Thursday, January 24, 2013

Accident Defense - The Costa Corcordia

Costa Concordia lays on the rocks Isola del Giglio
The Costa Concordia sank about a year ago, there have been numerous reports and commentaries  I thought the his one:   Costa Concordia   Anatomy of an organizational accident was interesting.

The report listed 6 errors which lead to the grounding. The errors were referred to as breaches of a defense. Defenses against incidents can be compared to a defense in a game such as soccer  against the opposing team scoring a goal.

In the case of a soccer team the defense is also in layers.

The first layer  is a good offense. If your team has possession of the ball and is in scoring position there is little chance the opposing team can score.

The second layer is keeping the opposition out of scoring position. The last layer of defense is the goalie.  If at all possible the goal of the defense is to avoid allowing shots on goal.

Looking at the 6 errors;

 This was where the captain allowed the opposition to have possession of the ball.
 The first error was made by the Captain, when he decided to change his original voyage plan without the agreement of the Company and local authorities
On the second and third errors  the opposition is moving the ball down the field.

The second error was a shortfall in voyage planning. According to the Safety Officer8 - who arrived on the bridge just after the impact with the rock – only the original route was drawn on the paper chart, a few miles off the island.

The third error relates to route monitoring, a specific task of the Officer Of the Watch (OOW). The bridge team was composed of a Senior OOW, a Junior OOW, a deck cadet, and a seaman with either lookout or helmsman functions. The SOOW was in charge of the conduct of navigation, with regards to conning orders, collision avoidance and route monitoring on the INS. The JOOW was assisting him fixing the ship’s position on paper charts, which has to be considered with priority over the INS route monitoring. The JOOW could not correctly monitor the approach to Giglio Island, firstly because there were no routes drawn on larger scale charts than 1:100.000, and secondly because she left the chart table to assist the helmsman when the Captain took the command of navigation

Now the opposition is moving the ball into scoring position
The fourth error also relates to route monitoring. In contrast to the third error, this involved the INS, to be officially used only as an aid to navigation. The equipment was operated by the SOOW, who used the radar distances and the electronic chart overlay to monitor the approach to the island. The error consisted in assessing the distance from the furthermost radar echo of Le Scole rocks, and not from the limit of the no-go area, that is the 10 meters bathymetric line.

 The fifth error is in the area of Bridge Resource Management (BRM), and it can be attributed to the Captain, as team leader. Indeed the effectiveness of BRM practices - essentially aiming at optimizing team work – depends heavily on the leadership skills of the Captain. That night, since the Captain arrived on the bridge at about 5 miles from Giglio Island, a series of erroneous BRM practices can be extracted from the depositions. These shortfalls are of a non-technical nature, involving mainly lack of team briefing, and lack of formal handover. In short, the Captain did not share intentions and expected outcomes of the decisions made, both before and during the manoeuvre.
 On the sixth and last error nothing stands between the opposition and a goal except the goalie.

 The sixth error is of a shiphandling nature. It was the one breaching the last available defence: the human expertise. The error consisted in failing to maintain the newly established safety margin of about 0.25 nautical miles.

The captain worked himself into a position where he had only his shiphandling skills to prevent disaster.

A good defense in sports reduces the number of shots on goal rather then depending upon the goalie to make saves. Careful voyage planning and good bridge team management likewise reduces the number of "saves", situations which in which the crew has little room for error.



Anonymous said...

This series of basic rules applies to small watercraft and airplanes.As a boater with 40 years experience and a private pilot with 35 years, I agree with your synopsysis.Boat charts are to be used,not ignored.This was the reason the Rena hit the reef,the captain ignored the chart.A video was just on the internet reguarding a small airplane that could not gain altitude due to density altitude.It safely landed on an airstrip in Alaska, but on takeoff it went into ground effect and flew at treetop height until striking a series of trees and crashed.All of this was caught on two cameras by the passengers.The pilot broke the golden rule of flying,trying to take off an overloaded airplane for the altitude of the departure airport.They were lucky to has survived the crash with just some broken bones and cuts.

Matt said...

That's all true but also there is quite some pressure on the crew to not state mistakes, bad management or working processes. Many manager within the shipping company do not wish to hear about problems - especially not in writing! That's an interesting blog post related to this: