• Comments on the Costa Concordia Grounding 13 January 2012. Part 1 The Ship Evacuation Process.  http://fseg.gre.ac.uk/blog/?p=110
• Comments on the Costa Concordia Grounding 13 January 2012. Part 2 What do we currently know about the Costa Concordia Incident. http://fseg.gre.ac.uk/blog/?p=117
• Comments on the Costa Concordia Grounding 13 January 2012. Part 3 Repercussions for Passenger Ship Safety. http://fseg.gre.ac.uk/blog/?p=126

In my previous blog I reported what we currently know about the Sewol disaster, based on current media accounts.  Here I will explore to explore the ship evacuation process, what hampered the evacuation of the passengers on the Sewol and some of the implications for passenger ship safety.

The latest reports from South Korea now suggest that of the 476 people on board the Sewol, 174 were rescued, 54 bodies have been recovered and 248 people are still missing.

The sinking of the Sewol bears a striking resemblance to the Costa Concordia incident.  Many factors strongly influential to evacuation outcomes were common to both cases.  Some of these should have assisted the passengers, while others undoubtedly impeded their safe evacuation. The common factors that should have contributed to a favourable evacuation include:

1)    The incidents occurred under the jurisdiction of modern well-developed countries

This should have helped, but it does not mean that the shipping companies involved have a well-developed safety culture, or the regulatory and inspection facilities in each country are well developed and appropriate.

2)    The vessels were relatively modern

The Costa Concordia was launched in 2005, and the Sewol in 1994.  As both are relatively modern vessels they would have benefited from modern design practices and knowledge of safety issues. However, the Sewol was completed in the year of the Estonia disaster.  This disaster lead to a number of significant changes to IMO regulations for Ro-Ro ferries such as the Sewol, but they came too late to impact the design of the Sewol.

3)    The weather was calm

Bad weather can complicate the evacuation process, making it difficult to safely evacuate a large passenger vessel; however, in both cases, the sea was calm, and the conditions were not harsh.  While the water temperature in the case of the Sewol incident was cool, it is unlikely that the passengers would have remained in the water for a dangerously long period of time, especially given (4), (5) and (6).

4)    The vessels were on well-known routes and in busy shipping lanes

If the ship is in unfamiliar waters with little traffic it may complicate the decision to evacuate the vessel as the survivors may have to spend a long time in the water in lifeboats.  However, this was not the case in either of these incidents.

5)    The vessels were close to land

The fact the vessels were close to land meant that help was not far away.

6)    The vessels were in radio contact with the coast guard at the time of the incident

The fact that the vessels were in contact with the coast guard from the start of the incident meant that help was be quick in arriving.

7)    The vessels were not overcrowded and there were sufficient lifeboats for the population

In the case of the Sewol, the vessel was carrying significantly less than the maximum capacity of the vessel. In both cases, there was ample capacity in the available life boats.

8)    The captains were experienced master mariners

Both captains had considerable experience and should have been expert in the handling of their vessels, and the dangers associated with taking on water, particularly, in the case of the Sewol, of taking on water on the car deck.  Both should also have had a good working knowledge of the evacuation process and the need for speed.

Items (1) to (8) meant that the in both cases, these disasters occurred under somewhat ideal conditions and so we should have expected a much better outcome.  Indeed, both cases should have been more survivable, had the evacuation been managed in a more efficient and timely manner. 

In both cases the factors that contributed to the disastrous outcome of these evacuations include: 

9)    The passengers were not required to complete an assembly drill to familiarise themselves with the evacuation process prior to departure

In the case of the Costa Concordia an evacuation drill was not required prior to departure, but within 24 hours of departure.  In the case of the Sewol, as the journey was less than 24 hours an evacuation drill was not required at all.  This meant that it was unlikely that the passengers were familiar with the evacuation procedures.

10) Both Captains failed to start the assembly process within a reasonable period of time

This meant that the passengers were not in a position from where they could rapidly and easily abandon the vessel or be easily rescued by emergency responders, should this prove to be necessary.

11) Counter intuitive instructions were given to the passengers

Not only were passengers not given the command to assemble, they were effectively given instructions NOT TO assemble.  In the case of the Sewol, it is reported that the passengers were instructed to stay where they were, while in the case of the Costa Concordia, passengers were told that there was not a serious problem and that they should go to their cabins.

12) Both vessels capsized but this took more than 30 minutes

In both cases, there would have been sufficient time for most, if not all of the passengers to get to their assembly stations from where they could abandon the ship, had the assembly process started sufficiently early.

13) Failure to launch sufficient lifeboats (or liferafts)

Delay in starting the evacuation process meant that it was impossible to launch sufficient lifeboats in the case of the Costa Concordia, or virtually any liferafts in the case of the Sewol.  Davet launched lifeboats cannot be launched when the angle of heel exceeds 20^O and the liferafts cannot be launched if the crew cannot reach them due to adverse angles of heel.

14) Both captains abandoned the vessel before their passengers and crew had safely evacuated.

In both cases it is reported that the Captain did not remain on board to manage the evacuation of the people in their care.  Essentially they left the passengers to fend for themselves.

Failure to start the assembly process as soon as possible contributed to the disastrous outcome in both cases.

• Why is it so important to start the assembly stage as early as possible?

In an evacuation situation, every second counts and seconds can mean the difference between life and death.  On board a large passenger ship, the evacuation process is usually undertaken in two parts: the assembly phase, and the abandonment phase.  This is explained in more detail in an earlier blog concerning the Costa Concordia (http://fseg.gre.ac.uk/blog/?p=110).

During the assembly phase, passengers are instructed to go to their assembly stations. Passengers will be given lifejackets at the assembly stations, or they will bring their lifejackets from their cabins.  Assembly stations are close to the points from which passengers can embark onto the lifeboats if the captain decides to go to the second phase of the evacuation, the abandon ship phase.  It is vitally important that the assembly phase is completed as quickly as possible because conditions on board may make it impossible for passengers to get to a place from where they can abandon the vessel, if conditions deteriorate, such as if there is a fire on board, or if the vessel is heeling over, as in the case of the Costa Concordia and the Sewol.  If passengers are in the assembly stations it will also be easier for emergency teams to rescue the passengers compared to if they are located deep within the vessel.

Imagine you are in your cabin and you need to get to the assembly station.  Let’s assume that the assembly station is on your deck so you don’t have to climb or descend any stairs.  You will have to get out of your cabin, pass along a corridor running along the length of the vessel and then eventually pass through a corridor running across the vessel linking the left with the right part of the vessel.

When the vessel is upright, this is a relatively easy thing to do and you can pass from left to right or from right to left easily, depending on which side you need to move to (see Figure 1).  If the vessel takes on a slight heel, say less than 5^O, movement is still relatively easy, assuming that you are not elderly or disabled (see Figure 2); however at 20^O of heel, it starts to become very difficult to move up the slope and to control your movement going  down the slope (see Figure 3).  Your travel speed up and down the slope is greatly reduced, resulting in it taking considerably longer to assemble the passengers.  If you have elderly or disabled passengers, it is unlikely that they will be able to move unaided.

Angles of heel from 0 degrees to 20 degrees

When the angle of heel reaches 45^O, it is extremely difficult to move up the slope without travelling at a crawling pace, and you will need to hold onto things such as handrails to progress (see Figure 4).  Going down the slope in a controlled manner also becomes very difficult. If you are elderly or disabled, it is unlikely that you will be able to move, even with assistance. 

At 60^O of heel, it is unlikely anyone will be able to move up the slope, and the only way is down or staying where you are (see Figure 5).  If the passengers have not reached the assembly stations by the time the angle of heel has reached 60^O, it is unlikely that they are going to be able to move across the vessel against the slope. 

Angles of heel from 45 degrees to 60 degrees

If passengers are still in their cabins when the heel is much greater than 20^O, it is unlikely that they will be able to get out of their cabins, let alone make it to their assembly station.  Imagine now that if you had to ascend or descend stairs to reach your assembly station, how much more difficult it would be, compared with simply walking along a corridor!  Even walking along the long corridors running the length of the vessel becomes difficult when the ship takes on an angle of heel greater than 20^O.  The passenger is pulled down to the low side of the corridor and has to walk partially on the floor and partially on the bottom of the wall.  Here again the speed at which the passenger can move is greatly reduced AND the effective width of the corridor is greatly reduced, making it more difficult for crowds to move along the corridor.

This is why it is essential that passengers must complete the assembly process and locate themselves in a place from which they can abandon the vessel easily or be easily rescued if necessary.  So it is essential that the assembly phase of the evacuation is started as soon as possible.  Assembling the passengers does not necessarily mean that they will have to abandon the vessel, but if they need to do so, they will at least be able to.  I find it hard to understand why a captain of a vessel that is in distress – so much so that they have alerted the coast guard – would not have started the assembly process, if for no other reason than as a precaution. In my earlier blog concerning the Costa Concordia (http://fseg.gre.ac.uk/blog/?p=126) I offer some suggestions as why this may happen.  But it may also simply be down to denial.  The captain and senior officers may simply be denying the seriousness of the situation, believing that they can remedy it, and there is no need to evacuate.  If so, this becomes a training issue and one concerned with safety culture, both on board the vessel and also in the operating company that runs the vessel.

• Did social culture play a role in the outcome of the Sewol disaster?

It has been suggested that social culture of the South Korean people had a role to play in the outcome of the Sewol evacuation.  In particular, the suggestion is that South Korean culture demands that people are respectful of authority and are compliant with the wishes of those in authority.  Had the passengers been from a different cultural group they may have reacted differently to the order to stay where they were.

Recent work by my research team as part of an EU FP7-funded project BeSeCu [1,2,3] suggests that social culture may influence the way in which people respond to alarms.  It was noted in this research that when faced with virtually identical situations, groups of people from one culture tended to react significantly more rapidly than groups from other cultures when faced with a fire alarm.  This is further discussed in a paper we published recently with the Royal Institution of Naval Architects, concerning evacuation from large passenger ships [4], as part of the EU FP7 SAFEGUARD project [5].  

However, I am not convinced that simply responding to an instruction from an authority figure is a cultural trait unique to the South Korean people.  Our research into the World Trade Center evacuation [6] suggested that when people in the South Tower of the WTC heard the instructions over the PA system that they should return to their offices, as they were safe in the South Tower, (as only the North Tower had been hit at this time), many did so – and died [7]. Also, many passengers on the Costa Concordia also complied with the instructions of the crew, at least initially. 

Perhaps it is more relevant that the majority of people on board the Sewol were children and so more likely to follow the commands of an authority figure.  This is probably likely to be the case in most cultures.  Furthermore, as with the Costa Concordia disaster, safety culture (or the lack of a healthy safety culture), as opposed to social culture, may have played a more important role in this disaster.

• Assembly drill requirements

As has already been stated, according to IMO regulations, it is not compulsory to have an assembly drill prior to the departure of the vessel for voyages of less than 24 hours; however, as the Sewol and Costa Concordia incidents have tragically demonstrated, fatal accidents requiring the abandonment of the vessel can occur at any point of a voyage, even as little as a few hours after departure. In both cases, the passengers would have benefited from having experienced the assembly process prior to the fatal accident.

The point of the assembly drill is twofold: firstly, and most importantly, to familiarise passengers with the assembly procedures and the location of the assembly stations; secondly, to provide the crew with training in the management of large crowds of passengers.  The need to undertake the assembly drill becomes more critical the larger the number of passengers on board, and the more complex the layout of the vessel.  Indeed, the duration of the voyage is somewhat irrelevant when setting a lower limit for the need to undertake an assembly drill. 

The difficulty for a regulatory body is in defining critical limits on duration of voyage, population size and complexity of vessel layout that are meaningful and not arbitrary; nevertheless, in addition to the current voyage duration criterion, sensible limits could be placed on the other factors.  Addressing complexity, if a significant number of the passenger population is accommodated within cabins, the layout of the vessel will be more complex than a vessel not having cabins.  Thus if a significant number of passengers are accommodated within cabins, the complexity criteria will require an assembly drill.  In terms of the size of the passenger population, if the predicted assembly time for the vessel is within 20% of the maximum allowed assembly time, then the population criteria will be met to require an assembly drill.

So rather than having a single factor (duration of voyage) determining whether or not an assembly drill is required prior to departure, three factors addressing different challenging evacuation issues should be considered:

• Duration of voyage: if the voyage is greater than 24 hours, an assembly drill must be undertaken.  This ensures that the current criterion is maintained.  The longer the voyage the greater the chance that an accident may occur and, hence, that an assembly may be required.
• Complexity of vessel: if more than 30% of the passengers on the voyage are to be accommodated within cabins, then an assembly drill must be undertaken.  This ensures that passengers travelling on vessels with complex layouts will undergo an assembly drill prior to departure.
• Number of passengers: if the predicted assembly time for the vessel is within 20% of the maximum allowed assembly time, an assembly drill must be undertaken.  This ensures that vessels with large numbers of passengers for their size will have an assembly drill prior to departure.

REFERENCES:

1: http://fseg.gre.ac.uk/fire/besecu.html

2: “Behaviour – Security – Culture. Human behaviour in emergencies and disasters: A cross-cultural Investigation.”, Silke Schmidt and Ed Galea (Eds), 2013, Pabst Science Publishers. ISBN: 978-3-89967-867-3

3: Galea, E.R., Sharp, G., Sauter, M., Deere, S.J., Filippidis, L., “Investigating the impact of culture on evacuation behaviour – A Polish Data-Set”, Proceedings of the 5th International Symposium, Human Behaviour in Fire, Cambridge UK, 2012, Interscience Communications Ltd, ISBN 978-0-9556548-8-6, pp 62-73, 2012.

4: Brown, R., Galea, E.R., Deere, S., Filippidis, L., “Passenger Response Time Data-Sets for Large Passenger Ferries and Cruise Ships Derived from Sea Trials”, Trans RINA, Vol 155, A2, International Journal of Maritime Engineering, April-June 2013, pp A97-A103.

5. http://fseg.gre.ac.uk/fire/safeguard.html

6: http://fseg2.gre.ac.uk/HEED/

7: Galea, E.R., Hulse, L., Day, R. Siddiqui, A., and Sharp. G. “The UK WTC 9/11 evacuation study: An overview of findings derived from first-hand interview data and computer modelling”, Fire and Materials, Vol 36, pp501-521, 2012, DOI: 10.1002/fam.1070

http://www.youtube.com/FSEGresearch/

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.

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.

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:

• The BBC Radio 4 “Today programme” interview I gave with Dr Drury on the 17 January 2012 at 07:41 http://news.bbc.co.uk/today/hi/today/newsid_9679000/9679490.stm
• An interview I gave for BBC NEWS on the 16 January in the article, “Costa Concordia: The rules of evacuating a ship”, http://www.bbc.co.uk/news/magazine-16576289
• My blog on the Love Parade 24 July 2010.

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.