The Italian Ministry of Infrastructure and Transport’s report on the safety technical investigation into the marine casualty with the cruise ship Costa Concordia states the human element as the root cause of the incident.
The report states ‘the human element is the root cause in the Costa Concordia casualty, both for the first phase of it, which means the unconventional action which caused the contact with the rocks, and for the general emergency management.’ The incident resulted in the death of 32 persons and the injury of 157 others, as well as the loss of the ship and significant environmental damage.
In Compliance with Solas Regulations
The report also stated that the Consta Concordia was in full compliance with all applicable Solas regulations.
Errors on the Bridge
The following critical points can be preliminarily indicated as contributing factors to the accident:
- Shifting from a perpendicular to a parallel course extremely close to the coast by intervening softly for accomplishing a smooth and broad turn.
- Instead of choosing, as reference point for turning, the most extreme landmark (Scole reef, close to Giglio town lights) the ship proceeded toward the inner coastline (Punta del Faro, southern and almost uninhabited area, with scarce illumination).
- Keeping a high speed (16 kts) in night conditions, too close to the shore line (breakers/reef).
- Using an inappropriate cartography, that is use of Italian Hydrographical Institute. chart nr. 6 (1/100.000 size scale), instead of at least nr. 122 (1/50.000 size scale) and failing to use nautical publications.
- Handover between the Master and the Chief Mate did not concretely occur.
- Bridge (full closed by glass windows) did not allow verifying physically outside, a clears outlook in night-time (which instead could have made easier the Master eyes adaptation towards the dark scenario), catching moreover noise by sea slamming to the rocks/beach.
- Master’s inattention/distraction due to the presence of persons extraneous to Bridge watch and a phone call not related to the navigation operations.
- Master’s orders to the helmsman aimed at providing the compass course to be followed instead of the rudder angle.
- Bridge Team, although more than suitable in terms of number of crewmembers, not paying the required attention (e.g. ship steering, acquisition of the ship position, lookout).
- Master’s arbitrary attitude in reviewing the initial navigation plan (making it quite hazardous in including a passage 0,5 mile off the coast by using an inappropriate nautical chart), disregarding to properly consider the distance from the coast and not relying on the support of the Bridge Team.
- Overall passive attitude of the Bridge Staff. Nobody seemed to have urged the Master to accelerate the turn or to give warning on the looming danger.
The present case demonstrates the inadequacy, in terms of organization and then about "who does what" of the Bridge Team. This incident can be useful as a warning for a revision of the guidelines now taken by the various Conventions (SOLAS, STCW, ISM Code), and included with the ISM procedures on board.
Recommendations from the Report
- Double-skin to protect the equipment vital for the propulsion and electrical production.
- Limiting the down flooding points on the bulkhead deck.
- Provision of a computerised stability support for the master in case of flooding.
- Interface between the flooding detection and monitoring system and the on board stability computer.
- Discontinuity between compartments containing ship's essential systems (such as propulsion sets or main generators sets) in order to preserve their functional integrity.
- More detailed criteria for the distribution, along the length of the ship, of bilge pumps and requirement for the availability of at least one pump having the capacity to drain huge quantities of water.
- Relocation of the main switchboard rooms above the bulkhead deck.
- Relocation of the UHF radio switchboard above the bulkhead deck.
- Increasing the emergency generator capacity to feed the high capacity pump(s) as well.
- 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.
- Provision of an emergency light (both by UPS and emergency generator) in all cabins in order to directly highlight the life jacket location.
- Bridge management, considering aspects such as the definition of a more flexible use of the resources, an enhanced collective decision making process and "thinking aloud" attitude.
- Bridge Team Management course for certifications renewal should be mandatory by the 1st January 2015.
- Principles of Minimum Safe Manning that should be updated to better suit to large passenger ships.
- Muster list, showing the proper certification/documentary evidence necessary for crew members having safety tasks.
- Inclusion of the inclinometer measurements in the VDR.
- For new ships, it would be useful to require an evacuation analysis to be carried out at the early stage of a project.
- It may be necessary to consider whether the minimum number of embarkation ladders (one) on each side should be increased.
- SAR patrol boat should be supplied with fix fenders, blocked in the upper side of the hull, to approach other ships/boats safely in case of extraordinary evacuation of persons. This should be able to load at least 100 passengers in their deck;
- SAR divers speleologist should be available, able to rescue, even in dark condition, persons standing into the ravines of ships/wrecks.
Download the full report here.
Picture: The Costa Concordia on Its Side (picture by R. Vongher, Wikipedia)
