UPDATE: parbuckling behind them, the ship may be moved in June. http://feedly.com/k/1aOdphx
I finally plowed through all 181 pages of the investigation conducted by the Italian Ministry of Infrastructures and Transports Marine Casualties Investigative Body. You can find the full report here.
The report, as I understand it, was translated from Italian to English, so there is some loss of fidelity on grammar and syntax making for some heavy going but it’s worth the read.
As a former USMC helicopter pilot, reading these types of technical reports on aircraft accidents was an all too frequent, but extremely valuable, exercise. Every mishap is the result of a chain of events that in most instances could have been avoided if just one link in that chain had been broken. It is in this analytical observation of the facts, painstakingly reconstructed piece by piece by, that shows the linkage from event to event how things go ‘wrong’ and thus how to avoid such incidents in the future. These investigations can take days, weeks and months to reconstruct what may have happened over the course of 30 seconds or less.
In this case, with a vessel plying the water instead of an aircraft moving through the air, events took not seconds but minutes to unfold, which would have allowed time for a prudent mariner to take corrective action. However, time to take action does not help when the crucial link in the chain consists of the egregiously reckless actions of a ship’s master.
Some of the more interesting snippets are quoted below. When reading them, keep in mind there were 4,229 souls on board that evening, including 3,206 passengers who blindly put their faith in the hands of the ship’s Master.
“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 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:
- 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
“…at 21 45 07 LT (local time) the ship suddenly collided with the “Scole Rocks” at the Giglio Island.” (I find curious the use of the term ‘suddenly’, as though if one were to drive a steam roller off a cliff the end would come suddenly despite knowing for minutes that was precisely where it was headed. Perhaps it was not intended to read that way and fell victim to translation.)
“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°).”
“The “general emergency” announcement was not given with the right schedule, when the awareness of the scenario was known. The general emergency alarm would have permitted the gathering of the passengers and crew in the Master Stations; this action, if carried out in the right manner, would have permitted to call the roll of all persons (passengers and crew) at the Muster Stations, ready for the possible abandon ship. In fact, despite the first warning about three contiguous WTC [water tight compartment] flooded, given to the Master at 22.01, he, in an unbelievable criteria, waited 32 minutes to launch the general emergency announcement, and three minutes later he launched one more announcement that was something like an abandon ship, but not so clear.”
“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.”
“Crewmembers, Master included, abandoned the bridge at about 23 20 (one officer only remained on the bridge to coordinate the abandon ship). At 00 34 the Master communicated to the SAR Authorities that he was on board a lifeboat with other officers.”
“At 01:11 the Master, contacted by OR [Operations Room where Search and Rescue officials directed the rescue effort] explains to stay on the island and that he was somehow forced to disembark, going on one of the boats, because of the high list of the ship, otherwise would have slipped into the sea. At 1:46 the OR contacts the Master ordering him again to go back on board and provide a situation report.” (he did not return to the ship)
“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).”
I will follow with great interest the trial of this ship’s Master…
Howard Boat Works, Inc. 