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SUMMARIES OF MAJOR  ACCIDENT REPORTS
(In event order)

THE KULLUK INCIDENT
December 2012
THE COSTA CONCORDIA
January 2012
THE TRINITY II
September 2011
THE DEEPWATER HORIZON
April 2010
THE BOURBON DOLPHIN
April 2007
THE STEVNS POWER
October 2003
THE OCEAN RANGER
February 1982
THE OCEAN EXPRESS
April 1976

PICTURE OF THE DAY
PIC OF THE DAY ARCHIVES
2007 - 77 Photographs
2008 - 101 Photographs
2009 - 124 Photographs
2010 - 118 Photographs
2011 - 100 Photographs
2012 - 97 Photographs

 

 

THE COSTA CONCORDIA REPORT.

Time flies and it is now eighteen months since the Costa Concordia disaster. And the other day the report by the Italian Marine Casualties Investigative Body was released. One assumes that it must have appeared in Italian and then translated into English. Now I don’t speak Italian so why should I expect the report to be published in English? Well, as far as I know English is the generally accepted international marine language, and more of that later. However the report has been translated into a version of the language which makes the result at best obscure. Indeed I wondered if they had used Google, but surely it is a bit too technical for that. The result of this translation is that the report in some areas is open to interpretation, and as a result my summary of it is completely my own view and has no legal standing whatsoever.

The first item of interest in the report is the vessel details, which tell us that the ship is 247 metres long, and 35 metres wide, with a passenger capacity of 3780. Also it has two main engines connected to electric generators , which in turn power electric motors to power two fixed pitch propellers. It has three large bow thrusters and three large stern thrusters. The ship was built in 2006 in the Fincantieri Shipyard. Although not mentioned, I assume that there were two rudders, and also not mentioned was the emergency generator of which much is made later.

The next item is the safe manning certificate which says that the ship requires a crew of 75. They would be made up as follows: 7 deck officers and 10 deck ratings, 8 engineer officers, 5 electricians and 8 lesser engine staff, a purser a radio operator, doctor and a nurse. Actually if you add these number up they only come to 42, leaving an unidentified 33 crew members. One assumes that they are probably catering staff, including one cook at least. The one man a British registered ship cannot sail without.

The ship was on a regular run, starting at Savona, making the port from which it departed before the accident, Civitavecchia, the last port of call, not the first port of the cruise as we all though initially.

The accident resulted in the 32 people dead or missing and 157 people injured, of which according to the report 20 required hospital treatment.

It appears from the narrative in the report that the master had given instructions that the ship is to head for Giglio, maybe for the benefit of the Chief Purser, the Catering Services Manager and the ‘Metre’ (actual position unknown), and at 2103 the ship takes up a course of 279º towards the island.

At 2134 the Captain arrives on the bridge and instructs the helmsman to put the steering into manual (from autopilot one assumes), and shortly afterwards the 1st Officer gives instructions in course headings to take the ship starboard. Although this is not specifically expressed in the report one assumes that the alteration was to take the ship clear of the North end of the island.

At 2138 the Captain is on the telephone to some-one asking about the safe distance off the island. (the investigation was unable to name the person being called).

2139 with the ship on a heading of 290º the Captain takes over the watch, although later narrative in the report seems to indicate some uncertainty in this area.

2140. The Captain orders an increase in speed to 16 knots and for the course to be altered ‘easy’ to 310º.

At about 2141 only seven minutes after the Captain’s arrival on the Bridge he begins to give a succession of helm instructions firstly to turn the bow away from the island (so it seems, although the translation is confusing) and then to port to stop the stern hitting the rocks. It appears that during every change of course the ship moved laterally towards the rocks, and since the Captain sent the Second Mate to the port wing, he was aware that there was a risk of grounding. Finally when giving orders to put the rudders to port the helmsman makes an error and puts them to starboard, but corrects himself and goes hard aport, the correction taking eight seconds.

At 2145 the Second Officer warns that the ship has gone aground, and there is a loud crash. Judging by the photographs and the description of the damage, the grinding of tortured metal must have gone on for about ten seconds, and it would only be the distance from the location of the impact and the enclosed design of the bridge which might have reduced the bridge team’s understanding of the full extent of the disaster. The ship continues to move northwards, and within a minute is blacked out.

At 2146 the emergency generator starts up and provides power for 41 seconds. Within a minute the ship is blacked out, but during that time the master has given a number of helm orders ending up with the rudders hard to starboard. And the ship continues to move northward, the speed gradually decreasing.

By 2152 it is evident that serious flooding of a number of compartments has taken place and this has resulted in the failure of the main engines and almost all other systems. The emergency generator which has operated briefly is attended by an Electrician who finds that the automatic switch, which will start up the generator on main power failure, is disengaged, and applies a screwdriver to the switch. But a cooling system failure, as far as I can tell the reason for which has never been identified, results in the generator stopping.

At 2155 the passengers are reassured by the PA system that all is well, and not to worry, and that ‘the technicians are working to restore the functionality of the ship’.

At 2158 The Captain makes telephone contact with the company Fleet Crisis Co-ordinator and says according to the report that the ship hit a rock with the left side towards the stern, reports the dynamics of the casualty, adds that the propellers were not affected and is being assessed for damages, also announces that the ship is in blackout and that water is entering the stern that has reached the main electrical panel.

Obviously this was an optimistic report and in no way really flagged up the level of the crisis, and the technical staff back in the headquarters suggest that the ship be taken to anchor by the use of the bowthrusters.

At 2207 there is a conversation between the Civitavecchia Harbour Operations Room and the ship, which refers only to the blackout and that the situation is under control. By this time it is evident to the 1st Officer and the Deputy Chief Engineer that there are probably at least four compartments flooded. In addition the Italian Search and Rescue services have received several calls from the relatives of passengers on the ship who have been in contact to tell them that there is something wrong.

By 2212 with the rudders still hard to starboard the ship’s forward motion has virtually ceased and maybe as a result, not explicitly stated in the report, the list changes from ten degrees to port to a list to starboard. The staff in the emergency generator room have found that they cannot maintain power using it due to the virtual failure of the cooling system, and that therefore there can be no provision of power to pumps, steering or other normally available systems powered from the emergency switchboard.

At 2218 the Captain communicates with the company Crisis Centre again to tell them that several compartments are flooded and that there is no real power available from the emergency generator. The report suggests that the captain believes that there are only two compartments flooded and that therefore the ship can survive. Hence he has not made contract with the SAR services. Not only that, at this point the passengers have not been alerted to the emergency.

By 2228 the Captain has asked for the assistance of a tug, and has made a more realistic report to the company. It is evident that the water level is still rising in the lower compartments of the ship, and by now some of the catering areas have been flooded.

At 2230 the Chief Engineer suggests to the Captain that the ship should be abandoned.

At 2233 the ‘General Alarm’ is raised, followed by a PA announcement (I think the report says ‘ads are then issued’) to reassure the passengers that all is under control. Despite this reassurance some passengers have apparently already got into the lifeboats.

Possibly the next really salient point in the report is that at 2240 the ship is resting on the bottom, and at that time a distress message is broadcast using Inmarsat C.

By 2247 an SAR patrol vessel and a helicopter have been launched, and at that time the Captain orders the dropping of the starboard anchor, and then when it stops the release of the port anchor. The Captain has also told the Coastguard Operations Room that he is continuing to manoeuvre the ship towards an anchorage, even though he has no engines, no rudders and the ship is aground.

Whatever else, the grounding of the ship opposite Giglio harbour was phenomenally lucky. As the salvagers have found only a few metres to seaward and it would have turned over.

At 2251 the report states the following: Master informs the bridge to raise abandon ship order, and then urges it, but when asked to make the announcement he points out that it should be said, "Let passengers on shore." rather than that. You can see that there might be a bit of trouble interpreting the content of the report just from this statement, even though we think we know what they mean.

At 2257 there are lifeboats in the water, and the ship makes contact with the ‘SO’ maybe a misprint, they could mean the Coastguard Operations Room and says they are evacuating as a precaution.

At 2311 the starboard list may be between 20 and 30 degrees and the Captain in his last call to the company crisis unit describes the situation as being less serious than the reality.

Up to now most of the content of the report has been taken from the VDR, the Voyage Data Recorder, but at 2332 even the Second Master who was left on the bridge to co-ordinate the evacuation, has left, so from this point one assumes that either witness statements have been used, or else transcripts of communications from the shore. And at 2338 all control of the evacuation having been abandoned, there were still 300 passengers and crew on board. They were still trying to escape, or disembark if you were following the Captain’s view, and those who had jumped into the sea were being picked up by SAR patrol boats.

At 0042 with about 80 people still on board the Captain reveals to the Coastguard Operations Room that he is on shore, and over time and after further communications at 0146 the report says that the OR contacts the Master ordering him again to go back on board and provide a situation report. This ordering back on board was broadcast around the world at the time and the succinct phrases used were soon to be found on tee-shirts and being used as ring tones.

The rescue efforts continue with crew from one of the patrol boats going aboard to sort it all out and at 0617 the report says that the rescue operations connected with the evacuation of the persons on board were declared complete.

The remainder of the report could be considered to be assessment and analysis. Quite a lot of it against the requirements of the ISM Code. For instance the safe manning certificate apparently suggests 78 people. Actually we might by now be becoming confused because we have already seen two number for safe manning, and does it matter since the crew list submitted 16th May named 1023 crew members. The crew was made up of 38 nationalities, of which 149 were Italian. And the language to be used on the ship was officially named as being Italian.

So there were problems with Italian being the named language, since quite a few of the crew did not apparently understand it. The helmsman was Indonesian and in extremis the Captain spoke to him in English. According to crew members most instructions were given in Italian and English. American passengers testified that during the emergency several crewmembers were unable to speak English. But we have to ask, why should they? The official language was Italian, so that is what the passengers should have been able to speak.

In addition to the crew problems with language, the report also details the problems with the emergency qualifications of those who were in charge of the lifeboats and the liferafts. And the answer seems to be that those in charge of the lifeboats had mostly been qualified at some time to be in charge, but that the certificates held by many of them were out of date, and in the main most of the liferaft guys were unqualified. I’m having a job to stick to the script here, since I heard a BBC report where native English speakers from the crew and the passengers were interviewed.

There is then a quite lengthy discussion on the adequacy of the chart being used, and there is a photograph of the actual chart which had been recover from the ship. They should apparently have used chart 119 with a scale of 1:20000 rather than a chart with a scale of 1:100000, and if you look at the photo no wonder the Captain called some-one. There only three soundings on the side of the island along which the ship was to pass. But of course this would hardly have mattered if he had passed at a safe distance.

And now we move on to watchkeeping and navigation, and I am going to include the full introductory paragraph in order to illustrate the problems anyone would have in trying to understand what was going on. And I am beginning to think that the Italian investigators meant this to be unintelligible. How else could it have been. Even I know an Italian who is completely bilingual and could tell them where the problems were. And by reading on I have found that the word ‘guard’ is probably a mistranslation of the word ‘watch’ in Italian.

The navigation area must be monitored visually with the navigation instruments and must be evaluated every dangerous situation.
The officer on duty on the bridge is responsible for the conduct of navigation, that is to perform according to the schedule of the voyage, even in the presence of the master on the bridge. It 'the same Master who must explicitly take the guard on the bridge pointing to the officer on duty.
The guard must be structured so that it can be ensured the safety of navigation.
Similar service should be carried in the car unless the vessel is not certified UMS (unattended machinery spaces) that the machine is "periodically unattended."
The "Costa Concordia" is in possession of the record class AUT-CCS then there is a guard in the "central control station".
The organization of the guard is deducible from the "planning board of the guard."

The report goes into considerable detail on the final few moments before the grounding, showing photographically the actual rudder positions obtained against the headings or angles required by the master. It also suggests that the main reason for the grounding was the fact that the ship had passed the point at half a mile off when a large alteration to starboard should have been ordered.

As usual in any investigation the investigators find many thing are amiss in the operation of the object, of what-ever sort, and the Costa Concordia accident was no exception. They found that the report of passenger and crew numbers was incorrect, and wrongly reported several times. They found that even though the Abandon Ship drill had been carried out on departure from Savona, other passengers had joined later, but no subsequent drills had been undertaken. And it also found that despite the close approach to the shore, and the number of personnel on the bridge, no formal process had been set up for what was effectively a manoeuvring operation.

There-after, rather unusually the report considers the means by which the grounding could have been avoided, and although I found it quite difficult to understand, it appeared that the simulations carried out indicate that had the last order to starboard been avoided then the ship would have passed clear of the rocks. This view is certainly born out by the fact that finally the captain ordered hard to port to clear the stern, but of course the helmsman put the rudders over to starboard.

Of course we are already aware that subsequent to the grounding things did not go according to plan. The plan actually is the ‘Decisional Support System’ provided by the company in accordance with SOLAS requirements. It seems that neither the ship’s staff, or the Company itself followed their own guidance. Even at 2221 when the DPA (Designated Person Ashore), who had been contacted by the Captain, called the CMD (Probably the Crisis Management Director, but not names in the glossary of terms), that person accepted the responsibility although according to the company requirements it should have been a different person. And only at 2300 was the Crisis Committee formed.

Indeed the report goes on to list all the failings in the emergency process, which were considerable, and all in all it was luck that so many boats got away virtually under the individual command of the crew members who were in charge of them. If I understand it correctly they are commended for their efforts. The report then goes into some detail about what happened to the ship ending up with it grounding outside the harbour at Giglio, all of it intended to refute the Captain’s public declarations that it had been his intention to ground the ship to save the personnel on board. Indeed it appears that the Captain was actually trying to prevent the ship from grounding by having the anchors let go.

Of course the extent of the damage directly caused by that big rock sticking through the side of the ship was considerable, and connected four large compartments, and therefore exceeding the capabilities of the ship to remain afloat (Two compartment damage). The fact that the watertight doors were closed is hardly material. At various points the report states that no consideration was made to attempting to pump out these compartments, but of course even if such a course of action had been considered there was no power so no pumping would have been possible. The failing on the Captain’s part, according to one of the subsections, was that he did not have sufficient knowledge of his own ship. The investigators also commissioned a separate stability report to assist with their understanding of the accident, of which we casual readers do not really need to know the details. You could probably say that it confirmed our suspicions that the ship would have sunk had it not fortuitously gone aground.

There are pages and pages in the report given over the analysis of the operation, and non operation of the emergency generator, and in an attempt to understand what went wrong simulations were carried out on an similarly equipped ship. It is important to understand why the emergency generator did not work as required, and as far as I can tell, no real conclusions were made. It could have been that the submergence of the ship to shore connection could have prevented the switching system working, and as far as I could see they found no reason for the generator overheating.

So we move on to the summary and the recommendations. In the summary the Master and the deck officers are collectively blamed for the grounding, and for most of the failings in the evacuation process, in which the management ashore are also included, specifically the Designated Person Ashore.

The recommendations are divided up in various ways, and I will try to summarize them. You may need your copy of SOLAS to hand.

Proposals Accepted by the Flag Administration

1. The information required by SOLAS regulation III/27 and European Directive 98/41/EC should be integrated with the indication of the nationality of each passenger. This would help communications, in case of accident, between SAR Centres and Administrations whose citizens are on board.

2. The voyage plan requested by SOLAS regulation V/34 should be made available by the master to the Company prior to the ship's departure and be kept available until the next DOC audit.

3. Instructions to passengers: the following measures should be implemented:

a) at their embarkation, passengers are to be provided with a brochure containing all the essential emergency information; these brochures are to be available in the Flag language and in the languages spoken by the passengers on board;

b) in addition to what is prescribed by SOLAS regulation III/19.2.2, safety information is to be available through the ship's TV system, both in cabins and in conspicuous points in the public areas, at the embarkation and throughout the voyage;

4. The muster of passengers as per SOLAS regulation III/19.2.2, is carried out at the ship's departure from the home port; where embarkation takes place in different ports, separate and dedicated musters are to be performed for passengers embarking in those ports.

Improvements caused by the Ratification of the MLC Convention (August 2013)

There are a variety of statements made in relation to the audit and validation of manning agencies, but it was unclear to me whether these items were suggested as possibilities or will be in place if the convention is followed properly.

What the Company did as a direct result of the Casualty

A guest safety drill is to be performed before the departure of the ship from the embarkation port, and those guests identified as not participants are re-invited to another event organized on-purpose (We understand the intent of this I think).

The Company also creating a new Maritime Development & Compliance Dept, which reports directly to the CEO.

The Company implemented an advanced system to manage and monitor fleet route the "High Tech Safety Monitoring System" (HT-SMS), involving both on board and ground staff. The system enables the Company to monitor position and course of the entire fleet in real time.

The Company is creating a dedicated "F.O.C." Fleet Operations Centre in Genoa HQ to monitor and manage any alarm generated by the system.

The “Crisis Management Preparedness Plan Operational & Reporting Procedure” is to be replaced by a brand new E.S.U. [Emergency Support Unit] Manual, prepared by a working team lead by another new role, the Crisis Management Director who reports directly to the President.

Implementing the training of Deck Officers, through a mandatory policy adopted by Carnival Corporation on 1st September 2012. These courses are as follows:
- Bridge Resources Management (BRM - two levels);
- ECDIS-NACOS (two levels);
- Ship Handling;
- Stability.

Recommendations as a result of the Investigation.

1. The recommendations may, according to the investigation, result in a need to revisit some SOLAS requirements (See the report for these).

2. Vessels should be double-skinned for protecting the watertight compartments containing equipment vital for the propulsion and electrical production.

3. The limiting of the down flooding points on the bulkhead deck to be discussed in the light of Part B-2 of Chapter II-1of SOLAS 74, as amended .

4. The provision of a computerized stability support for the master in case of flooding.

5. An interface to be provide between the flooding detection and monitoring system and the on board stability computer, taking into consideration regulations II-1/8-1 and 22-1 of Chapter II-1of SOLAS 74 as amended.

6. The following issues need to be discussed for possible improvements of the existing requirements:

a. discontinuity between compartments containing ship's essential systems (such as propulsion sets or main generators sets).

b. more detailed criteria for the distribution and type of bilge pumps.

c. relocation of the main switchboard rooms above the bulkhead deck.

c. relocation of the UHF radio switchboard above the bulkhead deck.

7. Consider increasing the emergency generator capacity to feed also the high capacity pump(s) mentioned in the previous paragraph.

8. Consider the provision of a second emergency diesel generator located in another main vertical zone in respect to the first emergency generator and above the most continuous deck.

9. Consider the provision of an emergency light (both by UPS and emergency generator) in all cabins in order to directly highlight the life jacket location.

10. Bridge management should consider aspects such as the definition of a more flexible use of the resources (that may be tailored for responding to ordinary, critical, emergency conditions), an enhanced collective decision making process and "thinking aloud" attitude.

11. Bridge Team Management course for certifications renewal should be mandatory by the 1st January 2015.

12. Principles of Minimum Safe Manning (resolution A.1047(27) as amended by resolution A.955(23)) should be updated to better suit to large passenger ships.

13. Muster list, showing the proper certification/documentary evidence necessary for crew members having safety tasks to be provided.

14. The inclusion of the inclinometer measurements in the VDR.

15. For new ships, it would be useful to require an evacuation analysis to be carried out at the early stage of a project (ref. regulation II-2/13-7.4, SOLAS 74 as amended), extending in mandatory way the above regulation, actually limited to ro-ro passenger ships.

16. Regarding the embarkation ladders: with the ship listed at an angle exceeding 20°, it was demonstrated that traditional embarkation ladders were more useful. Therefore, it may be necessary to consider whether the minimum number of embarkation ladders (one) on each side should be increased.

17. The final recommendation relates to the provision of an SAR vessel and divers, probably in Italian waters.

(It should be noted that I have summarized these recommendations, and in some cases interpreted them, so if you are seriously interested in them you should access the original report.)

I realized that not only have I summarized what happened to the ship, I have also reported on the report. I can only ask a question. Is this report absolutely suitable for international scrutiny, considering the seriousness of the event?

 TO RETURN TO FEATURES INDEX CLICK HERE

 
 
FEATURES

THE DEEPWATER HORIZON
Deepwater Horizon -The President's Report
Deepwater Horizon - The Progess of the Event

OTHER ACCIDENTS
The KULLUK Grounding
The Costa Concordia Report
The Costa Concordia Grounding
The Elgin Gas Leak
The Loss of the Normand Rough
The Bourbon Dolphin Accident
The Loss of the Stevns Power
Another Marine Disaster
Something About the P36
The Cormorant Alpha Accident
The Ocean Ranger Disaster
The Loss of the Ocean Express

OPERATIONS
The Life of the Oil Mariner
Offshore Technology and the Kursk
The Sovereign Explorer and the Black Marlin

SAFETY
Safety Case and SEMS
Practical Safety Case Development
Preventing Fires and Explosions Offshore
The ALARP Demonstration
PFEER, DCR and Verification
PFEER and the Dacon Scoop
Human Error and Heavy Weather Damage
Lifeboats & Offshore Installations
More about PFEER
The Offshore Safety Regime - Fit for the Next Decade
The Safety Case and its Future
Jigsaw
Collision Risk Management
Shuttle Tanker Collisions
A Good Prospect of Recovery

TECHNICAL
The History of the UT 704
The Peterhead Connection
Goodbye Kiss
Uses for New Ships
Supporting Deepwater Drilling
Jack-up Moving - An Overview
Seismic Surveying
Breaking the Ice
Tank Cleaning and the Environment
More about Mud Tank Cleaning
Datatrac
Tank Cleaning in 2004
Glossary of Terms

CREATIVE WRITING
An Unusual Investigation
Gaia and Oil Pollution
The True Price of Oil
Icebergs and Anchor-Handlers
Atlantic SOS
The Greatest Influence
How It Used to Be
Homemade Pizza
Goodbye Far Turbot
The Ship Manager
Running Aground
A Cook's Tale
Navigating the Channel
The Captain's Letter

GENERAL INTEREST
The Sealaunch Project
Ghost Ships of Hartlepool
Beam Him Up Scotty
Q790
The Bilbao OSV Conference