aware that something very significant had happened to the ship.  At this stage we would hope that the Captain was also aware that something was very seriously wrong. 

Determining an incident timeline is essential if we are to understand what happened during this incident.  However, it is very difficult to put the survivor accounts published by the media together into a coherent sequence of events as most of the interviews with survivors fail to provide an indication of when the reported events occurred.  This makes it very difficult to put an incident timeline together.  A couple of media outlets have attempted to put timelines together.  One timeline was put together by the National Post on 15 January.  An extract from this timeline is as follows:

21:30 – The ship strikes an outcropping.

21:35 – The electricity goes off.

21:45 – A first alarm is sounded: two long whistles and one short, informing the crew of a problem.

21:50 – The ship begins to list. In the restaurants, dinnerware falls off the tables. Some passengers rush to their cabins for their life vests.

22:00 – Some passengers begin gathering on the fourth deck where the lifeboats are located, as the captain tries to maneuver the vessel closer to shore.

22:10 – The “abandon ship” signal is given: seven short whistles and one long. Lifeboats begin their deployment.

22:20 – The coastguard launches rescue operations with the help of speedboats and helicopters.

23:15: The first lifeboat reaches Giglio. In all, some 4,000 of the ship’s 4,229 make it to safety aboard a lifeboat.

From: “The Costa Concordia’s final moments caught on camera”, National Post, 15 Jan 2012.

http://news.nationalpost.com/2012/01/15/timeline-the-costa-concordias-last-minutes/

The UK television programme, Channel 4 News have put together a timeline and broadcast it on their 19:00 programme on the 19 January 2012.  According to this timeline we have the following events:

21:45   – Costa Concordia hit the rocks and continued on its way.

21:52   – Costa Concordia starts to turn towards shore.

21:58   – Costa Concordia loses power and the coastguard, alerted by the family of a passenger, begins their rescue operation.

22:42   – Costa Concordia stops, evacuation starts and people begin to get into lifeboats.

22:58   – Abandon ship call is made

23:15   – Costa Concordia begins to heel over. 

There is clearly some confusion as to when the incident started and the timing of how it progressed.  However, we know that about 3900 people made it to shore in lifeboats and that about 300 people were left onboard as the ship heeled over.

According to the Channel 4 timeline there was some 90 minutes between hitting the rock and the point where it was impossible to launch the lifeboats.  It is inconceivable that the Captain was not aware very early on in the incident that his ship was holed and taking on water.

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Comments on the Costa Concordia Grounding 13 January 2012. Part 1 The Ship Evacuation Process – written by Prof Ed Galea, 20 January 2012 11:00

Posted on 20/01/2012 by Prof Ed Galea

As in most disasters of this type, so soon after the incident, information concerning the nature of this incident is far too sketchy to draw any firm conclusions.  Indeed, at the time of writing there are more questions than answers.  In my next few blogs I would like to make a few general comments related to issues associated with ship evacuation, and based on media accounts, attempt to put together a picture of what we currently know.  Finally, I would like to make some tentative comments about the incident and its repercussions for passenger ship safety.   In the first blog I want to discuss the ship evacuation process.

Evacuating a large passenger ship, even in ideal conditions, is a complex and dangerous task.  Large passenger ships are normally evacuated in a two phase process, first the assembly phase and then the abandonment phase.  Each phase of the evacuation is initiated by a command from the Master of the vessel i.e. the Captain. 

 a) Assembly Phase

On the command of the Captain, usually designated by seven short and one long blast on the ships horn, the assembly phase can commence.  In the assembly phase, passengers are instructed by the crew to go to their designated assembly station, this is usually designated by a letter e.g. A, B, C, etc.  The assembly stations are usually spread over one or two decks and can be indoors (the norm) but can also be out doors (not so common).  How the ship conducts the assembly process is down to the company operating the ship and the Captain and so may differ from ship to ship.  For example, some ship operating companies assemble passengers by sending them direct to their designated assembly stations where they will be issued with life jackets.  Other ship operating companies will assemble passengers by first sending them to their cabins to collect life jackets, warm clothing and any essential medication, from their cabin, the passengers then make for their designated assembly station. 

During the assembly phase, crew should be stationed at key locations throughout the vessel to help direct passengers to their cabin and/or assembly station.  Once in the assembly station, passengers will don their lifejackets, or have lifejackets issued to them by the crew assigned to the assembly station. 

How long should the assembly process take?  As part of the ship design process, the duration of the assembly phase is determined through computer simulation, using evacuation simulation software such as maritimeEXODUS (see http://fseg.gre.ac.uk/exodus/air.html#maritime).  The maximum time for the assembly process determined by computer simulation for a ship the size of the Costa Concordia, as set out in IMO MSC circ 1238, is 48 minutes.  It should be noted that according to IMO MSC circ 1238, the simulation of the assembly process is intended to benchmark the evacuation capability of the ship and so an ideal benchmark scenario is used in the assessment.  The benchmark scenarios currently used assume that the ship is in an upright condition and in dead calm conditions.  A safety factor of 25% is added to the predicted time to take account of all the factors that are missed out in ideal benchmark scenario, such as fire and heel and the inherent simplifications in the simulation software. So in reality it should take no more than 1 hour to assemble a ship the size of the Costa Concordia.

My research group (FSEG) is part of an EU FP7 project called SAFEGUARD (see paper 252 at http://fseg.gre.ac.uk/fire/pub.asp).  As part of project SAFEGUARD we have performed five semi-unannounced ship assemblies at sea (not along side as is usual practice for the ship assembly drill).  One of these assemblies was on a ship of roughly similar size to the Costa Concordia but with fewer passengers.  The assembly time for this ship took was about 30 minutes – in ideal conditions but unannounced.   So if the assembly process had started before the ship had taken on a severe heel, I estimate that it should be possible to assemble the Costa Concordia passengers in about 40 to 60 minutes.

b) Abandonment Phase

On the command of the Captain, the abandonment phase can commence.  Starting the abandonment phase is not taken lightly, as boarding and lowering lifeboats filled with people, even in ideal situations, is not a trivial task and one with its own inherent dangers.  This is why it is the Captain who gives the command to commence the abandonment phase.  Furthermore, the abandonment phase can commence before all the passengers have assembled if necessary.  As with the assembly phase, the manner in which the ship conducts the abandonment phase is not set down in regulation, but each shipping company will have its own procedures.  Some companies may board those in greatest need first, perhaps the injured.  Others will board people in no particular order, just simply the order in which they turn up.  From the assembly station a member of the crew assigned to the assembly station will take a group of passengers to the lifeboat and will assist them to board the lifeboat, there will usually be a member of the crew already in the lifeboat to assist passengers as they board.  Large modern lifeboats have a capacity of up to 150 passengers.  Even larger lifeboats with twice the capacity are used on the super large cruise ships. Once the lifeboat is fully loaded, the crew assigned to the boat station will lower the lifeboat and once in the water it is expected to move away from the ship.  However, if the ships angle of heel is greater than 20 degrees, the lifeboats cannot be launched.  Lifeboats are normally lowered into the water only when the ship has come to a full stop.

The entire process of boarding all the passengers into the lifeboats and launching all the lifeboats should take no more than 30 minutes according to IMO SOLAS regulations.

c) Assembly Drills

Assembly drills are mandatory on any passenger ship which undertakes a journey of more than 24 hours.  According to IMO SOLAS regulations, the drill must be undertaken within 24 hours of passenger embarkation.

d) Lifeboats and Lifejackets

Under IMO SOLAS regulations, modern large passenger ships must have lifeboat and liferaft capacity for 125% of the people on board.  There must also be lifejackets for 105% of the people on board.  Lifeboats cannot be launched once the angle of heel exceeds 20 degrees and lifeboats cannot be launched while the ship is still underway.

e) Crew

Most of the ships crew, including waiters, entertainers, bar staff and cabin attendants will have a role in the evacuation process.  They will be positioned at key locations throughout the ship to direct passengers to their cabins and assembly stations, they will be in the assembly stations to manage the passengers, they will be at the lifeboats to assist the boarding of the lifeboats, they will control the lowering of the lifeboats and they will be in the lifeboats to control the lifeboats.   In addition to the assembly drills, which are also a form of training for the crew, the crew will have assembly drill training (without passengers ensuring that they know where to go) and lifeboat drills were they practice releasing and lowering the lifeboats.  Training sessions for crew must occur on a weekly basis, and each member of the crew must undergo training at least once per month (according to SOLAS regulations).

f) Women and Children First

There are no IMO regulations that states women and children must be given preference in boarding lifeboats.  It is not clear where this code of practice originates, but it is suggested to have arisen out of the sinking of HMS Birkenhead in 1852.  The Birkenhead was carrying troops to South Africa when she struck an uncharted rock and started to sink.  The soldiers commanding officer gave the order for the soldiers on board to stand firm and let the women and children, of which there where seven women and 13 children, board the two lifeboats that had successfully been launched.  The soldiers did as they were told and most perished.  The bravery of the Birkenhead soldiers is remembered in the Rudyard Kipling poem (1896) “Soldier an’ Sailor Too”:  

“To stand and be still

To the Birken’ead drill

Is a damn tough bullet to chew.”

The Titanic disaster of 1912 was another example where the “women and children first” tradition was upheld.  The combination of insufficient lifeboats and the Birkenhead tradition, meant that disproportionally more men then women died in this disaster. 

The concept of “Women and children first” is not mandated and it is not necessarily such a good idea.  Most emergency evacuation situations are characterised as being time critical.  In such situations every second counts and can literately make the difference between life and death.   In ship based disasters, the quicker you can get the lifeboats loaded and launched the better.  If you had to prioritise people at the boarding stage this is simply going to waste precious time and may delay the launching of the lifeboats.  Furthermore, family groups have very strong emotional and social bonds.  It is difficult to break these bonds.  To separate a family group on the basis of gender (the men folk being left behind) at the point of boarding the lifeboat would not be easy and is likely to be met with opposition, again delaying the boarding process.

Perhaps Somerset Maugham was a little ahead of his time concerning the position he took on the “Women and Children First” tradition.  He is quoted as once saying:

“I much prefer travelling in non-British ships.

There’s none of that nonsense about women and children first”

If you would like to know more about this, try listening to my BBC Radio 4 Women’s Hour (17/01/12 10:00am) interview from http://www.bbc.co.uk/programmes/b019f9h9#p00n9wlf.

Also check out the Guardian website article, “Costa Concordia: are women still prioritised over men in evacuation procedures?” at: http://www.guardian.co.uk/politics/reality-check-with-polly-curtis/2012/jan/16/costa-concordia-women?newsfeed=true 

g) Panic

I am not going to say anymore about panic, but I refer you to:

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Rescue Operations on the Costa Concordia – written by Prof Ed Galea, 20 January 2012 09:50

Posted on 20/01/2012 by Prof Ed Galea

I hope that the rescue divers have searched the lifts/elevators onboard the Costa Concordia. It is not clear when the power went out, and the ship did rapidly heel over so there may have been passengers trapped in the lifts/elevators.

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Costa Concordia Grounding 13 January 2012 – written by Prof Ed Galea, 18 January 2012 16:00

Posted on 18/01/2012 by Prof Ed Galea

I would like to express my deepest sympathies to the families and loved ones of the 11 confirmed dead and the 21 still missing in the tragic incident on the Costa Concordia off the Island of Giglio on the 13 January 2012. My best wishes also go out to the many injured and traumatised in the incident. I would also like to commend those members of the crew of the Costa Concordia who assisted passengers, under extremely difficult conditions, during the assembly and abandonment phases of the evacuation. The fact that so many lifeboats were launched at all and so many lives were saved is testimony to their actions. Thanks and praise should also be heaped on the Italian Coastguard and Fire Fighters who assisted in the rescue of hundreds of passengers and crew stranded on the Costa Concordia after she heeled over to almost 90 degrees and who are still putting themselves in harm’s way, searching the flooded interior of the stricken vessel in the hope of finding survivors. Finally, we must not forget the 1500 inhabitants of the Island of Giglio, who comforted and supported the 4000+ survivors of the Costa Concordia into the night and early hours of the morning on the 13th and 14th of January.

As in most disasters of this type, so soon after the incident, information concerning the nature of this incident is far too sketchy to draw any firm conclusions. Indeed, at the time of writing there are more questions than answers. Hopefully the inquiry into this incident will reveal what happened and why it happened. It is hoped that from this tragic incident lessons will be learned that will lead to the improved safety of those who take to the sea.

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Stay safe on bonfire night!

Posted on 06/11/2010 by Prof Ed Galea

Tonight is Bonfire night, follow these guidelines, enjoy the festivities and stay safe!

  • Don’t start your own bonfire, safest way to enjoy the festivities is to go to an organised display.
  • If you are going to set off your own fireworks remember:
    • Only buy fireworks marked BS 7114.
    • Don’t drink alcohol if setting off fireworks.
    • Store fireworks in a closed box; make sure the lid is firmly closed.
    • Have a bucket of water handy.
    • Make sure you have a torch with you.
    • Light fireworks at arm’s length with a taper.
    • Never go near a firework that has been lit.  Even if it hasn’t gone off, it could still explode.
    • Never put fireworks in your pocket.
    • Never throw fireworks – this is illegal and you could get a fine of up to UK£5000!
    • Always supervise children around fireworks.
    • Light sparklers one at a time and wear gloves.
    • Never give sparklers to a child under five.
    • Keep pets indoors.

Have fun!

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The tragedy of 9/11

Posted on 10/09/2010 by Prof Ed Galea

Our hearts and thoughts are with the innocent victims and the family and friends they left behind.
We honour the fire fighters and rescue workers who gave their lives.
We salute their colleagues who continue to put themselves in harm’s way.
Let their sacrifice be our spur to making the world a safer place.

Ed Galea
12 Sept 2001

http://fseg2.gre.ac.uk/HEED/sept_11_short.html

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Duisburg Love Parade Crowd Tragedy 24 July 2010 – written by Prof Ed Galea, 25 July 2010, 14:00

Posted on 25/07/2010 by Prof Ed Galea

Our deepest sympathies go out to the families and loved ones of the 19 people killed in the tragic incident at the Duisburg Love Parade on the 24 July 2010, and our best wishes go to the 340 people who were injured in the incident.

At the time of writing, information concerning the nature of this incident is far too sketchy to draw any firm conclusions.  Hopefully the enquiry will reveal what actually happened and, more importantly, why it happened, so that those charged with the safety of crowds around the world can learn from this tragic incident.

At this point I have two observations I would like to share with you.

(1) What appears to be the situation a few hours after the incident?

Here’s what I know at the moment, based on as yet uncorroborated media reports:

  • The Duisburg Love Parade reportedly attracted a crowd of 1.4 million people – this number has not confirmed by the authorities.
  • The event began at 14:00 and took place in a former railway freight yard.
  • The event has a single entry point, a tunnel located on Karl-Lehr Street. The tunnel is actually a highway underpass. Dimensions of the tunnel are not known, but photographs suggest that it is about 15m wide at the entrance.  Its depth is also unknown; one media report suggested that it was 600m long (Voice of America Online) and another suggested it was 100m long (Guardian).  Photographs I have seen suggest that the tunnel was very long and appears to be made up of several separate underpasses.
  • Photographs appearing in the media also suggest that the crowd outside the mouth of the tunnel and inside the tunnel was enormous.  While it is difficult to get an accurate measurement from the available photographs, they suggest to me that the crowd density was well in excess of 4 people/m2 and may have been in excess of 6 people/m2.  From the photographs there also appears to be no crowd management officials in sight and the random nature of the crowd further suggests that there was little organisation or control in the dispersal of the crowd.  It is not clear when the photographs I have seen were taken, but I assume that they were just before the event or during the event.
  • 19 people were killed in the incident and 340 people were injured.  It is not clear where the fatalities occurred.

I would emphasise again that the information at this stage is sketchy and there are many important details missing.  However, if the little information that is available proves to be correct, I would offer the following observations:

  • A single entry point for an event of this magnitude is not a good idea.  Given the size of the crowds expected, a single entry point was bound to make crowd management more complex and difficult with implications for crowd safety.    
  • I currently have to assume that there was also only a single way out of the event – the entry point.  If this is the case, again it is poor planning for the same reason that a single entry is not a good idea.  I would hope that other emergency exit points were available which the crowd could use in the event of an emergency, but this is currently unknown to me.
  • Another issue with having a single entry/exit point is that it may have to support quite sizeable bi-directional flows as people arrive and leave the event.  If controlled bi-directional flow is planned, this further reduces the effective width of the opening, increasing potential crowd management issues associated with the single entry point.  If the bi-directional flow was not controlled, this could have led to chaotic situations within the tunnel, especially with large flows of people.  From observation of the tunnel layout, I can see no evidence that there was a controlled bi-directional flow environment e.g. barriers in the tunnel to segregate entering and exiting patrons.
  • Having a tunnel, and such a long tunnel, as the only entry/exit point, when large crowds are expected is not a good idea for several reasons.  Perhaps the most significant is that it provides poor visual access to what is happening within the tunnel.  In certain circumstances this will potentially have a negative influence on the behaviour of the crowds as they cannot see what is happening further into the tunnel and so cannot perceive that a problem such as a blockage may have developed within or beyond the tunnel.  Indeed, if one end of the tunnel was closed by crowd management officials, as some reports suggests, it would have been extremely difficult for people within the tunnel, at the other end of the tunnel and approaching the entrance to the tunnel to know this and hence would persist in trying to enter the tunnel or continue moving along the tunnel.  Perhaps more importantly, if the crowd management officials cannot see what is happening within the tunnel, it is more difficult to detect a problem in its early stages, which makes diffusing a minor crowd event and preventing it from developing into a tragic event extremely difficult, if not impossible.  It even makes it difficult for crowd management officials to know with any degree of certainty the number of people within the tunnel.  This is potentially a recipe for disaster.
  • From what I can see in the photographs of the crowds approaching the tunnel from the station end i.e. the entrance, there appears to be no attempt at managing this flow.  It appears that there was no attempt to meter or regulate the flow of people or to channel the flow of people into the entrance.  I assume that the same was happening at the other end of the tunnel i.e. the event end.  From the pictures I have seen, the approach to the tunnel appears to have been a ‘free for all’.  If a small number of people had been expected to utilise the exit e.g. if there had been a smaller crowd or more entrances/exits, it may not have been necessary to provide this type of crowd management at the entry to the tunnel.  However, for an event attracting an audience of 1.4 million with a single entrance/exit, I suggest such measures would have been essential. 

(2) Subtle blaming of the victims.

As soon as news of the incident in Duisburg began to hit the front pages of the world’s newspapers and websites, familiar terms such as “crowd panic” and “crowd stampede” began to be used to describe the tragic incident in Duisburg.   For example:

  • “Stampede at German Love Parade festival kills 19”

BBC online news 25 July 2010
http://www.bbc.co.uk/news/world-europe-10751899

  • Sky News Headline live to air 25 July 2010 11:00

“Police in Germany have begun an investigation into how a stampede at a music festival left 19 people dead and nearly 350 others injured.  Panic broke out at yesterdays Love Parade event at the city of Duisburg where crowds of party goers tried to force their way through a narrow tunnel and were crushed.”

  • “Stampede at German Music Festival Kills 19”

Voice of America News, 25 July 2010
http://www1.voanews.com/english/news/europe/10-Killed-in-German-Techno-Parade-Panic-99171424.html

  • “Officials said the deaths and injuries occurred when panic broke out among huge crowds in a roughly 600 meter long tunnel leading towards the day-long open air Love Parade festival in the German city of Duisburg.”
    Voice of America News, 25 July 2010 
  • “A mass panic resulting in a stampede reportedly led to the deaths near a tunnel at the Love Parade electronic music festival in the western German city of Duisburg.”

The Sun 25 July 2010
http://www.thesun.co.uk/sol/homepage/news/3067817/19-die-at-German-street-festival.html

  • Love Parade stampede in Germany kills at least 18

Los Angeles Times 25 July 2020
http://www.latimes.com/news/nationworld/world/la-fg-germany-love-parade-20100725,0,2079922.story

  • “10 killed in mass panic at Germany’s Love Parade”

Business Week.
http://www.businessweek.com/ap/financialnews/D9H5HJ3G1.htm

  • “At least 10 people were killed and another 15 injured when mass panic broke out Saturday in a tunnel at an annual celebration of techno music in western Germany.”

Business Week.
http://www.businessweek.com/ap/financialnews/D9H5HJ3G1.htm

This is the typical media response, and of more concern, the typical first response from officials to fatal crowd incidents all around the world.  I don’t intend to discuss here the lack of understanding that the media, the public and officialdom have of words such as ‘panic’ and ‘stampede’.  Rather, I want to discuss the implications that using such phrases have on the public’s understanding of the event. 

While not directly stated, the implication conveyed when these types of phrases are used is that the incident was the fault of the victims, that it was their ‘unreasonable’ behaviour that caused or substantially contributed to the incident and resulted in the tragic loss of life.  Using such phrases is unhelpful, as it immediately diverts attention from other factors that may have contributed to or indeed been the root cause of the tragic event.  There are many other plausible explanations that may have contributed to this and similar tragedies that must be thoroughly investigated rather than go for the easy option of blaming the behaviour of the crowds.  For example, event planners may have designed an environment (both the physical space and the crowd management systems) that was unsafe for the size of crowds that were expected; approval authorities, charged with ensuring event design and crowd management provision is fit for purpose, may have failed to identify potential problems with the proposed event design and crowd management provision; and finally on-ground crowd management officials, charged with the safety of the public may have been unable to safely manage the crowd or may have allowed dangerous conditions to develop. 

It is all too easy to use these phrases when describing tragic crowd incidents, and thereby pass the blame for the incident onto the victims. In my experience of these types of incidents, it is seldom the victims who are the root cause of the incident, but failures during planning, approval and management of the event.

Keep Safe

Prof Ed Galea, 25 July 2010, 14:00

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