10. Three Italian Investigations of the Accident ... and none investigates if ship was seaworthy
At least three investigations or procedures why Costa Concordia capsized outside Isola del Giglio on January 14, 2012 were started soon after the incident. But none of the three investigations were really interested in the abandon ship and the capsize and the loss of the ship or why innocent people still aboard drowned on January 14, 2012.
None of the three investigations established if the ship was seaworthy prior the capsize!
None of the three investigations established whether there was sufficient crew aboard to muster, to escort and to assist passengers to abandon ship safely using lifeboats and life rafts.
All three investigations - cheered on by media and Italian prosecutors and judges - just blamed the Master for an accidental contact January 13, 2012:
1. The criminal Court at Grosseto 2012
The criminal court at Tuscan city Grosseto appointed four experts that on March 9, 2012 started its investigation why the ship contacted a rock on 13 January 2012 (an accident) and capsized on 14 January 2012 off the Tuscan island of Giglio, to help the criminal court in deciding its verdict whether Captain S, the shipowner and others are responsible for manslaughter, etc. The experts were military and civilian from La Spezia, Livorno and Trieste. Lawyers representing victims and their families have said that the report by the four experts was due to be presented on July 21, 2012. It seems the date was later delayed until October 15, 2012.
However the preliminary report by the Italian experts was issued around 13 September 2012 and given to the Italian court that handles the criminal side of the incident and sections of the report were apparently (!) leaked to Italian newspapers that in turn were quoted by media worldwide.
The report does not establish, if the ship was seaworthy. This important matter is not mentioned at all.
The report - only 270 pages - shows what happened before the first incident - the contact on 13 January 2012 - and afterwards but does not explain the second incident - the capsize at 00.34 hrs on 14 Januart 2012 - and what caused it and does not consider the watertight doors at all, whether the ship was seaworthy, etc. The report is just based on communications between Master/ship and shore and at 00.18 hrs Master is still aboard and at 00.32 hrs he is on a lifeboat in the water.
The report does not look into why all persons aboard didn't get evacuated before capsize, i.e. why the Abandon ship exercise was not done correctly - no muster stations, no crew escorting passengers to lifeboats and life rafts, no crew launching loaded lifeboats and life rafts full of passengers into the sea before they, themselves, abandoned ship! It seems the experts did not interview any such crew.
Why did 12 German, 6 French, 5 Italian and 2 US American passengers and 1 Spanish passenger not understand that they had to go to the muster stations to be escorted by crew to the lifeboats? The passengers spent all their time high up in the deck house of the ship and it was ample time between first contact at 21.45 hrs and capsize 00.34 hrs early next morning to get off the ship via life saving appliances or go higher up. Six other crew members apparently also drowned but maybe they were doing their jobs and were surprised down below by the capsize. Or all these unfortunate persons were high up on the starboard side of the ship, when it capsized to starboard, and were pushed down below water and drowned.
a complete criminal investigation will
clarify why these people drowned or were killed on
14 January, 2012. Heiwa Co recommends any
investigator not to blame any officer, crew member
or office staff ashore for killing people before
that investigation is done.
Only a complete criminal investigation will clarify why these people drowned or were killed on 14 January, 2012. Heiwa Co recommends any investigator not to blame any officer, crew member or office staff ashore for killing people before that investigation is done.
The Italian experts and the prosecutor seem not to understand that the vessel neither ran aground, nor collided with anything as explained above on this web page but apparently, under strange circumstances, at 21.45 hrs contacted a rock on the sea floor that, mysteriously, ripped open the ships vertical port side aft! How that - the structural damages - happened is not explained and seems not to be considered, but the ship was stable, upright and floated for hours afterwards in spite of several up flooded compartments, ship was anchored and >99% of people aboard were brought ashore. Nobody had died then.
Only later at 00.34 hrs next day the vessel suddenly capsized and crushed on the rocky shore with 90° heel and probably caught some people inside that drowned then or later, when the vessel partly sank and displaced down the sloping shore. Apparently the Master was responsible for that too ... but then he was thrown into the water.
The experts have not presented any evidence why the Master should be responsible for the accidental contact and what followed.
The Master appears to think he/ship was in safe waters all the time and that the planned turn was proceeding correctly, while the helmsman didn't follow any orders and nobody saw that the ship was heading straight up on shore.
That's how accidents occur.
Furthermore the court-appointed experts say that Costa's Fleet Crisis Coordinator, Roberto Ferrarini ashore at Genova:
"seems not to have the pulse of the conditions of the ship".
When the captain told him (on phone at 22 hrs a Friday night) that three (sic) sections of the vessel were flooded, he should have immediately told the captain to declare a general emergency and abandon ship, the report said.
"Instead, from that moment, six minutes passed before Captain Schettino announced a general emergency and around 27 minutes before he called for the ship to be abandoned."
But with three sections up flooded the ship was safe! But an employee ashore is criminally responsible for the incident 9 months later according the Italian experts. Amazing.
I once had, for many years, a job like Mr. Ferrarinis and assisted to sort out many incidents but was never blamed for causing them.
It seems the Italian experts report September 2012 is a joke and leaked to put the blame on wrong people ... as usual.
I had a boss and my boss had a boss who was the shipowner. It wasn't difficult to know who was in charge and responsible for the action and to ensure safety at sea.
But again, the Italian experts did not present any evidence why the Costa's Fleet Crisis Coordinator should be responsible for what followed.
It seems that four watertight hull sections were partly up-flooded (most double bottom tanks were intact) and that calculations confirmed that the damaged ship was stable and floating in that condition.
It evidently takes time to review any damage situation and the right decisions were quickly taken - abandon ship as per pre-made plans and instructions. The report and its findings have not really been used in the court. Instead ...
On October 15, 2012, the
criminal court case re-started at Grosseto (now at
seats Teatro Moderno). The court should only decide
whether the Master should be prosecuted ... or any
of nine others ... later. A total of 10 people were
being investigated, including the Master and six
other crew members, as well as three shore based
managers from shipowner Costa Crociere, which is
part of the worlds biggest cruise operator,
US-based Carnival. The shipowner himself, MA, and
his sister or top management responsible that ship
was seaworthy was, strangely, not
investigated. The public and media were not
permitted into the court room in spite of it having
1 000 seats and only 200 persons in
attendance. The VDR
or not, was first going to be made official
showing, i.a. the course and speed prior
other things, e.g. what the Master did ... or did
not. Unfortunately the VDR data was not made
On October 15, 2012, the criminal court case re-started at Grosseto (now at 1.000 seats Teatro Moderno). The court should only decide whether the Master should be prosecuted ... or any of nine others ... later. A total of 10 people were being investigated, including the Master and six other crew members, as well as three shore based managers from shipowner Costa Crociere, which is part of the worlds biggest cruise operator, US-based Carnival. The shipowner himself, MA, and his sister or top management responsible that ship was seaworthy was, strangely, not investigated.
The public and media were not permitted into the court room in spite of it having 1 000 seats and only 200 persons in attendance. The VDR data, defective(?) or not, was first going to be made official showing, i.a. the course and speed prior first contact and other things, e.g. what the Master did ... or did not. Unfortunately the VDR data was not made available.
It was suggested that the Indonesian helmsman had misunderstood the Master's command to turn starboard (see above) and instead turned port (and therefore caused the incident!).
It seems the experts forgot to mention that there was a helmsman on the bridge!
The American shipowner's legal counsel commented that, regardless, the Master is solely responsible for the reckless maneuver, which is also the reason why the Master had been fired (!) from the company five months after the incident without pay, etc. If the watertight doors existed on the ship and were open or closed were not discussed. No VDR data was made available to clarify what really happened. Only some voice recordings of the confusion on the bridge; Master ordered one thing, someone else something else. It seems the Master was not steering the ship himself in the dark. If a proper lookout was kept or whether the Master became distracted by various reasons remained unresolved.
The shipowner had created his own web page (!) about the proceedings suggesting that ship was in perfect order and that he had never heard about or even recommended fly by show offs of any of the cruise ships close to islands and ports, that all was the fault of the stupid, incompetent Master who therefore had been fired, etc. The shipowner didn't seem really interested in what really happened. I was surprised that the shipowner was not in the court room himself. Normally the shipowner is responsible for what happens on his ships. Of course Mickey only inherited the company from his father Ted, but ... . Case continued Tuesday.
Blame the echo sounder ...
On Tuesday October 16 the case continued, the Indonesian helmsman was forgotten, and it was suggested that the echo sounder was not switched on at the incident. Maybe the echo sounder caused the first incident? It seemed the whole court case was now becoming an Italian comedy. Anyway, it was impossible to know what was really happening in the Teatro Moderno as the public was not allowed in.
On Wednesday October 17 Italian prosecutor Francesco Verusio explained to anybody wanting to listen that, if (sic) there had been no wind the January night of the maritime mishap, "the ship would have capsized and sank in a minute" with 4 200 people on board.
"It was the hand of God that drew the Costa Concordia towards Giglio island after the collision with the rocks at Giglio, not Capt. [Francesco] Schettino's maneuver,"
Verusio said. Amazing! The prosecutor believes that the hand of God prevented capsize! A miracle took place at Isola del Giglio!
Fact remained however that vessel floated and was stable for about three hours after first contact and flooding of hull compartments and never aground and only then capsized - the second, fatal incident, apparently due to a leaking watertight door and more hull flooding as explained elsewhere in this report. It was therefore unlikely that wind or the hand of God (sic) prevented the ship from capsize. Ignorant prosecutors should not be permitted investigating ship incidents. The case continued and became stranger each day.
It is very disturbing that prosecutors can present anything in court without evidence of any sort.
On Thursday October 18 the case apparently continued but ... nothing was reported on the Internet or anywhere (Hand of God?). It seems it was better not to tell anybody about the VDR, watertight doors, mustering passengers, safety at sea, etc.
On Friday October 19 the hearings ended. When the decision, who was going to be prosecuted for causing the incidents and when it will take place, was not announced.
Who really caused the capsize on January 14 remained unclear because what caused the capsize killing people was not discussed.
The judge would decide if there was enough evidence to warrant a trial. Prosecutors said they hoped to wrap up their investigations by the end of year 2012.
The shipowner's counsel claimed to anybody wanting to listen that the hearings had found that the vessel had been designed and built in line with prevailing international safety regulations, that it was fully certified, when it left Civitavecchia as well as correctly maintained and functioning, and that its safety procedures were adequate and lawful. It is his job! But evidently the court had not even looked into these questions. And there is no evidence that the ship with 25 watertight doors was built according SOLAS. It would on the other hand appear that the ship was unseaworthy all the time.
The tragedy was, as usual, that the Master was not considered innocent, until it was clarified what really happened, e.g.
a) the contact was a stupid accident caused by incorrect charts, bad bridge routines, etc, and
b) the incomplete abandon ship was due to lack of crew aboard, and
c) the capsize killing people was due to a ship design fault (watertight doors!) and incorrect procedures to ensure the doors were closed at sea, etc, and who could be held responsible for a), b) and c). The Master alone? Or the shipowner, personally?
The shipowner made the very serious, stupid mistake firing the Master from the company. The Master is evidently innocent ... until the court of justice at Grosseto decides otherwise.
A good shipowner should always support his Masters under all circumstances, e.g. in this case keep the Master employed at the office at Genoa and out of the limelight. Unfortunately the shipowner, Costa, has instead fired the Master suggesting he alone made a serious, professional mistake and wanted December 5, 2012, at Genoa that the labor court confirmed this decision. The Master evidently didn't agree and suggested mediation or arbitration or awaiting clarification from other parties. Hopefully the mistake by the shipowner, Costa, to fire the Master will not influence other Italian authorities' investigation the incident to simply just blame the Master.
Prosecutors concluded 20 December 2012 the criminal investigation into the shipwreck of the Costa Concordia cruise liner and are preparing to seek a trial for its captain and eight other people.
Captain Francesco Schettino is accused of (A) manslaughter, (B) causing a shipwreck and (C) abandoning the ship, when the vessel first contacted rocks and then capsized after he brought it too close to the island of Giglio.
Francesco Verusio, who headed the investigation and believes that the Hand of God steered the ship after the contact, said he expected to file a request for an indictment at the end of January 2013. He said Schettino faces up to 20 years in jail. A judge will then decide if there is enough evidence to hold a trial. Five other members of the crew, including Schetttino's first officer, and three members of a crisis unit set up by Costa to deal with the accident also face indictment and trial.
It is evidently a bad conclusion.
Because who really decided the strange itinerary close to Isola del Giglio at dark, cold night time January 13? And why was it so badly executed by the team, aboard and ashore, in charge? Were the charts OK? And where exactly was the accidental contact made at 21.45 hrs? Can really a 100 tons piece of granite rock cause the structural damages seen on photos above? And what happened then? The ship was apparently floating, upright and stable but with a black out and lack of propulsion. The emergency lighting worked. The situation was not too bad! There was no real panic. The ship was successfully abandoned - 99% of all aboard made it to shore - within a couple of hours. Were the flooded compartments isolated? Were bilge pumps started to empty part flooded compartments?
And then - suddenly - the ship capsized at 00.34 hrs the next day - the second incident - and the Master fell into the water and some people still aboard drowned. Did the Master cause the capsize? It is not certain at all. The Master appears to have been surprised by the capsize, whil he tried, with his crew, to do the best under the circumstances after the first, stupid contact incident. The Master is evidently innocent for killing people. The people drowned due to the capsize.
The open, leaking, watertight doors that evidently made the ship not seaworthy and maybe were closed after the first contact incident ... maybe causing the second incident, the capsize ... were not even discussed at the hearings.
On February 23, 2013 the names of 10 persons (the person that had the same job I had in a different company have been dropped off the list!) and a company charged with crimes and infractions of the Costa Concordia incident January 13, 2012 were confusingly made public on Youtube in English. The Italian version may be different? Note that the crimes have been softened; unintentional manslaughter/personal injuries, lack of cooperation (after the incident?) and destruction/deterioation of a habitat (that probably can be restored). The video is maybe addressed to any person, passenger, crew, inhabitant on Isola del Giglio having been offended (?) by the events on January 13, 2012, ... but not the real drama on January 14, 2002:
The preliminary investigations about the COSTA CONCORDIA shipwreck (that) occurred on the 13th (?) of January 2012 in front of Giglio Island have been concluded and a request for committing the responsible persons for trial has been lodged.
- the infraction of lack of cooperation with the maritime Authorities against:
died on January 13, 2012, there apparently can be
no talk about manslaughter, etc, any longer.
Actually, the ship was still afloat on January 13,
2012, after a fairly successful evacuation of most
persons aboard (only >300+ persons remaining due
to lack of crew to launch lifesaving appliances)
and there were no shipwreck, no lack of cooperation
and no destruction or deterioration of a protected
habitat inside a natural site, etc.
As nobody died on January 13, 2012, there apparently can be no talk about manslaughter, etc, any longer. Actually, the ship was still afloat on January 13, 2012, after a fairly successful evacuation of most persons aboard (only >300+ persons remaining due to lack of crew to launch lifesaving appliances) and there were no shipwreck, no lack of cooperation and no destruction or deterioration of a protected habitat inside a natural site, etc.
Hopefully the offended people will then understand that the fatal incident, also affecting the habitat, - the capsize - actually took place January 14, 2012, resulting in the shipwreck, killing people and affecting the habitat, etc.
The proximate cause of the capsize is apparently 25 illegal watertight doors fitted by the shipyard and approved by the Italian maritime Authorites and the shipowner 2006, which was left open or was leaking and allowed progressive flooding of an intact, watertight compartment resulting in negative stability, capsize and downflooding/sinking of the hull/ship. Instructions that the (illegal) doors should have been closed at sea seems to be lacking. Evidently it is a scandal that unseaworthy ships are permitted to cruise out of Italian ports.
Here (you cannot copy the document!) six persons, including the person having the identical job I had with another company, are accused of various crimes in connection with the two incidents. The Master, some crew and some office staff are apparently held responsible for the capsize, etc, etc. The shipowner is not mentioned at all.
The human factor
On 25 February 2013 Chief Prosecutor Francesco Verusio said after a sophisticated scientific and other technological investigation was carried out:
"the determining cause of the events of the shipwreck, deaths and injuries, is, unfortunately, dramatically due to the human factor."
He also said Costa Crociere SpA, the Italian cruise company and ship owner, has asked for a plea bargain agreement which, if it was accepted, could see Costa pay a €1 million ($1.35 million) fine. The ship owner has tried to put all the blame on the shoulders of Schettino.
Verusio has not understood that humans designed and certified a ship with 25 illegal watertight doors that capsized due to progressive flooding. Verusio has not understood that humans did not provide and train sufficient crew to safely evacuate all aboard during the abandon ship operation. Verusio apparently believes that a lonely Master aboard intentionally steered the ship close to the shore, so a planned contact occurred. Verusio has not understood that a planned change of heading leading to the contact went wrong for unknown reasons - faulty steering gear, incompetent helmsman, confusing orders, etc. As a result the prosecutor makes a fool of himself but media don't notice.
The trial was supposed to
take place 15-24 April, 2013 at Grosseto,
apparently behind closed doors, so the public and
media could not attend. On April 17 the presiding
judge postponed the hearings until May 14. On May
22, 2013, it was announced that the trial will
begin on July 9 and that only Captain Schettino
will be tried for causing the shipwreck by
navigating too close to shore producing a contact
with a rock on January 13, 2012, that damaged and
flooded the hull which floated stably enabling
evacuation ... after which something produced the
sudden capsizing of the vessel the next day January
14, 2012, killing 32 persons. The other persons
accused of assisting the Captain will only be
judged later if agreeing with the findings of the
court about Schettino. Verusio does not seem to know
about some of the 25 illegal watertight doors kept
open causing a sudden capsize killing innocent
people ... so maybe they will be investigated by
The trial was supposed to take place 15-24 April, 2013 at Grosseto, apparently behind closed doors, so the public and media could not attend. On April 17 the presiding judge postponed the hearings until May 14. On May 22, 2013, it was announced that the trial will begin on July 9 and that only Captain Schettino will be tried for causing the shipwreck by navigating too close to shore producing a contact with a rock on January 13, 2012, that damaged and flooded the hull which floated stably enabling evacuation ... after which something produced the sudden capsizing of the vessel the next day January 14, 2012, killing 32 persons. The other persons accused of assisting the Captain will only be judged later if agreeing with the findings of the court about Schettino.
Verusio does not seem to know about some of the 25 illegal watertight doors kept open causing a sudden capsize killing innocent people ... so maybe they will be investigated by MCICB?
The second investigation was done by the Italian Marine Casualty Investigation Central Board, MCICB, that started latest March 13, 2012. MCICB is located at Viale dell'Arte, 16, 00144 Roma and can be reached on Tel: +39 06 45489209 and Fax: +39 06 96519919 or email: firstname.lastname@example.org .
The MCICB report would take at least one year to produce. It shall only find out what happened and proximately caused the incidents in order to prevent similar incidents in the future and shall not consider personal responsibilities, etc. It is possible that the contact was due to incorrect charts and the capsize was due to incorrect watertight doors kept open. It would have been nice if the MCICB reported the progress of its investigation at regular intervals but ... nothing. The report should of course confirm that the ship was seaworthy. But ... the matter is not mentioned.
Italy, being a member of EU, should ensure that safety investigations are conducted under the responsibility of an impartial permanent investigative body, endowed with the necessary powers, and by suitably qualified investigators, competent in matters relating to marine casualties and incidents.
The entry into force on 17 June 2011 of Directive 2009/18/EC establishing the fundamental principles governing the investigation of accidents in the maritime transport sector implies new obligations for Italy, namely: to ensure proper safety-focused investigation systems, to investigate very serious marine casualties and decide on the investigation of others, as well as to send commonly structured investigation reports and to populate the European Marine Casualty Information Database (EMCIP) ... not just summaries, please.
The Rules of Procedure of the permanent cooperation framework prescribed by Article 10 of Directive 2009/18/EC were adopted on 5 July 2011 through a Commission Implementing Regulation (EU) N° 651/2011.
The common methodology for investigating marine casualties and incidents prescribed by Article 5.4 of Directive 2009/18/EC was adopted on 9 December 2011 through Commission Regulation (EU) N° 1286/2011.
It was interesting to see if Italy/MCICB planned to follow Directive 2009/18/EC . It was not the case.
The main duty of the Italian Marine Casualty Investigation Central Board was to clarify as quickly as possible the proximate cause of passengers and crew being killed, i.e. why did the vessel suddenly capsize on January 14, 2012?
According a preliminary MCICM report dated 18 May 2012 about a:
"touristic sailing course envisaging an approach to the Island of Giglio up to a bathymetric contour line at 10 meters depth"
apparently ordered by the shipowner, we learn:
"Five minutes after completing the turning to port maneuver (at 09.16 pm), the Chief Officer on duty contacts the Ship Master who arrives to the bridge and takes over the con."
From above it would appear that the Master was on bridge 30 minutes (!) prior the first incident (the accidental contact, not a collision or an impact because stationary rocks do not collide or impact anything) and steering the vessel himself (?) in the dark at 16 knots with watch keeping officers, seamen and blond women just looking on. Why he was doing that and what he could see outside at 21.40 hrs, if anything, is not clear. Nothing is clear. Just nonsense is reported.
The first incident, the contact in the side, apparently caused upflooding of three or four watertight compartments, which the vessel survived with positive stability and buoyancy for about three hours. How the ship could scoop up a 100 tons piece of rock on the inner bottom and only damage the side 1 meter below waterline due to this contact is not clear (and should be explained).
A 60 meters hole is reported - in reality the hole is 36.5 meters long? Why is false information reported?
However, one more compartment was apparently progressively flooded through a leaking watertight door (#24), which produced further loss of stability and buoyancy and max GZ = -0.04 meter, which means the second incident: the capsize at 00.34 hrs the next day!
It seems the vessel was incorrectly designed as, apart from incorrectly lettering and not numbering the decks from bottom up, there were too many (at least 17 on below picture and 25 on picture above!) watertight doors in the watertight bulkheads below the bulkhead deck of the M/S Costa Concordia.
However, the very big vessel was very well subdivided and survived three or four compartments upflooding with positive, remaining both buoyancy and stability, one reason being that most double bottom compartments were not damaged or flooded. But apparently a serious mistake had been done: to fit watertight doors in the bulkheads.
The Costa Concordia has several sisterships and it is probable that they are also incorrectly designed and operated. A competent shipowner should of course immediately improve procedures on those and similar ships.
It is a distinct possibility that the proximate cause of the second incident, i.e. the capsize (and people drowning) is a leaking watertight door (#24). The person responsible for the leaking watertight door is therefore responsible for the death of people on the Costa Concordia. Who can it be? The shipowner? The maritime administration? Last Port State Control inspectors? The shipyard?
The final MCICB report should furthermore clarify why all persons aboard didn't get evacuated before capsize? It would appear that the life rafts that could evacuate >1 000 persons were hardly used. Why?
Why did 12 German, 6 French, 5 Italian and 2 US American passengers and 1 Spanish passenger not understand that they had to go to the muster stations to be escorted by crew to the lifeboats? The passengers spent all their time high up in the deck house of the ship and it was ample time between first contact at 21.45 hrs and capsize early next morning to get off the ship or go higher up. Six other crew members apparently also drowned but maybe they were doing their jobs and were surprised by the capsize down below. Or all these unfortunate persons were high up on the starboard side of the ship, when it capsized, and were pushed down below water and drowned.
complete safety investigation will clarify
why these people drowned or were killed on 14
January, 2012. And Heiwa Co recommends any
investigator not to blame any officer, crew member
or office staff ashore for killing people before
that investigation is done.
Only a complete safety investigation will clarify why these people drowned or were killed on 14 January, 2012. And Heiwa Co recommends any investigator not to blame any officer, crew member or office staff ashore for killing people before that investigation is done.
The U.S. Coast Guard on Monday November 19, 2012, said that it, joined by the National Transportation Safety Board, will be part of the Italian-led investigation into the fatal grounding of the Costa Concordia off the coast of Italy which left 32 people dead, including two Americans. Merchant Captain Timothy J. Farley, Deputy Chief, Office of Investigations and Casualty Analysis (CG-INV) of the USCG will visit Rome in this respect.
Actually neither USCG nor the NTSB can become part of the investigation team as per international law. They can only register as interested parties as observers subject to approval by the Italians.
On 16 November 2012 Italy submitted to the IMO MARITIME SAFETY COMMITTEE, 91st session as Agenda item 7, MSC 91/7/7, an update of the latest developments of its investigation into the Costa Concordia accident. The update "quoted below" is not very good and a sign of lack of competence in Italy to investigate a marine casualty:
There are apparently "(6) three different types of investigation (i.e. administrative; technical and criminal) still in progress".
What the administrative investigation is doing is not clear to Heiwa Co. And who is doing the safety investigation as per EU Directive 2009/18/EC ?
Five watertight compartments damaged - the structural damages involved five watertight compartments:
The vessel was thus floating stably with five compartments flooded after the 21.45 hrs contact.
Actually only four compartments were up-flooded and the damaged ship was stable and floating. It means that vessel was very well subdivided. Had five compartments been up-flooded, the vessel would immediately have capsized.
Stability was thus good during up-flooding of four damaged compartments. And the heel angle didn't prevent evacuation. You would expect that heel would be greater during up-flooding and later be reduced when more water flowed in, but it didn't happen here:
"15. A combination of factors caused the immediate and irreversible flooding of the ship beyond any manageable level. The scenario of two contiguous compartments (WTCs 5 and 6) being rapidly flooded in a very short period of time after the collision (for WTC 5 the time for its complete flooding was only a few minutes) placed a limit on the time available, as far as buoyancy, trim and list are concerned, to give an order for ship's abandon to allow for a safe and orderly evacuation.
A correct simulation of initial upflooding, apparent progressive flooding and down-flooding due to capsize would be valuable. It is very easy - just use the loading computers on the sister ships or in the main office. The fact remains that the ship was stable and upright for more than an hour after the accidental contact.
It seems that progressive flooding of WTC 3 caused the capsize. There is no mention of watertight doors, their positions (open or closed), etc.
"On 15 October 2012, a hearing was carried out where all the data retrieved from the Voyage Data Recorder (VDR) as well as other relevant documents that were under seizure, were made available to all interested parties. Data of interest for the Technical Investigation are currently under examination."
There are plenty errors in the report:
"The extension of the damage of the hull (7) (in terms of both deformations and breaches) extends for about 53 m, from frame 52 to frame 125, with a variable width, up to about 7.30 m."
Actually the extension is 36.5 meters. Why the damage vertical extent is only in the side below waterline is not clear to Heiwa Co and not explained.
"A computer simulation has been developed (9), taking into account information from various sources, such as witness statements, survey reports and VDR recording data available, to obtain a reconstruction of the maneuvering before the event and the ship's behavior after the event. The results of the simulation, following the first grounding (sic) up until the ship's rolls from port to starboard, correlate well with the flood water heights in various spaces provided in the statements from crew members. The outcome of the simulation shows the progression and magnitude of the heel angle following the roll to starboard until the final grounding (sic), which does not currently match stated heel angles read from the onboard inclinometer."
It is very easy to simulate and/or reconstruct the contact incident and upflooding of four compartments as there are several sister ships that can be used. According Heiwa Co there was no first or second groundings (sic) but only one contact and, after vessel was anchored but still floating and upright and 99% of persons aboard were evacuated, a capsize event. The ship was never aground! It suffered a contact and capsized and sank much later! Italy must find out what caused the contact, e.g. faulty charts/navigation/outlook, incompetent crew and what proximately caused the capsize, e.g. leaking or incorrectly installed W/T doors. The findings may be used to improve design and operation of sister ships and similar ships.
"The navigation phases (10) before the impact (sic) are to be considered as a crucial aspect of the technical investigation because they relate to the causes originating from the accident. In particular, the focus is on the behavior of the Master and his decision to make that hazardous passage in shallow waters."
According Heiwa Co there was no impact (sic) but only a contact and a technical investigation shall not concern itself with the alleged behavior of the Master who apparently believes the contact took place in deep waters and was an accident.
"The general emergency alarm (11) was not activated immediately after the impact (sic)."
Reason for this according Heiwa Co is that before any alarms are activated the Master and crew must review the situation and prepare for evacuation. To give a public alarm seconds after impact (?) with ship at high, forward speed is evidently crazy. It seems the abandon ship alarm was correctly given, when ship was anchored.
"A combination of factors (15) caused the immediate and irreversible flooding of the ship beyond any manageable level."
Not true. The vessel survived the upflooding of four damaged compartments due to the accidental contact. According Heiwa Co the critical factor causing capsize that surprised the crew is apparently the irregular watertight doors kept open on the ship and permitting progressive flooding of a fifth, intact compartment. Most watertight doors on the Costa Concordia and similar ships should not have been fitted in the first place and the ones permitted should have been kept closed at sea.
"It was noted (18) that the rules applicable to the Costa Concordia did not require the installation of a flood detection system in watertight compartments."
Heiwa Co has already 1994-1998 as part of the M/S Estonia incident investigation suggested that bilge alarms are fitted on passenger ships to alert the crew of leakages into watertight hull compartments (and then close W/T doors) but the IMO ignored the advice.
"In respect to the navigation phases before the impact (sic), the following critical points (sic) (21) can be preliminarily indicated as contributing factors to the accident: 1 Master's arbitrary attitude , 2 Master's inattention/distraction 3 shifting from a perpendicular to a parallel course 4 the ship proceeded toward an uninhabited area, with scarce illumination 5 keeping a high speed (16 kts) in night conditions 6 using an inappropriate cartography 7 Master's orders to the helmsman aimed at providing the compass course to be followed instead of the rudder angle."
In Heiwa Co's opinion a safety investigation (EU Directive 2009/18/EC) shall not judge the Master's role causing a contact but explain what took place resulting in a contact and later capsize and the proximate cause of the capsize. It seems the Master was as surprised as everybody else, when the contact took place due to crew errors, and then did a good job leading the evacuation of persons aboard. A safety investigation shall only find out what happened and proximately caused the two incidents in this case in order to prevent similar incidents in the future and shall not consider personal responsibilities, etc.
It is a good idea to ensure that the same info is used in any criminal investigations.
"The immediate flooding of five (sic) watertight compartments (23), where most of the vital equipment of the ship was located, makes the Costa Concordia casualty quite a unique event. The extent of damage is well beyond the survivability standard applicable to the ship according to her keel laying date (sic)."
In Heiwa Co's opinion the Costa Concordia evidently survived the stupid contact causing upflooding of four, relative small compartments of the very big ship with 16+ watertight compartments and was floating stably for almost 3 hours allowing evacuation of 99% of persons aboard before sudden capsize throwing, e.g. the Master into the water.
It is interesting to note that it is taken for granted by Italy that ship - and the sisters - were seaworthy prior departure, while in the opinion of Heiwa Co they weren't.
No reports or presentations by the Italian Marine Casualty Investigation Central Board, MCICB, establish, if the ship was seaworthy. This important matter is not mentioned at all.
A ship with 25 W/T doors must be considered unsafe and not seaworthy at any time. Only idiots operate ships with so many W/T doors and no proper maritime authority could have approved such a monster.
It is certain that vessel capsized due progressive flooding of an intact watertight compartment through an open watertight (non-regulatory) door producing righting arm GZ<0 at any angle of heel.
It is clear that a proper incident investigation has not been done!
It should be recalled that the analysis part of a correct safety investigation shall include a number of discrete sections, providing an analysis of each accidental event, with comments relating to the results of any relevant examinations or tests conducted during the course of the safety investigation and to any safety action that might already have been taken to prevent marine casualties.
These sections should thus cover issues such as:
- the context and environment of (A) the contact at 21.45 hrs and (B) the capsize at 00.34 hrs the next day,
It does not consider above. It mainly blames the Master for everything forgetting the Company and authorities ashore in Italy (and France and Spain). It is full of factual errors, e.g. (page 152):
"According with the evidences found at the end of the present investigation, it is necessary to put in evidence that 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".
The vessel was not seaworthy on departure and not in compliance with SOLAS, e.g. watertight doors. Crew was lacking to handle the Life Saving Appliances that were not used leaving people behind that drowned. To suggest that M/S Costa Concordia was in full compliance with rules and regulations is simply not true.
3. Investigation of leading Hull & Machinery underwriters
Finally, there is the incident investigation of leading Hull & Machinery underwriter RSA (insurance company) in relation to the casualty.
It is also conducting a full investigation into the circumstances of the casualty (first the contact and then the capsize) and has appointed experts in all relevant disciplines to assist with its investigation and the public is assured that all aspects of the casualty are being investigated, I have been told. Underwriters consider that they now have in place all the necessary expertise in the relevant disciplines for the purpose of the proper investigation of the casualty. Underwriters are of course only interested if they must pay for the losses incurred at the incidents. If the ship was not seaworthy with the knowledge of the shipowner, underwriters do not pay!
Evidently underwriters are not liable to pay anything if the ship was not seaworthy and fitted with incorrect watertight doors and lacked crew to launch lifeboats and save passengers?
Underwriters are strangely silent about their investigation but are apparently paying for the crazy salvage operation - next Part!
Sadly underwriters have not published any of their reports or findings on the Internet. It would be interesting to know if underwriters considered the ship seaworthy ... and insured.
How to do a proper incident investigation is described here!
Not to be out-done on April 20, 2012 the Cruise Industry Appoints Panel to Evaluate Recommendations of Cruise Industry Operational Safety Review. However, the four 'experts' are just retired military persons or government civil servants with little experience of passenger cruise ship design, operation and crew training so you get a feeling of an IMO panel of experts review of safety after the M/S Estonia incident 1994. Then 21 'experts' in three months recommended numerous changes to SOLAS which were quickly adopted by a diplomatic conference at the IMO. None of the changes improved safety at sea! The IMO panel of experts didn't even bother to check if M/S Estonia was seaworthy, e.g. with 22 watertight doors in the hull bulkheads that were always open at sea.
Other interested parties are the Protection & Indemnity, P&I, Clubs that pay third party claims. In this case Steamship Mutual P&I and the Standard P&I clubs shared the responsiblity. Without establishing if the ship was seaworthy it appears they just paid any claims.
It is very strange that nobody has confirmed that M/S Costa Concordia was seaworthy on departure the last voyage 13 January 2012.
Go to Part 11.