Italy's MIT Releases Costa Concordia's Safety Technical Investigation Report

Oh how I wish the forthcoming report of the KULLUK’s grounding reads with so much detail!

[B]Italy’s MIT Releases Costa Concordia’s Safety Technical Investigation Report[/B]
May 24, 2013
By MarEx

Below is a summary of the long-awaited marine casualty investigation surrounding the fatal Costa Concordia cruise ship accident that resulted in the loss of 32 lives on January 13,2012:

If the danger of fire has always been the utmost threat for passenger vessels and still is, despite the technological evolution and the progress of rules and regulations as well as the higher skills resulting from the training and from the severe safety management system (on board and ashore), in the Concordia casualty we have discovered that a contact characterized by the dynamic that occurred in this event also represents a serious risk.

Efforts made in the issue of flooding after a contact also regarding passenger vessels, have in particular recently produced the “safety return to the port” SOLAS package of regulations. These have already been considered, as you will note at the end of this Report, as recommendations to improve safety against flooding after a contact.

We point out, first of all, that 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. Although, if we want to analyse this casualty (as we did) to try, in the end, to avoid similar consequences, the related correction measures should be truly significant, despite the measures may not be sufficient to render the ship unsinkable when more than two contiguous watertight compartments are flooded.

Despite the above mentioned, we anticipate that we however carried out the present investigation to identify some concrete practical solutions which could provide certain useful indications for possible future improvements of the current regulations.

The aim of this Report is therefore to set the serious flooding in an analytical and complete way, by means of a detailed analysis of the phenomenon, supported by scientific methods, with the purpose to reduce, as far as practicable, the range of variables - among those which contribute to cause a flooding - predictable, thus preventable.

On 13 January 2012, whilst the Costa Concordia was in navigation in the Mediterranean Sea (Tyrrhenian sea, Italian coastline) with 4229 persons on board (3206 passengers and 1023 crewmembers), in favourable meteo-marine conditions, at 21 45 07 LT (local time) the ship suddenly collided with the “Scole Rocks” at the Giglio Island. The ship had just left the port of Civitavecchia and was directed to Savona (Italy).

The ship was sailing too close to the coastline, in a poorly lit shore area, under the Master’s command who had planned to pass at an unsafe distance at night time and at high speed (15.5 kts). The danger was considered so late that the attempt to avoid the grounding was useless, and everyone on board realized that something very serious was happening, because the ship violently heeled and the speed immediately decreased.

The vessel immediately lost propulsion and was consequently effected by a black-out. The Emergency Generator Power switched on as expected, but was not able to supply the utilities to handle the emergency and on the other hand worked in a discontinuous way. The rudder remained blocked completely starboard and no longer handled. The ship turned starboard by herself and finally grounded (due to favourable wind and current) at the Giglio Island at around 23.00 and was seriously heeled (approximately 15°).

From the analysis carried out under the direct coordination of the Master, the seriousness of the scenario was reported after 16 minutes. After about 40 minutes (22 27) the water reached the bulkhead deck in the aft area.

The assessment of the damage was continued by the crew, realizing, at the end, that watertight compartments (WTC) nos. 4, 5, 6, 7 and 8 were involved. These WTCs accommodated, among others, machinery and equipment vital for the propulsion and steering of the ship, such as:

  • within WTC 4 - main thrusts bearings and hydraulic units, machinery spaces air conditioning compressors;
  • within WTC 5 - propulsion electric motors (PEM), fire and bilge pumps, propulsion and engine room ventilation transformers, propulsion transformers;
  • within WTC 6 - three main diesel generators (aft);
  • within WTC 7 - three main diesel generators (fwd); and
  • within WTC 8 - ballast and bilge pumps.

Only after the following days, it was discovered that the breach was 53 meters long.

The Master did not warn the SAR Authority of his own initiative (the warning was received by a person calling from shore) and, despite the SAR Authority started to contact the ship few minutes after 22 00, he informed these Authorities about a breach only at 22 26 02, launching the related distress only at 22 38 (on insistence of Livorno SAR Authority).

However SAR activities had started at 22 16, when Livorno Authority had ordered the GDF Patrol Boat 104, already in the area, to approach the Concordia. From the above mentioned time the following SAR resources were involved: 25 patrol boats, 14 vessels, 4 tugs, 8 helicopters.

Only at 22 54 10 the abandon ship was ordered but it was not preceded by an effective general emergency alarm definitely (several passengers – in fact - testified that they did not catch those signal-voice announcement). The first lifeboats result being lowered at 22.55 and at 23:10 they moved to the shore with the first passengers on board.

Crewmembers, Master included, abandoned the bridge at about 23 20 (one officer only remained on the bridge to coordinate the abandon ship).

At about 24 00 the heeling of the vessel seriously increased reaching a value of 40°. During the rescue operations it reached 80°.

At 00 34 the Master communicated to the SAR Authorities that he was on board a lifeboat with other officers.

All the saved passengers and crewmembers reached Giglio Island (the ship had grounded just few meters from the port of Giglio). First rescue operations were completed at 06 17, saving 4194 persons. Three more persons were put in safety on 15 January.

The rescue operations continued and on 22nd March the last victim was found. The number of victim is 32, and 2 of these are still missing (one passenger, one crewmember). The person died are 26 passengers and 4 crewmembers. Environment operations immediately took place recovering within the 24 March the 2042.5mc of oils.

Caretaking of seabed is still underway, as well as wreck recovering, which started last June.

The analysis of this casualty briefly puts in evidence the following results:

a. The navigation phases before the impact are to be considered as a crucial aspect, because they relate with the causes originating the accident. In particular, the focus is on the behaviour of the Master and his decision to make that hazardous passage in shallow waters. The computer simulation somewhat confirmed delays in the ship’s manoeuvring in that particular circumstance. In this respect, 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 is too close to the shore line (breakers/reef);
  • using an inappropriate cartography, i.e. 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 with glasses) did not allow verifying, physically outside, a clear outlook in nighttime (which instead could have made easier the Master eyes adaptation towards the dark scenario).
  • 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.

Therefore the accident may lead to an overall discussion on the adequacy, in terms of organization and roles of Bridge Teams.

b. The General Emergency Alarm was not activated immediately after the impact. This fact led to a delay in the management of the subsequent phases of the emergency (flooding-abandon ship process). With regard to the organization on board, the analysis of crew certification, of the Muster List (ML) and of the familiarization and training highlighted some inconsistencies in the assignment of duties to some crewmembers.

c. In addition, the lack of direct orders from the Bridge to crew involved in safety issues somehow hindered the management of the general emergency-abandon ship phase and contributed to initiatives being taken by individuals. The presence of different backgrounds and basic training of crew members may have played a role in the management of emergencies.

d. About the different scope of the Minimum Safe Manning (MSM) document and the Muster List (ML), the SOLAS regulation V/14.1 requires that the ship shall be sufficiently and efficiently manned, from the point of view of the protection of the safety of life at sea. This regulation makes reference, but not in a mandatory way, to the Principles of Safe Manning adopted by the Organization by Resolution A.890(21) as amended by resolution A.955(23).

e. Too often the scope of the Muster List is confused with that of the Minimum Safe Manning. In fact, while the crew designated in the MSM has to meet the STCW requirements for being appointed to specific safety tasks aboard the ship, this may not be the case for those crew members to whom the same safety tasks are assigned through the ML (and not through the MSM).

f. A combination of factors has caused the immediate and irreversible flooding of the ship beyond any manageable level. The scenario of two contiguous compartments (WTC 5 and 6) being violently flooded - thus in a very short period of time after the contact (for WTC 5 the time for its complete flooding was only few minutes) - already represents a limit condition, as far as buoyancy, trim and list are concerned, in which the order for ship’s abandon is given to allow a safe and orderly evacuation.

g. The ship stability was further hampered by the simultaneous flooding of other three contiguous compartments, namely WTCs 4, 7 and 8. The flooding of these additional compartments dramatically increased the ship’s draught so that Deck 0 (bulkhead deck) started to be submerged. Also, the effect of the free surface created in these compartments prior to their complete flooding (occurred in about 40 minutes) was detrimental for the stability of the ship, causing the first significant heeling to starboard, which increased more and more the progressive flooding of adjacent WTC 3. In WTC 3 the water entered from the bulkhead deck (Deck 0), through the stairway enclosures connecting such deck to Deck C. 45 minutes after the contact, the heeling to starboard reached 10°, and just before grounded 1h 09’ after the impact almost 20°. Then, 15’ after grounded, the heeling was more than 30°.

h. A concomitant critical factor, caused by the severe and fast income of water, was the immediate loss of propulsion and general services located in WTCs 5 and 6.

i. One of the consequences was that the various high capacity sea-water service pumps (capacity between 500 to 1300 m3/h, fed by the main switchboard only) that were fitted with a direct suction in the space where they were located, became unavailable.

j. It is noted that the rules applicable to the Costa Concordia did not require the installation of a flood detection system in watertight compartments, and that the ship was fitted, on a voluntary basis, with a computerized program capable to verify the compliance of the loading conditions with the acceptance criteria set out in SOLAS Chapter II-1. Therefore, said program was not (and was not required to be) designed to provide direct information on the calculation of the residual damage stability during the flooding.

k. The further analysis related to the sequence of the functioning of the Emergency Diesel Generator (black-out of the main electrical network, isolation of the emergency network and automatic starting of the emergency diesel generator), allowed to show that due to the high complexity of the electric production/distribution network (bearing in mind that the violent impact and the enormous quantity of water that invaded the vital parts of the ship) created critical aspects that generated uncontrollable consequences and damage, even invisible, rightly so imponderable. For this reason the connection between the Emergency Diesel Generator and the related Switchboard, which initially worked and after collapsed, and then worked forcedly in a discontinuous way.

l. Another factor that may have impaired the management of the situation was the lack of orders according to the Muster List addressing disoriented - of course - the crew assigned on the base of the Muster List, taking into account this specific emergency. Some contribution in the disorienting situation could be due also to the wireless communication system, which is not supplied by emergency power but the key persons were all equipped with PMR devices, and therefore those wireless breakdown was not influent.

m. Poor consideration can be made about the five contiguous watertight compartments, where most of the vital equipment of the ship was located, because no residual stability could have been maintained either by the Costa Concordia or any other ship. However the stability calculation and simulation showed that the ship responded to the SOLAS requirement applied to her.

Finally, after the casualty, caused by the Master in combine with his officers staff present with him on the bridge, the coordination lack in the emergency - due to not applying the related SMS procedures and not following these as the best guideline to face the serious event - resulted the main and crucial unsuccessful factor for its management. Master together with some of the staff deck officers, as well the Hotel Director, failed their role determining a fundamental influence for reaching the above mentioned fail. Moreover, spite off the DPA was continually warned about the serious development of the scenario (meanwhile the Master was in the bridge, in fact their dialogue, although discontinue, started at 21 57 58 and finished at 23 14 34), he never thought (as declared during two interviews with the Prosecutor) to speed up the Master to plan the abandon ship. This could represents an indirectly contributing factor, even if the Master minimized (till 22.27 hours) the information about the seriousness of the situation towards the DPA. In fact, this last key person should have speed up the Master, at least in terms of his own moral obligation.

It is worth to anticipate that, according with the evidences found at the end of the present investigation, Costa Concordia resulted in full compliance with all the SOLAS applicable regulations, matching therefore all the related requirements once she left the Civitavecchia Port on the evening of the 13 January 2013.

As above anticipated, the analysis and the relevant lessons learnt allowed however the identification of a series of interesting measures, for details we readdress you to chapter VI, titled “recommendations”. They regard, among other things, stability and flooding, hull, vital equipment, emergency powering, redundancy of equipment, emergency management, minimum safe manning, muster list, and so on. Some of them could represent, if accepted and brought into force in a very short time, a must to improve the safety of very large cruise ships, even for existing ship.

Those above mentioned recommendations have been made, despite the human element is the root cause in the Costa Concordia casualty.

After this investigation, there is the opportunity to deliver in the hands of the International Maritime Community some suggestions regarding as the naval gigantism, represented in this case by the Very Large Cruise Ships, to face this actually and rising wonder through to the following items should be focused systematically also in the future:

  • mitigate the human contribution factor with education, training and technology;
  • operate day by day directly to support the shipping industry (shipbuilding), investing in the innovation technology;
  • stress all the maritime field cluster to make the maximum contribute for the related study and consequent technical research.

Therefore, the above summarized recommendations have to be considered the starting point of the action taken consequently to this extraordinary tragedy, since we believe that many other things could be done, reflecting on the deep and taking time to react more, among others, with the three suggestions fore mentioned.

In conclusion it is needless to put in evidence that the case of the Costa Concordia is considered by this Investigative Body (and we believe by everyone in the maritime field) a unique example for the lessons which may be learnt, despite the human tragedy and the Master’s unconventional behaviour, which represents the main cause of the shipwreck.

It is worth to anticipate, closing this summary, that the human element is again 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.

It is also worth to point out, moreover, that the Costa Concordia casualty is, first of all, a tragedy, where and that the fact of 32 decedents and 157 injured, would have depended only by the above mentioned human element, which shows inadequate proficiency by key crewmembers.

The full report can be viewed here.

Read the full report. Think it means he was a moron for doing what he did in the first place, then missed the turn and hit the rock.

And yes, it apparently was “the hand of God” that put the ship on the shore afterward, since there was no capacity on the ship to maneuver - at all - within a few seconds of the impact. There is a real good plot of this and the ship’s heading in the Report.

The stability study shows that bad boy was going down and darned fast. Many innocents lived only because of the second grounding.

And finally, don’t take the elevator. Many that died were found trapped in various elevators. Jeez.

I tried to read it and it hurt my brain. The English I found was pretty badly translated. Interesting what you found in it though.

I’m curious about the elevators though. I wonder if some of those people had been trapped in the elevators very soon after the grounding or if they tried to use them later and then got stuck. Doesn’t really matter just curious.

Having determined most of the facts surrounding the grounding and subsequent abandonment of the Concordia, it was inevitable than the Italian Authorities would conclude that the Captain was primarily to blame. We are all well aware that he was the primary cause of this disaster and should answer for his reckless actions, but this will not stop a similar accident happening again.
Although this report by the Italian investigators clearly identifies the primary and many of the contributary causes, it fails to identify a root cause. As commentators in other blogs have quite correctly indicated, the root cause was a systemic failure of the management system, which was not fully addressed in the investigation, for whatever reason, and until effectively corrected similar accidents are likely to occur.
If the root cause had been identified, some of the conclusions and recommendations would be changed and have a more effective impact on cruise liner operations in particular and the maritime industry in general. The SMS would have been found defective and the ship owner/operators’ management systems would have been examined in greater detail. This was not the case, hence the Investigators end up placing all the blame on the Master, when others were also at fault.
This is a disappointing report and indicates major inadequacies in the competence of the Italian Authorities to conduct an impartial investigation.