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Costa Concordia casualty probe pinpoints series of human failures

Concordia grounding and evacuation riddled with human blunders
A series of human errors, from sailing too fast, too close to shore to the captain’s distraction and the bridge team’s failure to question his orders or warn of the looming danger, contributed to Costa Concordia’s catastrophic grounding, according to the report by Italy’s Marine Casualties Investigative Body.

The captain’s long delay in sounding the emergency alarm, his failure to promptly notify the search and rescue authority, his downplaying of the serious situation and the lack of direct orders from the bridge to the crew were additional factors in the tragedy that killed 32 people after the ship rammed into rocks off Giglio island on Jan. 13, 2012.

Crew training deficiencies and language problems were still other faults identified by the casualty investigators. In addition, passengers were not effectively drilled for an emergency.

Though the captain claimed he saved lives by maneuvering the disabled vessel toward the shore, the investigators found no evidence of an intended shoreward direction. Instead, they said, he believed he could keep the ship afloat and use the anchors to stop it at a manageable depth, thereby sparing the passengers and the vessel.

The immediate flooding of five contiguous watertight compartments, where most of the vital equipment of the ship was located, makes the Costa Concordia casualty ‘quite a unique event, because of the extent of damage is well beyond the survivability standard applicable to the ship according to her keel-laying date,’ according to the findings.

A stability calculation and simulation showed that the 2006-built ship responded to the SOLAS requirement applied to it, but no vessel could have survived such extensive damage, the report stated. The investigators confirmed the ship was in full SOLAS compliance at the time of the accident.

The report emerged within days of an Italian court ordering the trial of Capt. Francesco Schettino for manslaughter, shipwreck and abandoning ship. He is the sole defendant after plea bargains were accepted for five others including four shipboard officers and Costa Crociere’s Designated Person Ashore (DPA).

Deck officers, the key figures in the incident, were ‘disoriented’ and didn’t perform any significant role, the report found, while at the lifeboats, ‘There was chaos and confusion, lack of communication, in other words a complete disorganization, mainly because nobody on the bridge coordinated the emergency according to the muster list and the related procedure for abandon ship.’

While investigators acknowledged the crew ‘on the whole, gave an adequate performance in the core phase of the evacuation,’ there were many deficiencies. For example, nobody attempted a roll call or counted the passengers as they boarded the lifeboats and rafts.

Passengers who embarked at Barcelona recounted an inadequate drill consisting of a video and lacking any practical instruction by the crew In the lounge where it was performed. Passengers who joined the ship at Civitavecchia the evening of the accident had not received any emergency instruction.

(Existing regulation allows for instruction within 24 hours of embarkation. Shortly after the accident, Cruise Lines International Association members immediately implemented a policy requiring the muster drill prior to sailing, and this is one of several new procedures emerging from the incident that are expected to be codified into IMO regulations.)

What happened after the captain decided to take the ship closer to Giglio for an unscheduled ‘salute’ is already well-known but closely documented by the casualty investigation report. Traveling at a too-fast-for-conditions 15.5 knots, Costa Concordia clipped the Scole rocks off Giglio at 9:45 p.m., immediately losing propulsion power, suffering a blackout and taking on water.

With the rudder frozen, the ship was carried by wind and current, eventually grounding an hour and 15 minutes later, initially at an angle of about 15 degrees that quickly went to 80 degrees.

The gash in the 247-meter ship stretched 53 meters.

The report details how Schettino left the planned course, ordering the rudder to manual at 9:34 p.m. then having a phone conversation about the water depth near Giglio. He issued a series of orders to the helmsman; some were confirmed incorrectly and some were performed incorrectly. At a critical moment, the helmsman erroneously headed to starboard, then pulled to port as the master had requested.

The helmsman later testified, with the help of a translator, that at times he did not understand the captain’s orders. Other officers and passengers reported language-related confusion during the emergency and evacuation.

From the bridge wing at 9:45 p.m. the second officer reported the port side gone aground and everyone heard a loud crash as the ship hit the rocks. Schettino ordered the watertight doors closed then continued to direct the helmsman but the rudder was frozen. The emergency generator started for 41 seconds but going forward was not able to provide continuous electrical power for essential functions like the rudder and the bilge pump.

Crew checking damage on the lower decks found water in two adjacent engine compartments after only six minutes. The ship listed to port.

During the blackout, passengers were assured the situation was under control and technicians were working to restore functionality.

An engineer informed the bridge at least three watertight compartments were flooded. In accordance with SOLAS, the vessel was built to withstand the flooding of two adjacent compartments. At 9:57 p.m., Schettino made his first call to Costa’s fleet crisis coordinator. Contacted by Civitavecchia’s harbor master at 10:07, the ship reported a blackout but said the situation was under control. On board, officers reported to the bridge that at least four compartments were flooded.

By 10:11 p.m., Costa Concordia was practically motionless, then it began to drift, propelled by the wind. Pushed by wind and current and with the rudder positioned to starboard, within minutes the list shifted to starboard.

According to the report, the dire situation on board was repeatedly downplayed. With at least two watertight compartments flooded, lack of propulsion, lack of power from the emergency generators and the failure of the bilge pumps, the ship had not declared a general emergency and the company had not made direct contact with Italy’s national search and rescue organization.

Shoreside authorities were first alerted to a problem when a passenger’s mother called the local carabinieri to report passengers were donning life jackets. The police in turn alerted Livorno’s Maritime Rescue Sub Center of an unspecified problem aboard at 10:06 p.m., triggering the search and rescue operation.

By then, the captain had already known that three adjacent compartments were flooded but he did not formally request assistance until 10:25. When contacted by MRSC Livorno he reported a breach, and asked only for one tug. At that point, shoreside authorities alerted all ships in the area to assist.

Still, no general emergency alarm was activated. Some passengers had already begun to enter the lifeboats at 10:30 p.m. The first general alarm came three minutes later, and passengers were ordered to their muster stations at 10:36.

The first patrol boat reached Costa Concordia three minutes later. Shortly before, after being contacted by MRSC Livorno, the bridge reported increased heeling and only then declared the ship to be in distress. At 10:40, with the ship already resting on the bottom, ‘distress’ was issued through INMARSAT ‘C.’

According to the voyage data recorder, the abandon-ship order was first given in English over the public address system at 10:54 p.m. The operation, in fact, had already begun: Arriving on scene, local police reported three lifeboats already in the water. Other vessels were converging. By 11:11 p.m., the ship was listing at 25 to 30 degrees.

The last communication by Schettino recorded on the VDR was at 11:19, when he ordered everyone on the bridge—five other officers at that time—outside. At 11:32, the bridge was abandoned when about 300 people, passengers and crew, were still on board.

At midnight, Costa Concordia’s list to starboard became so sharp that it was very difficult to embark lifesaving appliances from the port side. Several people panicked and jumped into the sea. Helicopters assisted, divers were activated, and vessels were ordered to release their life rafts to facilitate rescues.

At 12:34 a.m., MRSC Livorno reached Schettino by mobile phone. He was aboard a lifeboat and when asked who remained on board to coordinate operations, he said the entire crew had landed. Scores of people including elderly and children were still on board, and Schettino was told to return to the ship.

Shortly after, the captain was on the island. Later, he said he had been forced into one of the lifeboats as the ship listed or he would have fallen into the water.

At 2 a.m. firefighters with thermal cutting equipment were deployed to free any people trapped inside. At 5:15 a.m. another team of rescuers found two ‘traumatized’ people. Other rescue units had recovered three bodies from the water. At 6:17 a.m., evacuation operations were declared completed. 

There had been 4,229 people on board, 3,206 passengers and 1,023 crew. Some 4,197 people were rescued. Of those, 157 reported injuries, with 20 needing hospitalization.

According to the investigation report, 1,270 people were rescued by units coordinated by MRSC Livorno with the Coast Guard Patrol Boat 305 taking in around 545 people and 235 going aboard life rafts deployed by four other patrol boats. Rescue craft towed 80 people to shore on Costa Concordia life rafts, 16 were picked up by helicopters, four people were plucked from the sea and the remaining approximately 2,930 were able to reach land, without other assistance, aboard lifeboats and life rafts from the ship.

A total of 23 lifeboats out of 26 and six life rafts out of 69 were used, some to transfer people to rescue vessels and some towed ashore. Approximately two-thirds of the people on board were saved by Costa Concordia’s own lifesaving equipment. Some people who didn’t get to the boats in time left by the only two disembarkation ladders, positioned at the bow and stern.

The investigation report deemed the operational capacity of MRSC Livorno had been adequate to manage rescue operations and said the exchange of information between Livorno and MRSC Rome, the Coast Guard and other resources made available by government and private individuals was ‘fast and efficient.’

The search for missing persons at sea went to Jan. 25, while operations inside Costa Concordia and the surrounding seabed continued. On Jan. 15, two passengers and a crew member were found alive on board. Bodies eventually were discovered in the corridor leading to the lifeboats on Deck 4, in elevators and in or near cabins. On March 22, a remotely operated vehicle entered through a new hole opened in the hull and found five more victims. Of the 32 people who died, two remain missing.

The casualty investigators said the DPA failed to speed Schettino’s abandon-ship plan, despite being in touch with him from 9:57 p.m. until 11:14 p.m. The captain had downplayed the severity of the situation until 10:27.

The report found no evidence of company rules addressing the unscheduled detour close to Giglio. It said a previous passage near the island was recorded on the prior August, in daylight, keeping a safe distance from the shoreline and proceeding slowly.

On the night of Jan. 13, in violation of safety rules, a number of people were on the bridge who had nothing to do with navigation, and the captain used a private mobile phone while maneuvering. Immediately before impact, the helmsman made several errors.

A company procedure that allowed the master to keep some watertight doors open while underway did not comply with SOLAS, the report said, and this was immediately brought to the attention of the flag-state administration (Italy’s Coast Guard). However, evidence showed that at the time of grounding, and confirmed by VDR data, the watertight doors were closed. Appropriate actions to manage stability, however, were not carried out.

The investigation found that only some lifeboats and life rafts were managed by assigned, qualified crew members. Emergency procedures were not conducted in accordance with the muster list.

The hotel director did not follow his assigned duties and allowed the captain to make false statements on the public address system, fatally delaying the ability of passengers and crew to reach the muster stations. The cruise director ‘arbitrarily sent passengers away from muster stations, [telling] them to return to the lounges,’ and some crew directed passengers to their cabins.

‘On the whole, human factors characterized this casualty,’ the report concluded, citing a lack of competence, particularly on the part of the officers, distractions and errors by the captain and the bridge team, and delays and mistakes by officers in handling the emergency.

Among a host of recommendations, the investigators included education and training, and assessment and control of manning agencies that supply personnel to ships sailing under the Italian flag.

Among a number of actions already carried out were an audit of Costa’s safety management system, a new policy that passenger emergency drills be conducted before sailing—which was immediately adopted by the entire industry, and the creation of a new maritime development and compliance department that reports directly to the ceo.

Further actions include the provision for the automatic detection of a course diversion away from the approved planned route and a mandate by Carnival Corp. & plc that officers undergo specific training in areas including bridge resource management, ECDIS-NACOS, ship handling and stability.

Recommendations were also made for improving the requirements related to stability and vital equipment, electric distribution and emergency power generation, as well as verifying provisions in international instruments such as SOLAS, STCW and ISM Code related to bridge management plus the consideration of mandatory application of the principles of minimum safe manning.

TAGS: Training