Learning from OPM (Other People’s Mistakes)
Indeed, technology can always assist in reduction and prevention of accidents. Nevertheless, human beings in responsible positions need to behave responsibly. When responsible people behave in an irresponsible manner, no technology and no amount of preventive actions and systems can help in accident/loss prevention.
Let’s compare the two catastrophic maritime accidents (Costa Concordia and Wakashio) resulting from irresponsible and negligent behaviours by very experienced professionals (an Italian and an Indian Mater and his teams who didn’t challenge the unsafe behaviour and actions) resulting in loss of lives, severe damage to marine environment, total constructive loss of the ships, huge loss to marine insurance market, reputation loss of the companies and the shipping industry at large.
While the preventive actions on Wakashio by MOL, Tokyo highlights training of experienced professionals with several decades of experience on the job, technological assistance is also being sought, effectiveness of which is to be seen.
Costa Concordia Casualty off Italy on 13 January 2012
Loss of 32 lives (27 passengers and 5 crewmembers) on board the Italian cruise ship Costa Concordia and the management of crisis by the Italian Master on 13 January 2012, made international headlines after the cruise ship with 4229 persons on board (3206 passengers and 1023 crewmembers), hit the “Scole Rocks” at the Giglio Island in favourable meteo-marine conditions, at 21:45 local time. The ship had just left the port of Civitavecchia (Italy) enroute to Savona (Italy).
She was partially sunk along the coast of the small Mediterranean island resulting in total constructive loss, and was one of the worst, costly wreck removal operation in the marine insurance history.
Every shipping company with a loss prevention and training team must have discussed the valuable lessons learned from this tragedy, with their seafarers to drive home the importance of voyage planning and maintaining a safe distance off navigational hazards for safe navigation of the ship along with crisis management training.
Italy’s Ministry of Infrastructures and Transport’s marine casualty investigation report is lengthy, but it can be summed up in one line that 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 of 0.5 nautical miles at night time and at high speed of 15.5 kts.
- The danger was considered so late that the attempt to avoid the grounding was useless. Everyone on board realized that something very serious was happening, as the ship heeled and the speed decreased.
- The vessel immediately lost propulsion and was consequently blacked out. The Emergency Generator Power was not able to supply the utilities to handle the emergency.
- 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. It was later discovered that the breach of hull was 53 meters long.
- The Master did not warn the SAR (search and rescue) 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, launching the related distress only at 22:38 (on insistence of Livorno SAR Authority).
- Only at 22:54 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 were 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 increased to 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.
- Analyses of investigation focus is on the behaviour of the Master and his decision to make that hazardous passage in shallow waters.
- Master’s arbitrary attitude in reviewing the initial navigation plan (making it quite hazardous in including a passage 0.5 n mile off the coast (Punta del Faro, southern and almost uninhabited area, with scarce illumination) at 16 kts in night conditions, 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;
- Master’s inattention/distraction due to the presence of persons extraneous to Bridge watch and a phone call not related to the navigation operations;
- 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);
- 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.
Wakashio ran aground off the island of Mauritius on 25 July 2020 resulting in leakage and pollution of about 1000 mt fuel oil as the hull started cracking up on the reef from 6 August 2020.
Why did such a grounding happen in this modern day and age with sophisticated navigation and accurate position monitoring systems such as GPS and ECDIS?
It seems grave behavioural error by the experienced Master and senior officers (to sail the ship 2 nautical miles off the coastline, to be within mobile communication range, on a chart of inadequate scale, and neglecting the visual and radar watch keeping while navigating dangerously close to shore) was not challenged by the bridge team or any of the crew members on board.
It also appears that the crew members learned nothing from OPM (for example, the Costa Concordia Master and the bridge team) and have been overconfident from repeated success or absence of incidents from previous unsafe behaviours.
Background of grounding incident
- On 23 July, 2 days before the grounding of Wakashio, Master changed the distance off the coast line of the Mauritius island from 22 nautical miles to 5 nautical miles.
- On the day of grounding on 25 July, Master tried to further reduce the distance from the coast from 5 nautical miles to 2 nautical miles, to enter an area within the communication range of mobile phones and used a nautical chart without sufficient scale to confirm the accurate distance from the coast and water depth.
- In addition, a navigating officer (and Master?) neglected appropriate watch-keeping (visually and by radar), even though she was trying to sail 2 nautical miles off the coast. As a result, she ran aground in shallow water (10m deep) 0.9 nautical miles off the coast of Mauritius.
Probable causes (complacency, overconfidence from repeated success from previous unsafe behaviours and lack of safety awareness)
- Crew had approached other coasts several times even before the incident, they may have taken unsafe behaviours due to overconfidence that stems from complacency.
- Such behaviour on a large vessel reflects a lack of safety culture and awareness. Crewmembers lacked awareness of the guidelines on performing navigation in a safe manner and their efforts to conform were insufficient, because they did not prepare an appropriate passage plan that would have ensured appropriate performance, did not obtain and use the correct nautical chart of adequate scale for navigating dangerously close to the shore at 2 nautical miles, and neglected visual and radar watch keeping.
While MOL elaborates on the preventive measures, it’s interesting as to how such behavioural errors, made by the very experienced Master went unchallenged by his very experienced senior Officers and other crew members with huge risk to their own lives. Vessel was a constructive total loss and the hull except for the stern area broke free on 15 August, which was towed and scuttled on 24 August at deep seas.
Measures to prevent reoccurrence
MOL will invest the equivalent of about JPY 500 million in measures to prevent reoccurrence of probable causes, based on the following measures.
1) Addressing the lack of safety awareness by circulars, safety campaigns, safety awareness surveys…etc.
2) Addressing the lack of awareness of regulations on safe navigation and insufficient performance by providing ECDIS training, introducing fail-safe operation of electronic nautical charts (introducing a service plan for MOL Vessels, which allows browsing of worldwide electronic charts at all scales, without requiring purchase of the chart), ensuring thorough awareness and performance with guidelines for safe navigation, through circulars and safety campaigns.
3) Enhancement of ship operation quality by strengthening shore-based support system. Safety Operation Supporting Center (SOSC), 24-hour monitoring system, use of multi-faceted methods as well as manned monitoring and plan to put in place a new grounding risk monitoring system. Enhancing involvement with shipowners, mutual visits between MOL and shipowners, enhance involvement in selection of senior officers
4) Response on hardware side - Strengthening deterrent capacity by monitoring cameras on bridge, upgrading on board communication systems with high-speed and large-capacity communication systems on MOL Vessels and exploring this option on chartered vessels.
My concluding remarks
I can't agree more with MOL - "To continually nurture and protect the natural environment by maintaining the highest standards of operational safety and navigation," as stated in the MOL Corporate Principles, every MOL Group member must take to heart the message that safe operation is the major premise for corporate activities and work to prevent the reoccurrence of this incident".
I strongly believe that unless each and every company staff on shore and on board ships (for that matter in any industry) uphold the company principles, mission, vision, policies, procedures, and implement them with full passion and conviction, and do the job as Michelangelo painted the Sistine chapel with deep commitment and consistency, companies will struggle to uphold their brand and stop such accidents.
- Indeed, technology can always assist. Nevertheless, human beings in responsible positions need to behave responsibly.
- Would we tolerate irresponsible behavior from others (an airline pilot while we are flying in the plane or from a surgeon, while we are sedated and on the table under his/her disposal)?
- We expect others to behave with utmost professionalism and responsibility.
- Complacency and overconfidence has no place in any industry and it's of concern that we have high profile accidents with very experienced people. It's time for inner reflection and always better to learn from OPM.
A chain smoker can learn from OPM and at least stop smoking after learning about the tragedy of a smoker, known to him, who succumbed to lung cancer from smoking. Isn't prevention better than cure?
Don't we want the other professionals (Airline Pilots, Doctors, Drivers…….) to learn from OPM? If yes, don't we also need to start learning from OPM?