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

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.  

The aviation industry addressed the problem through the introduction of a process known as Crew Resource Management or CRM.  The process relies on the flight deck crew working as a team.  No single person has all the anwers and things can be overlooked by one person and picked up by another.  At the end of the day it is still up to the Captain to make the decision (on an aircraft or on a ship), but it is useful to have a helpful team that are not afraid to bring things to his/her attention.  It involves junior officers being prepared to :
State their concern
State the problem as they interpret it
Suggest a solution
Seek confirmation

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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