concordia investigation

[ ]The following document describes the events of the Costa Concordia accident and the findings of our investigation team. (by: Ken Barrett, Corey Decker, Bonnie Hynes, Calvin Keats, James Chatman,)

2012

Accident Investigation Team ~ Loss of Life

KLWK

Overview Introduction

January 17th 2012, our team was given the task of investigating the causations regarding the loss of life during the Costa Concordia's accident, which occurred on January 13 of 2012. Since that time members of the investigation team recognized/researched the different systems of safety implemented within the protocols of the IMO (International Marine Organization), ICOH (International Commission of Occupational Health & Safety) as well as Carnival Cruise lines published Safety Policies and Procedures Manual. With all available information gathered (via Internet, Television, Magazines,) our team has uncovered numerous faults and can determine, thus far, that failures in Carnival Cruise lines Safety Program implementation & execution coupled with the Capitan Francesco Schettino's actions during the events, were the main causations regarding the loss of life aboard the vessel.

All collected available information has allowed our team to create and develop various fault tree diagrams. Under the guidance of the Chief investigator, our team also organized a strategic approach with regard to workload of team, team leader, and overall end result. Each member was given a specific task with regards to research and fact/fault finding. After due diligent examination of regulations and laws, and ongoing investigation by our team, we have identified the following Intelligence:

COSTA CONCORDIA

What: Cruise ship partially sinks

When: Date January 13, 2012

Unique circumstances: Captain took ship off course; ship severely listed, preventing deploying all lifeboats.

Where: Off the coast of Italy off island of Giglio

Facility: Costa Concordia

Task being performed: Vessel diverted onto unauthorized route

Impact to the Goals

Safety: 11 confirmed deaths (24 passengers missing)*

Environmental: Potential for oil spill

Customer Service: Evacuation of ship,

Accident Investigation Progress Report

Production: Loss of use of ship $85-$95 million, Decrease in bookings?

Property, Equip, Materials: Damage to ship ~$575 million

Labour, Time: Rescue & recovery efforts?

Total cost of this incident >$650 million

Action Item Cause

Remove fuel from ship 500,000 gallons of fuel onboardRestrict ship access to area Ship ran aground on rocksReview policy of when to hold lifeboat drills Lifeboat drill not yet heldRequire drill before leaving port Lifeboat drill required within 24 hours of departing

The Costa Concordia DisasterOn January 13, 2012, Costa Concordia hit a rock off the coast of Giglio, an island on Italy's Tuscan coast. Several hours later, the ship capsized under the cover of night. Before then, more than 4,000 passengers and crew were able to abandon ship, though by all accounts under chaotic circumstances. Thirty-two passengers and crew perished in the tragedy, with more than a dozen bodies unrecovered when the search was ended due to safety concerns. Costa Cruises has indicated that the ship's captain was in the wrong when he directed Concordia too close to Giglio on an unauthorized "sail-by."

The impact to the safety goal - dead and missing passengers and crew - were caused by the ship running aground on rocks and some issues with the evacuation process. The ship ran aground on rocks because it got too close to the island in a manually programmed unauthorized deviation of the ship's route, potentially to provide passengers with a better view. This deviation in route, sometimes called a "fly by", had been previously authorized by the company. No crewmembers questioned the change in route by the Captain, noting that onboard he is solely responsible for the ship. Although the ship contains alarms meant to warn the crew when the ship goes off-course, these alarms are deactivated when the ship is manually controlled.

There were some issues with the evacuation of the ship, though as the company notes "not due to the evacuation procedure, which was externally reviewed in November." Rather the issues were caused by the severe list of the ship (it was leaning almost completely to one side), which affects the ability to use the lifeboats. Additionally, some of the passengers (who had just come aboard) had not yet completed a lifeboat drill. The drill is required to be performed within 24 hours of boarding the ship and was scheduled for the morning after departure.

http://www.cruisecritic.com/reviews/review.cfm?ShipID=371&kw=52777&eagid=1366180749&eng=CCSEM&content=&gclid=CNjkntGjr64CFYgRNAodJEa3Sw


Analysis of the Costa ConcordiaThe Costa Concordia ran aground on January 13, 2012 because it was performing a “fly by” this

is when a cruise ship comes in close to shores/coasts of places that run along its plotted route for the cruise. The “fly bys” are performed for a number of reasons to name a few, entertainment for the passengers, publicity for the company, and many other reasons that we will not discuss in this analysis.

Not only was this “fly by” performed but, because of the evacuation plans the Costa Concordia had in place many people lost their lives because of the inefficient plan. Namely the biggest concern for the poor planning is the lifeboats.

The Costa Company boasts a very prestigious array of safety records (Cruises has been certified by RINA (Italian Shipping Register) with the B.E.S.T.4, an integrated system of voluntary certification of corporate compliance with the highest standards governing social accountability (SA 8000), environment (UNI EN ISO 14001), safety (OHSAS 18001) and quality (UNI EN ISO 9001))

The ship ran aground because of a number of reasons and this analysis will be giving an overview of a number of these, the “fly by”, the overriding of alarms, and the ineffective evacuation plan.

The “fly by” is not an uncommon practice of any cruise ship, whether it be an authorized or unauthorized event. The Costa Concordia had done “fly bys” on many occasions, this should have been like any other time but this time the Captain of the ship was going to go closer than ever before because him and the other cruise ship captains would have a competition to see who could get the closest to the shores/coasts.

The “fly by” usually happens with no problems but this time the Captain of the Costa Concordia went closer than anyone had ever done before (230 meters), in order to go this close the Captain had to take manual control of the ship and shutdown nearly all alarms systems so that it would not alert the passengers, since this was a regular concurrence the crew did not question anything. Once they are started the “fly by” everything was going well until the left of the ship struck a rock(which the Captain claimed was not on his navigational map) tearing a hole in the ship’s hull (160 ft gash) this caused a massive jut in the ships movement which was noticed by everyone on board.

The Captain then turned the ship around to bring the ship closer to shore in attempt to not have it sink out in the ocean, all the while he had the attendants tell everyone to go back to their cabins and not to worry. Mean while the ship had lost power and was slowly turning into an emergency situation but the Captain did nothing to prepare or alert the passengers.

Since no one was informed until the ship had come to rest on a sand bar and began to list to right (opposite of the tear in the hull) did he tell everyone that it was now an emergency situation and everyone needed to start evacuating. Now that the Ship was listing it was making using the emergency boats nearly impossible either because the boat had sank to the point on the left were no one could get inside of them or because on the left side of the ship the boats listing had made it impossible to launch the boats because they would catch on the lower railing of the ship’s lower levels.


Since we looked at the “engineering” side of the evacuation we will now look at the emergency preparedness of the Ship’s short comings.

The ship is supposed to do an emergency drill every twenty-four hours (24hrs) after picking up new passengers. Since they had picked up passengers in the last port they did not want to do the emergency drill until the next day, so the new passengers were completely oblivious to the emergency plan. The emergency plan was not translated into all languages of the passengers, and they were no employees would could speak all the languages of the passengers so many passengers during the evacuation had no idea what to do because they could not understand the instructions they were being given which lend to chaos.

There have been bodies found at muster stations on the boat which suggest that some of the passengers were well informed to go in case of an emergency but were not informed enough about the ships condition, if they had of been more informed then they would not of went to a dangerous muster station.

The Costa Company has many safety awards and program that they have in place (Costa Cruises has been certified by RINA (Italian Shipping Register) with the B.E.S.T.4, an integrated system of voluntary certification of corporate compliance with the highest standards governing social accountability (SA 8000), environment (UNI EN ISO 14001), safety (OHSAS 18001) and quality (UNI EN ISO 9001)). With these safety awards, systems, and programs in place the emergency should not of even happen, and even if it did happen the emergency plan should have been more encompassing so that no one lost their lives.

Even with this myriad of safety items the company has not taken any ownership of the accident, and now are playing the “blame” game until someone can take the fall for the entire event.

To conclude with this analysis we can say that the Captain was incorrect in not preparing everyone of the worst possible outcome when he had the chance and because of that many people lost their lives, if they had of been prepared and ready to go just in case everyone could have been saved because there were more than enough life boats to hold everyone on board. Also since they was not an effective emergency plan in place many people were frightened, confused, and in a state of panic on what they should do in this type of emergency.


(4:20 p.m. EST) -- A "salute" -- or "sail-by" as it's also known -- loosely refers to taking a cruise ship closer to shore to give passengers and/or land-based onlookers a thrilling view. But since the Costa Concordia disaster, (which put sail-bys in the spotlight for all the wrong reasons,) cruisers may be wondering how often lines participate in the practice, just for the sake of scenery. Ex-Costa captain Francesco Schettino claimed in court that his bosses ordered him to "salute" the Italian island of Giglio -- an accusation the line has vehemently denied. Schettino told magistrates that his Costa superiors had insisted on the move, which took Concordia within 150 meters of Giglio, to please passengers and attract publicity, reported Reuters. And it may not have been an

isolated incident: Schettino conducted similar sail-bys at the island of Capri and the Sorrento coast near Naples, as well as previously at Giglio, because Costa thought "it was a good way to promote its cruises," said the U.K.'s Guardian. Costa's top executive, Pier Luigi Foschi, has asserted that Schettino's diversion, which led to the sinking of the ship, was "unauthorized, unapproved and unknown to Costa."

Is it a common practice? Cruise Critic reached out to a number of popular operators to ask if they had official sail-by policies. All but two declined to comment, referring us to the Cruise Lines International Association, the industry's trade organization. Those that responded said the practice was extremely rare or non-existent.For its part, Costa has admitted to at least one previous salute of Giglio. On the Monday after the disaster, Foschi revealed that a pre-authorized sail-by in August was timed to coincide with the island's patron saint day. The Costa chief said that route was planned with the local maritime authority. Last week, Carnival Corporation, the parent company of Costa and nine other cruise lines, announced that it would be auditing and reviewing safety and emergency response procedures across all of its cruise lines. When asked if the review would include examining sail-bys, a spokesman for Carnival would not comment. by Chris Gray Faust, Cruise Critic Contributor

http://www.cruisecritic.com/news/news.cfm?ID=4727

As of 02/10/2012, and after a review of effective safety measures prompted by the grounding of the Costa Concordia, cruise passengers will now be obligated to attend a pre-departure safety drill before leaving the port. The industry’s governing bodies including the Cruise Lines International Association, the European Cruise Council and the Passenger Shipping Association announced the new policy. (Maritime Executive)

http://blog.firestorm.com/ Seventeen bodies have been recovered from the wreck, and 15 people are still missing and presumed dead, including two Americans, retirees Gerald and Barbara Heil of Minnesota, and a 5-year-old girl. The accident occurred on the evening of Friday the 13th after the ship's captain, Francesco Schettino, deviated from the approved route to "salute" the Tuscan island of Giglio. http://www.cruisecritic.com/news/news.cfm?ID=4710



http://blog.firestorm.com/

http://www.maritime-executive.com/article/cruise-industry-introduces-new-mandatory-pre-departure-safety-drills-following-concordia-incident

http://www.cruisecritic.com/news/%20http:/www.guardian.co.uk/world/2012/jan/22/costa-concordia-captain-salute-island-claim

http://www.reuters.com/article/2012/01/23/uk-italy-ship-idUSLNE80M00H20120123%20

http://www.cruisecritic.com/reviews/review.cfm?ShipID=371

CEO's Testimony

Costa's chief executive acknowledged publicly that Concordia's captain, Francesco Schettino, kept the company apprised of events in the hours after the ship struck a reef off the Italian island of Giglio.

According to the Wall Street Journal, Pier Luigi Foschi's testimony before the Italian Senate revealed that Schettino contacted Costa Crociere's head of marine operations, Roberto Ferrarini, at least six times during the 73-minute gap between the ship's collision on the evening of Friday, January 13, and the sounding of its evacuation alarm. Foschi's testimony was based on a memorandum prepared by Ferrarini detailing conversations in which Schettino explained that water was entering the hull, and causing the ship to list.

"At 9:57 [p.m. local time], Schettino said he had a huge problem onboard, that a blackout was in course, that there wasn't any electrical current. He told Ferrarini that he hit a rock," Foschi said.

"In that first call, the commander said that only one compartment was flooded," he said. "In a second call, at 10:06, the captain reported the flooding of a second compartment but said the ship's ability to float 'wasn't compromised.'"

At 10:16, Ferrarini and the captain had a 10-minute discussion concerning "the size of the breach," Foschi said, and at 10:33, Schettino informed Ferrarini that the boat was listing and that he had contacted Italian authorities. At 10:35, he called back to say he planned to abandon ship.

The accounts apparently contradict Foschi's prior assertion that Captain Schettino gave the cruise line only vague warnings of an "unidentified" emergency at 10:06 p.m. http://www.cruisecritic.com/news/news.cfm?ID=4710

Ship's Course Under Investigation

Concordia began its ill-fated voyage in Civitavecchia (Rome) en route to Savona with 3206 passengers and roughly 1000 crewmembers onboard. About 8 p.m. Friday local time, several hours after departing, the ship hit a rock, listed and capsized.

Schettino has admitted to making a navigational error when he "ordered a turn too late" as the ship was passing close to the island.Still, questions remain why the ship was on that course in the first place. Foschi revealed that Schettino deviated from the official route taken by more than 100 Costa ships a year and took Concordia within 150 meters (about 488 feet) of Giglio, though black box data is needed to confirm the distance.

But according to transcripts of his hearing with investigators leaked to the Italian press, Schettino told prosecutors he had been instructed to perform the sail-by. Schettino told magistrates Costa had insisted on the move to please passengers and attract publicity, reported Reuters.



Italian newspaper Corriere della Sera reported that Schettino brought the ship close to shore so that the head waiter, Antonello Tievoli, could see his native Giglio up close. Tievoli was supposed to disembark the week prior and take some time off but had to cover for an ill co-worker. In an interview with the newspaper, Tievoli's father, who still lives on the island, said: “Antonello called me earlier to say the ship would be passing by the island around 9:30, and they would come and give us a whistle to say hello. It was something they often did."

In August 2010, a similar manoeuvre off Giglio's coast earned Schettino a letter of thanks from the island's mayor. Foschi said that particular sail-by, timed in conjunction with Giglio's patron saint day, was pre-authorized by Costa and local maritime authorities. Plus, the ship stayed at least 500 meters (1625 feet) from the coast, said Foschi.

But, citing Automatic Identification System tracking data, which cruise ships with gross tonnage of 300 or more are required to broadcast, shipping publication Lloyd's List reported that the August sail-by "took the vessel far closer to Giglio than the 500 meters claimed by [Foschi]" -- and even closer to Friday's "point of collision." --by John Deiner, Managing Editor, with Dan Askin, News Editor; Jamey Bergman, U.K. Web Content Producer; Carolyn Spencer Brown, Editor in Chief; Sue Bryant, Contributing Editor;

and Elissa Leibowitz Poma, Cruise Critic Contributor http://www.cruisecritic.com/news/news.cfm?ID=4710

Passenger vessels can experience large angles of heel for a number of reasons including: heavy weather; mechanical fault, such as steering gear failure; or human error, and the resulting heel angles can be unpredictable. Regardless of the cause of the large angles of heel, cruise vessels should be able to withstand such incidents without endangering passengers through unsecured and insufficiently secured furnishings and equipment breaking loose.

2009/139 Cruise Lines International Association and the Passenger Shipping Association are recommended to:• Use the Princess Cruises’ standard for securing furnishings and equipment in passenger vessels (once completed) as a basis for developing a guide on industry best practice.http://www.maib.gov.uk/cms_resources.cfm?file=/Pacific_Sun_Report.pdf

The STCW Convention focuses on training standards and working procedures for seafarers, including officers and captains. It includes specific training requirements for crew on passenger ships, such as training in crowd management, for use in emergency evacuation. http://www.europeancruisecouncil.com/content/Cruise%20ship

%20safety%20%20An%20overview%20of%20the%20international%20and%20European%20regulatory%20framework%20.pdf

Accidents happen. They are a fact of life. Planes crash, bridges collapse, trains collide not to mention the car accidents. But here is one accident that should not have happened. This one was not because of machinery failure or navigational error or weather or act of god or any of that. It was because of stupidity. It was about a man's ego and narcissism interfering with his rational thinking making him reckless and dangerous.The cruise industry is not a transportation industry. It is a hospitality and entertainment industry. It is


http://www.europeancruisecouncil.com/content/Cruise%20ship%20safety%20%20An%20overview%20of%20the%20international%20and%20European%20regulatory%20framework%20.pdf

http://www.europeancruisecouncil.com/content/Cruise%20ship%20safety%20%20An%20overview%20of%20the%20international%20and%20European%20regulatory%20framework%20.pdf

http://www.maib.gov.uk/cms_resources.cfm?file=/Pacific_Sun_Report.pdf


"show biz". So though it is governed by mostly the same rules and regulations, things are often done differently. For example:

An oil tanker or cargo ship (regardless of its size) will never deliberately navigate so close to the shore.

A berth to berth passage plan on a tanker would not have allowed a casual deviation towards Isola Del Giglio.

Most tanker operators have a zero tolerance policy on board. Most cruise ships don't.

Very rarely will a tanker master allow unauthorized personnel on the bridge especially when the vessel is in a situation that demands great concentration. (I refer to the presence of the Moldovan lady on the bridge when the Concordia hit the rocks) http://www.safety4sea.com/analysis/72/110/costa-

concordia-accident:-a-fine-balance

Human ErrorHuman errors features as the main cause of most marine accidents and very often include those made by people divorced in time and distance from the actual event. Although no vessel can ever expect to be risk free from accidents, human errors tend to escalate if insufficient care is taking with how the crew is selected, maintained, motivated, treated and trained on-board. A thorough accident investigation carried out by a totally independent body {such as our own team} without any vested interest other than preventing something similar happening again, is more likely to ensure effective corrective action is taken and that the correct lessons are learned.

Life boats and Rescue stations Chutes or slides are now available for passengers to enter lifeboats already in the water, either directly into the lifeboat, or by means of a transfer platform. This design of the giant super-ship does not permit old-fashioned muster lifeboat drills, familiar to film-goers of a certain age, in which passengers were sent to boat stations shortly after a voyage began. Today, such drills are often merely simulations, in which passengers are shown a video or other form of demonstration. The logistical problems of evacuating a giant cruise-ship, carrying thousands of passengers and crew, are in urgent need of reassessment.

Among the unresolved or unpredictable variables is what happens if a significant number of lifeboats are submerged when a passenger-ship develops a rapid and extreme list. The question is not simply whether there are enough lifeboats or rafts, but whether passengers will have a reasonable amount of time to gain safe access to them. If a list develops quickly, or if weather is bad, the ship's design must permit every possible means to safely evacuate passengers and crew. A well-trained crew, specially trained to handle the evacuation of a large number of passengers and staff, is indispensable.http://www.safety4sea.com/analysis/25/108/costa-concordia-lessons-

Costa Concordia - in the context of workplace and public safety, interpret the elements. This is a massive failure in duty of care - to passengers, to workers on the ship - and to the ship's captain, placed in a job


http://www.safety4sea.com/analysis/72/110/costa-concordia-accident:-a-fine-balance

http://www.safety4sea.com/analysis/72/110/costa-concordia-accident:-a-fine-balance

for which he seems to have been ultimately unfitted. The big question is not 'what did the captain do, or not do?' but rather how in an age of extraordinary, magical, technology could the ship sail blindly into danger? What did the ship's owners Costa Cruises do, or not do, that allowed no over-ride of the decision to go too close to shore?

If furnishings and fittings had been sufficiently secured, so as to resist moving when the ship listed, the number of injuries would have been greatly reduced. Review the risk of injury from moving furnishings and objects, and develop suitable means of securing such items for heavy weather; develop a standard for securing furnishings and equipment in public spaces. Safety was compromised by poor communication from the crew, poor communications between the captain and the crew, and safety systems that are not substantial for this scenario with regards to the ship listing so sharply. In our view the captain had ample time to evacuate the passengers of the ship safely, without casualties. The parent company should never allow such dangerous manoeuvres. Safety training should occur before leaving port and cleared by authorities.

The Mystery of the Muster Drill: Cruise Ship Safety Laws Explained

(12:08 p.m. EST) -- Anyone who has ever cruised is familiar with the muster drill. Vacation fun is put on hold as the powers-that-be close the bars and order passengers to gather at an assigned meeting place for a lesson on how to don a life jacket and what to do in case of an emergency.

While many people listen attentively, every muster has a few of these types: The guy swilling a beer and laughing with his buddies, even though passengers have been told no drinking is allowed during the drill. The couple who hid in their cabin, thinking they've pulled one over on the authorities; the mom and her kids who stood in the back of the lounge during the presentation and sneaked out after a few minutes.

Even some of the most flagrant violators must be rethinking that behaviour in light of the Costa Concordia disaster. But inattention at the muster drill played no part in this tragedy. The drill had not yet been held for the 696 passengers who boarded in Rome, even though the ship was some three hours out of port and passengers were eating dinner when the accident occurred. Yet the ship appears to have been in compliance with muster drill requirements.

So what exactly must cruise ships do to ensure that passengers are educated about emergency evacuation procedures? Cruise Critic examined the rules and regulations, and interviewed representatives of governing agencies and the major cruise lines, to figure out the nitty-gritty on these drills.

All cruise lines have to follow regulations called Safety of Life at Sea (SOLAS), which were adopted following the sinking of the Titanic and are administered by the United Nation's International Maritime Organization (IMO). The U.S. Coast Guard also gets involved by making sure those regulations are followed by passenger ships that stop in the United States.

The SOLAS regulations pertaining to muster drills are fairly short and straightforward. They require that




the drill take place within 24 hours of embarkation. The regulations differentiate between a muster and a "safety briefing." According to SOLAS rules, whenever new passengers embark, a safety briefing must be held "immediately before sailing, or immediately after sailing," consisting of at least a PA announcement. This may be supplemented with other info -- by written materials contained within each cabin, for instance. Regulations require that the safety briefing provides "clear instructions" that "detail the actions each person on board should follow in the event of an emergency." But a muster, where passengers are physically assembled, is required only within 24 hours of sailing. (In Concordia's case, the muster drill was scheduled to take place after additional passengers boarded on Day 2 in Savona, Italy, which would have been within the required 24-hour window.)

As for life jackets, the rules don't specifically say that passengers must don them during the drills -- but they must be shown how to put them on.

In recent years, lines with bigger ships, including Royal Caribbean and Carnival, have concluded that moving upward of 5,000 passengers, outfitted in bulky life jackets, to their muster stations had become unmanageable. These lines have instituted a new version of the muster drill. According to Bud Darr, director of environmental and health programs for the Cruise Line International Association (CLIA), a membership organization that represents the major cruise lines, passengers now assemble in large public rooms, instead of on the open decks, where they await further instructions.

On some ships, including Royal Caribbean's Oasis of the Seas and Allure of the Seas, life jackets are kept at the muster stations rather than in individual cabins; ship safety officials made the switch for a couple reasons. One was that in a real emergency, forcing thousands of passengers back to their cabins to grab their life vests would work against an evacuation. Another had to do with dangerous dangling belts. "'Slips, trips and falls' during the drills was one of the most cited reasons cruise lines gave us for the change," said Brad Schoenwald, Senior Marine Inspector for the U.S. Coast Guard's Cruise Ship National Center of Expertise. "Passengers would slip on a belt strap on the way down the stairs, and you'd potentially have an injury."

As to when the drills are held, Darr said the norm, at least in most major lines that cater to American passengers, is to hold the muster drill and safety briefing simultaneously before the ship embarks. This way, the lines can cover both requirements at one time. But, again, maritime regulations require only that a safety briefing be held "immediately before sailing, or immediately after sailing," and that the muster shall be held within 24 hours. So, some cruise ships, such as Costa Concordia, that stop at multiple ports to pick up passengers, do not hold a muster until some passengers have already been onboard overnight.

"The important thing is that each line has standard methods and procedures and a well-trained crew," Darr said.

To that end, the Carnival Corporation -- parent company of Costa, as well as nine other cruise lines -- announced that it will conduct "a comprehensive audit and review of all safety and emergency response


procedures across all of the company's cruise lines." Captain James Hunn, a retired U.S. Navy Captain and Carnival's senior vice president of Maritime Policy & Compliance, will lead the effort, working with health and safety executives from the Carnival Corporation cruise lines and outside experts. The team, according to the company statement, "will review all safety and emergency response policies and procedures, officer and crew training and evaluation, bridge management and company-wide response and support efforts." The goal is to identify the best practices to put in place to make sure that a Concordia-like incident does not happen again.

In addition, the Cruise Lines International Association (CLIA) will also be conducting an industry-wide operational safety review, which will include internal reviews by the organization's 26 cruise line members, consultation with experts and regulatory agencies, and the development and sharing of best practices.

We reached out to various cruise lines to find out how they interpret safety regulations and handle mustering, but most weren't that forthcoming about the details. Several, including Crystal Cruises, Disney Cruise Line, Norwegian Cruise Line, Oceania Cruises and Regent Seven Seas Cruises, would not comment, referring all questions to CLIA. At press time, Costa has not responded to our requests for information. However, several others did respond, and here is the official word, albeit often quite generic, from each of the other major lines:

Azamara Club Cruises, Royal Caribbean International and Celebrity Cruises (all part of the Royal Caribbean Cruises Ltd. brand): All passengers and crew must complete an abandon ship drill "at the beginning of each voyage." Muster drills are conducted without passengers donning life jackets. On Royal Caribbean's largest ships, Oasis and Allure of the Seas, life jackets are held at muster stations to be distributed by crewmembers in case of emergency, rather than in cabins; on other ships, life jackets are also kept in cabins and in emergencies, crew will make sure life jackets are distributed at the muster stations. To ensure that passengers are aware of their specific muster location, each cabin key is individually imprinted with that location. The location is also noted on the back of each cabin door. Officers and crewmembers additionally conduct weekly, monthly and annual drills to train and prepare in case of emergencies. All ships have enough lifesaving craft to accommodate every person onboard, with additional reserve capacity.

Carnival Cruise Lines: "Normal procedure" is to conduct the safety drill prior to departure. The safety briefing is held at dedicated muster stations where crewmembers demonstrate how to wear life jackets. Passengers are not required to wear life jackets during muster; life jackets are kept in the cabins. The briefing is conducted in English, but may also be conducted in other languages if there are a significant number of passengers from a particular country or region. During the drill, every cabin is checked by cabin stewards and a red card is placed in each key slot showing that no guests are present inside. Written materials, available in different languages, are also provided. A safety video, which is played nonstop during the drill, is available via in-cabin TV; it outlines evacuation routes, muster station locations, assistance for physically challenged guests, life jacket instructions, etc. Lifeboats are tested during regularly scheduled drills to make sure they are in proper working order. A full-scale life boat


exercise, during which lifeboats are launched and manoeuvred in the water by assigned crew, is conducted each month, exceeding the quarterly regulatory requirement.

Cunard Line: The line adheres to the SOLAS requirement that a safety drill be held within 24 hours, and "in many instances" the drill is conducted prior to sailing. Each passenger is assigned a specific area to muster and the use of life jackets is demonstrated and practiced during the drill, which also instructs passengers regarding what to do and where to go in case of an emergency. Crew proficiencies are verified during drills and exercises, including periodic exercises with the U.S. Coast Guard.

Holland America Line: The line follows international maritime law by requiring a mandatory lifeboat drill for all passengers within 24 hours of departure. "In many instances," the drill is conducted prior to sailing.

MSC Cruises: Upon embarkation in the main ports, passengers participate in a one-hour muster drill conducted in six official languages, and any other language spoken by a guest. Passengers take their life jackets from their staterooms and go to their assigned muster station. The drill involves the entire crew and simulates the evacuation process. Staterooms are checked during the drill. In secondary ports, before the ship's departure, a detailed safety briefing is held for all newly embarked passengers. The briefing is normally held in a dedicated area, usually the theatre or a muster station. Each passenger's muster station is printed on his/her stateroom key. Written safety materials include maps of the muster stations displayed in all public areas, a safety page within the cabin's booklet that is left open and is pointed out by the housekeeper, and maps on the back of each stateroom door with instructions in six languages. A safety video in English is broadcast 24/7 on the stateroom television system on Channel 1. Children ages 12 and younger are given a bracelet at embarkation to wear with their muster station printed on it.

Princess Cruises: Muster drills are held before departure "whenever possible." Passengers are sent to their respective muster stations, which may be in a public room or near the lifeboat embarkation deck. Passengers wear life jackets during the drill. Passengers are required to attend, but a safety video covering evacuation procedures is also played on the in-cabin television. If a large number of passengers speaking a language other than English are onboard, a separate drill is held in that language. Each stateroom has a map of the route to its muster station, and signs are also posted on the staircases.

Seabourn: The line follows international maritime law by requiring a mandatory lifeboat drill for all passengers within 24 hours of embarkation. "In many instances," the drills are conducted prior to departure. Passengers are instructed where to go and what to do in case of an emergency.

--by Carol Sottili, Cruise Critic Contributor


Company Onus



Pre-departure musters, training and familiarization must be mandatory. At the moment, these pre-departure programs outlined in company policies under the ISM program, which is to say a company defines when and where they will conducts these passenger familiarization programs, and the company must follow its’ own policy or risk losing the Safety Management Certificate (SMC) needed for ship operations. Most cruise lines require this prior to a ship pulling away from the port, but in the Costa Concordia, this seems to not have been conducted, as Costa Crociere seems to verify that the procedure was such musters and drills must take place within 24 hours of ships departing from port. The ship is usually asked by the port authority prior to being issued “clearance” to depart port if all safety and security measures have been followed – however, what the port authority is really saying is “have you complied with YOUR specific ship safety and security procedures that YOU defined in YOUR ISM?” Port authorities need to create higher level accountability of ship captains for passenger safety and provide an actionable form which can be included in the ships pre-departure documents requiring a captain to affirmatively denote that such trainings have been conducted prior to departure.

These are the main quarrels facing this incident at this time. Our team is committed to keep researching the facts/faults as they arise and to be due diligent towards Occupational and Public Safety minded solutions as this case unfolds... there are other systemic and relevant causes in which we have not covered at this time due to either lack of credibility, evidence, and or lack of sound knowledge at this period in our investigation. The team remains focused in finding all "Just cause" and "Occupational Health & Safety violations" within the confines of due process.

Other substantial evidence exists within the hands of the Italian Coast Guard as well as the investigation team representation from the IMO and other legal authorities. With that in context, the team strives to uncover the true nature of this accident as well as recommendations to prevent such un-warranted occurrences from taking place in the future.

Tips/Recommendations:

TIP 1 – Visualize – Health and Safety Becomes a Habit - This “TIP” applies to each and every one of us. We take life for granted until something tragically happens. Our philosophy is not about living in a glass bubble. It is about taking responsibility of our health and wellbeing 24/7 while building a habit. Be aware of the consequences when there is horseplay, when we take short cuts or ignore procedures, when we are complacent or distracted.

TIP 2 – Leadership Commitment – The first step is a Health and Safety policy that is more than a piece of paper. It is your commitment as an owner or CEO. This includes providing systems, communication and correcting unsafe practices and conditions. It also includes “Leading by Example” and supporting your Joint Health and Safety Committee through training, providing time and listening to their concerns.

TIP 3 – Communication and Training – It is imperative that you have an orientation program in place, safety talks to continuously remind people, management staff that is willing to listen and act on concerns or ideas and continual training on safe operating procedures, protocols and expectations. It should be no surprise when someone is disciplined for unsafe behaviors such as horseplay or failing to


follow the rules. Include employees in the process seeking their buy in that following protocols is necessary so we can all enjoy life to the fullest.

Tip 4 - Implement systems including policies and procedures that are communicated and reinforced. Find the hook that will engage employees in owning health and safety.

TIP 5 – Accountability - It is important to hold people accountable for their actions at all levels. For success in this area, we need to ensure supervisory staff are not only aware of their legislative requirements, company policies and procedures but are competent in how they manage people.

TIP 6 – Remove the “Blame Game” and “Fear/Bully Factor” attitude – Before blaming, ask yourself if you failed to provide the training, equipment and safe work environment. Promote a culture of caring, listening, teamwork and respecting one another. Eliminate the fear/bully factor environment.

TIP 7 – Recognize, Assess and Control hazards. Conduct a hazard analysis on job functions determining risk factors and necessary controls. When unsafe conditions or practices are observed, take action. If you are looking at building trust, respect and buy in from employees, they need to know you are serious about eliminating potential hazards that could cause injury.

TIP 8 - Continuous Improvement Plan – Develop a plan where you are continually raising the bar with initiatives. This keeps you on track and eliminates complacency or reverting back to the way it was.

TIP 9 – Consequences - Communicate consequences when rules are not followed including your management and supervisory staff.

TIP 10 – Acknowledge Success – It is important to acknowledge a job well done on an ongoing basis, as part of a performance appraisal or through various incentive programs.

Provided within this document is an appendix of evidence to support our claims at such time. We are looking forward to providing you with a full clear and concise written report within the next few weeks.


System Safety

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Costa Concordia Cruise Ship, Italy

Key Data

Costa Concordia is a Concordia-Class cruise ship, owned and operated by the Carnival Corporation's subsidiary Costa Cruises. She was the first in the Concordia Class, sistering Costa Serena, Costa Pacific, Costa Favolosa, Costa Fascinosa and Carnival Splendor.

She was built at Fincantieri's Sestri Ponente shipyards in Genoa, Italy, at a cost of €450m ($570m) following an order placed on 19 January 2004.

She was launched at Sestri Ponente on 2 September 2005 and delivered to Costa Cruises on 30 June 2006. At the time of construction, she was the largest Italian cruise ship ever built.

The vessel has an overall length of 290.2m, a beam of 35.5m and a draught of 8.2m. The overall tonnage of the Concordia is 114,500 GT and she is capable of speeds around 21.5kt, powered by six Wärtsilä diesel engines.

Onboard amenities of Costa Cruises' Concordia

"Costa Concordia is a Concordia-Class cruise ship, owned and operated by the Carnival Corporation's subsidiary Costa Cruises."

Concordia had the capacity to host 3,700 passengers and 1100 crew in 1500 cabins, situated across 17 decks. She also has 505 private balconies, with 58 suites having private balconies.

The vessel boasts one of the world's largest at-sea exercise facilities, called the Samsara Spa. It is a two-level, 6,000m² fitness centre which comprises a gym, a thalassic-therapy pool, sauna, Turkish bath and solarium.

The ship has four swimming pools in total, five whirlpool baths, five spas and a poolside screen on the pool deck.

She has five onboard restaurants for passengers to choose from, with Club Concordia and Samsara available for reservation-only dining. Also on board are 13 bars, a three-level theatre, a casino, a Grand Prix motor racing simulator and a discotheque.


Concordia made her maiden voyage on 14 July 2006, and remained in service until 13 January 2012, when she ran aground off the coast of Italy.

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Accidents and incidents involving the Concordia-Class cruise ship

The Costa Concordia sustained damage to its bow when high winds hit Southern Italy on 23 November 2008.

"On 13 January 2012, Costa Concordia suffered much worse damage when it ran aground on rocks off Isola del Giglio, an Italian island in the Tyrrhenian Sea."

The cruise liner, which left Malta two days earlier, was rammed against its dock in the storm, which stopped several other vessels from continuing their journeys. No passengers were injured during the incident and the damage was repaired soon after.

On 13 January 2012, Costa Concordia suffered much worse damage when she ran aground on rocks off Isola del Giglio, an Italian island in the Tyrrhenian Sea. The ship began listing heavily towards the starboard side, killing six of the 4,229 people onboard. Two days after the disaster, 15 people were still unaccounted for.

Costa Crociere, the operator of the vessel, responded to the incident by saying the ship may have been sailing too close to the land before she hit the rocks. They added that Capt Francesco Schettino made errors of judgement that had serious consequences.

Capt Schettino was arrested on suspicion of multiple manslaughter charges on 15 January, but he denied any wrongdoing and blamed incorrect information on nautical charts for the accident, adding that rocks were not detected.

As of 16 January 2012, the ship was lying on her side just metres from the coast off of Isola del Giglio.


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On the same day, Reuters reported that the cruise ship is insured for $513 million by insurers including XL and RSA, with marine insurers providing cover for potential injury claims. Comments from various insurers, however, suggested the insurance loss to be up to $1 billion.

Costa Concordia ran aground on rocks off Isola del Giglio on 13 January 2012.

The vessel was built at Fincantieri's Sestri Ponente shipyards in Genoa, Italy.

Two days after the 2012 disaster near Giglio Island off the coast of Tuscany in the Tyrrhenian Sea, 15 people were still unaccounted for.


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