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MINISTRY OF INFRASTRUCTURES AND TRANSPORTS (sic) Marine Casualties Investigative Body Cruise Ship COSTA CONCORDIA Marine casualty on January 13, 2012 Report on the safety technical investigation The Costa Concordia incident report by the Italian investigators (without date and not signed) was May 2013 available at www.safety4sea.com/images/media/pdf/Costa_Concordia_-_Full_Investigation_Report.pdf (copy/paste the link). It is 181 pages and was handed in to IMO/MSC 92 to assist them to improve safety at sea. My analysis below of the report is concluded by: The Italian incident investigation report is a joke and a scandal. The incompetent investigators should be put in jail. But we do not know the names of the investigators, so it is difficult. The Italian report is not done in accordance with DIRECTIVE 2009/18/EC OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL of 23 April 2009, which states: (12) Directive 2002/59/EC of the European Parliament and of the Council of 27 June 2002 establishing a Community vessel traffic monitoring and information system (6) requires Member States to comply with the IMO Code for the Investigation of Marine Casualties and Incidents and ensure that the findings of the accident investigations are published as soon as possible after its conclusion. Evidently the wreck was still at Isola del Giglio when the report was written, but an internal inspection of the wreck had not really taken place; only a superficial external inspection had been done using photos. There are many grammatical and syntax errors and sentences that do not make sense in the report. When I quote the report in this review, these errors are left in. The wreck was January 2017 in drydock at Genoa and could be examined there. It is never too late to do a proper investigation! But it seems the wreck was towed out to sea again and was ... sunk! It really is amazing. Others have reviewed the report to explain what happened, e.g. http://worldmaritimenews.com/archives/84984/costa-concordia-investigation-report-published/ and http://www.safety4sea.com/costa-concordia-investigation-report-available-16106 . Both believe: The ship capsized as a result of large-scale internal flooding from a 53-meter long breach of its hull involving five watertight compartments. The breach occurred when the ship collided at a speed of 16 knots with the Scole Rocks off Giglio Island in the Tyrrhenian Sea at 21 45 07 local time. However all survivors know that the ship did not capsize, when the breach occurred hours earlier. The Master thought that the ship was safe and could be towed for repairs. The ship capsized the next morning after Abandon ship was completed. Another suggestion is http://gcaptain.com/full-costa-concordia-investigation/#.Vje4KiyFM5s : The report is lengthy, but I think its findings can be summed up in this one sentence copied from the report's SUMMARY: However the plan was to pass at a safe distance. The Master had decided
before departing Civitavecchia on the
way to Savona to pass close to the
Giglio island. To do so you evidently set
course straight for the Giglio island at
departure to pass the island from the South at a
safe distance ... without turning (figure left) ...
but NO! The ship went straight for
Savona at departure and only later, during
the leg between Civitavecchia and
Savona, some officers aboard turned the ship
port straight towards the Giglio
island for the Master to carry out a
sharp starboard turn at the last moment to
impress the passengers & Co. Of course no
passenger aboard was told about it! So just before all incidents
that followed, the ship was heading perpendicular
towards the Giglio island ... and the
Master forgot to turn correctly! Can we
believe that? Later we have been told the
Master was chatting with his mistress all
the time. ...Up to now most of the content of the report has been taken from the VDR, the Voyage Data Recorder, but at 2332 even the Second Master who was left on the bridge to co-ordinate the evacuation, has left, so from this point one assumes that either witness statements have been used, or else transcripts of communications from the shore. And at 2338 all control of the evacuation having been abandoned, there were still 300 passengers and crew on board. They were still trying to escape, or disembark if you were following the Captain's view, and those who had jumped into the sea were being picked up by SAR patrol boats. However the Master and officers abandoned the Emergency centre in the wheel house, when Abandon ship was ongoing to assist getting six lifeboats into water whose davits didn't function! It seems the ship contacted a submerged rock at 21 45 07 local time, when carrying out a pre-planned (?) manual (??) turn, but that nobody died then. It seems the Master was at fault one way or other but it is not clear why. The Master thought much later that the ship was safe and could be towed for repairs. But with no electricity the Abandon ship was ordered. A safe port was only 300 metres away. It seems the ship was stable at 23.32 and 23.38 hrs local time, almost two hours later, when the Emergency centre was abandoned, when apparently the Abandon ship was completed. What happened afterwards is not really reported. Maybe the Master went to his no. 1 lifeboat to be the last to leave the ship and ... found his lifeboat gone. Had somebody stolen it? So you have to read the full story here and here. The ship was not seaworthy. Insurances were not valid! Crew was missing to prepare lifesaving appliances and to escort passengers to the lifeboats and life rafts to carry them to safety ashore. And six lifeboat davits didn't work correctly! The ship was incorrectly designed with 25 illegal watertight doors that produced progressive flooding of intact hull compartments that produced loss of stability, capsize and down flooding and sinking. The poor Master cannot be blamed for it. He was only aboard to keep the passengers and girl friends happy and carry out the instructions of the ship owner. The incidents killing people, capsize and sinking, took place January 14, 2012! And isn't it the Ministry of Infrastructure and Transport that should issue the report? It is worthwhile to recall that the incident investigators in their report shall first establish that the ship was seaworthy and then only find out what happened and proximately caused the various incidents, viz. accidental contact, confused mustering, incomplete abandon ship, plenty life saving appliances not used, watertight doors not closed, capsize, sinking, etc., in order to prevent similar incidents in the future. It is a good idea to confirm that vessel was in compliance with the International Safety Management, ISM, system/code incl. a Procedures Manual with ship/shore job descriptions and routine and emergency procedures decided by the ship owner, i.e. Document of Compliance. The ISM Code requires that the ship owner establishes, e.g. procedures and drills for (1) navigation to avoid incidents like contacts and (2) mustering and abandon ship to avoid that persons aboard drown and (3) watertight doors to avoid they are open at sea causing capsize, when the ship is leaking. The Code also establishes about safety meetings aboard and audits that they are done, etc. The report shall not consider personal, individual responsibilities of, e.g. the 1.000+ crew on the ship, the officers, the Master, etc. It is noteworthy (p 51 of the report) that "The helmsman, just in the phases immediately before impact (sic), has made mistakes in the handling of the helm than the orders given by the Master". It apparently means that errors by the helmsman maybe produced the first incident - an accidental contact. Cause? Bad training? Bad language knowledge? Who hired the helmsman? Was the helmsman qualified? We are not told. It is further established that the Abandon ship was unsuccessful due to lack of trained crew aboard. Why is that? We don't know as the matter is not investigated. What kind of report is this? The report is not written as per the Code of the International Standards and Recommended Practices for a Safety Investigation into a Marine Casualty or Marine Incident (Casualty Investigation Code) adopted by the IMO as Resolution MSC.255(84), 16 May 2008. Its purpose is very simple: To establish what happened and why it happened so that the causal factors are fully understood and action can be taken to:
In conclusion - the report is extremely bad and incomplete ... maybe therefore it is not signed, so nobody can be held responsible. It is a pity that IMO/MSC 92 accepted the report at all.
Part 1
SUMMARY, pp 3-10, should just outline the
basic facts of the marine casualty or incident:
what happened, when, where and how it
happened; it should also state whether any deaths,
injuries, damage to the ship, cargo, third parties
or environment occurred as a result. The Summary does not describe what happened after the January 13, 2012 accidental contact, i.e. that passengers and staff were not being mustered due to lack of muster stations, that an incomplete abandon ship leaving >300 persons aboard took place due to lack of skilled and trained crew to launch all lifeboats and life rafts and that six lifeboat davits were not working, that progressive flooding of intact hull compartments through illegal watertight doors took place, the capsize the next day and the sinking, when people died or whether the ship was seaworthy. We are instead told the following (p 3): "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 (sic) with the "Scole Rocks" at the Giglio Island. The ship had just left the port of Civitavecchia and was directed to Savona (Italy). Actually the ship was on a planned itinerary to Savona and a strange change of course at Isola del Giglio at 21.40 hrs was badly executed. It had been decided
before departing Civitavecchia to
sail to Savona to pass close to the
Giglio island. To do so you evidently set
course straight for the Giglio island at
departure to pass the island from the South at a
safe distance ... without turning (figure left) ...
but NO! The ship went straight for
Savona at departure and only later, during
the leg between Civitavecchia and
Savona, some officers aboard turned the ship
port straight towards the Giglio
island for the Master to carry out a sharp
starboard turn at the last moment to impress
the passengers & Co. Of course no passenger
aboard was told about it! So just before all incidents the
ship was heading perpendicular towards the
Giglio island ... and the Master forgot to
turn correctly! Nobody died! And the ship didn't heel. It remained floating and upright for several hours. But after a while there was a black-out. The vessel immediately lost propulsion and was consequently effected (sic) by a black-out. The Emergency Generator Power switched on as expected, but was not able to supply the utilities (sic) 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 (sic) (due to favourable wind and current) at the Giglio Island at around 23.00 and was seriously heeled (approximately 15°)." Due to the contact the vessel lost propulsion and there was a black-out. Correct. We know that ship did not heel then and that you could launch most lifeboats until 23.37 hrs (some davits didn't work), when heel became >20°. We know that passengers in the restaurants panicked and that crew and staff didn't know what to do and that later things calmed down ... and little happened. The vessel's bilge finally touched two rocky outreaches of the island at 23.00 hrs ... due to drifting and favourable wind. Nobody had died! The vessel did not ground due to wind! The starboard bilge was just touching bottom at two locations. "...it was discovered that the breach was 53 meters long."
So it is suggested in the pp 3-10 SUMMARY that five watertight compartments were immediately up-flooded due to the breach caused by the contact. There is no evidence for this. The crew reported only four compartments up-flooded above the intact double bottom due to the contact. The ship remained stable with no heel and was floating. My photo below of the damage indicates that the deformed and ripped open hull plate was only 43.5 meters long between frame #112 and frame #52 affecting hull compartments #4, 5, 6 and 7 and that the fractured part is only 36.5 meters long (starting at fr. #100), while 7.0 meters of hull plate, frs. #112-100, is only deformed but not ripped apart. All information suggests that only four hull compartments were up-flooded at the contact incident and that the ship was stable and up right with sufficient buoyancy enabling mustering and abandoning ship. The double bottom appears mostly intact. Later a fifth compartment (no. 3 or no. 8) was slowly, progressively flooded (a new incident!) through an open, illegal watertight door (e.g. no. 10 and or 6) reducing stability (GZ) and causing capsize. The floating, not aground ship suddenly capsized at 00.34 hrs on 14 January. This was a new incident leading to sinking killing people.
Photo Anders Björkman
The SUMMARY continues (p 8): "Finally, after the casualty (i.e. the first incident = the contact), caused by the Master (sic - it was caused by the object on the sea floor) 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." There are evidently no evidence showing that the Master, his staff or the DPA (Designated Person Ashore) intentionally caused a collision, actually a less than 10 seconds contact, with the "Scole Rocks" and later delayed any actions to Abandon ship that only takes place after a serious assessment of the situation. It would appear that it was the "Scole Rocks" that caused the collision (by being in the way and/or not moving away from Costa Concordia)? Everything happens at sea. You wonder if the Italian incident investigators have the relevant training and education to carry out a correct incident investigation. Is the above the result of in depth interviews of crewmembers and passengers ... or just made up based on media reports? Or just invented to protect certain interests and focus the blame on innocent people? The SUMMARY is concluded by (pp 9-10): "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." So it is a tragedy that 32 people apparently died and 157 were injured because the "Scole Rocks" collided with the Costa Concordia apart from inaction by incompetent crew members employed by the ship owner. It sounds strange. Isn't it more likely that people were injured during the chaotic attempt to abandon the ship more than hours later and that people drowned/died the next day, when the ship sank? And that open watertight doors and progressive flooding of intact hull compartments produced the capsize, when the ship lost stability the next day! People were injured and died because the ship owner failed to provide a trained crew that didn't inform the passengers of how to muster in an emergency and didn't collect and accompany all aboard to embark into lifeboats and life rafts. The ship was not seaworthy at any time. It is sad that the report cannot summarize evident defects of ship and crew ... a responsibility of the ship owner.
Part 2
FACTUAL INFORMATION should include a number
of discrete sections, providing sufficient
information that the investigating body interprets
to be factual, substantiate the analysis and ease
understanding. These sections include, in
particular, the following information: 2.1. Ship
particulars - Flag/register, Identification,
Main characteristics, Ownership and
management, Construction details, Minimum safe
manning, Authorised cargo. 2.2. Voyage particulars
- Ports of call, Type of voyage, Cargo information,
Minimum safe manning. 2.3. Marine casualty or
incident information - Type of marine casualty or
incident, Date and time, Position and location
of the marine casualty or incident, External
and internal environment, Ship operation and voyage
segment, Place on board, Human factors data,
Consequences (for people, ship, cargo, environment,
other). 2.4. Shore authority involvement and
emergency response - Who was involved, Means used,
Speed of response, Actions taken, Results
achieved. According p 11: "Flag: ITALY Actually the International Registers (sic) is an open register similar to a Flag of Convenience allowing the use of foreign, low paid crew under long duration without vacation, EU social benefits, etc. The report correctly states that the passenger capacity was 3 780 but we are also told that Minimum Safe Manning of the big cruise ship was only 75 seamen. How 75 seamen can safely handle 3 780 passengers is not clear. There is no data how many persons (passengers + crew) the ship could carry and what the life saving appliances consisted of - lifeboats and rafts. We are not told how the ship was classed and certified and whether it was seaworthy at departure before the incidents occurred. Ship's draught is given to 14.18 mt but it is the moulded Depth D. Ships draught may have been <9 meters and the freeboard >5 meters. The Load Line certificate seems to be missing. The accident appears due to strange manoeuvring and we know the ship's "manoeuvring characteristics" addressed by the IMO Standards for ship manoeuvrability (IMO MSC.137(76) resolution on Standards for ship manoeuvrability) in one appendix. Of particular interests are the advance and transfer, i.e. the distances travelled forward and sideways to carry out a 90° change of heading at constant cruise speed/engine power and the head reach and lateral deviation, i.e. the distances travelled forward and sideways during a crash stop; ship's speed reduced from cruise speed to zero with propellers rotation reversed at full power. Evidently the vessel could change heading 45° in less than two minutes. It would appear that the ship could be manoeuvred from the bridge wings without giving orders to the helmsman and you wonder why the procedure Master giving orders to the helmsman was used. Had it ever been tested and practised? The report states in 2.3 Event type: CONTACT-BREACH-BLACK-OUT and that it took place 21.45 hrs on 13/01/2012. It seems nobody died or was injured at that event. It is suggested that the ship was a total loss due to the CONTACT-BREACH-BLACK-OUT. It is incorrect. The ship was stable and floating after the CONTACT and BREACH. And the emergency lights worked. The report fails to point out the second event, after partial abandon ship had taken place, the next morning at 00.34 hrs - capsize killing people and sinking the ship and why the capsize took place; progressive flooding and open watertight doors. 2.4. Shore authority involvement and emergency response is described on pp 14-26. The Livorno (Leghorn) Maritime Rescue Sub Centre, MRSC, immediately came to assistance starting at 22.06 hrs and all info was recorded there. Therefore we are told: "At 22:25:15 (VDR) the Master of the ship, contacted by MRSC Livorno, communicates that the ship has a hull breach, on the left side, that is causing a gradual heel, that on board there are dead or injured (sic) people and he only requires the assistance of a tug." You wonder what people could have died or been injured due to "Scole Rocks" collision. There is no evidence of any fatalities - dead and injured - at this time. The ship carried medical staff and a little hospital but what they did is not mentioned. Why does the report indicate that 159 persons were already injured due to the collision? "22:54:10 hours (VDR) Through the "Publ address system" is communicated the "Abandon ship order" (solicited to the ship by MRSC Livorno)". At 22.54 hrs "Abandon ship" was ordered. It means that all 26 lifeboats shall be lowered by assigned crew to the embarkation deck level, so that passengers can embark. It should have taken maximum 10 minutes, i.e. a little after 23.04 hrs embarkation of lifeboats could start. With three seamen assigned to each lifeboat 78 seamen should have made the lifeboats ready. The lead seaman of each lifeboat should report when job was done. At same time other seamen hook up and inflate the first eight life rafts (of >65) to enable staff and crew to abandon ship. So at 23.38 hrs the Master - apparently still on the ship - reports that evacuation was almost complete with some hundreds people still aboard. This is not correct! We know that three port lifeboats were never launched and that most life rafts were not used at all. Then, around 00.34 hrs the next day, the ship capsized and the Master fell overboard on top of a lifeboat. The remaining people were then rescued apart from 32 that drowned. It would appear that people were killed due to capsize and sinking on January 14 and to not abandoning the ship in time. The "Scole Rock" collision, actually contact, at 21.45 hrs January 13 evidently didn't kill anybody. "A total of 23 lifeboats out of 26 and 6 liferafts out of 69 were used and allowed rescue of survivors. ... . Around 2/3 of those total people on board have been saved by the life saving equipment belonging to C/s Concordia. ... People who delayed to leave the ship because they were not gathered on time for disembarking - due to short time available for arranging the abandon ship when the ship was not heavily listed - disembarked themselves by the only two embarkation ladders available on board (stern and bow positioned). Those two are in compliance with reg. III/11.7 - Solas 74 as amended, but not enough in this case (heeling > 20°), since the alternative hydraulic devices, that should have replaced those fittings, didn’t run due to the heavy list. It is not clear if mustering of all passengers and crew had ever been tested in port, but it seems that the life saving appliances and the evacuation worked well. However it is not explained why only 6 (!) of 69 life rafts were used. 30 life rafts could easily have evacuated 750 persons of the staff! Wasn't there crew to launch the life rafts? And was really 23 lifeboats lowered and launched. On photos of ship after capsize we see three port lifeboats not lowered/launched and still in the davits. Why weren't they lowered and ready to be used, when the General Alarm was raised and never used? They could save 450 passengers! Lack of crew. On photos of ship before capsize we also see three starboard lifeboats still in the davits, while other lifeboats have already reached the Port of Giglio. On the photo we see persons walking to the port side. Were the three starboard lifeboats actually launched? They could also have saved 450 passengers. The report does not analyze why all LSA were not used. It is very easy to find out why LSA was not used: interview the crew! But it seems the investigators didn't interview any crew members. The report fails to describe the International Safety Management, ISM, system aboard M/S Costa Concordia and ashore. Every crew member aboard must have an ISM job description so everybody knows who is responsible for what, e.g. Master - keep passengers happy, Staff Captain assists the Master, 1st Officer - safety, evacuation, fire fighting, 2nd Officer - navigation, 3rd Officer - equipment in order, ... Chief Eng. - engine room, 1st Eng - main engines ... Bosun - head of seamen, AB - , OS -, etc., etc. According ISM officers/engineers meet regularly to discuss situation and analyse incidents. All must be recorded. The ISM system is internally audited, etc, etc. The ISM system is very simple to understand, e.g. the Master is not responsible for everything. The ship's doctor looks after health matters. Food and beverages are looked after by dedicated manager, etc, etc. But the Italian marine incident investigators do not seem to know about ISM. They make the Master responsible for everything. Forgetting the ship owner. And the sister ships. On any cruise vessel there are minor incidents every day to be handled according to ISM but ... nothing is reported. Strange. There shall be regular safety meetings, etc, aboard but we do not know if they were done. The report fails to describe whether the crew was paid and treated according the Maritime Labour Convention. It is likely that the non-Italian crew worked under illegal conditions in spite of what is said on pp 39-42 of the report. In 4.2.1 Certificates of safety and operating limitations (p. 42) it says: "The ship left the port of Civitavecchia with all the Statutory (Annex 19) and Class (Annex 20) certificates in regular validity." It is not correct. M/S Costa Concordia should have had the following certificates to be able to trade and be prepared for Port State Control, flag state control and class inspections and to carry passengers. 1. Passenger Ship Safety Certificate - that vessel is in compliance with SOLAS safety at sea requirements, incl. radio and navigation equipment and stability instructions. 2. SOLAS exemption certificates - that when vessel does not comply with one or more particular SOLAS requirements (e.g. watertight doors), alternative arrangements provide equivalent safety at sea (to be explained). 3. International Oil Pollution Prevention Certificate - that vessel is in compliance Marpol pollution prevention requirements, not only regarding oil but also sewage, garbage, etc. 4. International Load Line Certificate - that vessel is in compliance with ILLC requirements about operating draught, freeboard, openings/closing devices in hull, superstructure, deck house, Plimsoll mark, stability information, etc. 5. Tonnage certificates - different types to calculate port/canal fees. 6. International Safety Management Certificate - that vessel is in compliance with the International Safety Management, ISM, system/code incl. a Procedures Manual with ship/shore job descriptions and routine and emergency procedures decided by the ship owner, i.e. Document of Compliance. The ISM Code requires procedures and drills for mustering and abandon ship and audits that they are done but the investigators do not tell us anyting about them. 7. International Ship and Port Facility Security Code certificate - to ensure security aboard, e.g. against terrorists and gangsters. 8. ITF Blue card/certificate or similar - to ensure crew social welfare according the Maritime Labour Convention. It is likely that the non-Italian crew worked under illegal conditions. 9. The Classification certificate - that ship's structure, engines, pressure vessels, equipment, etc., are in order. 10. Others - cargo gear, elevators, medical, health, food handling, cleanliness of galley & store rooms, fire extinguishers, life rafts, etc. Some certificates are valid five years subject to annual endorsements, some for shorter or longer durations. No certificate evidently guarantees that the ship is seaworthy. The report only provides 1. and 9, thus most certificates are missing. Part 3
NARRATIVE shall reconstruct the marine
casualty or incident through a sequence of events,
in a chronological order leading up to, during and
following the marine casualty or incident and the
involvement of each actor (i.e. person,
material, environment, equipment or external
agent). The period covered by the narrative depends
on the timing of those particular accidental events
that directly contributed to the marine casualty or
incident. This part also includes any relevant
details of the safety investigation conducted,
including the results of examinations or
tests. It had been decided
before departing Civitavecchia to
sail to Savona and to pass close to the
Giglio island. To do so you evidently set
course straight for the Giglio island at
departure to pass the island from the South at a
safe distance ... without turning (figure left) ...
but NO! The ship went straight for
Savona at departure and only later, during
the leg between Civitavecchia and
Savona, some officers aboard turned the ship
port straight towards the Giglio
island for the Master to carry out a sharp
starboard turn at the last moment to impress
the passengers & Co. Of course no passenger
aboard was told about it! So just before all incidents the
ship was heading perpendicular towards the
Giglio island ... and the Master forgot to
turn correctly! The report does not say what events were planned and how these events were executed. It would appear that a change of course from 278° to 334° was planned at 21.40 hrs:
It would thus be very interesting to know how the change of course was executed around 21.40 hrs. Why not interview the persons on the bridge - officers and crew? Why just reconstruct the events based on voice data recordings? According the report: "At 21.34.36 hrs the Master comes on the bridge and orders the helmsman to move the rudder in manual mode. … It seems the ship had already turned 12° from 278° to 290° but we do not know how. What happened on the ship during these 4 minutes and 48 seconds? At 21.39.30 hrs with speed 3.15 (??) Master orders the helmsman to go for 300°, and at 21.40.00 hrs orders to increase to 16 knots and then to pull "gently" to 310 °. Till this point the ship is still on the course as planned and the radar displays a VRM at 0.5 miles. The bow heads towards "Punta Capo Marino" and the ship proceeds, at a distance of 1.35 miles and a speed of 15.4 knots. … Actually "the course as planned" was to change heading 278/334° at 21.40 hrs. It would be interesting to know the heading/course "towards "Punta Capo Marino"". As you lose speed when turning it was a good idea to speed up a little to assist the turning. But it seems the turning has started. At 21.40.48 the Master orders, in English, ".. 325 .." the helmsman answers, to confirm the order ".. 315 ..", the First Deck Officer intervenes to correct the interpretation of the helmsman but pronounces ".. 335 .." then the Master reiterates its order ".. 325 .." and then the Helmsman confirms ".. 325 ..". The above info is apparently from a voice recording. So the Master orders in English (in spite of working language being Italian) a starboard turn, three, two, five (to 325°) but the helmsman answers 315, three, one (!), five and may have turned to port. Maybe here the ship got on the wrong heading? But it is still another 5 minutes until contact occurs. It should be very simple to find out what really happened during the following five minutes as the Voyage Data Recorder, VDR, records (i) Speed log - Speed through water or speed over ground before and after the first contact, capsize and final sinking, (ii) Gyro compass - Heading before and after the contact, (iii) Radar - it gives ship's position at any time and before and after the contact, capsize and final sinking and, (iv) Rudder - Position, order and feedback response. Unfortunately these data are not made public or has gone missing. So we do not know if the compass and the steering gear were working. We are just told that: The ship is at about 0.5 miles far from the coast. But we do not know the course and speed. What kind of incident report is this? The data show that VDR when the VRM circle "touches" the shore is going to be deactivated. This is strange as the turn should be terminated at course 334°. And a minute earlier the course was ordered 330°. With that course you will not run up on the island. At 21.43.33 hrs is ordered 340°. Voice recordings or orders and replies are interesting but more interesting is to know the actual headings and rudder positions at the given times. Did the helmsman actually turn the rudders at all? Was the helmsman interviewed? Did the steering gear work? What does the VDR say? Again there are misunderstandings and maybe the incident really occurred here: The turn is still in progress when the ship is at 21.44.05 hrs in position 42°21'05 "N 010°56 'E, with the bow in the direction of "Le Scole " at 0.3 miles and a speed of 16 knots. This means that the ship was heading straight up on land (Le Scole) 550 meters ahead. With a speed 8.23 m/s you will crash after 67 seconds. Evidently no turn is in progress! The description cannot be correct. The turning radius is such that the ship is located 0.5 miles SW of the planned (!) route so much closer to the coast than planned. Is the ship really 900 meters SW of the planned route at 21.44.05 hrs? A map of planned and actual routes is missing. How could the ship be 900 meters off course heading up on land after five minutes, when it started turning starboard away from land at 21.39.30 hrs? From this moment the Master starts giving orders no more for bows but for rudder angles and in sequence gives: This is very strange! The rudders must have been starboard 10 already at 21.39.30 hrs, when the planned turn was started going for 300°/310°. The description seems unreal. Has it taken 4 minutes 41 seconds to execute a simple turn? - 21.44.15 hrs - Starboard 20 (twenty degrees to starboard); Again the helmsman doesn't understand what to do - a second incident. From p 51 of the report we learn: "The helmsman, just in the phases immediately before impact (sic), has made mistakes in the handling of the helm than the orders given by the Master." So it seems a major contributory factor of the contact that follows is the helmsman not following the orders of the Master or rudder gear didn't function. It seems the helmsman didn't understand Italian and didn't understand the English spoken by the Italian officers. - 21.45.05 hrs - hard to port (rudder to the left). The helmsman runs correctly. The five minutes (sic) turn seems extremely strange. Easiest way to turn the ship starboard was to turn the rudder to starboard once and note how the course changed until the new course was attained, when you turn the rudder to midship. Did the vessel actually respond to the rudder movements, i.e. was the steering installation in order? Does a normal turn 56° starboard take five minutes? I would expect the vessel would turn in less than two, three minutes after one rudder movement. Evidently the stationary rocks did not collide with the ship but the ship just unfortunately, accidentally contacted the rocks on the sea floor damaging its port side causing up-flooding of some hull compartments. Vessel neither sank nor capsized and nobody died due to the contact. And any watertight door permitted by SOLAS with operational instructions provided by the Italian Maritime Authority should have been closed at departure. Were they? Regarding up-flooding of watertight compartments, we learn: (p 30) "At about 21:55 the Deputy Chief Engineer comes in the SCP (Electric Engine Control Room ) and verifies that the local PEM (local electric propulsion engines- compartment 5) is flooded meaning therefore that the compartments flooded are at least 3 (WTC5, WTC6 and WTC7 ). This situation is communicated to the bridge." ... "At 22:07, the ship contacted by the Operations Room of the Civitavecchia Harbour Master, refers only to have a black-out, but that the situation is under control". ...
It is thus clear that neither compartment #8 nor #3 was up-flooded due to the contact and that the ship was stable with four up-flooded compartments at abt. 22.20 hrs. The situation wasn't so bad. There is no information about soundings of double bottom tanks. It seems most double bottom tanks were intact as the structural damages were in the ship's side above the double bottom. In principle it should still have been possible to pump out intact hull spaces being flooded, e.g. through leaking watertight doors, using the ship ordinary and emergency bilge pump systems and thus preventing capsize. The incident investigators have not studied the matter and verified, if the systems were correct. The report is incomplete. It would be interesting to know if both bilge pump systems were disabled due to the accidental up-flooding of four hull compartments. If that were the case, the ship was incorrectly built and not seaworthy. But it was a good idea to disembark the passengers: "At 22.33.26 hrs the "general emergency" alarm is raised."… If a general emergency were raised 22.33 hrs, already then lifeboats and life rafts should have been made ready. The Abandon ship order 22.54 hrs apparently meant that embarkation could start. And most persons aboard were then safely evacuated. It seems the Master, crew and Italian MRSC units saved most persons aboard. Very good. But the Abandon Ship is not really described and why three lifeboats and >60 life rafts were not used and ~300 persons were left aboard, when the ship capsized. A proper investigation should of course interview all the survivors what really happened. The report thus fails to describe the lack of muster stations aboard and that little info was given to passengers and staff how to Abandon Ship. These defects indicate that the ship was not seaworthy. The report then fails to describe the sudden capsize at 00.34 hrs the next day sinking the ship and killing people in front of Italian MRSC. It mentions that 159 passengers much later have made claims for injuries but there are no details. There were a ship's Doctor and nurses aboard but ... what they did, we do not know. Evidently the fault of the Master, again. The report has no description and analysis of the Abandon Ship. Therefore we do not know why the LSA were not used except that it is indicated crew and personnel were lacking, i.e. the ship was not seaworthy. But this serious matter is not pursued. What kind of incident investigation report is this?
Part 4 -
ANALYSIS 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
cover issues such as: - accidental event context
and environment, - human erroneous actions and
omissions, events involving hazardous material,
environmental effects, equipment failures, and
external influences, - contributing factors
involving person-related functions, shipboard
operations, shore management or regulatory
influence. The analysis and comment enable the
report to reach logical conclusions, establishing
all of the contributing factors, including those
with risks for which existing defences aimed at
preventing an accidental event, and/or those aimed
at eliminating or reducing its consequences, are
assessed to be either inadequate or
missing. According to the report (p37): "Since the wreck was not available (sic), it has been evaluated to carry out the investigation, as well, using the first sister ship in the area." Evidently the wreck is available for inspection with the structural damage above water. But the investigators visited 2 sister ships that also had 25 watertight doors and foreign crew. If the sister ships could evacuate 5 000 persons aboard in 60 minutes is not clear. The investigators just assume that the sister ship is seaworthy in lieu of establishing facts. As all non-Italian crew was immediately repatriated, they were never interviewed by neither police nor maritime safety authorities. Imagine doing an incident investigation and not interviewing the crew! The report (pp 37-38) correctly points out that "The Company must ensure that personnel employed on board obtained own certification in compliance with the STCW and the Domestic requirements. Moreover, the Company ensures that the related familiarization for their duty and for tasks linked with an emergency, etc, etc." The Company is the ship owner and it would appear that it failed to provide qualified crew. If anybody is to be blamed for anything, it is the Company. It must be assumed that equally unqualified crew is provided to other ships. According to the report (p 41): "4.1.4 Muster List Strangely the report fails to describe how the 1 109 crew members (or 1 023 crew actually aboard) shall muster and assist the 3.780 passengers, when abandoning the vessel using the Life Saving Appliances and how this event was executed after the first incident - the contact. It seems the vessel had only two big muster stations somewhere (for 1.890 pax each!), from where groups of passengers, after being counted, were supposed to be guided to lifeboats and rafts by crew ... and this system didn't really work ... so people died. Who can be responsible? The Master? No, the ship owner and the maritime administration. You really wonder if the Muster system had been tested and trained. The report has not one word about it. The sister ships apparently use the same, ineffective system! According to the report (p 42): "... the language of work on board ... is the Italian language." If all foreign crew and staff actually knew Italian is not clarified. The crew had disappeared (been repatriated). According to the report (p 74): "The above mentioned activity is regulated by the SMS P.5.2109 procedure, which refers to the ILO regulations; and it is detailed in the requests and the selection procedure. However, after the ISM audit carried out by the Flag Administration in the Company headquarters (6 and 7 March 2012), the following weakness, which originated a specific “not conformity”, have been found in the above mentioned procedure:a. The procedure for the evaluation related to the recruitment of the deck and engine personnel does not provide for the assessment of the work language. It would appear most crew and some foreign officers (e.g. the Bulgarian 1st Engineer) assigned to emergency duties didn't speak Italian, i.e. the working language aboard. According to the report (pp 43-44): "Planning the voyage of the "Costa Concordia" - January 13, 2012 - was carried out using the chart 6 Hydrographic Institute of the Navy. This paper, scale 1:100 000, is not, …, for adequate planning of the route close to the coast which requires more detailed information in consideration of the preliminary assessments for the safety of navigation, taking into account the parameters and criteria just set forth and contained in the ISM procedure mentioned above." So it appears the wrong charts were used at the incident. And (p 47): "The officer on duty on the bridge is responsible for the conduct of navigation, that is to be performed according to the schedule of the voyage, even in the presence of the Master on the bridge." … So it appears that the Master was not alone on the bridge, when the accidental contact occurred. On pp. 51 the report, considers Actuating the rudder. The helmsman, just in the phases immediately before impact (sic), has made mistakes in the handling of the helm than the orders given by the Master. So it appears the helmsman didn't follow orders causing the contact. The matter is not pursued. The helmsman is not interviewed in the report. We do not really know on what evidence the report makes the statement.
Open watertight doors at sea On pp. 56+ the report, confusingly, considers the watertight doors on Costa Concordia: "All watertight doors shall be inspected by an engineer and subsequently closed by designated staff, before the departure of the ship.
This procedure does not comply with the requirements of SOLAS as it is not allowed to open or keep open during navigation those watertight doors. That the watertight doors were not closed is clear from the VDR recordings made public October 2012. Various doors were opened closed all the time before, during and after the turn and the contact. Here the investigators report incorrect information. The report suggests that WTC8 was not up-flooded at all but only the double bottom below - the port bilge part - was maybe flooded (if the bilge plate was ripped open, which is unlikely). The only way WTC 8 could then be flooded was via open (illegal) watertight door #6 ... and at 21.44.03 hrs it was open! Just a minute before the contact!
The fact is that all 25 watertight doors on Costa Concordia were incorrectly fitted and not as per SOLAS and that any instructions regarding these doors were wrong. I explain why here. Furthermore it would appear that several doors were open before and after the 21.45 hrs contact and up-flooding and caused, by allowing progressive flooding of intact compartments, capsize that killed and injured people. On pp 97+ of the report are photos of illegal and incorrect watertight doors on … a sister ship! Imagine that - there are other dangerous, unseaworthy Costa sister ships around! And nothing is done about it.
On pp. 58+ the report, considers Control Life Saving And Checking The Fitness 'Ship (sic) Before the ship leaves a port and at all times during the voyage, all life-saving appliances shall be kept in working order and ready for immediate use. Actually a 3/O under the 1/O or similar is responsible that LSA is in working order and that crew is available to handle the LSA. They report any deficiencies to the Master. It would appear that crew was missing to launch the LSA as three lifeboats and 60 life rafts were not launched. The matter is not investigated.
According to the report (p 67): "- it was therefore too dark outside; So another reason for the accidental contact is that it was too dark outside to see land, etc. It sounds strange. Wasn't weather good with a Moon shining? The report doesn't say! What is the purpose of saluting an island, if the island cannot be seen in the dark? The report informs about what actions should be taken in the event of an accidental contact (pp 70+): "1. Second Master or the Officer on duty verifies the damage; The above is evidently correct and was apparently done (the investigators have not really checked it) but it takes certain time to, e.g. verify all watertight compartments/tanks on a big ship by sounding and until it is done you cannot raise alarms and abandon ships. And you wonder if the crew had ever trained it. To suggest (p 72) that "The general emergency alarm on board was given at 22.33.26 hrs, with great delay", is unfair, as the accidental contact occurred at 21.45 hrs and 10 items above take at least 45 minutes to carry out. It seems the General Alarm was given according schedule, i.e. after assessment and evaluation of the findings. The report states (pp 74-75): "Recruiting the personnel through the external manning agencies – often situated in countries that have dubious or recent seamanship tradition – sets the problem for the Flag Administration of controlling the effective good quality of the recruited personnel." So it would appear that the ship owner supplies crew with dubious seamanship and language skills. What could the Master do about it? Provide training aboard? And why does the Italian Maritime administration permit incompetent non-Italians to work on Italian ships? Aha - foreign registry = Flag of Convenience. The report states (p 78): "a. About the lifeboats, the Muster List establishes the assignment of two persons for each lifeboat, as provided for the Solas regulation; according to the law for 52 necessary persons (taking into account that the lifeboats are 26), 34 of them are deck officers or certified seafarers, while 18 of them resulted without the MAMS certification, or their certification had expired because issued more than 5 years before thus considered not valid. It is the reason why only six life rafts were launched and why three port side lifeboats with capacity >400 persons were not launched at all leaving 100's of passengers behind on the vessel out of which 32 drowned. The report states (p 85): "It should be noted that 1 270 (those embarked in Savona) out of 3 206 passengers attended to the “muster of passengers”, while the remaining ones received by video the safety instructions (Annex 52 which includes also the passenger list)." It must be assumed that all persons aboard + the crew attended the Muster after leaving Savona (not just the newcomers) ... and it would be interesting to know the details of crew participation. But there are no details. The report states (p 87): "Moreover it must be noted that, according to the rule established in the article 303 of the Codice della Navigazione, “the Master cannot order the abandon ship in distress, if he does not carry out, without success, all the instrument suggested by the seamanship to save her, and without any consulting with the Deck Officers or, if they are not on the scene, the two best seafarers of the crew. It is clear that the Master gave the Abandon ship order after carrying out the checks about saving the ship (that evidently takes time). The suggestion that the Master must abandon the ship as the last person on board is not logical at all. However, in this case, while evacuation was done, the ship unexpectedly capsized and many persons, incl. the Master, was slipping into the sea. Thus the Master never willingly abandoned the ship.
The report has a section (p 91) about 4.7 Second grounding, flooding and stability phases. Evidently there was no first grounding or any collision but only one contact (lasting maybe 10 seconds) and the vessel later, for at least two hours, floated upright and stable in spite of up-flooding of four hull compartments, lack of power and black-out. And then the ship drifted and touched the shore and anchored. It was not a grounding. Actually the floating ship or rather its bilge touched an outreach of one coral reef aft and another outreach of a coral reef forward with ~150 meters deep water in between. To suggest that the ship was aground is incorrect. And then the ship capsized 90° starboard at 00.34 hrs and landed on the two outreaches of coral reef damaging the deck house. Then the hull was down-flooded and the ship sank on the sharp rocks and slid away from shore. In the process the starboard hull was ripped open forward and aft. The ship probably came to rest in the sunken position at around 02.00 hrs. At that time still ~300 persons were on the dry, port top side trying to get off. The report does not really describe these events.
The report states (p 92): "In few words, we confirm that there is no evidence about Master intentions to approach the shore; rather than we realized his opposite will to keep her floating, as he meant when declared to the Prosecutor that he never would unload 4.000 persons till he was not so quite sure that the ship would have sunk." You wonder what the incident investigators means with such nonsense in the ANALYSIS section of an incident investigation report. It seems the Master has later told the Prosecutor (in the criminal case) that before order abandoning ship, he must assess the situation as per the emergency plan. The report states (p 96) about the breach or structural damages: "The hole on the left side upon impact, it is continuous for about 60 meters (about frames 52 to 124) located too far above the deck of the Double Bottom (so well over two meters from keel line)." This statement is wrong and due to the fact that the investigators never inspected the wreck. My photo below of the damage indicates that the deformed and ripped open plate was only 43.5 meters long between frame #112 and frame #52 affecting hull compartments #4, 5, 6 and 7. The fractured part is only 36.5 meters long (starting at fr. #100), while 7.0 meters of hull plate, frs. #112-100, is only deformed but not ripped apart. Early information also suggests that only four hull compartments were up-flooded at the contact incident and that the ship was stable with sufficient buoyancy enabling mustering and abandoning ship. Later a fifth compartment (no. 3 or no. 8) was slowly, progressively flooded (a new incident!) through an open, illegal watertight door (e.g. no. 10 and or 6) reducing stability (GZ) ... and the ship capsized at 00.34 hrs. Damage stability calculations show that vessel will neither sink nor capsize due to up-flooding of four compartments above double bottom. Ergo - open watertight doors caused progressive flooding of intact compartments, loss of stability and capsize.
Photo Anders Björkman The report states (pp 101-102) completely other data about the breach: "According to the photogrammetric investigations (sic) carried out and, considering that in the area interested by the damage the frame interval is equal to 725 mm, we can deduct that the deformed (sic) part extends in length from 413 mm forward of frame no. 124 until 330 mm aft of frame no. 52, for a total length of 52,943 m. ... So only four compartments could be up-flooded due to the breach and that would not cause capsize. We know the ship was stable and up right one hour after contact. And the ripped open part of the side plate damage was only 36.5 meters with a deformed 7 meters section (no leakages) of shell plates ahead. (The damage can easily be inspected in dry-dock at Genoa - April 2017) Section 4.7.3 of the report (pp105+) describes the 25 watertight doors on Costa Concordia. All the doors were evidently incorrectly fitted as SOLAS does not permit them but the investigators do not understand this simple fact. It is furthermore suggested that they were all closed at 21.45 hrs, when the contact occurred, while VDR data shows that doors open/close before the incident. No VDR data of the door position between 22.00 and 00.30 hrs exists. It would appear that progressive flooding of an intact, fifth compartment through an open watertight door produced final loss of stability, capsize and killing people. Section 4.7.9 of the report (pp116+) describes a flooding simulation on the time domain carried out by technical bureau Safety at Sea (Glasgow). That company, Safety at Sea (Glasgow), is infamous for its 2008 falsified flooding/sinking simulation of M/S Estonia 1994 (https://heiwaco.tripod.com/vassalos.htm and https://heiwaco.tripod.com/strathclyde.htm). It is sad that more reputable companies are not used. It is suggested that (p 119) that: "Main (sic) WT door into PEM room is opened and water floods into Refrigerator Comp. room due to water level difference. Vertical escape trunk access door starts to submerge stopping crew member from opening door and escaping from Refrigerator Comp. room via vertical escape." So it is suggested that open watertight doors/progressive flooding of intact compartments are required to produce the final capsize killing people. The simulation apparently shows that the Costa Concordia survived the up-flooding of four hull compartments due to the accidental contact at 21.45 hrs with positive buoyancy/stability and that capsize/loss of stability ending at 00.34 hrs the next day was in fact due to progressive flooding through open, illegal watertight doors. Section 4.7.10 of the report (pp125+) confirms that vessel is stable with 3, 4 and even 5 up-flooded compartments. Loss of stability, i.e. GZ<0, apparently only takes place when five compartments are flooded and it is likely that it happened due to open watertight doors.
Part 5
CONCLUSIONS should consolidate the
established contributing factors and missing or
inadequate defences (material, functional, symbolic
or procedural) for which safety actions should be
developed to prevent marine casualties. The report states (p 152): "It is worth to summarize that the human element is 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." Evidently faulty navigation/charts or maybe a defective steering gear (not a human element) produced the first phase (?) accidental contact but it didn't kill anybody. To blame the Master for the missing charts, crew not understanding the working language aboard and/or an accidental contact is wrong. It is clear from above that many other incompetent persons recruited by the ship owner aboard and ashore were involved producing the disaster. Some passengers evidently got scared when the ship stopped and there was black-out but that is expected. More correct is to blame, if any, the responsible party - the ship owner, that should provide the charts and good seamen and ensure that the ship is seaworthy! But it is not the purpose of this investigation. The report is very vague concerning what caused the second phase (?) or incident - capsize killing people. It is a scandal that the Italian investigators do not know that SOLAS does not permit watertight doors in passenger ships except under very strict conditions/procedures, HAZOP, FSA and written instructions. A ship like Costa Concordia (and sisters) with 25 watertight doors was unsafe and unseaworthy all the time. And approved by the Italian Maritime Authority. It appears the accident investigators are protecting people and blame innocent people in the report when no blame at all should be apportioned in a report at this stage. Instead we are told the following nonsense (p 160) - the sentence contains 110 words: It is evident that the Master of the Concordia:- not promptly declaring the general emergency, despite the premises occurred; thus seriously delaying the gathering of the passengers and crew in the Muster Stations; Evidently "general emergency" was declared 22.33 hrs as soon as the situation due to the contact 21.45 hrs was clear. No Muster List was 'activated' as there were no muster stations, the passengers didn't know how to muster and abandon ship - most had not even seen the video - and crew was not trained to do a muster. The Master apparently abandoned the ship, when it capsized and could then not assist the >300 persons left aboard as all lifeboats and life rafts were not used due to lack of skilled crew. And this nonsense (p 161): It is likewise evident - also because we have no elements to say the opposite - that the casualty and the related failure in terms of emergency handling was characterized by the lack of alertness. Evidently people were killed as all LSA were not used. The crew to launch the lifesaving appliances, LSA, was either missing or abandoned ship earlier not giving a damn about their tasks. The ship was not seaworthy. And the report fails to establish this fact!
Part 6 SAFETY
RECOMMENDATIONS shall contain safety
recommendations derived from the analysis and
conclusions and related to particular subject
areas, such as legislation, design, procedures,
inspection, management, health and safety at work,
training, repair work, maintenance, shore
assistance and emergency response. The safety
recommendations are addressed to those that are
best placed to implement them, such as ship owners,
managers, recognised organisations, maritime
authorities, vessel traffic services, emergency
bodies, international maritime organisations and
European institutions, with the aim of preventing
marine casualties. This part also includes any
interim safety recommendations that may have been
made or any safety actions taken during the course
of the safety investigation. The Italian report unfortunately does not recommend that SOLAS must be followed and that watertight doors shall not be fitted on passenger ships. The investigators have been informed by Heiwa Co about the SOLAS requirements and that Costa Concordia did not comply with them. The investigators have then ignored the information. The suggestion (p168) that "The immediate flooding of five (sic) watertight compartments" took place at 21.45 hrs on January 13 due to a contact is wrong, because then the ship would have capsized/turned upside down already at 21.46 hrs and floated upside down and all 4 200+ persons aboard would have died. Imagine
that 4 200 persons would have died, if the
contact was a little bigger! The capsize sinking the ship and killing people 00.34 hrs the next day January 14 appears to be due to progressive flooding of an intact, fifth compartment via an open, illegal watertight door and that mustering and abandoning ship were not done properly. The ship appears to have been not seaworthy all the time. The non-European crew didn't know the working language (Italian) aboard and misunderstood orders given in English. The ship owner used cheap, incompetent non-Italian crew. The useless Muster system had never been tested by anybody. 25 watertight doors were not permitted by SOLAS. 60 life rafts and three lifeboats were not used at evacuation and abandon ship. And the Italian marine incident investigators suggest that all is the fault of the Master. But the Master just did his job as instructed by the ship owner. The main faults are defective systems and arrangements developed by the Company and approved by the Administration. The vessel was not seaworthy. And this probably applies to all other ships of the Costa and Carnival Companies. And nothing is done about it. Therefore there will be more incidents of all kind at sea. The report ends: "This report is not written for the purpose of litigation and will not be eligible for use in any judicial proceedings whose purpose, or one of whose purposes is to assign responsibility or accusation." The Italian incident investigation report is a joke and a scandal. The incompetent investigators should be put in jail.
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