THE SINKING OF A SHIP

COSTA CONCORDIA REVISITED.

Captain Michael Lloyd, RD**, MNM, CMMar, FNI.

Kate Hopkins

COSTA CONCORDIA IN GENOA, 2010 « A commander should be able to hold his ship and everything on board of her in the hollow of hishand, as it were. But with the modern foolish trust in material, and with those floating hotels, this hasbecome impossible. A man may do his best, but he cannot succeed in a task which from greed, ormore likely from sheer stupidity, has been made too great for anybody’s strength». Joseph Conrad, “Some Reflections on the Loss of the Titanic” 1912 INDEX PAGEGlossary 5

Introduction 7

Ө

Introduction 7

Ship Particulars 10

Preliminary 11

The Company 11

The Charges 13

1st PHASE 15

Timeline 16

The Initiation 18

The Bridge Organisation 20

The Navigation 21

Course Alteration 25

Wheel Over 26

The 8 Second delay 28

Language Influence 28

2ND PHASE. THE DAMAGE 32

Time Line 33

The Damage 35

Watertight Doors 36

The Emergency Generator 38

3RD PHASE.THE ABANDONMENT 40

The Criteria of Abandonment 41

Alcohol 43

Lifejackets 43

The Mustering points 43

Stairways 44

Timeline 44

The Mental State of the Captain 46

Passenger Announcements 49 First Report 50 Rescue Services Response 50 General Emergency Alarm 52 Lifeboats 53 Life-rafts 55 Lifeboat/life-raft Capacity 55

The Abandonment Begins 56 Warm Clothing 57 Crew Training 57 4TH PHASE. CHAOS 59 Hypothermia 60 Lifejackets 61 Jumping from the ship 61 Shore services take over the abandonment 63 Witnesses statements 63 MRSC talking with Captain 69 The Shore rescue services 70 The last survivor 73 Search for the Dead 74 Resignation of the President of RINA 74Rescue Data 75 5TH PHASE. THE GIGLIO MAGISTRATES INQUIRY 76 Inquiry Transcript 77 The ISM Code 87 The decision of the Criminal Inquiry 90 6TH PHASE. COSTA CROCIERE PLEA BARGAIN 97 7TH PHASE. SAFETY REPORT CONCLUSIONS 100 8TH PHASE. THE TRIALS 122 Italian Criminal Law 123 The Preliminary Investigation 123 The Trial Phase 123 Appeals 123 Plea bargaining 124 The Trial 124 The Appeal 126 FINAL ANALYSIS 127 1st Phase. The Collision 128

Responsibilities 131 2nd Phase. The Damage 133 3rd Phase the Abandonment 134 4th Phase Chaos 136 Responsibility 137 Seaworthy and Safe 140 Epilogue 142 References 148

Glossary of abbreviations and acronyms

ARES-AutomatedsearchandrescueAIS–Automa5cTrackingSystemCarabinieri–ItalianNa5onalMilitaryPoliceCE-ChiefEngineerD/G-DieselGeneratorDCP–DamageControlPlanDOC-DocumentofComplianceDPA-DesignatedPersonAshoreECC-EuropeanCruiseCouncilECDIS-ElectronicComputerisedDisplay(Naviga5on)ECR–EngineControlRoomEDG-EmergencyDieselGenerator EEBD-EmergencyEscapeBreathingDeviceETA-Es5matedTimeofArrivalEU-EuropeanUnion FCC–FleetCrisisCoordinatorGdF-GuardiadeFinanzia.BranchoftheItalianPoliceForce.GRT-GrossRegisteredTons IB–Inves5ga5veBodyLSA–Life-SavingApplianceIMO–Interna5onalMari5meOrganiza5onISMCode–Interna5onalManagementCodefortheSafeOpera5onofShipsandforPollu5onPreven5onITCG–ItalianCoastGuardMAMS-MarineAssetManagementcer5fica5onMartecsystem–SoQwarethatmanagestheStabilitycontrolsforemergencyHullbreachandfireMLC–Mari5meLabourConven5onMRCC–Mari5meRescueCoordina5onCentreMRSC–Mari5meRescueSubCentreMSC–Mari5meSafetyCommiTeeNAPA-ShipstabilitysoQwareNGO-Non-Governmentalorganisa5onOSC–OnSceneCommanderOOW-OfficeroftheWatch

OOW-OfficeroftheWatchPAX-PassengersPSA-PassengerShipAssocia5onRINA-ItalianClassifica5onSociety RO-PAX–High-speedroll-on/roll-offferryRO-RO–Roll-on/roll-offferrySAR–Mari5meSearchandRescueSOLAS–Interna5onalConven5onfortheSafetyofLifeatSeaSMS–SafetyManagementSystemSTCW–Interna5onalConven5ononStandardsofTraining,Cer5fica5onandWatchkeepingforSeafarersUCG–CoastalGuardUnitUMS–UnaTendedmachineryspaces VDR-VoyageDataRecorderVHF-VeryHighFrequencyradio W/T-Water5ghtWTC–Water5ghtcompartmentCCTV-CloseCircuitTelevision Introduc)on ThiswasintendedtobeabriefaccountofthesinkingoftheCostaConcordia.IhadnopreconceivedopinionsexceptthatofthestupidityoftheMasterandsurprisethat,accordingtothecourts,nooneelsewasheldresponsible.Ididhowever,makeprotestinthefirstmonthsofcoverageaboutprejudgingtheMasterbasedonvariousoQenluridaccountsofac5onsandourna5onalconceptsofmoralbehavior.Onlyafewofusinthemarineindustrydidspeakoutandwewerecri5cizedforthisatthe5me.AsIworkedmywaythroughthevariousdocumentsandaccounts,IbegantorealisethattherewasfarmoretothiscasualtythatwhatIhadbeenledtobelievebytheofficialandmediareports.

Themoderncruiseship,ortobemorefactuallyaccurate‘hotelship,’isanewphenomenonontheseas.TheCompaniesthatownandoperatethemevenstatethattheyarenotintheshippingbusiness,theyareintheentertainmentindustry.Theirshipscon5nuetogrowinsizeandthecompaniesincorporatepower,consequentlytheirinfluenceinthemarineindustrygrowsinpropor5on.Thelegisla5veregula5onsofvariousgoverningins5tu5onshavebeenoverwhelmedbytherapiddevelopmentofthesizeandpassengercapacityoftheirshipsashavethemari5mebodiesoftheflagstatesthat,theore5cally,aresupposedtogoverntheirmari5meresponsibili5es.Theirfinancialpower,coupledwiththebackingoftheirsuppor5venon-GovernmentalAgencies(NGO’s)intheIMOandtheirfinancialinfluenceovertheirflagstatesisincreasingtheirimpactinallaspectsofmari5meendeavour. Thejoiningoftheentertainmentandmarineindustriesisanuneasyrela5onship,asoneisdevotedtopassengercomfortandpleasureasapriorityandtheotherhasthesafetyofthepassengersandshipastheirpriority. Eventhemanagementoftheshiphasrequiredchangewiththetradi5onalMasterandexecu5veofficerslosingareasofresponsibilityfortheoveralldaytodayrunningoftheshipinfavourofthehotelstaffandthusthelossofexecu5vecontrol.Thisisnotacri5cism,asthesizeofship,thehotelexper5seandstaff,nowrequiressuchconsidera5onsforthemoreefficientmanagement.However,itdoesraiseadichotomyastotheleadershipandchainofcommandintheeventofemergencies.FortheCaptainandhisseniorofficersthereisalsothedangerthattheyareenvelopedintheentertainmentrequirementsinterferingwiththeirsafetyresponsibili5esandaswesee,thenaviga5onandhandlingoftheshipwiththemarke5ngdepartmentsincreasedinfluenceovertheopera5onsDepartmentwithinthesecompanies. Italsocanaffecttherecruitmentandpromo5onoftheofficersas,iftheentertainmentopera5onshavethemajorvoiceinthecontrolofthecompany,itisobviousthatthoseamenabletothehotelsideonboardarepreferabletothosewhoseethemselvespurelyasseamen. ThecaseoftheCostaConcordiashouldserveasawarningtoallofusontheneedtoclarifythechainofcommandonsuchvesselsandtoplacetheprofessionalabilityofthoseinseniorposi5onsabovethatoftheirsocialaffability. Whilethisisintendedtobeatechnicalstudy,basedonthevariouslegisla5onandruleswhichgovernourindustry,itgraduallyalsobecamesomethingmore.Itbecameastory.Unfortunatelyforthedead,theinjuredandthetrauma5zed,atruestory.Itisastoryofships,theseaandpeople.Itisastoryofwhatiswrongwiththemarineindustry,especiallythelackofpropergovernancebytheveryins5tu5onsthatpurporttooverseethisvastinterna5onalindustryandthedisinterestofmarineorganisa5onsandgovernmentdepartmentsthatknowthetruthbutremainsilent. TheTitanicsankalmost100yearstothedayinsimilarcircumstances.ACaptainwhofailedtolisten,goingatspeedthroughaknownicefieldandwhobelievedthathisshipcouldnotsink.Butonthatoccasion,thediscipline,theshipboardorganisa5on,theprofessionalskillsandthestandardofmoralcourageofthedayandthoseinvolved,heldtheshipfrompanic,andallowedthemajorityofthewomenandchildrenbesavedinwhatlifeboatstheyhad.Eventhennotallwasperfect,manylifeboatsdepartedwithoutbeingfilled,andsomewithoutseamen.TheCaptaindiedand,throughtheskillsoftheCompanythatstoodbyhim,becameaheroratherthanthevillain,whichhesoeasilycouldhavebecome,andaTen5onwasdivertedawaytowardsthetragicheroismofmanyonboardtowardsanotherCaptainandshipthatwasclaimedtohaveignoredthedistresscalls,butofcourse,neverproved.OverathousanddiedwhentheTitanicsank.IfthewindandcurrenthadnottakentheCostaConcordiaintoshallowwatersandagroundwithinmetersoftheland,farmorewouldhavedied. FromtheTitanicsinkingcameaninterna5onalbodythencalledTheSafetyofLifeatSeaConven5on,nowevolvedintotheInterna5onalmari5meOrganisa5on(IMO),s5llresponsibleforsafetyatsea.In2006,thisorganisa5onbegan,despitetheprotestsofmany

responsibleforsafetyatsea.In2006,thisorganisa5onbegan,despitetheprotestsofmanyprofessionalmariners,toparrotthemediaoutputofthecruiseshipIndustrythat‘Theshipisalifeboat’themeonceagain,similartothatatthe5meoftheTitanic,oftheunsinkableship.TheCostaConcordiagroundingcame19monthsaQeramendmentstoexis5nginterna5onalpassengershipsafetyregula5onscameintoforce.

AdoptedbytheInterna5onalMari5meOrganiza5on,(IMO),theamendmentsintroducedinJuly2010weredesignedtoimprovedsurvivalrates,presen5ngashipas“itsownbestlifeboat”howevertherealreasonfortheintroduc5onofthisphrasewasnotthattheIMOnecessarilybelieveditbutiftheycouldhaveitadopted,itavoidedthenecessarycostlychangestothesafetyequipment,theconstruc5onandespecially,thewater5ghtintegrityissue.

Theamendmentstopassenger-shipregula5onsintheInterna5onalConven5onfortheSafetyofLifeatSeacameaboutaQerareviewofpassenger-shipsafetyini5atedin2000bytheIMO.ThechangesmainlyaffectshipsbuiltfromJuly12010onwards.CostaConcordia,builtin2006,wouldhavecompliedfullywithearlieramendments.

AQerthesinkingoftheCostaConcordia,theIMOhasnotusedtheabsurd‘theshipisalifeboat’phraseagain.However,theorganisa5onhasignoredtheurgentrequirementforinves5ga5onoftherealreasonsbehindthedisaster,especiallythefailureofthecourtstofollowandrecognisethattheshipwasundertheISMcode,possiblybecauseoftheorganisa5on’sassocia5onwiththefailures.Thismeansthat,onceagain,wearelosingtheopportunitytomaketheessen5alchangesthatarerequiredtoreducetheprobabilityofsucheventsfromoccurringagain. ShipPar)culars. Name: Costa ConcordiaFlag: ITALY

Flag: ITALYIMO number: 9320544Number of registration: Nr. 73 of the International Registers of the Port of GenoaShip Type: INTERNATIONAL PASSENGERIdentification: IBHDOwnership and management: COSTA CROCIERE SPAClass: RINADetails of construction: YEAR 2006 - FINCANTIERI BOATYARDS SPASet keel: (to be added)Length: 247.37 mtWidth: 35.5 mtHeight: 11.2 mtDraft: 14.18 mtTonnage: 114,147 t.Length in between pp.: 247.4 mtHull Material: SteelPassenger capacity: 3780Propulsion Type: Fixed pitch propellerMain engines: 2Electricity generation: Diesel ElectricPropellers: 2 fixed pitchThrusters: (aft 3 x 1720 KW - bow 3 x 1720 KW)Maximum speed: 21.5 kts

PRELIMINARY TheCompany InJune2005,theItaliannewsmedia“LiberoQuo5diano”reportedaboutanear-sinkingaccidentinvolvingthecruiseshipCostaFortuna.InJune2005,thevesselwasnaviga5ngalongItaly’swesterncoast,passingbyCapriisland.Duringthatvoyage,theshipcarried~3500people(passengersandcrew)aboard.

Accordingtothemediasource,thevesselperformeda“salute”-cruisingintotheshallowwaters.Un5ltheConcordiadisaster,thiswasanunofficialtradi5ononCostaships–toperformsail-bys–justtoentertaintheirpassengers.

Duringthatpar5cular“salute”,theFortunashipruptureditshullontherocksoffCapriandstartedtotakeonwater.Thecrewusedthewaterpumpsatmaxtokeeptheshipfromsinking.ThevesselwasabletomovetothenextcallportPalermoSicily,wheretheholeinthehullwasrepairedovernight.NeithertheCaptainorCompanyreportedthisaccidenttotheItalianmari5meauthori5es(includingItaly’sCoastGuard).TheonlythingthatCostaCrocierereportedonthatvoyagewasariseinthemainengine’stemperature.

ThisseriousaccidentcametolightduringCostaConcordia'ssinkinginves5ga5on,whenthePalermoPortauthori5esmen5onedareportbyoneontheship’sphotographerswhowasonboardwhenthecollisionhappened.Theinves5gatorsconcludedthattheincidentwasa

onboardwhenthecollisionhappened.Theinves5gatorsconcludedthattheincidentwasa“cri5cal”one,andonlythefavourableweatherpreventedaConcordia-likesinkingdisaster.

Whilethe CostaFortunawasmakingacloseapproachtotheislandofSorrento,therewasa“loudbang”aQerwhichthevesselrolledfromleQtorightaccordingtotheship’sphotographerRobertoCappello,59.Helaterwouldphotographdamagetotheship’skeelandabrokenpropellerblade,onlytohavethephotographsandfilesconfiscatedbyCosta.Costaapparentlylaterclaimedthattheshiphadstuckawhale.

Costa’sservicerecordishardlyunblemished.InOctoberof2010,therewasacollisionbetweentheCostaClassicaandacargovesselatthemouthoftheYangtzeRiver,leavinga60feetlonggashinthesideoftheship.Threepassengerswerehospitalizedbuttheretherewerenofatali5es.TheCostaClassicawasalsoinvolvedinacollisionwiththeMSCPoesiainJuneof2008.Therewerenoinjuries. InFebruaryof2010,threecrewmemberswerekilledandthreepassengersinjuredwhentheCostaEuropastruckapierinhighwindsintheEgyp5anportofSharmel-Sheikh.In2009,theCostaEuropa’s“JewelsoftheIndianOcean”cruisewasbesetbyarangeofmechanicalfailuresleadingtothecancella5onofseveralportcallsandanearmu5nybypassengers. AlthoughthreecrewmembersdiedwhentheCostaEuropastruckthepierinEgypt,thecasualtywasneversubmiTedtoIMO’sMarineCasual5esdatabase. TheCostaConcordiawasownedbyCostaCrociere,asubsidiaryofCarnivalCorpora5on&PLC.Whenlaunchedin2005,itwasItaly’slargestcruiseship,measuring951feet(290metres)longwithapassengercapacityof3,780;bycomparison,theTitanicwas882.5feet(269metres)longandcouldaccommodateupto2,435passengers.TheConcordiawasknownforitsluxuries.Itfeaturedfourswimmingpools,acasino,andreportedlythelargestspaonaship.InJuly2006thevesselundertookitsmaidenvoyage,aseven-daycruiseoftheMediterraneanSea,withstopsinItaly,France,andSpain.Thatbecameitsstandardroute. On January the12th/13th, 2012, theCostaConcordia,waswreckedonGiglio island in theMediterranean.Atthe5metherewere4229personsonboardthevessel;3206passengersand1023crew.

This resulted in the deaths of 32 persons, crew and passengers, very low for such anincident,howeverthiswasonlybecausetherewasnopowertotheengineorrudderandthattheshipdriQedbacktotheshallowsofftheIslandwhereshorebasesrescueservicescouldbeandwerespeedilyini5ated.Asaresultoftheinquiriesandtrials,oneman,CaptainFrancesco Schetno, was held to be criminally liable and sentenced to 16 years’imprisonment,adecisionthatwasupheldonappeal.]

CostaCrociereS.p.A.alsodoesbusinessusingthename"CostaCruises".CostaCruisesisjointlyownedbyadual-listedcompanycomprisingthetwoseparatecompaniesCarnivalCorpora5onandCarnivalplc.CarnivalCorpora5onannouncedon30January2012thatitsboardofdirectorswillengageoutsideconsultantsinvariousdisciplines,includingemergencyresponse,organisa5on,trainingandimplementa5on,toconductacomprehensivereviewoftheaccidentandthecompany'sprocedures.

CostaCruisesatfirstofferedtopayCaptainSchetno'slegalcostsbutdecidedlaterthattheywouldnotdoso.

Thepurposeofthispaper isnottoaTempttoexonerateCaptainSchetnofromhismanyerrorsofjudgementmadeonthatnight,buttoexaminetheotherfactorstotwoevents,thefirst, thegrounding,which isasafety issue,andsecond,thedeathsofthepassengersandcrew,whichwasregardedbytheItalianjus5cesystemasacriminalissue.Finally,toconsidertheinquiryandtheresultantcourtcases.

Thereport,onwhichthechargeswerebased,waspublishedonthe24thofMay2013,bytheMarineCasual5esinves5ga5vebody,undertheauspicesoftheItalianMinistryof

MarineCasual5esinves5ga5vebody,undertheauspicesoftheItalianMinistryofInfrastructureandTransportsandwasen5tleda‘ReportontheSafetyTechnicalInves@ga@onofthecasualty.’ TheCharges Criminalcomplaintsweremadeagainst; SirJohnParker,chairmanofAngloAmericanplcandvicechairmanofDPWorldLimited;SirJonathonBand,formerFirstSeaLordandChiefofNavalStaff;ArnoldDonald,presidentandCEOoftheExecu5veLeadershipCounsel;DebraKelly-Ennis,formerpresidentandCEOofDiageoCanada;MickyArison,ChiefExecu5veofCarnival. On11February2012

Apleabargainbythecompanyforalltheirexecu5veswasreachedforthepaymentofonemillionEuros.Thisavoidedanyinves5ga5onoftheirac5onsandanychargesbeingmadeagainstthem.TheCompanypleadedguiltyto ‘the administrative offense resulting from thecrime of destruction or deterioration of a protected habitat inside a protected site’On20July2013,

fiveindividualsalsoreachedpleabargainswiththeprosecu5onwherebytheyweregivensuspendedprisonsentencesoflessthanthreeyearsfortheirrespec5veroles.Theseindividualswere:

1)RobertoFerrarini,thecompany’semergencymanagerondutyinGenovaatthe5meofthedisaster2)ManricoGiampedroni,theConcordia’shoteldirector3)CiroAmbrosio,theConcordia’sfirstofficerandtheofficerofthewatchatthe5meoftheincident.4)SilviaCoronica,theConcordia’sthirdofficer,juniorofficerofthewatch.5)JacobRusliBin,thehelmsmansteeringtheConcordiaatthe5meofthedisaster. 2015,attheculmina5onofatriallas5ng19months,CaptainSchetnowasfoundguiltyofmul5plecountsofmanslaughter,abandoningshipandcausingamari5medisaster.Hewassentencedtoatotalof16yearsandonemonthinprison(10yearsformul5plemanslaughter,fiveyearsforcausingtheshipwreck,oneyearforabandoningtheConcordiabeforeallthepassengersandcrewhadbeenevacuated,andonemonthforprovidingfalseinforma5ontotheauthori5es).Boththeprosecu5onandthedefenceenteredappealsagainstsentencing.Defencelawyersrequestedthatthesentencebereducedtothreeyearsandfivemonths,whilsttheprosecu5oncalledforittobelengthenedto26yearsandthreemonths.Ignoringbothappeals,on31May2016,Florence’sappealscourtupheldtheoriginal16-yearandone-monthsentenceimposedbythelowercourt. On12May2017,thePresidentoftheCourtofCassa5on(Italy’shighestcourt)announcedthefinaldecisiontoupholdSchetno’slowercourtconvic5onsandsentence.Ingivingreasonsforthecourt’sdecision,thePresidentre-affirmedthelowercourts’findings: 1)Schetnowaswhollyresponsibleforthecollision. 2)Heshouldhavegiventheordertoabandonshipmuchsoonerthanhedid. 3)HeshouldnothaveleQtheConcordiabeforehehadoverseenitsfullevacua5on.

1STPHASE.THEGROUNDING

Isjc99TheScolaRock

Timeline

19:18:hrsof13January2012;SailedfromCivitavecchia.

21:00:10hrs:inposi5on42°18'25"N-011°10'48"Ecourseof302°ataspeedof15.8knots.

21:03theshipstartsaseriesofturnstoportendingat21:11:35inposi5on42°19'18"N011°06'57"E,wherethecourseis279°,speed16knots;theshipisheadingdirectlytowardsGiglioisland.

21:19:02theSeniorOOWcontactstheCaptainbyphone,aspertheinstruc5onsgivenaQerthedeparturefromCivitavecchia,informinghimthattheshipis6milesfromtheGiglioislandandthatwillbeabeamat21:44.

21:34:36theMastercomesonthebridgeandsuggeststhatthehelmshouldbeinmanualandthatpaperchartsshouldbeusedforplotng,sincethiswastheapprovedmethod,giventhelackofrequiredtrainingfortheuseofECDIS.Courseiss5ll279degrees.

213602theSeniorOOWorderedthehelmsmantosteer285and290degreesaQerabout1minute.

213711to213847Masterisengagedinaphoneconversa5onwithapersonandaskhimaboutthesafedistancefromthecoastofGigliothereisasafedepthenoughtopass,herepliesthatitissafeupto0.3/0.4milesawayfromtheisland.

21:36:35Mastersorderstosetonradaradistancecircleof0.5miles.

213914,witha290heading,theMastertakesthecommandofthewatch.

213930withspeed15.3Masterordersthehelmsmantosteer300.Theshipisnowalmostatthealtera5onofcourseposi5on.Thenewcourserequiredonthechartis334.

214000orderstoincreaseto16knotsandthensteer310°.

21:40:48theMasterorders,inEnglish,"325"thehelmsmananswers,toconfirmtheorder“.315.",theFirstDeckOfficerintervenestocorrecttheinterpreta5onofthehelmsmanbutpronounces"..335.."thentheMasterreiteratesitsorder"..325.."andthentheHelmsmanconfirms"..325..".

Theshipisatabout0.5milesdistancefromtheland.

214207orderedcourse330andthehelmsmanansweredcorrectly.

214240Mastersendsthe2ndOfficerontheleQwing,thespeedisabout16knots.

214308orderedcourse335.

214333orderedcourse340.

214344thespeedis15.9,theMasterorders,alwaysinEnglishdespiteItalianbeingtheworkinglanguageoftheship,"350",thehelmsmanwhosefirstlanguageisnotEnglishdoesnotconfirmproperly(repeats340)andtheorderisconfirmedagain,specifyingtheside"starboard"andwarningthatotherwisewouldendupontherocks

214346thebowisorientedto327°

21:44:05inposi5on42°21'05"N010°56'E,withthebowinthedirec5onof"LeScole"at0.3milesandaspeedof16knots.Theturningradiusissuchthattheshipislocated0.5milesSWoftheplannedroute,somuchclosertothecoastthanplanned.

214411MasterordersStarboard10

214415Starboard20

214420hardtostarboard

214436midship(centre)-thebowislessthan150metersfromScolerock,whiletheshipisofftheplannedcoursebymorethan809meters

214443portten(tendegreestotheleQ),butthehelmsmanreachesonly5degreestotheleQ;

214445porttwentyaQerthisorderthehelmsmanheadserroneouslytostarboardtocorrecthimselfandgoestoportasrequestedbytheMaster,andthenpullingagaintotheleQasrequestedbythemaster,butspendabout8secondsforthecorrec5onofthemanoeuvre;

214505hardtoport

214507theshipcollidesintotherocks.Thespeeddecreasesto8.3knots,theshiplosespropulsionofthetwoengines,andadriQ,proceedsinadirec5onof350°

214533masterordersW/Tdoorsclosed.

21:46:05theemergencygeneratorthatprovidespowerstartsonlyfor41seconds.

21:55Bridgeadvisedatleastthreecompartmentsflooded.thecomputersoQwareusedforthecalcula5onofstability(NAPA),despitethededicatedUPS,isnotworking.

TheIni)a)on.

CaptainSchetnowascomplicitbyini5a5ngthecasualty.HiscareerpathbeganatNau5calCollegeandthenFerriesfollowedbytankersbeforejoiningtheCarnivalcruisegroupini5allyasSafetyOfficer,thentwoyearslatertoStafforSecondCaptainfortwoyearsfollowedbypromo5ontoMaster. Incomparisontothepastthiswouldbeconsideredrapidpromo5onbutprobablynormalthesedays.Hisposi5onasSafetyOfficerand laterasStafforSecondCaptainwouldnothaveinvolvedhimdirectlyinthenaviga5onopera5onsoftheship.

Hestatedthathehadpassedclosetothisislandinthepast,confirmedbytheAISplotsheldby the ItalianCoastguard. Thiswasnot anuncommonoccurrenceon ships in generalbutcruiseshipsinpar5cularandsuchcloseapproachesforamusementhavebeengoingonfarlongerthattheexistenceofthisshippinggroup.

DespitetheCompany’sdenials,OnAugustthe14th2011,withauthoritytodoso,theshipunder the sameCaptainmade an almost iden5cal pass by the island. Theonly differencebeingtheangleofapproachtotheislandasthediagrambelowshows.

IncourtatGroseTo,SimoneCanessa,theshipsnaviga5ngofficer,saidaformercaptainemployedbytheship'sowner,MarioPalombo,hadsuccessfullysailed100metresfromtheisland'scoastinadifferentshipin2005.

‘manyinstanceshavehighlightedthecommonprac@ceoflargecruiseliners,includingtheCostaConcordiaherself,cruisingunacceptablyclosetothecoast.Itisnotablethatlegisla@onhastobeenactedratherthanrelyingonthecruiseoperatorstorespectnormalprudenceandcau@on.’ TheEUCivilProtec5onTeamReport. 26-29January2012 PierluigiFoschi,chiefexecu5veofCostaCruises,hascondemnedCaptainSchetno’sac5onthatnight.ButhetoldanItalianSenatecommiTee,duringques5oning,thatcarefullyplanned“touris5cnaviga5on”was“acceptedbylawsanditenrichesthecruisepackage”.Ithelpsdrivesbusiness,hesaid.“Wedoitbecauseitisdesiredbypassengersandwearecompe5ngontheworldmarket.”Inotherwords,theCaptainwasquiteright,theCompanyknewofthesecloseapproachesandcondonedthem.Thiswasnottheonlycompanytocondonesuch‘touristnaviga5on’asthepicturebelowconfirms.

cruise ship Seven Seas Voyager of the American company RSSC. “bowing” to the Faraglioni rocksoff the island of Capri.

ThedailyLaRepubblicapublishedtranscriptsofaconversa5onCaptainFrancescoSchetnohadwithanunknownpersoniden5fiedonlyasFabrizioinwhichheimplicatesanunnamedmanagerofthevessel’sownersCostaCruises.“Fabri…anyoneelseinmyplacewouldn’thavebeensoniceastogotherebecausetheywerebreakingmyballs,sayinggothere,gothere,”Schetnosaysintheconversa5ontapedwhilehewasbeingheldfollowinghisarrestovertheincident.

“…therockwastherebutitdidn’tshowupintheinstrumentsIhadandIwentthere…tosa@sfythemanager,gothere,gothere,”hesays.

TheBridgeOrganisa)on.

Themodernwordadoptedbyourprofessionforthisis‘BridgeTeam’.Astrangeconceptinsuchahierarchicalshipboardorganiza5on.TheCaptainisnotpartoftheteamunlesshedirectlyassumesthenaviga5onofthevessel.Onlyatthatpointdoeshebecomestheleaderoftheteam.Asageneralisa5on,aconfidentCaptainwilldiscusshisinten5onswithwhoeverisdirectedtocarrythemoutpriortotheirini5a5on,otherwiseheimpartshiswishestotheseniorofficerpresentwhothendirectsthe‘Bridgeteam’,allofwhombasedonrank,aresubordinatetoanother.Priortotheshipsailing,thenaviga5ngofficeroftheshipwillpreparethecoursestothenextportandthesewillbeapprovedbytheCaptain.Onceunderway,shortdevia5onstotheplanwillbeini5atedbytheCaptainthroughtheOfficeroftheWatch,unlessthenaviga5ngofficerisnotawatchkeeper,inwhichcasehecouldbecalledforthistask.ItisfortheOOWorthenavigator,toadvisetheCaptainofanyimpedimentor

forthistask.ItisfortheOOWorthenavigator,toadvisetheCaptainofanyimpedimentordangerstotheshipcausedbythedevia5on.Theproblemof‘teams’istheytendtoseparatetheheadfromthebody,thelargerthenumberinvolved,thegreaterthedistanceofsepara5on. ThustheCaptainofacargoshipthesamesizeorevenlargerthattheCostaConcordia,withfewbridgepersonnel,willhaveagreater‘handson’approachthantheCaptainofalargecruiseship,whowill,ifheisnotcareful,becomemoreremotefromtheprimetaskofnaviga5on,leavingthistothebridgeteam,muchasheleavestheengineeringtotheChiefEngineerandthecateringtothePurserorHotelmanager.Now,insteadofguidingtheprogressofthefunc5onsofhisship,hebecomesadecisionmakerbasedonhisdirec5ontoothersandthendependantontheircomplianceandwhatheistold,ratherthanwhathesees. Heisthusdependantontheabili5esofhisofficersmorethanhisown. TheHelmsman,oranyhelmsmanforthatmaTer,whilebeingconsideredpartofthebridgeteamisanimportantfunc5onaryresponsibleforthephysicalsteeringoftheshipunderthedirec5onoftheCaptainorOOW,whoeverhasthecon,andrequiredtocarryouttheordersgiventohim.Heisnotmanagement,norisheanypartofthedecisionmakingprocessonthebridge.Itisessen5althatnotonlydoeshehavetheabilityandexperiencetosteerashipbuthasanexcellentunderstandingofthelanguageoftheship.Asanaside,allhelmsmenmakemistakes,especiallywhengivenindifferentlanguagestotheirown.Thatiswhythereisanageoldsystemofhelmordersonaship’sbridgeasfollows; The order is given.It is immediately repeated by the helmsman. This is to ensure that the wheel is going to be putthe correct wayOnce the order has been carried out, the helmsman states the order is carried out againrepeating it.That confirmation is then acknowledged by the officer who has given the order. Thisstandardsystemdesignedtoavoidmistakesbeingcarriedout,wasobviouslynotinforceontheship. TheNaviga)on TheCaptainorderedSimoneCanessa,theship’snavigator,tochangetheship’sroutejustbeforeleavingtheportofCivitavecchia.Canessastatedthathewasnotgivenanyreason,althoughthatwouldhavebeenobvious,butthathehearditwastogivetheislandasaluteforthosecrewonboardfromtheisland. Italy’sAutomatedSearchandRescueSystem(ARES)statesthatno5fica5onofadevia5onfromtheplannedrouteneedstobemadetotheportauthori5esonlyifthenewroutedeviatesfromtheplannedoneby15nau5calmilesormore.AstheConcordia’sdevia5onwaslessthanthis,itdidnotneedtobeno5fiedto,orapprovedby,theportauthori5es.TheCompany,aspreviouslyshown,deniedthatitknewabouttheirshipsdevia5ngtosailclosetoland,butthenadmiTedtheyknewandencouragedsuchac5ons. On13January2012,onlytheoriginalroutewasdrawnonapaperchart(withascaleof1:100,000).Thechartwasusedtoplanthedevia5on,butitwasnotactuallyploTedonthechart.Instead,theplanneddevia5onwasuploadedtotheship’sautomatednaviga5onsystem(theIntegratedNaviga5onSystem(INS)),which,accordingtointerna5onallaw,couldonlybeusedasanaidtonaviga5onwhensailingclosetoland;nottheprimarymeans.

Thedevia5onorderedbyCaptainSchetno. ThereportontheSafetyandTechnicalInves5ga5onoftheCasualtycitesThefirstofficer'stes5monythatdespitebeingrequiredtosailclosetoGiglio,theshipdidnothaveaccuratenau5calchartsfordoingso.TheCostaConcordiahada1:100,000scalemapforopenseas,notthe1:20,000scalemapforcoastalsailing,onwhichtherocksthattheshiphitaremarked.Ifthiswasthecase,thenthesamesitua5onmusthaveexistedfortheAugust2011closesailby. 21:19:02theSeniorOOWcontactsbyphonetheMaster,aspertheinstruc5onsgivenaQerthedeparturefromCivitavecchia,informinghimthattheshipis6milesfromtheGiglioislandandthatwillbeabeamat21:44.

Excerptofthenaviga5onchartinuseonthebridge.Thescaleonthischartis1:100,000Insteadofthecorrectchart119scale1:20,000.Thesecondofficer,astheshipsnaviga5onofficer,wouldberesponsibletotheCaptainforthecorrectchartsbeingavailable. The Captain arrived on the bridge at 21.34.36. The First Officer,CiroAmbrosio,astheSeniorOfficerofthewatch,wasinchargeofthebridgeteam,andthisposi5onwouldcon5nueevenwiththepresenceoftheCaptainonthebridgeunlesstheCaptaintookovertheCon.Bythisac5on,theCaptainwouldassumetheleadershipofthebridgeteam.TheFirstOfficer

Bythisac5on,theCaptainwouldassumetheleadershipofthebridgeteam.TheFirstOfficerwasassistedbytheThirdOfficer,SilviaCoronica,whowasplotngtheposi5onoftheship. Onhisarrivalonthebridge,Schetnono5cedtheuseoftheIner5aNaviga5onSystem(INS)beingusedastheprimarymeansofnaviga5onandtheshipinautopilot.Heasked,“Don’twenormallyusepaperchartsandmanualmanoeuvringwhenwearethisclosetoshore?” InordertousetheElectronicComputerisedDisplaysystem(ECDIS)itisrequiredbytheSTCWConven5onRegula5onA-II/1-asrewriTenbytheamendmentsof"Manila"enteredintoforceJanuary1,2012-thattheofficersrequiredtousesuchsystemhavespecifictraining;thecoursesforthatpurposehavebeenestablishedinItaly,inthelightoftheseamendments,byDecreeoftheMinistryofInfrastructureandTransportonDecember5,2011. None of the navigators, not even the Captain, had the IMO required ECDIS training inaccordancewiththeSTCWrequirement(bySTCWManilaAmendment2010)

Fromthis,theCaptainwascorrectinrequiringtheuseofpaperchartastheprimenaviga5onprocedure.ThisrenderedtheECDISalongwithanyradaruse,asnaviga5onalaids.ThelackoftrainingispurelytheresponsibilityoftheCompany.Thechangetomanualhelmisnormallythecorrectprocedurewhenclosetoland.Onthisshipatthat5me,TheECDIScouldonlyberegardedasatrainingmoduleasifithadbeenusedastheprimenaviga5onmethod,thiswouldhavebeenillegal. TheCompanybridgeprocedure"P.14-MAN01SMS-Proceduresforthebridge"(Para4.7.1)statesthatthechartsandnau5calpublica5onstobeusedfornaviga5onarethosepublishedbytheAdmiralty;vesselsopera5nginItalianportsmustalsousethechartspublishedbytheHydrographicauthorityand,inpar5cular,thechartsfortheharbourandthefirst2chartsofentry/exitusedforarrivingintheportmustbekept.Fromthisitisrequiredthatpaperchartsareusedastheprimemethodofnaviga5onplotng. TheFirstOfficerthenorderedtheswitchtopaperchartsforthemainnaviga5onandthehelmsmantotakethewheel.(Manualsteeringwasalsoarequirementofthecompanywhennaviga5nginperceivedhazardouswaters.)Thisac5onshouldhavebeentakenbeforetheCaptainhadtoremindtheOOW. At2139.14.theCaptainassumedtheconoftheship.Hehadbeenonthebridgelessthan5minutes.Allowingforthe5meitwouldtakeforhimtoadjusthiseyesighttonightcondi5onsthiswasinsufficient5meforhimtoabsorbtheinforma5onrequiredtoassumecommandofthebridgeandthebridgeteam.Thecourseatthis5mewas290andtheshipwasalmostatthenextcoursealtera5onmarkedonthechart.Itisalsoarecognisedprocedurethathandoversarenotcarriedoutun5lanyaltera5onofcourseismadeoringood5metomakeasafehandoverbeforesuchaltera5on.Alsothattheposi5onoftheshipbeestablishedtothesa5sfac5onofboththeofficerhandingoverandtheofficertakingover.Thiswasnotdone. Thereappearstobeadiscrepancyatthispointastothefunc5onoftheleaderofthebridgeteam.IfitistheCaptain,thenheshouldatleastchecktheposi5onoftheship.Alterna5vely,ifheisreliantontheFirstofficerfornaviga5onaldu5es,then,atleastrequireaposi5onchecktobemade.

Thealtera5onofcourseshouldhavebegunbeforetheCaptainassumedtheconortheCaptainshouldhavewaitedun5lthiswascompleted.

FirstOfficerCiroAmbrosiowasinchargeonthebridge,whentheplannedturnwasgoingtobeexecutedawayfromGiglioIsland.Ambrosiogavethefollowingreasonforthisnotbeingdone;

"Buthe(Schetno)didnotimmediatelyspeakthephrase'I'mtakingcontrol,'whichsignalsachangeincommand.However,giventhewayheposi@onedhimself,IassumedhehadtakencommandandIthoughtIwasnolongerincharge.Then,sincethecaptainwasdistracted,andweweregeSngclosertoGiglio,I(Ambrosio)gaveorderstothehelmsman.He(Schetno)wasonthetelephonewith(re5redCostaCapt.Mario)Palombo.Eventhough

He(Schetno)wasonthetelephonewith(re5redCostaCapt.Mario)Palombo.EventhoughI(Ambrosio)hadfinishedmyshiV,IfeltIhadtoretakecommandinordertogiveorderstothehelmsmantostartourapproachtoGiglioIsland,whichwasgeSngcloser." Atthe5meofhandover,theshipwasalmostatthenextploTedcoursealtera5onwhichwasintendedtobringtheshiptoaroutetakingitalongthecoastoftheisland.30secondsbeforearrivalatthisposi5ontheCaptainordersacourseof300.AgainthisdemonstratesthattheCaptaindidnotknowtheposi5onoftheshipasevenifhehadorderedthenextcourseof334asmarkedonthechart,hewoulds5llbetoport(closertoland)ofthethecourseline.Theshipisnow2.8cablesinsidetheintendedcourseline. Thiswasconfirmedintheinquirybyacomparisonoftheplannedrouteonthechartno.IIM6,recoveredonboardtheCostaConcordia(rebuiltalsobytheMate,withagoodapproxima5on,duringthetes5monyofMarch1,2012),andthelayoutsAIS/VDRship,itisclearthattheMasterhaspassedthepointofturnplannedtopasstheGiglioislandthusplacingtheshipintoposi5onmuchclosertothecoastthanthatlaiddownonthechart. CourseAltera)on Coursealtera5oncombinesalltheprincipalsofnaviga5on.Firsttheposi5onmustbeestablished,thenthealtera5onmustbemadeinsufficient5meandwithadegreeofwheelcommensuratewiththespeed,draQ,currentandweathercondi5ons,inorderthattheshiparrivesonhernewheadingexactlyonthecourseline.Theclosertheshipistoanypoten5alhazard,themoreaccuratethealtera5onmustbe.InthecaseoftheCostaConcordia,atthespeedtheshipwasproceeding,theweatherprevailingwouldnothaveeffectedanyaltera5on.BeingacruiseshipwithliTlevaria5onofdraQ,thisagain,onceestablished,wouldnotcauseanyvaria5onofdegreeofturn.Therefore,inthiscase,considera5oncanbeconfinedtospeedofshipanddegreeofturn.Proximitytolandenablestheposi5ontobefixedwithcompleteaccuracy,especiallywhenusingpaperchartsthatthecompanyrequiredinthesitua5onofcloseapproachtoland. Therearethreetypesofchangeofcoursemanoeuver; Thefirstisbyarrivingatorclosetothealtera5onposi5onandthentogivethehelmorderorusetheautopilottobringtheshipontothenextcourse.Onceonthatcourse,thenestablishtheposi5onandadjustthecoursetobringtheshipbackontotherequiredcourselineoriftheopenseasitua5onallows,thenanewcoursecanbemadetobringtheshiptothenextaltera5onposi5on.Whilethiscanbeusedonopenseasawayfromland,itisnotsuitableforclosecoastalnaviga5on. Thesecondisbyvisualandgradualchangesofcoursetogetherwiththeuseofotherposi5onaidssuchasparallelindexingtowatchtheprogressthroughthealtera5ontoachievethenextcourseontheline.Toachievethisrequiresagoodknowledgeofthemanoeuvrabilityoftheshipandconsiderableexperience,especiallywheninclosecoastalwaters. WheelOver Thethirdandmostaccurateisonebasedontheshipsmanoeuvringdatasheetandisreferredtoasa‘WheelOver’. Thealteringofcoursepriortoarrivingatthealtera5onposi5onisawell-knownandestablishedprocedure.Priortothedawnofthelargershipsexis5ngtoday,thiswasgenerallydonebytheofficerofthewatchfromhisexperienceandknowledgeoftheship,althoughevenonpassengershipsofthe50’s,amarkedwheeloverposi5onbasedonthedegreeofaltera5onrequiredwasused.Withthesizeofshiptoday,thisshouldbestandardprac5ceonlargevessels,whetherpassengerorcargo,especiallywhennearland.Experiencednavigatorsusuallymakeoutagraphbasedonthemanoeuvringdataandgraduatedforspeedanddegreeofchangeofcourse. Factors of a Wheel Over.

Factors of a Wheel Over.

Old Course Wheel over positions can be found from the ship’s manoeuvring data. These are of specialimportance when making passage in rivers or channels. Most ships have ready for use precalculated distances based on speed, degree of helm required, degree of turn and draft.F = Head Reach – Distance travelled by vessel after giving wheel over & before commencingturn, i.e. distance to overcome inertia.P = Perpendicular distance from wheel over point to new course extension.D + P = Parallel Index distance at W/O position.D = Parallel Index distance from new course, as obtained from chart.R = Radius of turn.Ө = Change of course angle. On the Costa Concordia, the Captain chose the second option of gradual changes of course.This was not carried out properly and placed the ship 2.8 cables within the required courselineImmediately after any alteration of course it is a basic professional requirement that aposition be established to ensure that the ship is on the required track. In this case, this wasnotdone,neitherwasthereanyevidenceofparallelindexingorevenvisualorradarobserva5on,eventhoughtheCaptainhadorderedtheradartobesetfor5cablesdistanceofftheland.Nomemberofthebridgeteamseemedtobeawareofthesafenaviga5onofthevessel,possiblyeachexpec5ngtheotherstodothis.Itshouldbepointedoutthatthedutyofthe3rdofficer,withinthebridgeteam,wastheplotngoftheshipsposi5on.OverthenextthreeminutestheCaptainordersthreemorecoursealtera5onsallturningtheshiptothenextcoursefinallyseTlingonacourseof330at2142.07andaspeedincreaseto16knots.Evennowtheshipiss5llnotsteeringthecourselaiddownandnoonehasyetno5cedthattheshipiswellinsidethecourseline.TheshipisnowheadingdirectlyfortheScolerocks.Duringthesecoursechanges,itisapparentthatthereisgeneralconfusionastothecoursesbeingorderedwithboththehelmsmanandtheFirstofficermisinterpre5ngtheordersgiven. At21:43,Schetnono5cedthewhitefoamofthewavesbreakingagainsttherocksinthedistanceandrealisedtheimmediatedangertheConcordiawasin.Thefactthathewastheonlypersononthebridgetoseethiswouldrefuteanyargumentthathiseyesightorfailuretowearglasseshadanybearingonthecase.Hegavetheordertoturn“350degreestostarboard”,butthehelmsmandidnotunderstandandsaidback,“340degrees”.BothSchetnoandthefirstofficershoutedback,“350degrees!”Itwasatthispointthatthethirdofficerhadtoleaveherposttoassistthehelmsman. Itisstrangethatevenatthispointthehelmorderswerebeinggivenascoursestosteerratherthandirecthelmorders.IwouldconsiderthatthehelmsmanwouldhaveunderstoodbeTerthedirectdegreeofhelmorderratherthancoursesandthatthismethodwouldhave

CentreӨW/O

P F

ӨCourse Alteration

D

R

beTerthedirectdegreeofhelmorderratherthancoursesandthatthismethodwouldhaveledtolesslanguageconfusion.However,thereisnosetrequirementastohowsuchaltera5onsareordered.

214346.thetheshipisheading327°

214411theCaptainordersStarboard10

214415TheCaptainordersStarboard20

214420TheCaptainordershardtostarboard

214436TheCaptainordersamidships.Attheposi5on,thebowislessthan150metersfromScolarocks,whiletheshipisofftheplannedcourselinebymorethan809meters

214443portten,butthehelmsmanreachesonly5degreestoportbeforethenextorderat214445ofporttwenty.BythistheCaptain,havingclearedtherockwiththebow,wasintendingtoclearthesternwhichwasnowswingingtowardstherock.

Itwasherethatthehelmsmanwenttostarboard,thencorrectedhimselfandwenttoportasrequested.Thedelaycausedbytheerrorwas8seconds.

214505hardtoport

214507theshipcollidesintotherocks.Thespeeddecreasesto8.3knots,losespropulsionofthetwoengines,andadriQinthedirec5onof350°

The8secondsdelay.

Atthetrial,TheJudge,basedonhisconsultant’sopinions,usingqualita5vearguments,statedthatthehelmsman’serrorhadbeeninconsequen5alontheimpact. InNovember2015,atthe2ndInterna5onalConferenceoninforma5onandcommunica5onTechnologiesfordisastermanagement,aconferencepaperwaspresentedbyPaoloGubianandMarioPiccinelliDept.ofInforma5onEngineeringUniversityofBresciaBrescia,Italy,andBrunoNeriandFrancescoGiurlandabothoftheUniversityofPisa.Theirstudiesarebasedonareconstruc5onofblackboxandautoma5onsystemdata.Inthefigurebelow,theblueoutlinerepresentstheactualshipposi5onatimpact5mewhilethegreenoutlinerepresentsthesimulatedshipposi5on,withoutthehelmsman’serror.Theblackellipserepresentstherock’sposi5on.Ascanbeseen,inthiscasetheleQbulkheadoftheshipsisabout10mfromtherock.Onecouldsafelystatethat,accordingtothesimulator,theshipwouldhavepassedclosetotherockwithoutimpac5ngor,consideringtheworstcaseforthesimula5onerrorandmodelapproxima5ons,theimpactcouldhaveoccurredabout18mbehind.

“Foracorrectreconstruc@onofthefacts,itwasveryimportanttoevaluatetheexact@meatwhichthehullhittherocks,aswellastheexactcontactpointwiththeshallows,inthecoordinatesystemoftheship’sGPS.Infact,anaccurate@me-reconstruc@oniscrucial,duetotheshort@meelapsedbetweentheerrorandtheimpact.TheJudge’sconsultantshad

theshort@meelapsedbetweentheerrorandtheimpact.TheJudge’sconsultantshadpreviouslyperformedanevalua@onoftheship’sposi@onatthees@matedimpact@me(21.45’.07’’).Thisreconstruc@on,inouropinion,wasnotconsistentwithcartographicdata:at21.45’.07’’,theposi@onofthebreachontheship’sbulkheadwasabout40mbehindtheshallows.Toinves@gatethispointinmoredepth,weperformedanaccurateanalysisofposi@on,headingand@medataoftheship.Fromthesedata,itwaspossibletocalculatetheinstantaneous(linearandangular)velocityandaccelera@on…………..TheJudge’sconsultants,usingqualita@vearguments,statedthatthehelmsman’serrorhadbeeninconsequen@alontheimpact.Thisconclusioninouropinionshouldbere-examinedusingaquan@ta@veapproachandtakingintoaccounttheaforemen@onedfacts.” Gubian,Paolo&Piccinelli,Mario&Neri,Bruno&Neri,Paolo&Giurlanda,Francesco.(2015).TheDisasterofCostaConcordiaCruiseShip:AnAccurateReconstruc5onBasedonBlackBoxandAutoma5onSystemData.10.13140/RG.2.1.1912.5522. Althoughanearlierversionofthispaperwasmadeavailabletothecourts,thejudgesdidnottaketheresultsintoconsidera5onandconsideredthemtobe’lackinginscien5ficvalidity’despitethe"bestpaperaward"assignedtothepaperbyajuryofinterna5onalexperts.

Thechairmanofanexpertwitnesspanel,AdmiralGiuseppeCavoDragone,headmasteroftheItalianNavalAcademyatLivorno,saidanydelaycausedbythehelmsman’serror‘appearedtobeirrelevant’furthersta5ng,"Theshipwouldhavehittherocksinanycase." LanguageInfluences Ontheapproachtothegroundingpoint,therearethreesteeringincidentswherethehelmsmanappearsconfusedastothecourseorhelmordersandonecasewheretheOOWismomentarilyconfused.Toassistinthelanguageissue,the3rdOfficeristakenfromhisposi5onatthecharttableandfromhisdu5esastheplotngofficertobesta5onedbytheHelmsman.

SOLASChapterV–Regula@on14,andISMCodeparagraph6.6.Eachcrewmembermusthavesuitableskilltounderstandtheworklanguageand,forsomeac@vi@es,togiveordersandinstruc@ons,andconsequentlytoanswerusingthelanguageofwork.

Thelanguageofworkmustassureaneffec@veskillofcommunica@onsuitableto:

1. 1)towarranteeadequateperformanceofthecrewintheac@onsrelatedtothesafety;

2. 2)receivetheinforma@onrelatedtotheapplica@onoftheSMSprocedures.

TheCompany“ManagementCompanySystemManual”(MAN01SMS–Annex-15),hasestablished,intheparagraph5-5-3,thatthelanguageofworkonboardofitsshipsistheItalianlanguage.

ProficiencyoftheEnglishlanguagewasinterna5onallymandatedforthoseatseanearly10yearsago,althoughperformancestandardswithasystemoftes5ngprotocolstoverifythatmarinerscanspeak,readandwriteEnglishinaccordancewiththeSTCWandSOLASregula5onshaveneverbeenformallyestablishedbytheIMO.WhilesomeshipregistriessuchastheUnitedKingdomandMarshallIslandshavetheirownspecificEnglishlanguagetes5ngrequirementsformariners,theinterna5onalregula5onsdonot.Itshouldalsobepointedoutthatalthoughthesecountrieshaveissuedates5ngrequirement,thattes5ngisinthehandsoftheshippingcompanyormanagementemployingthem.FlagStateInspec5onsandPortStateControlshavethepowerstocheckonlanguageused,andit’sunderstandingofthecrew.Thisrarelyoccurs. ANISMauditwascarriedoutbytheFlagState(Italy)onMarch6/7th2012duringwhichthefollowingnonconformitywasrecorded;

1. Theprocedurefortheevalua5onrelatedtotherecruitmentofthedeckandengine

1. Theprocedurefortheevalua5onrelatedtotherecruitmentofthedeckandenginepersonneldoesnotprovidefortheassessmentoftheworklanguage.

2. Theprocedurerelatedtotherecruitmentofthepersonnelassignedtothecomplementaryservicesdoesnotprovidefortheassessmentoftheworklanguage,whenthesepersonnelareengagedtobeassignedinatasklinkedwiththeMusterList.

Insupportofthisnonconformitythefollowingstatementsfromofficersandcrewonboardfollow;

Thehelmsman,JacobRusliBin,ofIndonesianna5onality,tes5fied(referencepapern.0267oftheJudicialAuthorityofGrosseto),thathedidnotat5mesunderstandtheMaster'sorders,eventhoughtheywereinEnglish.

The1stEngineer.Enginemanagement,(interviewon20March2012–Enc.384),ofBulgarianna5onality,tes5fiedhedoesnotfullyunderstandtheordersgivenintheItalianlanguage(theworkinglanguage),duringtheemergenciessitua5ons.

RadioOfficer(tes5monyon16March2012–Encl.383)tes5fied,thatwhileloweringofthelifeboat,theBoatswaingaveinstruc5onsbothinItalianandinEnglishtothecrewcomingfromSouthAmerica.

TheSafetytrainer(seeinterviewon23May2012–Encl.393)tes5fiedthatbothItalianandtheEnglishweretheworkinglanguageonboard,andthatthetrainingac5vi5eswereusuallycarriedoutinEnglish.

ThesecondBoatswain(interviewon30March2012–Encl.385)declaredthattheyusuallyspokeItalianexceptwhentheydidnotunderstandeachother,andtheythenspokeinEnglish,whereastheOfficersgavetheordersinbothlanguages.

TheSafetyOfficerinhisinterview(page7438andinthefolderofGrossetoJudicialAuthority)showedhewasnotfamiliarabouttheSMSinstruc5onsrelatedtothelanguageofworkonboard.

Asevidentonthebridgerecorder,theordersgivenonthebridgewereinbothItalianandEnglish,withtheCaptaingivinghishelmorderstothehelmsmaninEnglish.Fromthisitisproventhatthelanguagesitua5ononboardandmostimportantwithintheopera5onsstaff,waschao5c,withtheworkinglanguageofItaliannotbeingunderstoodbythemajorityofthecrewandmanynotunderstandingEnglish.Thecrewwereselectedonanop5mumcostbasiswithcommunica5onandsafetytakingasecondplace.Thishadconsiderablebearingonthegroundingandtheabandonmentphase.

2ND PHASE. THE DAMAGE

TimeLine.Event 2145 Grounding2150 Blackout2155 Ini5alAssessmentofFloodingreportedtobridge2212 Leghornmari5meRescuecontactsship.AdvisedofBlackout.2234 Heelincreases.Shipdeclaresdistresstomari5meRescueCentre2240 DistresssignalthroughINMARSAT2244 ShipreportedastouchingboTom2248 Abandonshipgeneralalarmini5ated2255 Firstlifeboatlaunched2258 ShipgroundingreportbyMaster2337 440personsreporteds5llremainingonboard0034 Shipfinalcapsize.Masterleavesship.Heel70-75degrees0041 50personsreporteds5llonboard0344 50personsreporteds5llonboard0422 30personsreporteds5llonboard0614 evacua5onreportedcompleted. AQerthecollisionwiththerocks,theshipgraduallylostherownmomentumand,withoutpowertoherenginesandsteeringbecamesubjecttothewindandthecurrent.Veryfortunately,thistooktheshipbacktogroundforasecond5meclosetothesmallharbour.

TrackoftheshipaQerthegrounding.TheBluetrackistheshipscon5nuingcourse.totheNorth.Asthemomentumofthecourseandspeedfollowingthecollisiongraduallyceases,theeffectsofcurrentandwindgraduallycontroltheshipandshedriQsSouthWestasshowninred. The Damage. Thedamagewascatastrophic,althoughunknownatthe5me.TheshiphadbeenbuilttoSOLAS90regula5onswhichspecifiedthatthenumberoffloodedcompartmentsthevesselwouldsurvivewouldbe2.Accordingtothereports,theHulldamagewasalengthof53metres(fromframe52to125)andvariablewidthupto7.3metres.

Compartment Frames ContentNo.3 28 44 Store roomNo.4 44 60 Main thrusters, bearings and hydraulic units

machinery space air conditioning compressorsNo. 5 60 76 Propulsion electric motors, fire and bilge pumps,

propulsion and engine room ventilation, propulsiontransformers

No.6 76 100 Three main diesel generators (aft)No.7 100 116 Three main diesel generators (fwd)No.8 116 140 Ballast and bilge pumps CompartmentNo.5completelyfloodedinminutes,withrapidfloodingoccurringinCompartment6andprogressivefloodingofCompartments4,7and8.Thefloodingofthesefivecompartmentsquicklyincreasedtheship'sdraughtsothatdeck0startedtobesubmerged.Thiswasthetermina5ondeckforthebulkheadssowateralsostartedtoenterWTCNo.3throughastairwayconnec5ngdeck0toDeckC.Thefloodedcompartmentscontainedanumberofcri5calsystemssuchasmaindieselgenerators,ballastandbilgepumps,electricalpropulsionmotors.Thefloodingofthesecompartmentsresultedinblackoutofmainelectricalnetwork,lossofpropulsionandvarioushighcapacitysea-waterservicepumps.6compartmentsfloodedwithin40minutes.

Water)ghtdoors. M/SCostaConcordiahad16water5ghtbulkheadsatframes28,36,60,74,100,126,140,156,180,196,220,236,252,264,284and308however9bulkheadsatframes28,36,140,156,180,196,220,236and252,hadtwodoorsmakingatotalof25W/Tdoors.

by MSC.1/Circ.138010December2010Annex

Guidanceforwater@ghtdoorsonpassengershipswhichmaybeopenedduringnaviga@on.

1.1 Water@ghtsubdivisionisvitaltoshipstabilityandsurvivabilitytoprotectlife,propertyandthemarineenvironmentincasesofhulldamageaVercollisionorgrounding.Thenumberofopeningsinwater@ghtbulkheadsonpassengershipsistobekepttoaminimuminaccordancewithSOLASregula@onII-1/13.1(previousSOLASregula@onII-1/15.1).

1.2Inordertomaintainwater@ghtsubdivision,whileallowingforthesafeandeffec@veopera@onoftheship,allwater@ghtdoorsaretobekeptclosedduringnaviga@on,exceptincertainlimitedcircumstances.SOLASregula@onII-1/22.3(previousSOLASregula@onII-1/15.9.2),allowsawater@ghtdoortobetemporarilyopenedtopermitthepassageofpassengersorcrew,orwhenworkintheimmediatevicinityofthedoornecessitatesitbeingopened.Inthiscase,thedoormustbeimmediatelyclosed,whentransitthroughthedooriscompleteortheworkisfinished.Addi@onally,SOLASregula@onII-1/22.4(previousSOLASregula@onII-1/15.9.3)permitscertainwater@ghtdoorstoremainopenduringnaviga@onbutonlyifconsideredabsolutelynecessarytothesafeandeffec@veopera@onoftheship'smachineryortopermitpassengers(*)normallyunrestrictedaccessthroughoutthepassengerarea(*).

SThisdetermina@onismadebytheAdministra@onaVercarefulconsidera@onoftheimpactonshipopera@onsandsurvivability.

7.4Thenecessityforawater@ghtdoortoremainopenduringnaviga@onshouldbedemonstratedbytheCompany.TheCompanyshouldsa@sfytheAdministra@onwithrelevantinforma@on,suchasopera@onalneeds,numberofpassagesthroughthewater@ghtdoorper@meunit,alterna@vepassagewaysaroundthewater@ghtdoorandresultsfromtheriskassessment.TheCompanyshouldalsosubmitacopyoftherelevantsec@onsoftheirsafetymanagementproceduresrela@ngtotheopera@onofwater@ghtdoorsduringnaviga@on,aswellasrelatedinforma@onsuchasrestric@onsorlimita@onsonwhenwater@ghtdoorsmayremainopen.

remainopen.

Appendix1:OnlyaVercarefulconsidera@onoftheimpactonshipopera@onsandsurvivabilityshouldanAdministra@onpermitawater@ghtdoortoremainopenduringnaviga@on.

ItshouldbenotedthattheUKobjectedtothisrelaxa5onoftheexis5ngrules.

SimoneCanessa,theship’snaviga5ngofficer,,saysinherstatement,"TheopeningofW/Tdoorswasstandardprac@ceduringnaviga@ontomakeiteasierforthosewhowereworking

tocomeandgo".WhilethisisnotcontrarytoMSC1/Circ,theresponsibilityisnowtransferredtotheshipsstaff,whichmeansthehotelsideoftheorganisa5on,astowhichdoorscanbeopenedandwhen.

Itshouldbenotedthatimmediatelyonimpactwiththerocks,theCaptainorderingtheclosingofboththewater5ghtdoorsinthebowandtheengineroomjustaQerthecollisionandthenagainsome5melateranotherorderto“Shutthedoor’s.Shutallthewater@ghtdoorsimmediately.”ThisalsoindicatesthattheleavingofW/Tdoorsopenwascommonprac5ceonboard.

InthecaseoftheCostaConcordiatheflagstateadministra5on(Italy)allowedsomewater5ghtdoorstobekeptopenatseaifdeemednecessary.Theseexcep5onsareWater5ghtDoors7,8,12,13and24.Theonlydoorsindicatedasopenatthe5meoftheaccidentwere12and13,whichwerelocatednearthelaundryonDeckB.ThesetwodoorswereapparentlyclosedbyorderoftheCaptain.However,weknowfromtheevidencepresented,thatadoorintheengineroomwasopen.

Otherdoorsinthedamagezonewereopenedandclosedbycrewtoassistwiththeirescape.Allwater5ghtcompartmentsarefiTedwithemergencyescapetrunksbutthesemaynothavebeenreachable.

OnTuesday12November2013MrHugodiPiazza,atechnicianintheengineroom,toldthetrial;

"Beforehecouldphonethebridge,hewashitontheshoulderbya10-metrejetofseawater.Hethenmanagedtocloseawater@ghtdoor,onlytoseewaterseepunderneathit,beforehefoundastairway,whichwasblocked,possiblyduetothebucklingcausedbythecollision",herecalled.

DiPiazza,whowasonhisfirstshiQintheengineroom,saidheopenedanotherdoorfromwhichwaterwasgushing,beforefindingasaferoutetohigherdecksasthewaterswirledtokneelevel.

AnotherenginecrewmemberMrTonioBorghero,saidtheengineroomwasfloodedwithin20minutesofthecollision.ThenatureoftheincidentwassofastthatitnecessitatedtheopeningandclosingofW/Tdoorsinordertoescapeandsecuretheengineroom. Whilethehullwasdamagedoveralengthof53meters,thereportdoesnotsayifthewater5ghtintegrityforthiswholelengthwasaffected.Manyshipshavehadquiteseveredamagetotheirhullswithoutlosingthewater5ghtintegrityinthosecompartmentsadjacenttothatarea.WhiletheopeningandclosingofW/Tdoorsisnotgoodprac5ce,therealityistheshiphadaninadequatesubdivisionandalowerachievablesurvivalstate.Greatersubdivision,orbeTerlongitudinalbulkheadswouldaddresstheissueofrakingsidedamageasrecommendedbyLordMerseyItheTitanicinquiryahundredyearsago.

Regardlessofthis,becauseoftheextensivehulldamage,theeventuallossoftheshipwasinevitable,especiallyas,throughthefailureoftheemergencygenerator,itwasnotpossibletousethepumps,thewater5ghtdoorswouldhavehadnoeffectonthefinallossoftheshipalthough,ifdoorswereopen,asseemstohavebeenthecaseintheengineroom,thenthereobviouslywascontribu5ontotherapidityofthefloodingresul5nginadecreaseinthe5methosehadonboardtoabandonthevessel.

Itshouldbenotedthatanyshipintendingtoapproachlandandnavigateatsuchaclosedistanceshouldhaveallthewater5ghtdoorsclosedwellbeforeclosingonthelandandduringtheclosepassagenodoorsshouldhavepermissiontobeopened.

TheEmergencyGenerator.

Withthelossofpowerfromthemaingeneratorsduetoflooding,theemergencygenerator

Withthelossofpowerfromthemaingeneratorsduetoflooding,theemergencygeneratorasessen5altokeeptheemergencyfunc5onsoftheshipsuchasthepumps,liQs,andessen5albridgeequipment.

ThreeElectricianstes5fiedthatallliQsreachedtheirscheduleddeckaQertheblackouthoweveroneelevatorwasfoundbythespeleologistdiverswiththedoorsopened,andbodieswerefoundontheboTomoftheshaQ.ThissuggeststhatthedoorswereopenedonthisliQ,whentheemergencyswitchboardwasconnectedintheforcedmodeataround22.15.

“TherewerepeoplestuckintheliVsscreamingsoweclimbedupthelargestaircase.”

MoniqueMaurek,41,andherhusbandAnton.

IMOdoesnothaveanyspecialinspec5onrequirementforelevatorsonship.However,theSOLASConven5onchapterl,partB(Surveysandcer5ficates)requiresthatitisestablishedthatallequipmentisinsa5sfactorycondi5onsandfitfortheserviceforwhichitisintended,sothatwouldalsoincludeelevators.

Itishardtoimagineamorefrighteningdeaththanthiswiththeshipslowlyturningoverandthewatergetngcloserun5litoverwhelmedthem.TheIMOhasnolegisla5ongoverningthecapabilityofliQstostopatadeckandopenthedoorsandthenensuringthedoorscloseagainifpowerislost.

3RD PHASE. THE ABANDONMENT

Rvongher LifeboatsinGiglioHarbourthenextday. Theevacua5onlastedformorethansixhours.Ofthe3229passengersand1023crewknowntohavebeenonboard–32peopledrowned,hundredswereinjuredandmanymoretrauma5sed. TheCriteriaofabandonment TheCriteriawasrelaxedtoaccommodatetheincreasedsizeofpassengershipsandreduceanyaddi5onalcosts. The Interna5onalMari5meOrganisa5on (IMO) under SOLAS Chapter III Regula5on 21.1.4requiresthatallsurvivalcraQshallbecapableofbeinglaunchedwiththeirfullcomplementofpersonswithin aperiodof 30minutes from the5me theabandon ship signal is given.However, this regula5on s5pulates that the30-minute5meframeonly startswhenall thepassengershavebeenmusteredwithlifejacketsdonned.

SOLASalsorequiresthelifeboatstobecapableofbeinglauncheduptoamaximumdegreeofheelof20degrees.

Tworeportersweretravellingonboardtheship.Theyboardedalifeboatbefore2300whentheshipwass5llatanangleoflistof15degreesorless;

Wesoonrealisedthattherewasabigproblem–theinclina@onoftheshipmeantourlifeboatcouldn'tbelowereddirectlyintothesea.Wewereononeofthehigherdecksbuttheshipwas@l@ngtotheoppositeside.Thelifeboatwasmoreorlessres@ngagainstthesideoftheConcordiawhichmeantthatitcouldn'tbeloweredintothewater.Threeyoungcrewmemberstriedineverywaypossibletofreeit,hackingawaywithaxesatanythingblockingourdescentandkickinghardatthesideoftheship.Theyweretryingtoworkasfastastheycould,whileanothermemberofthecrew,whowass@llondeck,wasshou@nginstruc@ons.BlowaVerblowtofreethelifeboat,buttheycouldn'tfreeit.Each@metheygainedsomespace,thelifeboatdroppedabruptly,makingthoseofusinsidefeelasifwewereplumme@ngintothesea.Butits@llwasn'tenough Castro,Luciano.Concordiagate-Thecruiseshiptragedyastoldbytworeportersonboard(FuturebookBook2).CUECEditrice.

Thetotalpassengershipevacua5on5mewillalsoincludethe5metakenbythepassengersandcrewtoactuallyassembleatthemustersta5onfromwherevertheyhappenedtobeontheshiponcetheini5alalarmhassounded.

TheIMO“GuidelinesforaSimplifiedEvacua5onAnalysisforNewandExis5ngPassengerShips”coveredbyMSCCirc1033anditssuccessorMSCCirc1238recommendamaximumallowabletotalpassengershipevacua5on5metobeintherangeof60to80minutesbasedonthefollowing:

• 60minutesshouldapplytoshipshavingnomorethanthreemainver5cal(fire)zones:and

• 80minutesapplyingtoshipshavingmorethanthreemainver5cal(fire)zones.

ItmustbenotedthattheseareguidelinesonlyanditisfortheFlagStatetodecideontheirimplementa5on.InthecaseoftheCostaConcordiathe5metakenwasover6hourswiththeverycloseproximitytolandandtheconsiderableassistanceofshorerescuefacili5es.

TheIMOCriteriaforabandonmentisbasedonthefollowing: 5.1thecrewwillimmediatelybeattheevacua@ondutysta@onsreadytoassistthePassengers. Itismyexperiencethatthisneveroccurs,especiallyatnight.Asabenchmark,10minutesshouldbeallowedforthis.Asmallpropor5onofthecrewwillnotevenappearattheircorrectsta5onsatall,manybeingstalledbytheneedforpassengeraTen5onorotherimmediatedu5esthatonlybecomeapparentattheonsetoftheemergency.Otherswillbemoreconcernedatensuringtheirownsafetythanthatofothers.ThisisexactlywhathappenedontheConcordia. 5.2passengersfollowthesignagesystemandcrewinstruc@ons(i.e.,routeselec@onisnotpredictedbytheanalysis). Withemergencyligh5ng,asoccurredontheConcordia,andnotconsideredinthemodel,thesignageandrou5ngcouldbeobscured.Asthenumberofpassengersgrow,thefollowingofthecrewrou5nginstruc5onswillslowdown. .5.4familygroupbehaviourisnotconsideredintheanalysis. Thisispar5cularlyimportant.Families,ifapart,willignorecrewinstruc5onsandlookfortheirfamilymembers,especiallyifparentsareontheupperdecksatthe5meofthealarmsandtheirchildrenareintheircabinsseveraldecksbelow.Anyinstruc5onstodeterfromthiswillbeignored. 5.5shipmo@on,heel,andtrimarenotconsidered. Thiswasamostcri5calfactorinthiscase.Anyrollingoftheshiphampersmovement,especiallyamongstthosenotexperiencedinmovementduringrolling.Anylistorrollingwillpar5cularlyhampertheinfirmanddisabled,especiallythoseinwheelchairs.Theques5onremainsastohowtheseshipsintendtomovethewheelchairboundpassengersdownseveraldeckswithoutliQs.Astheshiplistsfurther,thisimmediatelywillhamperthespeedatwhichtheboatscanbepreparedandincreasethecaserequiredduringtheboardingandloweringprocedures.Asthelistincreases,themoredifficultmovementaroundthevesselandthelaunchingprocedurewillbecome.Eventuallyboatsononeside,oncepassingthelegislatedlaunchinglistrequirementof20degreeswillbecomeunusable. Alcohol Thecruiseindustryoftodayreliesonahighalcoholconsump5onforaconsiderablepartofitsprofitsunlikethepastwherethecabincostwasthemainincome.Thismeansthattheoldcontrolsthatusedtobeimposedarenowgonewiththeresultthat,especiallyatnight,apropor5onofpassengerswillbeintoxicatedinvaryingdegrees.Thisintoxica5onwill

propor5onofpassengerswillbeintoxicatedinvaryingdegrees.Thisintoxica5onwillconsiderablyhampertheevacua5oneffortsandcauseasafetyconcernforthosepassengerswhoaresober.Thiswasnotconsideredintheinquiry. Lifejackets AmostimportantcriterionhasnotbeenconsideredintheIMOmodel.Thewearingoflifejacketsintheshipwilldoublethespacerequiredforpassengermovement,againincreasingtheevacua5on5me. TheMusteringPoints. ThisImpactsheavilyontheevacua5onoftheship.Asthedeckscon5nuedtogethigher,sodidthelifeboats.Eventually,theybecametoohighforsafeevacua5onandtheyweremovedbackdowntoalowerdistanceabovesealevel.Unfortunately,thedeckspaceformusteringbytheseboatswasnotdesignedintomanyshipsthereforethemusteringofpassengersiss5llcompletedinthepublicroomsontheupperdecks.Thenthelifejacketsareputonandtheyareleddowntotheboatembarka5ondeck.Thisnotsa5sfactoryformanyreasons.Passengersontheupperdeckshavetogototheircabins,oQenbelowtheboatdeckandthenreturntotheupperdecksformuster.Atthesame5mepassengersarecomingfromtheircabinsandgoinguptotheupperdeckstohavetogobackdownagaintotheembarka5ondeck.Givethesitua5onofnight5meandemergencyligh5ng,itisveryeasyforpassengerstogetmixedupandindeedlostfromtheirgroup.Thisinturnmeansthatmanypassengerswillnotbeinthecorrectboatsleadingtoapanicenhancingsitua5ontryingtofindspaceinotherboats.Thisisexactlywhathappenedinthiscase.Ifthemusteringsta5onisbythelifeboats,orthereisawai5ngareaforboardingtherehastobesufficientroomforpassengerstositwhilewai5ngwithoutbeingcrushedtogether. Stairways. Themaincriteriaforthedesignofstairwaysontheseshipsseemstobeaesthe5cratherthanprac5cal.Thestairwaysshouldbesodesignedtoavoidblockagewhichifoccurring,wouldleadtodelaysandtheinevitablestartofpaniccondi5ons.Itisthereforeessen5althattheyarewideenoughtoallowforthemovementofdensetwo-waytrafficwithsystemsthatallowfortheemergencymovementofwheelchairs.

Time Line.Time Events Angle

of list Source Time

after "contact"21.45 Contact with underwater

rock0° AIS 0

21.5021:52

Black outThe Chief Engineer andElectrical officer failed tostart emergency generator

0°00

CrewCrew

0 h 05 min0h 07min

21.55 -22.00

Initial assessment offlooding and reports topersonnel on the bridge

0° Chief Engineer2nd EngineerChief Mate

0 h 15 min

22.12 Leghorn Maritime RescueSub-centre Control contactsship and is informed aboutblack out

0 h 27 min

22.34 Ship reports increasing heeland declares the“DISTRESS” LeghornMRSC request informationon number of persons onboard

0 h 49 min

board22.36 Ship drifting 5° Crew 0 h 51 min22.39 Leghorn MRSC informed

about Ship’s sternheaviness

Patrol boat "G104"

0 h 54 min

22.40 Ship distress launchedthrough INMARSAT

0 h 55 min

22.44 Ship touching the seabottom

Patrol boat "G104"

0 h 59 min

22.48 General (Abandon ship)Alarm

1 h 03 min

22.55 First lifeboat launched Patrol boat "G104"

1 h 10 min

22.58 Ship grounding 15° Master 1 h 13 min23.37 440 persons still to

evacuate20° Livorno Coast

Guard1 h 52 min

00.34 Capsize - ship masterleaves the ship

70-75° Master 2 h 49 min

00.41 Helicopter ITCGintervention to recover 50persons still aboard

80° Livorno CoastGuard

2 h 56 min

01.46 Leghorn MRSC intimatesthe master to go on boardthe ship and to give anaccount of the actualsituation

Livorno CoastGuard

4 h 01 min

03.44 50 persons still to evacuate Livorno CoastGuard

5 h 59 min

04.22 30 persons still to evacuate Livorno CoastGuard

6 h 37 min

06.14 Evacuation completed Livorno CoastGuard

8 h 29 min

Note.Thenumbersofpersonswai5ngforevacua5onarefromtheofficialfiguresquotedatthe5meratherthantheactualfigurescalculatedbytherescueservices.

TheMentalStateoftheCaptain.

Itiswellknownthatdisastersandcatastrophiccrisesstronglyaffecthumanbehaviour:

"PeopleundergoingacrisisordealingwiththeaVermathofadisasterarenormally,well-func@oningpeoplewhoarestrugglingwiththedisrup@onandlosscausedbythedisaster.Theydonotseethemselvesasneedingmentalhealthservicesandareunlikelytorequestthem."Becauseofthis,itisimportantthatthosetrea@ngindividualsundergoingacrisislearntorecognizethecommonreac@onstoatrauma@cevent.Reac@onscanincludechangesinbehaviour,physicalwell-being,psychologicalhealth,thinkingpaqerns,andsocialinterac@ons.Thefollowingsigns,symptoms,andreac@onsarecommonpsychologicalresponsestoacrisisortrauma@cevent:disbelief,emo@onalnumbing,nightmaresandothersleepdisturbances,anger,moodiness,andirritabilityandforgerulness."

TheCaptainhasjustsufferedamostseveretrauma5cshock.Certainlymorethanmostpeoplehaveeverendured.

‘ImmediatelyaVeratrauma@cevent,itiscommonforpeopletofeelshocked,ornumb,orunabletoacceptwhathashappened.

Shock-wheninshockyoufeel:

• stunned or dazed or numb

• cut off from your feelings, or from what is going on around you.

Denial-whenindenial,youcan'tacceptthatithashappened,soyoubehaveasthoughithasn't.Otherpeoplemaythinkthatyouarebeingstrongorthatyoudon'tcareaboutwhathashappened.

Over several hours or days, the feelings of shock and denial gradually fade, and otherthoughts and feelings take their place’ The Royal College of Psychiatry In this case the trauma resulting from the accident was increased by the guilt. ‘Pa@entswithahigherlevelofshameandguiltatthestartoftreatmentdisplayedahigherlevelofPTSDsymptomsoverthecourseoftreatmentcomparedtootherpa@ents’.

Trauma-relatedshameandguiltas5me-varyingpredictorsofposTrauma5cstressdisordersymptomsduringimageryexposureandimageryrescrip5ng—Arandomizedcontrolledtrial

Asle Hoffart & Tomas Formo Langkaas, Oslo University. “Thecaptainappearstohavesuccumbedto“normalcybias”,wheredisbeliefandoverconfidenceobscurereali@estoohorribletocontemplate.“Hewantedtobelievethingswerenotasbadastheylooked,minimisingproblemsandstallingdecisions,whilegivingorreceivinginforma@on.Andthenthecommandstructuresimplycollapsed,”

Itiswellknownthatdisastersandcatastrophiccrisesstronglyaffecthumanbehaviour:

"PeopleundergoingacrisisordealingwiththeaVermathofadisasterarenormally,well-func@oningpeoplewhoarestrugglingwiththedisrup@onandlosscausedbythedisaster.Theydonotseethemselvesasneedingmentalhealthservicesandareunlikelytorequestthem."Becauseofthis,itisimportantthatthosetrea@ngindividualsundergoingacrisislearntorecognizethecommonreac@onstoatrauma@cevent.Reac@onscanincludechangesinbehaviour,physicalwell-being,psychologicalhealth,thinkingpaqerns,andsocialinterac@ons.Thefollowingsigns,symptoms,andreac@onsarecommonpsychologicalresponsestoacrisisortrauma@cevent:disbelief,emo@onalnumbing,nightmaresandothersleepdisturbances,anger,moodiness,andirritabilityandforgerulness”.CommentsareProfessorDavidAlexander,oftheIns5tuteforRiskandDisasterReduc5onandaspecialistindisastermanagementhasfollowedthecaseoftheCostaConcordia. Thesecommentsaresupportedbythebridgeofficers. CaptainSchetnocalledRobertoFerrarini,theheadofthecrisisunitofCostaCruises,theGenoa-basedcompanythatoperatedtheship. “Roberto,ItooktheshippastGiglio.Palombowastellingme‘sailclose,sailclose’.Ihittherocks.I’mdestroyed,I’mdead,don’tsayanythingtome.’’ FirstmateGiovanniLaccarino,saidthattheCaptainputhisheadinhishandsandtoldtheofficersonthebridge:“Imessedup”. Duringthetrial,MrLaccarinotoldthecourtthathewasusinghisPlaysta5oninacrewmate’scabinwhentheshiphittherocks.Herushedtothebridge,whereinstrumentsshowedthattheshiphadlostpropulsion,butwassurprisedatthecaptain’scalmdemeanour. "Hewascompletelylost,"hesaid."Hewasoutofhisrou@nementalstate.Hewasundershock.Hewasn'tthepersonIknew." MsCanessa,thenavigator,alsosaidCaptainSchetnoshowedchronicindecisionashecontemplatedthelossofhisship. “Iwassayingtohimveryinsistentlythatheneededtodosomething,togivethegeneralemergencysignal,buthewastellingustowait,”shetoldthecourt.“evenasofficers

emergencysignal,buthewastellingustowait,”shetoldthecourt.“evenasofficersscreamedathimtodoso”,saidCanessa."Hetoldustowait,hedidn'tgiveusanswer,"shesaid. Capt.DeFalcooftheCoastGuardstatedthat;“followingthecontactthattookplacebetweenthepersoninchargeoftheCompany,MrPaoloMaqesipresentintheopera@onsroomandCapt.ScheSno,itwasdecidedtosendanotherperson,subsequentlyiden@fiedasOfficerMar@noPellegrini,sincethecaptaindidnotappeartobelucid.” ‘Videoofthechaosonthebridgethatnightlatersurfaced,andwhileitshedsliqlelightonScheSno’stechnicaldecisions,itsaysworldsabouthisstateofmind.“Fromthevideo,youcantellhewasstunned,”saysJohnKonrad,aNau@calAnalyist.“Thecaptainreallyfroze.Itdoesn’tseemhisbrainwasprocessing.” InaninterviewwiththeNaplesdailynewspaperIlMaSno,GianlucaMarinoCosen@no,medicalofficeronboardtheCostaConcordia,alsomen@onsthelongdelaybeforeabandoningshipandaccusesScheSno,"Everyonewaslookingforthecaptain.Asadoctor,Ithoughtheappearedupsetandnolongerra@onal.Hedidnothingtocoordinatetherescue.Personally,IwasverysurprisedtoseeScheSnooutofuniformonthequaysideaVermidnight.Duringtherescueopera@onsonlandIcouldbeiden@fiedeasilybecausebecauseofmyuniform.” TheevidenceoverwhelminglysuggeststhatCaptainSchetnowassufferingfromtrauma5cshocksyndromeandwasinamentalstateofdenialthereforeobviouslyincapableoftakinganydecisiveac5on.Thiswassupportedbyvideoevidenceofthechaosonthebridge.Asthiswasrecognisedbytwoofficersonthebridge,thenthisshouldalsohavebeenrecognisedbytheStaffCaptainwhowasalsopresent.ItwasthereforehisdutytoassumecommandwhiletheCaptainwasinthisstate.Theques5onmustbethenwhydidn’the? TheCaptain’smentalstateandtheStaffCaptain’sfailuretoassumecommandwasnevermen5onedordiscussedattheini5alinquiryorthetrialoreventheappeal.Yetthiscontributedtothedelayinsoundingthegeneralalarmcallingalltotheirmustersta5onsandul5matelythedelayinabandoningthevesselandtothedeathsandinjuriestothepassengers.ThisdelaywasthecentralpartofthechargesofmanslaughteragainsttheCaptain.

214533masterordersW/Tdoorsclosed.

21:46:05theemergencygeneratorthatprovidespowerstartsonlyfor41seconds.:

21:52TheChiefEngineerandElectricalOfficertriedandfailedtostarttheship'semergencydieselgenerator. Passengerannouncement ShortlyaQerwards,passengersweretoldthattheshipwassufferinga"blackout",butthatthesitua5onwasundercontrol.Followingthemassivejoltandnoisecausedbytheoriginalcollision,andthesubsequentblackouttheini5almessagetothepassengersviathepublicannouncementsystemwasasfollows; “Ladiesandgentlemen,youraqen@onplease,IspeakonbehalfoftheCaptain,wearecurrentlyinablackoutexperienceanelectricalfault.Atthispointthesitua@onisundercontrol”. Atsomepoint,passengersandcrewstartedspontaneouslyputngonlifejackets,andassemblinginthelifeboatareas.Again,amemberofthecrew,underthecaptain’scommand,informedthepassengersthat;“Wekindlyaskyoutoreturntoyourcabinorifyoupreferyoucanstayinthelounges.Oncewe’vefinishedaddressingtheproblemthatwehavetheelectricalproblemwiththegeneratoreverythingwillbefine.Thisiswhywehavetheseemergencylights.Everythingisundercontrol.Ifyouwishtoremainhere,that’sfinebutIkindlyaskyoutoreturntoyourcabinandstaycalm”.

cabinandstaycalm”.Thiswasdespitethefactthattheshiphadano5ceablelistanditwouldhavebeenobvioustomostonboardthattherewasmorethanjustanelectricalproblem.

21:55Bridgeadvisedatleastthreecompartmentsflooded.thecomputersoQwareusedforthecalcula5onofstability(NAPA),despitethededicatedUPS,isnotworking.

1stDeckOfficerandtheDeputyChiefEngineerduringtheinspec5onmeetatDeck0andcon5nueinspec5onofthewater5ghtcompartments.ArrivedatthedeckAtoverifythatthereisaleakageofwaterfromthewater-5ghtdoor24andthendeducethatthe4compartmentisflooded.

Therefore,thefloodedcompartmentsappeartobeatleast4(compartments4,5,6and7)

Within10minutesofthecollisiontheChiefEngineerhadinformedthepersonnelonthebridgeaboutfloodingintwoWTC(No.6&7).The2ndEngineer’sreportonthefloodinginWTCNo.5waspassedontothebridge.TheChiefMatetheninformstheStaffCaptain(shipssecond-in-command)aboutfloodinginWTCNo.5,6&7.

21:57:58theMasterhasafirsttelephonecontactwiththeCompanyandreportstotheFleetCrisisCoordinatorthattheshiphitarockwiththeleQsidetowardsthestern,reportsthedynamicsofthecasualty,butnottheactualfloodedcompartments.

TheFleetCrisisCoordinator,receivedthisinforma5on,incorrectlyiden5fiesthefloodedlocalinthatoftheprincipalelectricalengines(localPEM-compartment5)andnotinthecompartment6,wheretheDieselGeneratorsandthemainelectricalpanelaresituatedandreferstheinforma5ontotheTechnicalInspectoroftheshipwhichislocatedattheheadquartersoftheCompany.

22:07,theship,contactedbytheOpera5onsRoomoftheCivitavecchiaHarbourMaster,

statesthatthereisonlyablack-out,butthatthesitua5onisundercontrol.

FirstReport Somewhereontheship,anItalianwomannamed,ConceTaRobi,tookouthercellphoneanddialledherdaughterinthecentralItaliantownofPrato,nearFlorence.Shedescribedscenesofchaos,ceilingpanelsfalling,waitersstumbling,passengersscramblingtoputonlifejackets.Thedaughtertelephonedthepolice,theCarabinieri. RescueServicesResponse ThecoastGuardHeadquarterofLivorno,hometo2ndMRSChasresponsibilityoveranareacorrespondingtothesurfaceoftheregionofTuscany.R.S.C.DepartmentofLivornoistheelementoforganiza5onthatat22:06receivedthenewsofunspecifiedproblemsonboardtheCostaConcordiabyPratoCarabinierista5on.Thesewere,inturn,informedbythemotherofashippassengerthatreportedthecollapseofapor5onofaroomceilingandalsospokeaboutanordergiventopassengersforwearinglifejackets.ItistheM.R.S.C.thathaskeptintouchwiththeshipandcoordinatedSARopera5onssincethecasualtyoccurredintheSRRofresponsibility.Theysentitsownnavalunitsandcoordinatedinterven5onofnavalandairunitsbelongingtootherItalianCoastGuardandothersgovernmentandprivate. Followingthis,thecoastGuardHeadquarters,throughtheopera5onsroomofLivorno,establishedafirstcontactwiththeship,whichwasfollowedbymanyothers,onVHFchannel16,inwhichthecoastGuardreceivedmisleadinginforma5onfromaboardtheship,apparentlyintendedtominimizetheriskonboardaswellasthetruescaleoftheemergency. Nevertheless,assoonasthemajorscaleoftheemergencybecameapparent,theSARchainwasimmediatelyac5vated,underthecoordina5onofthe2ndMRSCopera5onsroom,whichrespondedtotheemergencyaccordingtothedulyprovidedregula5onsbyorderingthede-rou5ngofmerchantshipsintransit,alsoiden5fiedbyAIS(Automa5cIden5fica5onSystem),andthealertanddispatchofvesselsofthecoastGuardandothergovernmentaldepartments,aswellasrescueaircraQandrescuetugs,un5lreachingthefinalmaximumdeploymentaslistedbelow: •14merchantvessels(divertedinthecourseofnaviga5onorsentoutofthenearby

•14merchantvessels(divertedinthecourseofnaviga5onorsentoutofthenearbyharbours);•4tugboats;•26patrolboats;•8helicopters. 22:09JudgesatthetrialplayedarecordingofacallbetweenSchetnoandtheengineroom5medat10.09pm,inwhichthecaptainasks,"Butwherehavewemadecontact?",onlytobetold,"Captain,hereeverythingislost." 22:10TheFleetCrisisCoordinatorcontacttheshipTechnicalInspectoragaininforminghimthattheshipisinblack-outandthereiswatereveninthesterngeneratorroom.

22:10to22:15thelistgoesfromtheporttostarboard.

22:10:36theNAPA(SoQwarestability)isrunningandisoperatedbytheRadioOfficersand3rdDeckOfficer.Itsopera5on,however,isnotconstant.

22:11theshipisprac5callymo5onless(0.3knots),beginsthentodriQandtoshiQthebowtostarboard,headingSWforthecombinedac5onofwind,NE,andrudderposi5onedalltostarboard.

22:18EngineControlRoomreportstothebridgelostallautoma5onandthatnosystem(balancingpumps,bilge,masses,etc..)canbeputintoopera5on.Thedataisreportedtothebridge.

22:18:19MasterrefersbyphonetotheFleetCrisisCoordinatoroftheCompanythatthereareproblemswiththeemergencydieselgenerator,alsoreportsthatthereareatleasttwocompartmentsflooded,thoseofdieselgenerators(compartments6and7);awareofnothavingpropulsion,heassumesthattheshipcansurvivewithonlytwocompartmentsflooded.

2220(35minutesaQerthecollision)theCaptainiss5llaskinghowmanycompartmentsarefloodingtowhichtheconfirma5on“3compartmentsflooded”isgiven.ItisnotclearwhenorifthebridgeteambecameawareoffloodinginWTCNo.4&8.AgainthisdisplaystheCaptain’smentalstateinnotrecognisingtheinforma5onthathasbeenpassedtohimindica5ngthattheshipisfloodingbeyondsaving.

22:20:45MasterisupdatedaboutthefloodingthataffectsthePEM,themainenginesandsterngeneratorsone,twoandthreethatisthecompartments5,6and7.

22.21TheDPAreachedamanageroftheCompanybytelephone,consideringhimtheCMD(andthelaTerdeclarestobesuch),toinformthispersonaboutthesitua5on.Butaccordingtotheabovemen5onedprocedure,theCMDwasadifferentperson,whowasnotimmediatelyinformed.

22:22:22Theshipcontactstheopera5onsroomofCivitavecchiaCoastGuardaskingtheassistanceoftwotugsduetoabreach,itisreportedthatthesitua5onisundercontrolthankstothecompartmentaliza5onoftheship.

22:25:15(VDR)theTheCaptain,contactedbyMRSCLivorno,statesthattheshiphasahullbreach,ontheleQside,thatiscausingagradualheel,thatonboardtherearedeadorinjuredpeopleandheonlyrequirestheassistanceofatug.AtthispointM.R.S.C.Livornoisreadytotakeonthecontrolofemergencyopera5ons:fromPortoSantoStefanoleavestheSARunit"CP803"leavesPortSantoStefano,andcrewsofallavailableSARpatrolboatsarealerted.Isdecidedtocallonallshipsinzonethatcanprovideassistanceandiden5fies,throughtheA.I.S,shipsALESSANDROF."and"GIUSEPPESA".

22:26:38theMastercontactsthecompanyupda5ngitontheactualsitua5on.

22:28:36The1stEngineerreportstotheECRthattherearecoolingproblemstotheEmergencyDG

22.29.27ChiefEngineerordersstaffpresentinDGEmergencyroomtore-startit.ThisaTemptfails.

22:30:08somepassengersenterlifeboats

22:30:07theChiefEngineer,suggeststotheMastertoabandonship.

22.31.33enginestaff,incleardanger,leavetheECRwiththepermissionoftheSafety

22.31.33enginestaff,incleardanger,leavetheECRwiththepermissionoftheSafetyOfficerandmovetoDeck4.

22:33:26the"generalemergency"alarmisraised.

TheGeneralEmergencyAlarm

Thegeneralemergencyalarmismeanttoannouncetothecrewthattheorganisa5onofmustersta5onswasnowtocommence.Itisbasicallyapreparatoryordergiveningood5metoprepareallreadyforabandoningthevesselinanorderly,disciplinedandcalmmanner.Atthesame5meallrelevantemergencyequipmentwastobepreparedreadyforuse.Thiswouldincludethelifeboatsbeingloweredtotheembarka5ondecks,enginestested,crewstandingbytoorganisethemusteringandembarka5on,theelderlyorinfirmpassengerstakencareofandcabinssearchedforpassengerswhomaynothaveheardthealarmsornotunderstoodthemeaning.

22:35:53theMasterdecidesto"abandonship”.

223605,passengersorderedtogototheirmustersta5on.

Therehasonlybeenanintervalof2minutes27secondsbetweenthegeneralalarmforthecrewandtheorderforpassengerstogototheirmustersta5on.Thisdoesnotgivethosewiththedutyofdealingwiththepassengers,sufficient5metoprepareforthemusteroreven5meforthemtogettotheirdutysta5ons.Thesitua5onwasaggravatedbythefactthatnopreliminarymusterdrillhadbeenheldforthe696passengerswhoboardedthevesselinCivitavecchiapriortosailing.WhilethiswasnotillegalandtheSOLASrequirementwasthatthisshouldbedonewithin24hoursofsailing,thismeantthatthesepassengers,especiallythoseexperiencingtheirfirst5meonaship,weres5llnotfamiliarwiththelayoutoftheship,notonlyastowherevariousmusterpointswereorhowtogettothem,butalsowiththecorrectwearingoflifejacketsorevenwherethelifeboatsandlife-raQswere.

PassengerswhoembarkedatBarcelonarecountedaninadequatedrillconsis5ngofavideoandlackinganyprac5calinstruc5onbythecrewintheloungewhereitwasperformed.

Whenanystudyofdesignofbothshipandequipmentismade,theprimeconsidera5onisthesafetyofthoseonboardand,inthefinalanalysis,tohavetheabilitytoabandontheshipsuccessfully.Forthisweshouldadoptaworsecasemodel.Obviouslyahurricanesitua5on,whiletheore5callypossible,cannotbeimposedoncompaniesasthestandardsrequiredwouldbeprohibi5vebutamediancanbeassumed. Lifeboats. Onpassengercarryingvessels,lifeboatscans5llonlybeprovidedfor75%ofthepersonsonboard. This places the cruise ships in the same posi5on of the Titanic. Putng this inperspec5ve on the costa Concordia the night of the sinking, therewere 4229 persons onboardthevessel;3206paxand1023crew.

Port Starboard12 x 150 person lifeboats1 x 60 person lifeboats33 x 35 person life rafts1 x 25 person lift raft

12 x 150 person lifeboats1 x 60 person lifeboats34 x 35 person life rafts1 x 25 person lift raft

The13boatsonthestarboardsideoddnumbered1to27withnonumber13.

The13boatsontheportsidenumbered2to26.

Presuming that thepassengersonboardhavepriority for lifeboats this gave a theore5calcapacityfor1860passengersoneachsidegivingatotalcapacityof3720.

AccordingtotheLSAcode2010,thelifeboats,whichareallowedtocarryupto150personsmustbeboardedin10minutes.Whichis15perminuteorifyoulike,apassengerevery4seconds.Thisisimpossible,especiallywithenclosedlifeboatswhichareboardedthroughnarrowopenings.

narrowopenings.Asthewholemarineindustryknows,whattheclasssocie5escer5fytheboatstocarryandtherealnumberscanbequitedifferentfigures.

Thespaceandweightalloca5ondefinedinthe2003IMOLifeSavingAppliance(LSA)Code,underwhichthisvesselfalls,of430mmbuTockwidthand75kgaverageweightwereestablishedmanyyearsago,beforepeoplestartedtogrowtallerandexpandtheirgirth.Formanyyearsnow,mostsurvivaltrainingschoolshaverealizedthatithasnotbeenpossibletoloadanyofthelifeboatstofullcapacity,evenwhenthestudentswerejustwearingworkcoverallsandnolifejackets. ‘In2005,atypicalmari@meoffshoreoiltrainingclassof41peoplewasmeasuredinDartmouth,NovaSco@a(39male,3female).Theiragesrangedfrom18–56years.Over70%ofthegroupmeasuredinworkclothesonlyexceededthe430mmspacealloca@onatthehips,andtheshoulderswereevenwider.Theaverageweightwas87kg,12kgovertheIMOspecifica@on.’ Ref;Ahumanfactorsstudyonthecompa@bilitybetweenhumananthropometry,shipabandonmentsuitsandthefitinarepresenta@vesampleoflifeboats–Apreliminaryreporton41subjects. Proceedingofthe4thInterna5onalCongressonMari5meTechnologicalInnova5onsandResearch,Barcelona,Spain,95-102.Brooks,C.,Kozey,J.,Dewey,S.andHoward,K.(2005). Ifthiswereappliedthenthetotallifeboatcapacitywouldbereducedbyapproximately15%andwouldnowbe3162,ashor~allof44passengers. Life-raUs Life-raQshavebeenalargestepforwardinsavinglifeatseahowevertorelyonlife-raQsaslifeboatreplacementiswrongandunsafe.Suchaninterpreta5onisnotplacedonconven5onalmerchantshipswherethelifeboatcapacityisrequiredforallonboard. Thecapacitycriterionoflife-raQsisthesameasthatforlifeboats. Thelegisla5onstates; ‘thenumberofpersonshavinganaveragemassof75kilogrammes,allwearingeitherimmersionsuitsandlifejacketsor,inthecaseofdavit-launchedliferaVs,thatcanbeseatedwithsufficientcomfortandheadroomwithoutinterferingwiththeopera@onofanyofthelife-raV’sequipment.’ Aspreviouslystated,theaverageweightwasproventobe87Kgwithoutanyextraweight.Iftheweightofimmersionsuits,wetclothingandlifejackets,Isuggestthataconserva5vefigurecanbeassumedtobeatleast90KgwhichmeansthatthecapacityisnowreducedbyonefiQhofthatstated.Thusa25personlife-raQisnowonlycapableofholding20personsanda35personlife-raQonlycapableofholding28persons. PassengerCapacity OntheCostaConcordia,therewere67x35personlife-raQswithatotalcapacityoncetheonefiQhisdeducted,of1878,and2x25personlife-raQswhichwiththeonefiQhdeduc5ongiveacapacityof40. 23ofthe26lifeboatswerelaunchedas3ofthelifeboatdavitsdidnotfunc5on.thelaunchingcrewexperiencedproblemswiththeerec5ngofthetelescopicdavitarms.ThetelescopicdavitshadquiterecentlybeenmodifiedinFinland,bytheinstalla5onofanextra"powerpacket"ofcompressedCO2"topushthedavitsout",andthissystemwerereportedtohavefailedforsomelifeboats.

tohavefailedforsomelifeboats.Lifeboatsmustbecapableofbeinglaunchedwhentheshiphasalistof20degreesineitherdirec5on.

OftheliferaQs,only3oftheships69raQswerelaunched.

Theselaunchingfiguresmeansthatthetotalcapacityofthefunc5oninglifeboatswas3270Addtothisthethreelife-raQswithacapacityof105.Thisgivesagrandtotalof3375seatsforatotalof3206passengersand1023crewgivingagrandtotalof4229.Thisleavesashor~allof715.IftheDartmouthfiguresofincreasedsizeweretobeapplied,thenonly2869seatsareavailablewhichleavesashor~allof1360. Followingthesefigures,itisinteres5ngtonotetheremarkablyclosefiguretotheshor~allof1270personswhowererescuedbyshorerescueservicesinterven5on. 2230.Reportedthatsomepassengershadalreadystartedtoenterthelifeboats.

223605,passengersorderedtogototheirmustersta5on. TheIMOLifeSavingAppliances(LSA)Code4.4.3.1states:“Everypassengershiplifeboatshallbesoarrangedthatitcanbeboardedbyitsfullcomplementofpersonsinnotmorethan10minutesfromthe@metheinstruc@ontoboardisgiven.”

Thistranslatesto15personsperminuteorifyoulike,apassengerevery4seconds.Again,asthoseintheindustryknow,thisisimpossible,especiallywithenclosedlifeboatswhichareboardedthroughnarrowopenings. 22:36:34LeghornCoastGuardsta5onadvisedthatthelistisgrowinganddeclares"DISTRESS".

2239ThefirstpatrolboatreachedCostaConcordia

22:40,withtheshipalreadyres5ngontheboTom,‘distress’wasissuedthroughINMARSAT‘C.’

22:47.22TheCaptainordersdroptheanchor.Thisorderwassuperfluoustothesitua5onastheshipwasalreadyres5ngontherocks.Photostakenlaterbydiversshowclearlythattheywerelyingflat,withtheirflukespointedupward;theyneverdugintotheseabed,renderingthemuseless.

2254TheCaptainorderstheabandon-shiporderthatwasgivenfirstinEnglishoverthepublicaddresssystem

TheAbandonmentBegins

Theopera5on,infact,hadalreadybegun:Arrivingonsceneat2239,localpolicereportedthreelifeboatsalreadyinthewater.SOLASregula5onsstatethatIfnecessary,theabandonmentphasecanstartbeforeallpassengershaveassembled.Manypassengerswerereadytoboardthelifeboatsmuchearlierintheevacua5onprocessbutwerepreventedfromdoingsobythecrewwhowereawai5ngthecaptainsabandonshiporder.

Notallthelifeboatsandlife-raQswerereadyby22.54hrs.Threeportlifeboatswerenotloweredtotheembarka5ondeckforpassengerstouseandnoliferaQswerelaunchedwithanycrewinside.Threelifeboatdavitsdidn'twork.

WarmClothing UnderSOLAS,allonboard,passengersandcrewarerequiredtohavewarmclothingandtowearthisatmuster,inorderthattheyrecognisetheneedtowearthisforabandonmentandfortheship’screwtocheckthattheyhavethis.

InCarnivalcruisegroup,thereisnopolicyforadvisingpassengerstobringwarmclothingwiththemnoraretheycheckedatmusterforwarmclothing.

CrewTraining

AllcrewmembersassignedtomanagethelifeboatsmusthavebeentrainedandreceivedaCer5ficateofproficiencyinSurvivalCraQandrescueBoat(MAMS)

Asrequiredbylegisla5on(SOLASregula5on10Chapterlllandar5cles205and209ofpresiden5aldecree435/91),twocrewmemberswereassignedtoeachlifeboatasLaunch

presiden5aldecree435/91),twocrewmemberswereassignedtoeachlifeboatasLaunchChiefandLaunchDeputy.

Ofthe52personsassigned35hadtherequiredlegalcer5fica5on.12crewhadMAMScer5fica5onissued5yearsearlierwithnocurrentvalida5onand5hadnoMAMScer5fica5on.

SOLASRegula5on10chapterlllstatesthateachlifeboatmustbecrewedwithcrewcapableofopera5ngthemotorandmakingminorrepairs.Thiswasnotmetforboats25and26.

SOLASRegula5on10Chapterlllrequiresasinglepersontomanageeachofthelife-raQs.

RaQ34didnothaveanyoneassigned.

Ofthe48crewmembersassignedtomanagethelife-raQs,only13hadvalidMAMScer5fica5on,4hadcer5fica5onover5yearsoldwithoutvalida5onand31hadnotrainingcer5fica5onatall.

Thismeantthatforthelife-raQs,only12raQsweremanagedbytrainedcrew,3raQswithcrewwithexpiredcer5ficates,18bycrewwithnotrainingcer5fica5onandoneraQwithnocrewatall.Thatcouldexplainthefailuretolaunchonly3ofthelife-raQsonboard.

TheMaster,aQeradrillforabandoningshipheldonthe15October2011,warnedtheCompanythattheperformanceofhiscrewwasdecreasingandshowedcri5calfindings.TheSafetytrainer,duringtheinterviewcarriedoutbytheLeghornMari5meAuthority,confirmedtohavefound,whenjoining,theunalignedtrainingofthecrewandthelackofanyevidencerelatedtothetrainingcarriedoutonboard,accordingwiththeISMprocedure,bythesamecrew.HeimmediatelyinformedtheMaster,andtheMasterreportedtohimthattheCompanyaddressedtheshipmanagementforimprovingthetrainingprogramonboard.

DuringaCompanyauditinthelastweekofJuly2011,theCompanynotedtheunsa5sfactoryperformanceofthecrewinthedrill

SeveralpassengersfromtheUSAtes5fiedabouttheinadequatepreparednesswiththesafetyproceduresshowedbycrewmembersassignedtomanagetheabandonship.Similarevidencescanbefoundintheinterviewstothepressgivenbyseveralpassengers.

22:57:41hoursTheCaptaininformstheMRSCLivornohehasorderedabandonship. 22:58initsfinalposi5on.Pointofsinkinginposi5on42°21'50.76"N010°55'17.40"E(IsoladelGiglio-CaladelLazzareTo). 23:00TheCrisisCommiTeewasformedbyCompany. 23:10thepatrolboat"G.104"tellsMRSCLivornothelifeboatsbegintomoveandheadfortheharbourofGiglioisland,theliferaQs,however,aretowedbytheSARUCGPortoSantoStefanoandplacedalongsidetheferry"Aegilium".Othervesselsconvergeinthearea. 23:16:36TheMasterorderseveryoneonthebridgetogotothebridgelifeboatsandtaketheirradios. 23:19:This5mewasthelastrecordedvoiceoftheCaptainfromthebridgeexceptfortheSecondMasterthatstaystocoordinatetheevacua5on.Hislastcommunica5onwasrecordedat233255. 23:32:56theBridgeisabandonedbytheSecondMaster(StaffCaptain) 23:35MRCCRomecontactstheFCCwhoannouncedthattheabandonmentisalmostcomplete.Thiswaswronginforma5on. 2337Thelistontheshipnowreaches20degrees.WiththedepartureoftheStaffCaptain,thebridgeisnowabandoned.

4THPHASE.CHAOS

23:38hoursMRSCLivornocontacttheship'sMasterbyphonewhoreportsthereiss5llabout200/300peoplepassengersandcrews5llonboard.300/400wasthees5matefromPatrolboat"G.104".Infact,thises5matewasconsiderablybelowthoseremaining. 23;45Ahelicopterarrivedfromthemainlandat11:45.Itcarriedadoctor,aparamedic,andtworescueswimmersfromtheVigilidelFuoco,Italy’sfire-and-rescueservice.Theswimmersboardedapolicelaunch,Beforethem,theConcordia,nowlis5ngata45-degreeangle,waslitbyspotlightsfromadozensmallboatsbobbingatitsside.Thelaunchheadedfortheportbow,wherepeoplehadbeenjumpingintothewater.Asitapproached,aFilipinocrewmanonahighdecksuddenlyleaptfromtheship,fallingnearly30feetintothesea.Hewastakenashore.Itwasthefirstofsixtripsthetwodiverswouldmakeinthenexttwohours.Onthesecondtriptheypulledina60-year-oldFrenchwomanfloa5nginherlife

jacketnearthebow.NexttheypulledinasecondFrenchwomaninanadvancedstateofhypothermia.“Shewasshakinguncontrollably,”Scipionirecalls.“Shewasconscious,butherfacewasvioletandherhandswerevioletandherfingerswerewhite.HercirculatorysystemwasshuSngdown.Shekeptsaying,‘Myhusband,Jean-Pierre!Myhusband!’Wetookherashoreandwentback.”

OntheirfourthtriptheyliQedanunconsciousmanintothepolicelaunch;thiswasprobablythewoman’shusband,Jean-PierreMicheaud,thenight’sfirstconfirmeddeath.Hehaddiedofhypothermia.

Twofactorsaffectthoseinthewater,Hypothermiaandthelifejacketsthemselves.

Hypothermia.

WATER TEMP WATER TEMP EXHAUSTION/UNCONSCIOUSNESS

EXPECTED TIMEOF SURVIVAL

32.5°F Less than 15 mins 15 to 45 mins0.28°C to 4.4°C 32.5°F to 40°F 15 to 30 mins 30 to 90 mins4.4°C to 10.0°C 40°F to 50°F 30 to 60 mins 1 to 3 hours

10.0°C to 15.6°C 50°F to 60°F 1 to 2 hours 1 to 6 hours15.6°C to 21.1°C 60°F to 70°F 2 to 7 hours 2 to 40 hours21.1°C to 26.6°C 70°F to 80°F 3 to 12 hours 3 hours to indefinite

>26.6°C Over 80°F indefinite ThewatertemperatureinGiglioislandisaround15cinJanuary.Ascanbeseenfromthechartabove,thisallows1to2hoursbeforeunconsciousnesssetsin.However,thisisalsoaffectedbytheageofthepersoninthewater.Theoldertheyaretheless5mecanbeallowed.Itisdifficultatnighttojudgethedistancefromlandtheshipmaybeandforanolderperson,aQerthefirstminutes,as5rednesssetsin,theslowertheabilitytoprogressinwaterbecomes. LifeJackets TheSOLASspecifica5onforlifejacketsareinadequateforallshippingregardlessoftype.Thestandardlifejacketcaninjurethewearerbyrisingupandpossiblybreakingtheneck.TheSOLASlifejackethaschangedliTlefromtheTitanicincidentwhenbodieswerefoundwithbrokennecks.Crotchstraps,whichwouldpreventthisfromhappening,arenotrequired.SomepassengerferrieswithMassevacua5onsystemsnowcarrylifejacketswithcrotchstraps. Thereisnohoodtopreventheatlossthroughtheheadorfacemasktokeeptheor-nasalcavi5escleartopreventdrowningbywaterinhala5on. Thetermlifejacketisamisnomerastheyarenotjacketsanddonotgiveanywarmthprotec5ontothebody.Thebulkinessofthesejacketsdoublethespacerequiredduringevacua5onandmustering. ‘Currently,thesepassengersareeachissuedalargebulkySOLASapprovedinherentlybuoyantlifejacket.Anyonemakingtheirwayfromacabintotheupperdeckforabandonmentwhentheshipislis@ngorfloodinghasanimpossibletasktodothiswhenwearingoneoftheseortryingtodragitbehindthemalongthecompanionways,stairwellsandstairs’ Markle,R.L.AStudyofLifesavingSystemsforSmallPassengerVessels.USCGStudyMarch

Markle,R.L.AStudyofLifesavingSystemsforSmallPassengerVessels.USCGStudyMarch29,1991. ‘Anyonewhohasspentany@meinopenwaterwithanywavesplashandwindunderstandsthehugeimprovementinperformancewiththeaddi@onofafaceshieldandcrotchstrapAllwhoaqendedtheexpertmee@ngwereinfavourofstronglypromo@ngfaceshieldsandcrotch strap’ TheconferenceondrowninginAmsterdaminJune2002. Jumpingfromtheship TheSOLAStrainingmanual3.2.statesthatthefollowingprocedurebefollowedwhenjumpingfromashipwearingthestandardlifejacket. CheckthewaterfordebrisHoldyournoseandcoveryourmouthwithyourleVhandChecktoseethelifejacketis@edandallthestrapssecuredCrossoveryourleVhandwithyourrighthandandholdontothelifejacketcollarHoldyourelbowsdowntothesideKeepthelegstogetherasyoujump.Crossovertheankleswillhelpwiththis. AlthoughthisisaSOLASrequirement,passengerswerenotinstructedinthisattheirmustersta5onsorbynoticesincabinsandonthedecks. Finally,andmostimportant,fromtheSOLAStrainingmanual; ‘Therecommendedmaximumheightforjumpinginthewaterwithalifejacketonis4.5meters.’ AlthoughmostoftheopendeckspaceontheCostaConcordiawereabovethisheight,passengerswerenotinstructedaboutthisnorwereno5cespostedonthosedecksabovethisheightorincabinswarningofthedangers. AsofFriday,January13th,2012,RINAsuspendedtheship'sclassstatusci5ngothercircumstancesasthereason. 14.01.2012 00:00Theshipincreasesthelisttostarboardsuchastocreatesignificantdifficul5esinembarkingonlife-savingcraQ,especiallyontheportside.TherearenowthreegroupsofpeopleleQonboardsituatedonthebow,inthecentreandatthestern. Diversteamsarealsoac5vatedbyLivornoMRSC. 00:15Despitethelackofleadership,confusedanduntrainedcrewmembers,thefailureof3lifeboatstooperatecorrectly,thefailureoftheemergencygeneratorcausingthelossofallpowerexceptforbaTeryemergencyligh5ng,almosttotalfailureofthelife-raQs,andhundredsofpassengersontheedgeofpanic,inthisfirststageoftheevacua5onbetweenapproximatelytwo-thirdsofthoseonboardtheship,somewherebetween2,500and3,300arenowofftheship,assistedconsiderablybythecloseproximityoftheharbourwhichallowedlifeboatstoreturntotheshipformoresurvivorsandthemanyshoreboatsassis5ngwiththeabandonment. Ontheship,atthisstage,anyaTemptatorganisedabandonmentwasgone.Theshipwasnowcapsizingonherstarboardsideandtheresul5nginclina5onmadeitextremelydifficulttoembarkthepassengersonsurvivalcraQontheportside. Owingtothisandthefactthattherewerenowsurvivorsintheseaandwithpartsoftheshipslowlysubmerginginthewatertherewasaneedtobeginsearchandrescue(SAR)opera5onsinthesubmergedpartofthehull,the2ndMRSCgavethefollowingorders:

AllnavalmeansreadytooperateinSARopera5ons,includingtherescueforcesdroppingtheirraQsintheseaaswellasboatsandfastrescueboatsweretorescuethoseinthewater. Alldiversweretobeemployedintheextrac5onofanypassengerss5lltrappedintheircabinsoraccommoda5onoftheship. Further,aQerrealizing,uponcontactviaphonewiththeCaptain,thattheshiphadbeenabandonedbyalmostalltheofficers and crew,theLivornoopera5onssta5onorderedthedispatchofaircraQrescuemeansovertheshiptorescuethepassengers. ShoreRescueservicestakeovertheAbandonment Inconsidera5onofthefactthatalmostalltheofficersandcrewhadabandonedtheship,theMRSCeffec5velyanduniquelytookovertheabandonmentoftheshiparrangingthepassengersonboardtobeledtoashipsladderloweredinthesternareatoallowamorerapidandlargerrecoveryofthesurvivorsbytherescuecraQ. AlthoughthemajorityofofficershadleQtheship,MarioPellegrini,thedeputymayorofGiglio,actuallywentontothesinkingshipandassistedwiththerescueeffort,ashecouldnotfindanyseniorofficersonboard"Therewerealotofpeoplewhowantedtohelpbuttherewasno-oneguidingthem;therewasnobodydirec@nganything....Atthebeginningtherewasn'tmuchpanic,justalotofconfusion.Peopledidn'tknowwhattodobuttherewasnorealfear.ThenIwentontheright-handsideoftheshipanditstarted@l@ngtowardsthesea.Bigpartsoftheshipweregoingunderwater-thenpanicerupted,peoplereallywerescared." Withthearrivalonloca5onofrescuepatrolboatCP305,sentfromCivitavecchia,duetothegreatersizeofthispatrolboatanunusualbutveryeffec5verescuetechniquewasdevised,usinganotherpatrolboattopushthelargerboatundertheladder.OnceonCP305,theywerethentransferredtothesmallerthrus5ngboatwhichwhenfulldepartedtobereplacedbyanotherboat.Thisallowedforthe700remainingpassengersandcrewtoberescued.ThistookaliTlelessthan3hours. WitnessesStatements Astothestateofaffairsonboardtheshipatthisstage,wearereliantonwitnessstatements,allofwhomaresufferingahighdegreeofstress.Forthisreason,carehastobetakenastotheirrecallofevents. ‘itishardtogeneralizeabouttheeffectsofstressoneyewitnessmemory.Thefindingsaresomewhatmixed,andtheexplana@onforstresseffectsonmemoryisfarfromclear,makinggeneraliza@ondifficult.Moreresearchisnecessarytoresolvethisuncertainty.However,itisclearthat,overall,highlevelsofstressharmeyewitnessmemoryinmorewaysthantheyhelpit.’ Aharonian,AniA.andBornstein,BrianH.,"StressandEyewitnessMemory"(2008).FacultyPublica5ons,DepartmentofPsychology.UniversityofNebrasca-Lincoln. Howeverascanbeseen,thegeneralaccountssupporteachotherastothestateofaffairsonboardtheship. GiuseppeGramma5cotoldreportersthatsomepassengers,includinghimself,seizedtheini5a5vetobeevacuated,becauseordersweren'tforthcomingfromtheship'sofficials.

"Justthink,ourlifeboatwasloweredintothewaterbecauseweinsistedthatitbedonewithoutanorderfromthecaptain,"Gramma5cosaid.

Acouple,whowerecelebra5ngtheirfourthweddinganniversary,wereea5nginMilano

Acouple,whowerecelebra5ngtheirfourthweddinganniversary,wereea5nginMilanowhentheordealbegan.MrRodford,46,a5lerandplastererfromRochesterinKent,said:“Itwasourfirstcruise.Ibookeditasasurprise.Wewereatdinnerwhentheshipseemedtohitsomethingandstartedswayingfromsidetoside.Suddenlythelightswentoutasifthegeneratorhadpackedin,andfromthenonitwasbedlam.“AVeralongwait–around10.15pm–wewereledouttothedeckbysomewaitersandtakentolifeboatnumber12,butitwouldn’tlowerdowntothewaterbecausetheleanontheshipwassobad.“Wehadtoclimboutofthatoneandclimbbackupontothedeckandslidedownitswidthtowardsthesideoftheshipthatwasleaningclosesttothewater.Fromtherewemanagedtojumpontotheboqomofanupturnedlifeboatandthenontoanotherlifeboatthatwass@llupright.Therewereabout30ofusthatgotintoit.”Itwas12.30amwhentheyreachedland. Bynowtwoswimmershadboardedapolicelaunch,Beforethem,theConcordia,nowlis5ngata45-degreeangle,waslitbyspotlightsfromadozensmallboatsbobbingatitsside.Thelaunchheadedfortheportbow,wherepeoplehadbeenjumpingintothewater.Asitapproached,aFilipinocrewmanonahighdecksuddenlyleaptfromtheship,fallingnearly30feetintothesea.HewastakenashoreandthenthelaunchreturnedtotheshipItwasthefirstofsixtripsthetwodiverswouldmakeinthenexttwohours.Onthesecondtriptheypulledina60-year-oldFrenchwomanfloa5nginherlifejacketnearthebow.NexttheypulledinasecondFrenchwomaninanadvancedstateofhypothermia.“Shewasshakinguncontrollably,”oneswimmerrecalled.“Shewasconscious,butherfacewasvioletandherhandswerevioletandherfingerswerewhite.Hercirculatorysystemwasshutngdown.Shekeptsaying,‘Myhusband,Jean-Pierre!Myhusband!’Wetookherashoreandwentback.” 3rdEngineerAndreaCarollowasasleepinhiscabinondeck3whenthecollisionoccurred.Bythe5meheopenedhisdoor,waterwasalreadyrushingdownthecorridor,andwhenhewenttohispostintheengineroomtheengineswerebeginningtoflood.“Within15minutes,theengineroomtoldthebridgethattherewasnothingtobedone,”hesaid.“Thesitua@onwasbeyondrepair.”Hethenreportedtohismusterpoint,alifeboatfor35crewmembers.“Unlikethecaptain,wewerethereun@ltheend.Wedidallwecouldtoavoidcatastrophe,”hesaid. AlbertoFiorito,28,anotherengineer,said:“Wedidn’twaitforthecaptaintogivetheordertoabandonship.Wesawhowseriousthesitua@onwas,andwediditourselves.” MissCacopardo,fromMessina,said:“Francescostayedverycalm,asifhewastryingtounderstandwhatwasgoingon,butIthoughtweweregoingtodie.Thatitwastheendforbothofus.Theymadeuswaitalong@megotowardsthelifeboats.Whenwefinallyboardedoneitwouldonlygodownbitbybitandkeptbangingagainstthesideoftheshipbecausethecablesseemedtangled.Evenonceitwasinthewatertheengineswouldn’tstart.“ThecrewwereallAsiananditwasveryhardtocommunicatewiththem.Theyweretryingtohelpusandworkinghardtogetusoff,buttherewassomuchconfusion. MrPagemadehiswaytoamustersta5ononDeck3–closetothefunnelonthesidewhichwasstar5ngto5pskywards–onlytofindthatallthelifeboatswerepacked.Thepeoplegatheredondeckweretoldtomaketheirwaytothebackoftheshiptoseeiftherewereanylifeboatsavailable.Butnotonlywerethesefull,theywereimpossibletolaunchbecauseonesideoftheConcordiawasbynowhighintheair.MrPageclimbedadeckandmadehiswaytowardsthebackoftheship,passingatleastfiveothermustersta5ons.Hereachedthehighestpointofthelinerandwasclingingontotherailstostophimselffalling,asitcon5nuedtolistandtheinclinegotsteeperandsteeper.“Iwasholdingontherailingsfordearlife,”hesaid.Anannouncementinstructedpeopletomovetotheotherside,whichwasclosertothewaterandfromwherelifeboatsweres5llbeinglaunched.MrPagewasoneofthefirsttoletgoandslideacrosstheboat,throughMilanorestaurant,beforecrashingintorailings.Hethenmanagedtosqueezethroughthem,droppinghimselffourfeetintoalifeboat.“BehinduspeopleweregeSngpushedandcrushedagainsttherailings,therewerepeople

“BehinduspeopleweregeSngpushedandcrushedagainsttherailings,therewerepeoplewithbrokenfingers,”hesaid.ThelifeboatwasreleasedandshortlyaQerMrPagefinallyreachedthesafetyoftheshore. InthetheatrewereMoniqueMaurek,41,andherhusbandAnton.“Therewasaloudtearingsoundandwefeltacrunch,”saidMrsMaurek,anundertakerfromRoTerdam,Holland.“Atfirstwethoughtitwaspartofthemagicshow.Butthentheboatstarted@l@ngtoonesideandwomanonawheelchaircameslidingpastusatspeedandthat’swhenthepanicstarted.Themagicianranoff.Hejustdisappeared.“Wedidn’thavelifejacketsandpeoplewereshou@ngthatweshouldgouptoDeck4togetsome.TherewerepeoplestuckintheliVsscreamingsoweclimbedupthelargestaircase.Whenwegotoutside–onthesideoftheshipfurthestawayfromthewater–wemanagedtogetsomeofthelastlifejackets.TherewasapanicandmyhusbandpushedmeintoalifeboattomakesureIgoton.OtherpeoplefellontopofmeandIwasscreaming.Peoplewerefallingoutofthelifeboatinfrontofusdownintothewater.”Thelifeboatwasstuckandittookfourcrewmembers20minutestoforceitdownintotheseabeforetheMaureksescaped. AmericanPatrickCapitoswamtoshoreaQerseveralaTemptstoboardlifeboats"Wewenttothefirstlifeboat.Ithitthesiderailingandwegotoutofthere.Thesecondlifeboat,thesamething.WhenwegotintoaraV,thewaterwasuptoournecks.Sowegotintothewaterandswamtoshore.Ididn'treallyfeelthewaterun@lIgotout.Thenitwasfreezing." MikevanDijk,a54-year-oldfromPretoria,SouthAfrica"Wehadtoscreamatthecontrollerstoreleasetheboatsfromtheside.Wewerestandinginthecorridorsandtheyweren'tallowingustogetontotheboats.Itwasascramble,anabsolutescramble.Everybodytriedtogetalifeboatandpeoplestartedtopanic.Alotofpeoplewerefallingdownthestairsandsomewerehurtbecausethingsfellonthem.Everybodywastryingtogetontheboatsatthesame@me.Whenpeoplehadtogetonthelifeboatstheywerepushingeachother.Itwasabitchao@c.Weweretryingtokeeppassengerscalm,butitwasjustimpossible.Nobodyknewwhatwasgoingon.Wewereonthesamelevelasthewatersosomepeoplestartedtoswimbecausetheyweren'tabletogetonthelifeboats." Steffano,a21-year-oldfromBuenosAires,whowasontheshipwithhismother,twobrothersandgirlfriend“Isawdesperatepeople.Allaroundmescreamingandterrorbutalsouncertaintyaboutwhattodo.Inmyopinion,wewerenotadequatelyhelpedbythecrewtoabandonship.”

"Therewasn'tanybodythatwasincontrol"JimSalzburgHewastravelingontheCostaConcordiawithhiswife,Jo,anddaughter,Mary-Jo."Weheardthisbigjoltanditwasthemostunusualnoiseyoucouldeverimagine,"saidJooftheship'sgrounding.Jimadded:"YoubegantorealizethattheCostacrewwasn'tgoingtosaveyou;ifyouweregoingtogetoffthisship,youweregoingtosaveyourself,"

“FortunatelyIwasabovethewaterline,butIcouldseethewatersclimbinghigherandhighertowardsus.Someofthecrewdidn’tseemtoevenknowhowtoreleasethelifeboatsorevenstartthelifeboatenginesoncetheyweredownonthewater.Thecrewmaninchargeofourlifeboatwasabsolutelyashen-faced,hejustdidn’tknowwhattodo.”MrTofanelli,a38-year-oldItalianstudyingEnglishinLondonwhowaswithhisfamilyonholiday,saidittooktwohoursforthelifeboatstodockattheislandofGiglio,wheretheyfoundshelterinsidethelocalchurch. GrandmotherSandraRogers,62,said:‘Therewasno“womenandchildrenfirst”policy.Therewerebigmen,crewmembers,pushingtheirwaypastustogetintothelifeboats.Itwasdisgus@ng.” BenjiSmith,fromBoston,saidhefashionedhisownropeladdertosavehimandhiswife"Ifeltlikethedisasteritselfwasmanageable,butIfeltlikethecrewwasgoingtokillus.Theyshoutedinstruc@ons,buttheinstruc@onscontradictedeachother."

FrancecsoVerusiorelivesthemomentwhentheyoungestvic5mofthedisaster,five-year-oldDayanaArlot,andherfather,William,drowned.

MrVerusiowrotethattheydied''becausetheywereunabletofindanyspaceinalifeboatondeckfour,ontheleV-handside,andtheywerethendirectedtotheright-handsidebycrewmembersonthesamedeckbutastheywerecrossingtheinsidecorridor...theyfellintoaholethathadbeencreatedwhentheshiprolledontoitsrightside.

"Theydroppedintoanareathatwasalreadyfloodedandtheydiedfromdrowning,"headded.

Oncesheboardedalifeboat,Ms.Grassosaid,thehelmsmanappearedillequippedtobringthescoresoftravellersonhisvesseltosafety:“hekeptbangingintotheship,unabletosteerthelifeboattotheshore,un@lapassengershovedhimasideandtookthelead”.

“Nocrewmemberwastrainedforanevacua@on,”shesaid.

Ofpar5cularinterestisthetes5monybeforeacongressionalhearinginWashington

DearMr.Chairmanandmembersofthesubcommiqee:

Thankyouforinvi@ngmetotes@fytoday.MynameisBrianAho.Mywife,JoanFleser,mydaughter,Alana,andIsetsailfromthePortofRome(Civitavecchia)onJanuary13,2012,aboardtheConcordiacruiselineroperatedbyCostaCrociereanditsparentcompany,CarnivalCorpora@on.

Thoughwehavebeenonmanycruisevaca@onswithseveralcruiselines,thiswasourfirstEuropeancruiseandourfirst@mesailingwithCosta.Wechosethispar@cularshipandi@neraryforour20thanniversarycruisebecauseoftheopportunitytovisitmanyportsinseveralcountries.

Asexperiencedcruisepassengers,wehavefallenintoapar@cularembarka@onpaqern.Onceaboardwelocateourstateroom,unpackourluggage(ifavailable)andtakeawalkingtouroftheship.Weinves@gatethetheatre,thepools,thedining-roomtowhichwehavebeenassignedandthesafetyfeatures.WemadenotethatourstateroomwasonDeck#2forward,ourdiningroomwasonDeck#3aV,andlifeboataccesswasonDeck#4.

AVerourinves@ga@on,wewentbacktoourstateroomtoprepareforalate-sea@ng(9p.m.)dinner.Onceseated--whileourappe@zerswerebeingserved--theshipbegantoshudder.Therhythmicvibra@onquicklybecameworseand,aVeratremendousgroanandcrash,theshipbegantolistseverely.Peoplewerefalling,glassesandplateswereslidingoffthetablesandsmashing,andpeoplewerescreaming.Thepanicgotworsewhenthelightsfailed.

Myfamilyformedathree-linkchainandweworkedourwaythroughthefallendebristowardanoutboardgangwayleadinguptoDeck#4andthelifeboats.Thecentral(Main)entrancetothediningroomwasblockedwithpanickingpassengersandcrew.Theonlycrewmemberofferingguidancewasawomaninashowgirl-stylegownnearthegangwaywhowasshowingthepassengersthewaytothelifeboats.

OnceonDeck#4,peoplewerepanickingandfigh@ngoverlifejackets.OnceIfoundanddeliveredonetomywife,anotherwomandamageditwhiletearingitoutofherarms.Theannouncementsindicatedthatitwasanelectricalproblemwiththegeneratorsandeverythingwasundercontrol.Evidenceindicatesthatsomepassengerswereinstructedbycrewtoreturntotheircabins.Astheseannouncementsweremade,theshipwaslis@ngmoreandsinkingdeeper.ImmediatelyaVerasimilarannouncement,weheardtheabandonshipsignal(sixshortsignalsandonelongsignal).Fewpeopleknewwhatitmeantastherewasnoverbalabandonshipannouncement.

Whenacrewmemberfinallyappeared,thepanickingpassengerspushedtheirwaytoward

Whenacrewmemberfinallyappeared,thepanickingpassengerspushedtheirwaytowardtheboat.Mywifehadtograbmydaughterandpullherintotheboatasacowardlymantriedtopushheroutoftheway.Oncetheboatwasfilled,thecrewmanhadtroublereadyingandreleasingtheboat.AVermuchhammeringnoise,theboatswungawayfromtheConcordia.Wewereshoweredwithwhitepaintchipsasifthisboathadnotbeenreleasedsincethegearhadbeenpaintedover.AVerbeinglowered,thecrewhaddifficultydisconnec@ngtheboatfromthedavits.Oncedisconnected,itwasclearthatthecrewdidnotknowhowtopilotthelifeboateffec@vely.Itkeptcollidingwithotherboatsand,eventually,thepier.

TherewereNOCostarepresenta@ves--neitherofficersnorcrew--onthepiertoprovideguidancetothepassengers.Theonlyhelpwereceivedwasfromtheresidentsoftheisland.Asexperiencedcruisevaca@onpassengers,wehaverecognizedsignificantproblemsthat,inouropinion,madeaterriblesitua@onevenworse:

Therewerenosafetydrillsorinstruc@onsdistributedtopassengersbeforesailingoutintotheopenMediterraneanSea.Thepublicaddressannouncementsprovidedfalseinforma@on.Themanninganddeploymentofthelifeboatswasdelayedthoughtheshipwasinimminentdanger.Thecrewwasunabletoinstructpassengersduringanemergency.Thecrewwasunabletolaunchandoperatethelifeboatseffec@vely.Accordingtoreports,thecaptainandseniorstaffabandonedtheshipwithpassengerss@llaboardthecapsizingvessel.Therewasnooneaboardtocoordinatetheevacua@on.

Thisaccidentwasnotcausedsolelybytheac@onsofasingleindividual.IthasbeenallegedthatCostaanditsparentcorpora@on,Carnival,allowedCaptainScheSnotodivertfromtheassignedcourseonpreviousvoyages.Clearly,thiscoursedevia@onwasnotduetoclima@corsafetyconcerns.Itisouropinionthat--withtoday'stechnology--centralmanagementofthecruiselinemusthavebeenabletolocatetheposi@onof--andtracktheprogressof--amassivelinerliketheConcordia.Eithertheywereawareofitsdevia@onfromthepre-determinedcourseandsanc@onedit,ortheywereill-equippedtomanagetheopera@onofthisandperhapsothervessels.

Thecourtswilldeterminewhoorwhatorganiza@onistoblameforthetragiclossoflifeinJanuaryof2012offthecoastofTuscany.

ItalsoemergedthatholidaymakerMariaD'Intronowastoldtogetoutofalifeboatbecauseitwastoofullandthe5ltoftheshipmadeitimpossibletolaunchsafely.Shewaslaterseenterrifiedbytheedgeoftheship,jumpingintothewaterwithoutalifejacketdespitenotbeingabletoswim.

Theques5onmustbeaskedastowhoweretheofficersinchargeofthelifeboatsandwherewerethey?

MRSCtalkswithCaptain

MRSCLivornocontactsonthemobilephone,theMasteroftheCostaConcordia,whichrefersaboutthelandingofallpersonsonboard.Totherequestsofclarifica5onsrela5ngtowhatishappeningontheportside,theMasterdeclaresheistotobefoundalongwithasailoronboardalifeboatontheoppositeside;healsoreportsthatitisengagedintherecoveryofsomesurvivors.Whenaskedtoknowwhohasremainedonboardtocoordinateabandonshipopera5ons,herepliesthattheen5recrewhaslanded.MRSCLivornothenorderedtheCaptaintoreboardhisvessel,althoughtheyhadnoauthoritytodoso. Itshouldbenotedthatwhenashipcapsizes,andthecircumstancesdictatetheMastertoorder‘AbandonShip”,allonboard,includingtheCaptainarerelievedoftheirdu5esandtrytosavethemselves.Inmanywar5meinstancesthisoccurred. HowtheCaptainabandonedtheshipisen5relysuperfluoustothecase.WhileagreeingwiththeprinciplethattheCaptainshouldbethelast,andrecognisingthatunderItalianlawthisisacriminaloffence,theques5onmustbeaskedthatonshipscarryingsomanypeopleover

isacriminaloffence,theques5onmustbeaskedthatonshipscarryingsomanypeopleoveravastareaofmanydecks,howcantheCaptainpossiblyknowifthereisanyoneleQonboard? 00:41TheFCCcallsMRCCRomeinordertoaskforassistanceasitconsiderstheactualsitua5onverycri5caloftheshipbeingcompletelylisted90°tostarboard,about50peoplearenolongerabletoleavetheship,andconsiderstheinterven5onofhelicoptersalsoannouncesthat-exceptforoneperson-hehasnonewsaboutinjuriesandthattheMasterisnotontheship. TheShoreRescueServices AlmostalltheOfficersandCrewhavenowabandonedthevesselandtheremainingpassengers.Therescueisinthehandofthoseashore. 00:42HoursMRSCLeghorncontacttheship'smasterwhosaysthatthereseemstobeahundredpassengersontheship;MRSCLivornostronglyurgestheship'sMastertogoonboardwiththeotherofficerstocoordinatethedisembarkingpassengerss5llonboard. 00:53rescueofpeoples5llontheshipbyhelicoptercommences 01:00withtheshipnowlyingalmostflatonitsside,between700and1,000peopleremainedonboard.ClumpsofpeoplewerescaTeredthroughouttheship,manyclingingtorailings.About40werehangingonaropeamidships.Almosteveryoneelsehadcongregatedinapanickycrowdof500ormoretowardthestern,ontheportsideofDeck4,facingthesea.Manyofthesehadtakenrefugeinacrampedpassageway;othersremainedonthedeckoutside.Dozensofboatshadgathered,about60feetbelow—theCoastGuardlatercounted44differentcraQinusebydawn—buttherewasnoeasyroutetothem. Manypassengersandcrewwerejumpinginthewatertoswimtothenearbyrocksandeventuallyover100peopleweregatheredthereawai5ngrescue.

01:04:HelicopterlowersAirForceofficeraboardtoassistwithevacua5on

01:35hourstheOSCupdatesMRSCLivornoaboutthesitua5onandreportinforma5ongatheredbyapassengerwhoreportedthatonboardthereares5llabout400peopleassistedbycrewmembersthatcoordinatethedisembarkingontheportside.02:00thepatrolSAR"CP892",asrequestedbyMRSCLivorno,takesonboardthefirstteamofsevenfire-fighterswiththermalcutngequipment(toreleaseanypeopletrappedinsidetheship).Thisteamwillbejoinedbytwoothersimilarlyequipped. 03:44Itises5matedthatthereares5llonboardatleast40/50people. 04:20hourstheOSCupdatesthesitua5on,inprogressisthedisembarka5onofpeople,throughtheaQsideladderofpeoples5llonboard,collectedbytheM/VSAR"CP305",Onboard,onpatrolarethreefire-fightersandtwoCoastGuardspecialistsrescuer. 04:30MRSCLivornoorders,aSafetyofficerwithaFireBrigadeteamtoboardtoassisttherescuersinthesearchforthemissingpeople. 05:15anotherteamofFireDepartmentpersonnelboardedtheshiptoseeifthereares5llpeopletrappedonboardandrecoveredtwotrauma5zedpassengers. 06:17hoursthefirstrescuerssuspendsearchopera5onsontheship.Subsequentlytheresearchonboardwillcon5nueseamlessly.TheFireDepartmentcon5nueexplora5onoftheship,bothintheemergedandimmersedpartoftheship,insearchingformissingpeople.MRSCLivorno,however,willcon5nueun5l25Januarythesearchatsea,onincreasinglylargeareas,basedonthecalcula5onofthedriQduetothecurrent.

Lastsurvivors FirebrigadepersonnelhaverescuedtwopassengersKoreansaliveinsidetheircabinandaninjuredcrewmember.ManricoGiampedroni,thehoteldirector,whoremainedtoassistwiththeevacua5onofthepassengerswasfoundaliveinthewreckaQerspending36hourswai5ngforrescue.hesaidhewashelpingdozensofpassengersevacuatethelis5ngshipwhenheslippedandfellabout20Qthroughadoorway,landinginafloodedrestaurantareaandbreakinghisleQlegintwoplaces.Hewasthelastpersonfoundaliveontheship ThesearchfortheDead Inthefollowingdayscon5nuedthesearchandrescueopera5onswiththeuseofdiversteamoftheCoastGuard,Police,NavyandFireDepartment.Thesearchofanyfurthersurvivoratseacon5nuedwiththepatrolboatsoftheCoastGuardandoftheothergovernmentdepartmentsthathavecontributedintherescueopera5onsaswellasbyhelicopters. 15.01.2012Thesurfacesearchesfortheiden5fica5onofpossiblesurvivorsendedonandcon5nuedforthoseinsidetheshipandthesurroundingseabed. Resigna)onofthePresidentofRINA January17thShortlyaQerCostaCrocierechairmanandCEOPierLuigiFoschiblamedthegroundingoftheCostaConcordiaonan”inexplicable”errorbythecaptain,GianniScerni,thepresidentofRINA,theItalianclassifica5onsocietythatissuedthecer5ficateofseaworthinessandtheSafetyManagementSystem(SMS)cer5fica5onfortheCostaConcordia.HeresignedaspresidentofRINA. Healsowascri5calofCostamanagementandques5onedtheclaimthatCostawasunawareoftheprac5ceofitsshipspresen5nga“salute”or“bow”intheformofaclosepassagebyislandofGiglio. RecoveryoftheDead DiversoftheCoastGuardrecoveredtwodeadbodiesinthecorridorleadingtotheboatsofthebridge4.FirebrigadepersonnelhaverescuedtwopassengersKoreansaliveinsidethebridge8andacrewmemberwounded.ThiswasManricoGiampedroni,theCruiseDirectorwhohadbeeninjuredwhileassis5ngpassengersescape.Hewasthelastsurvivortobefoundonboardtheship January16th,theFireDepartmentrecoveredthebodyofapassengerinthecorridoroftheseconddeckofthebridge. January17th,CoastGuarddiversfoundfivebodies,amemberofthecrewandfourpassengers,intheaQelevatorofthebridge4. OnJanuary21st,thebodyofapassengerisrecoveredbydiversoftheCoastGuardinthecorridorleadingtoliferaQstothebridge4. OnJanuary22nd,thebodyofapassengerinsidethecabinNo7421ofdeck7,isretrievedbytheFireDepartment OnJanuary23th.thebodiesoftwopassengersarerecoveredbydiversoftheCoastGuardbythedeck4nearthestairsconnec5ngthedeck3. OnJanuary24th.thebodyofapassengerattheendofdeck3starboardsideisrecovered,bytheFireDepartment OnJanuary28th.G.d.Frecoveredthebodyofamemberofacrewmemberoutsidethecabin

OnJanuary28th.G.d.FrecoveredthebodyofamemberofacrewmemberoutsidethecabinNo8389ofdeck8. OnFebruary22nd.,FireDepartmentrecovered4bodies,allpassengers,insidetheelevatorsintheatriumofdeck4. OnFebruary23th.fourbodiesarerecoveredbyfiremenneartheelevatoratdeck4. OnMarch22nd.,duringanexplora5onwiththeROVthroughtheopeningofanewpassageinthehull,thebodiesoffivevic5msaresighted.Thefivebodies,fourpassengersandonecrewmemberwereretrievedonMarch26bytheItalianNavy.

2014.

November3rd.ThelastmissingpersonfromthewreckofthecruiseshipCostaConcordiawasfinallyaccountedforonMondaywhenworkersdismantlingthehulkfoundtheremainsofRusselRebello,awaiterontheship. RescueData Thecompletepassengerdata,whichwaslatersuppliedbyCostaCruises,indicatethattherewereatotalof4229peopleonboardtheshipatthe5meoftheaccident,including3206passengersand1023crew.Outofthepassengers,therewere2954adults,200children(under12yearsold),and52babies(under3yearsold).Atotalof4197peoplewererescued.Amongthese,about1270wererescuedbytherescueunitsinterveneddirectlyunderthecoordina5onofMRSCofLivorno.-80peopleonboardtheCostaConcordialiferaQsweretuggedashore-16peoplewererescuedbyhelicopter-4peoplewererescuedfromtheseaItisthoughtthattheremainingsurvivorsabandonedtheshiponsurvivalcraQs(boatsandliferaQs)andreachedthecoastautonomously.

5THPHASE.THEGIGLIOMAGISTRATESINQUIRY/THEINTERNATIONALMANAGEMENTCODEFORTHESAFE

OPERATIONOFSHIPSANDFORPOLLUTIONPREVENTION(THEISMCODE)

ProsecutorGeneralDeiddamadeexplicitreferenceto“problemsandincredibleactsofirresponsibilityregardingsafetyandorganisa5on”andnotes:“Theemployerisguarantorandhasresponsibility.Decisionstakenbytheshippingcompanyshouldbeunderclosescru5ny”.

Thiswouldseemtoindicateanexplicitinvita5ontothemagistrateinchargeofthecase,publicprosecutorFrancescoVerusio,toformallyinvolvecompanymanagersbyaddingtheirnamestotheregisterofindividualsunderinves5ga5on.Sofar,magistrateshadrefrainedfromdoingsodespiteCaptainSchetno’sstatementthathehadtoldRobertoFerrarino,theheadofthecrisisunit,abouttheseriousnessofthesitua5onand,aboveall,thathehadbeenencouragedbythecompanytoperformsail-pastsasapublicitystunt.

MrFerrarino,spoketoCaptainSche5nnoatleastthree5mesontheeveningofthetragedyandreassuredhimthathewouldsendhelicoptersasrequested.TheCostaexecu5vewillhavetoexplainwhyevacua5onofthelinerwasdelayedeventhoughithadbeenconfirmedthatthevesselwasoutofcontrol.

MrDeiddawentfurtherandexplicitlyreferstoCosta’stopexecu5veswhenhelistedtheoffencescommiTed.TheProsecutorGeneralsaid:“Magistratesseekcauseandeffectlinksforevents.Up@llnow,aqen@onhasfocusedonthenegligenceofthecaptain,whowastragicallyinadequate.Butwhoselectsthecaptain?Decisionsmadeupstreambyhisemployer,theshippingcompany,needtobescru@nised.Thereisalsothefundamentalissueofsafetyorganisa@on–lifeboatsthatcouldnotbelowered,crewwithnoideaofwhattodo,pooremergencymanagementtrainingandincompetentordersliketheabsurdinstruc@ontoreturntothecabins.Theconfusionshowsincrediblenegligenceinapplyingsafetyregula@ons.Thisisanareathatshouldbeorganisedinadvancewithexercisesandsimula@ons.Actualemergencymanagementcomeslater”.Overthepastfewdays,theprocuratorgeneralhaspointedoutthatrescueopera@onsshowedthat“crewmembersassignedtothetaskwereunpreparedandbereVofanyspecialistknowledge.PassengersleVtotheirowndevicesreceivedconflic@ngmessagesfromthecaptainandotherofficers”.

CaptainSchetno’sdefencealsodistanceditselffromthecompany.ThestatementlodgedbylawyerBrunoLeporatwiththemagistratebeforetheeviden5aryhearingtoexaminetheship’sblackboxistantamounttoanaccusa5onofcomplicitydirectedatMrFerrarinobutitisalsoarequesttoverifythefunc5oningoftheship’sinstruments.CaptainSchetnohassaidthatvariousinstrumentsremainednon-func5onaldespiteeffortstoac5vatethemmanually.

MrLeporatstressedthat“thestatementsmadebyScheSnoabouthisconversa@onsthateveningwiththeheadofthecrisisunithaveopenedfurtherlinesofinves@ga@onthatcouldreasonablypointtoabroadeningofthesubjectsinvolvedintheinquiry”.

Transcript Onthe17thofJanuarythefirstlegalinquiryopenedontheIslandofGrosseto.Thefollowingisatranscriptofthathearing.

isatranscriptofthathearing.

No.12/285N.R.andNo.12/117MagistrateinChargeofPreliminaryInquiriesREPUBLICOFITALYCOURTOFGROSSETOOFFICEOFTHEMAGISTRATEINCHARGEOFPRELIMINARYINQUIRIES—————————–Themagistrateinchargeofpreliminaryinquiries,Dr.ValeriaMONTESARCHIO,havingseentherequestofthePublicProsecutor,receivedon16/01/2012at1:55PM,forvalida@onofthedeten@onof:

CAPTAINSCHETTINO,Francesco,borninNapleson14November1960,withcounselforthedefenceofchoiceBrunoLEPORATTI,aqorneyoflawoftheBarofGrosseto,forthefollowingviola@on:

a)113,inconjunc@onwithCiroAmbrosio,449(2)inreferencetoArt.428,589(3)ofthePenalCode,forhaving,inco-opera@onwithoneanother,ScheSnoascaptainoftheshipCostaConcordia,Ambrosioasfirstdeckofficer(responsibleforthewatch)–owingtoculpablebehaviourconsis@ngofimprudence,negligenceandincompetenceandinviola@onoftheregula@onsofthesector(andinpar@cularofArt.6ofLawNo.1085of27December1977,forhavingmaintainedaspeedover15knots,eventhoughintheproximityofobstacles,inawaysuchasnottobeabletoactinanappropriateandefficientmannersoastoavoidcollisionsandtohaltthecraVwithinadistanceappropriatetothecircumstancesandtothecondi@onsofthemoment),causedtheshipwreckofthesaidCostaConcordia,atthesame@methuscausingthedeathofTomasAlbertoCos@llaMendoza,JeanPierreMicheaudandFrancisServel,who,fallenoverboard,perishedduetodrowningorduetohypothermia.

b)81(1)and591ofthePenalCode,forhavingabandonedaboutthreehundredpersons(passengersonthecruiseshipCostaConcordia),unabletofendforthemselves(inpar@cular,sinces@llaboardthesaidmotorship,intheprocessofshipwreckandinthenight-@me,whohewassupposedtotakecareofinasmuchascaptainofthesaidmotorship.

c)1097oftheCodeofNaviga@on,fornothavingbeenthelasttoleavethemotorshipCostaConcordiaofwhichhewascaptain,duringtheabandonmentofthesame(indanger,beingintheprocessofshipwreck)ascertainedontheday.

Havingheardatthevalida@onhearingof17/01/2012thePublicProsecutor,thedetaineeandhiscounselforthedefence,pronouncedthefollowing

ORDER

Asconcernsthepresupposi@onsforthedecreeofdeten@onpursuanttoArt.384oftheCodeofCriminalProcedure,themagistrateobservesthefollowing:

Substan@alcircumstan@alevidenceexistswithregardtotheoffenceshypothesizedbythePublicProsecutor’sOfficechargedtoFrancescoScheSno,asemergesfromtherecordswithpar@cularreferencetothefirstreportoftheCoastguardofPortoSantoStefanoof14/1/2012,basedonthesummarytes@monialinforma@ongivenbythemembersoftheship’screw,thechronologyofeventsoftheHarbourOfficeofthePortofLivorno,theAISrecordingonrecord,andthePGAnnota@onoftheHarbourOfficeofthePortofLivorno.TheculpablebehaviourCapt.FrancescoScheSnoischargedwithresultsfromalltherecordsofinves@ga@oncompiledintheimmediacyofthetragicevent,who,withahighlyimprudentmanoeuvrebroughtthecruiseshipCostaConcordiatooclosetothecoastlineoftheislandIsoladelGiglio,changingfromtheordinaryroutetotheso-calledroutefor“touristnaviga@on”(seetheunambiguousdeclara@onsmadebyRobertoBosio,AlbertoFiorito,SilviaCoronika,JacobRusliBinandStefanoIannelli),causedtheimpactwithalargecoastalreefthatsprungaleakintheboqomofthecraV.Theroutedevia@onandthe

alargecoastalreefthatsprungaleakintheboqomofthecraV.Theroutedevia@onandtheapproachto0.28nau@calmilesfromthecoastoftheislandwasadmiqedevenbythecaptaininthecourseoftheguaranteeinterroga@on,affirmingbecomingawareonlyvisuallythattherewasajuSngreefwithwhichtheship’sboqomimpacted.

Thegraveimprudenceandincompetencethatmarkedtheconductofthesuspectatthe@mewhenheini@atedtherashmanoeuvrejustmen@onedisevidentandindisputable.Theimpactwiththereefcausedthespringingofaleak,withthewaterfloodingtheengineroomsandcausingtheelectricalsystemoftheenginestofail,leadingtotheblackoutwithintheship,whichfirstveeredontheportside,thenbegantoshipwaterandlistontheoppositeside.

Inthatpredicamentthecaptain,duetoincompetenceandnegligence,underes@matedtheextentofthedamageandfailedtono@fythecoastalauthori@esoftheaccidentin@melyfashion,repor@ngthatanelectricalproblemwasinvolved(blackout),withoutmen@oningimmediatelytheimpactthathadcausedthespringingoftheleakandtheflowofwaterintofivecompartmentsoftheship’sengineroomandthusdelayingtheimplementa@onofemergencyproceduresandrescueopera@ons(seethedaybookoftheopera@onsroomofthedistrictmari@meofficeofPortoSantoStefano,thechronologyofeventsoftheHarbourOfficeofthePortofLivorno,thereportoftheopera@onaldivisionoftheRevenueGuardCorpsofPortoSantoStefano,andthesummarytes@monialinforma@ongivenbySilviaCoronikaandbyStefanoIannelli).

Itisacer@fiedfact,notwithstandingthedeclara@onstothecontrarymadeatthe@meofinterroga@on,thatthecaptaincouldnothelpbeingawareimmediatelyoftheseriousnessofthedamageproducedbothduetotheeverincreasinglymoreevident@ltoftheshipandbecauseadvisedbythecrewofthehugeamountofwatershipped(seethesummarytes@monialinforma@ongivenbyGiuseppePiulonandSilviaCoronikaandothermembersofthetechnicalstaffonboard).

Intheaforesaidsitua@onthecaptainlostcontroloftheship,whichhaditsenginesoffandshiVedposi@ononlybymeansofiner@aandtherudders.TheSOSwasonlysent30-40minutesaVertheimpact(asreportedbyScheSnohimself);inthemean@menoexternalalarmsignalwasgiventothecoastalauthori@estomaketherealseriousnessofthesitua@onaboardunderstood.Atthispoint,asonealsolearnsfromthedeclara@onsofCapt.ScheSno(whicharecorroboratedbywhatwasreferredbythesecond-in-commandaspertable,RobertoBosio),heorderedtodroptheanchorsandtheship,progressivelyincreasingthe@ltstarboard,ranagroundintheproximityofthecoastoftheisland.ThesubsequentdevelopmentsofthetragicwreckoftheCostaConcordiaareonrecordandknownthroughtheofficialbulle@nsmen@oned(againseetheInforma@veReportoftheNavalOpera@onalDivisionoftheRevenueGuardCorpsofPortoSantoStefano,thechronologyofeventsoftheHarbourOfficeofthePortofLivorno,theservicereportanddaybookoftheopera@onsroomoftheDistrictMari@meOfficeofPortoSantoStefano,andfilmsshotbytherescuepatrolboats).

At10:58PMthecaptainorderedtheshiptobeabandonedandinformedthecoastalauthori@es(seetheinforma@vereportofthecommanderoftheNavalOpera@onalDivisionofPortoSantoStefano)but,duringthesaidopera@ons,leVtheshipwhenthereweres@llatleastahundredpersonsaboardship(seethePGannota@onoftheharbourmasterofLivorno,Aqachment23),accordingtosummarytes@monialinforma@ongivenbyDimitrosChris@disandStefanoIannelli,aswellassummarytes@monialinforma@ongivenbynumerousmembersoftheship’screw,whostatethatduringthedisembarka@onopera@onstheynolongersawthecaptainaboardship,PGAnnota@onofCFGregorioDeFalcoof15/1/2012,Aqachment170).

ThecircumstanceisadmiqedevenbyCapt.ScheSno,whonevertheless,inhisversionofthefactsatthevalida@onhearing,statedthattheabandonmentwasnotwilfulandthatinlightofthecondi@onofthedeckthathehadreached,itwasnecessitated.However,ithasbeenascertainedthatotherofficerss@llaboardco-ordinatedanddirectedtherescueopera@ons

ascertainedthatotherofficerss@llaboardco-ordinatedanddirectedtherescueopera@onswhilethecaptainhadreachedareefaboardalifeboatandrefusedtocomebackonboardtheship,consideringitanimpossiblefeat(againseedeclara@onsmadeinthecourseofthevalida@onhearing).

Thathavingbeenpremisedastotheeffec@veexistenceofseriouscircumstan@alevidenceofculpabilitywithregardtotheoffencesthesuspectischargedwith,thepartypassingjudgementdoesnotbelievethesecondpresupposi@onoflawexistsforthedecreeofdetainmentwithregardtoFrancescoScheSno,namelytheconcretedangerofflight,forthefollowingreasons.

Fromthetes@monygatheredintheimmediacyofthefactsthroughthesummaryinforma@ongivenbythepersonswhoaccompaniedthecaptainitappearsevidentthat,oncehavingabandonedtheship,albeitinun@melyfashion,heremainedinplaceonthereefofIsoladelGigliowherehehadlandedaboardalaunch,andwatchedtheshipsinkatthemercyofthetragiceventthatwasoccurring(seetheservicereportofCapt.RobertoGalli,HeadofAreaSecurityoftheMunicipalityofIsoladelGiglio,declara@onsmadebyDimitrosChris@disandbyStefanoIannelliandeyewitnesses,unambiguousonthepoint).

Uponthearrivaloftherescuepatrolboat,thecaptainclimbedaboardthesameandwastakentotheofficesoftheCarabiniericompanyofOrbetello,wherethedeten@onwasordered.Thereisnotraceintherecordsandinthechroniclesoftheevent(intheimmediacyCapt.ScheSnomadestatementstojournalistsinaninterviewairedonthena@onalnews)ofanyaqempttofleeduringorsubsequenttothecatastrophiceventformingtheobjectofinves@ga@on.Suchaqemptcannotbereadintothealbeitun@melyabandonmentoftheCostaConcordiabecauseitturnsoutthatinanycasethecaptainwasaccompaniedinthedebarka@onbymembersofthecrew,heremainedonthereeftowatchthedisastercaused,wasreachedbymembersoftheFireBrigadeandwasintouchbyphonewithCommanderDeFalco,whoorderedhimtogobackaboardtheship.Inanycase,ScheSnodidnotengageinanybehaviouraimedatleavingthecoastallocalitywheretherescueoftheshipwreckedwasmanagedorinanycaseaimedathinderinghisiden@fica@onwiththerolefilled.Aswasrecalledbythedefenceinthecourseofthevalida@onhearing,atthe@meofdisembarka@onthecaptainwaswithoutdocumentsandnonethelessnoaqempttohideorfleeisevidenced.Eveninlightofconstantjurisprudenceonlegi@macy(seepenalsentencesNo.15315of7/4/2010,No.5244of10/1/2006andNo.4089of18/12/2003)itisnotthoughtthatthepresupposi@onoftheconcretedangerofflighthasmarkedthebehaviourofthesuspecteitherinthecourseoftheeventoftheshipwreckorsubsequently,andthatalsoinconsidera@onofallthecircumstancesof@meandofplacesinwhichtheeventoccurred.

Onthispointitmustberememberedthatthepresupposi@onofthedangerofflightistheonlyrequirementthatcanjus@fytheprecau@onarymeasureofthedeten@onofthepersonsuspectedofcommiSngacrime,thesamemeasurenotbeingablebylawtobeadoptedtocopewiththeotherprecau@onaryrequirementspursuanttoArt.274oftheCodeofCriminalProcedureandsignallyofthatpursuanttoleqera)ofthenorma@veprovisioncited.Asforwhatpertainstothepossibility,fearedintherequestforvalida@on,thatCapt.ScheSno,becauseofhisposi@onandontheoccasionofhisac@vityofship’scaptain,mighthaveestablishedhumanrela@onsinoutsidelocali@esthathecouldhaveu@lizedtofleeandtoescapefromtheinves@ga@ons,itisevidentthatthiscircumstanceiswhollyhypothe@calandinanycasedevoidofsupportevenintermsofcircumstan@alevidence.

FORTHESEREASONS

Havingreadar@cles384and390oftheCodeofCriminalProcedureTheMagistrateinChargeofPreliminaryInquiriesDOESNOTVALIDATEthedecreeofdeten@onorderedwithregardtoFrancescoScheSnoon14/1/2012.

AsforthefurtherrequestofthePublicProsecutor’sOfficeofGrossetotosubjectFrancesco

AsforthefurtherrequestofthePublicProsecutor’sOfficeofGrossetotosubjectFrancescoScheSnotothemeasureofcustodyinprison,theMagistrateobserves:

Regardingtheexistenceofseriouscircumstan@alevidenceofculpabilitypursuanttoArt.273oftheCodeofCriminalProcedure,whatispremisedinthemaqerofthisordermustbeviewedinlightofthetotalityoftheverifiedfactsconcerningthedynamicoftheshipwreckformingtheobjectofinves@ga@on,andasconcernstheseriouslyculpablebehaviourengagedinbythecaptaininthecourseoftheen@reeventinques@on.Thegravityoftheculpablebehaviourofthecaptainisindeedverifiablefromthebeginning,withtheorderingandcarryingoutoftheill-consideredmanoeuvreofdrawingtooclosetotheisland;inthephaseoftheimpact,withtheunderes@ma@ngofthedamageproducedtothevitalpartoftheCostaConcordia;andinthephaseimmediatelysubsequenttotheimpactproduced,withthedelayofthealarmsignalsandinanycaseofthetardyrepor@ngtothecoastalauthori@esoftheactualsitua@oninwhichtheshipfounditself.Theemergencymanoeuvrethatthecaptainperformedtobringtheshipalongsidethecoastoftheisland(whichmanoeuvrewasdescribedbyhimindetailduringtheinterroga@on)isworthlessforexemp@nghimfromresponsibili@esorinanycaseforaqenua@ngthesaidresponsibili@es,sinceitisonlynaturalthatwhatwasinvolved,atthatpoint,wasadueacttolimitasmuchaspossiblethetragicconsequencesthattheseriouserrorcommiqedandadmiqedunfortunatelycaused.Butthereisalsoseriouscircumstan@alevidenceofculpabilityfortheotheroffencesFrancescoScheSnoischargedwith.

Onthispointitisinfactnecessarytorepeatthattherecordsshowandthatthesuspectalsohasdeclaredduringtheguaranteeinterroga@onthatScheSnoleVtheshipwhentheopera@onsofabandonmentofthesamebythepassengersweres@llunderway,assistedbymembersofthecrew.Thefactthatothermembersofthecrewandofficerss@llaboardtheshipweredoingeverythingtheycouldtomakepossiblethedisembarka@onofthepassengersobjec@velygainsayswhatthecaptaindeclaredabouttheobjec@veimpossibilityofdirec@ngandmanagingtheemergencyandrescueprocedures.Evenifwhatwasassertedabouttheobjec@veneedforthedisembarka@onweretrue(asstressedbythepublicprosecutor),noaqemptwasmadebythecaptaintoreturnatleastintheproximityoftheshipinthephasesimmediatelysubsequenttotheabandonmentoftheCostaConcordiathathadtakenplace.

Concerningtheexistenceoftheprecau@onaryneedspursuanttoArt.274oftheCodeofCriminalProcedure,itisnecessarytopointoutthat:Forthereasonsexplainedaboveconcerningthenon-valida@onofthedeten@on,theMagistratedeemsinexistentaconcretedangerofflightofthesuspect,sinceaccordingtolawandconstantjurisprudencetheaforesaidpresupposi@oncannottakeshapeasamereinves@ga@vehypothesisunsupportedbyanyelementreferabletohisbehaviour.ItisrepeatedthatScheSno,aVerhavingleVtheship,didnotcommitanyactfromwhichitcanbeinferredthathehadaninten@ontoescape.Thedeclara@onshemadeattheCarabinieriBarracksofOrbetelloabouthisinten@ontoturnoveranewleafandtonolongerwanttogoonshipsclearlyareduetodejec@onoverthedisastercausedandhavenoimportanceinthesenseofaninten@ontotakeflight.Therefore,theprecau@onarymeasurepursuanttoleqerb)ofArt.274oftheCodeofCriminalProcedureisruledout.

Comingtothedangeroftamperingwithevidence,itmustbepointedoutthatwhatwasini@allyhighlightedbythePublicProsecutorwithregardtothepresumedinten@onofthecaptainsomehowtoremovetheship’sVoyageDataRecorder(VDR),itisbeliedonrecordbyDocument170,PGannota@onofCapt.DeFalco,whichspecifiesthepossiblemisunderstandingofapieceofinforma@ongivenonthatpoint.Capt.DeFalcostatesthat“followingthecontactthattookplacebetweenthepersoninchargeoftheCompany,MrPaoloMaqesipresentintheopera@onsroomandCapt.ScheSno,itwasdecidedtosendanotherperson,subsequentlyiden@fiedasOfficerMar@noPellegrini,sincethecaptaindidnotappeartobelucid.”

Asforthepossibilitythatthecaptainmightmakeuseofhishierarchicposi@ontoinfluencethetes@monialdeclara@onsoftheofficialsandcrewmembersconcerningthefactsthatoccurred,astheinves@ga@onsstand,inwhichmanyofthesubordinatesofthecaptainhave

occurred,astheinves@ga@onsstand,inwhichmanyofthesubordinatesofthecaptainhavebeenheardwhohavemadedeclara@onsthatdonotcontradictoneanother,theaforesaiddangerappearsinexistent.Thepar@allycollabora@veaStudeassumedbythecaptainatthe@meofthevalida@onhearingmustalsobepointedout,where,asalreadysaid,headmiqedtheerrorcommiqedwiththeill-consideredmanoeuvreofdrawingneartheisland.Onedoesnotsee,basedontheresultsoftheinves@ga@ons,whatconvenientversionthecaptainmightconcoctforthepurposeofabsolvinghimselfofresponsibility.

Theobjec@vegravityoftheeventisunques@onable–aworld-scaledisaster–aswellastheseriouslyculpablebehaviourchargedtothecaptainoftheCostaConcordia.Thesefacts,ofanatureinanycaseobjec@ve,areinaddi@ontoanoverallnega@veevalua@onofthepersonalityoftheindividual.Inthemagistrate’sopinion,thisisnotspecificallyintermsoftheprecau@onaryneedspropoundedbythePublicProsecutor,butratherintermsofthedangerofrecidivisminvolvingoffenceswithaculpablebackgroundperpetratedtothedetrimentofthirdpar@esassignedtothecareandresponsibilityoftheindividualbeinginves@gated,owingtotheroleinvolvedandtheac@vityperformed.

Indeed,evenasrecalledabove,ScheSnoadmiqedhisimprudenceunderques@oningandtriedtomi@gatetheenormityofhiserrorwiththesubsequentmanoeuvre,effectedtopreventthemovingawayoftheshipfromthecoastofIsoladelGiglio.Recallingthatmanoeuvreindetail,ScheSnoaffirmsbeinga“goodcaptain.”Thatappearstoindicateanincrediblethoughtlessnessinassessingtheactualscopeofthebehaviourengagedintothedetrimentofover4,000personsentrustedtohisresponsibility.Itisindeedevidentthatwiththesaidmanoeuvrethecaptaincausedtheshipwreckofthepassengersandthedeathofverifiedvic@ms.Onthispoint,concerningtheerrorcommiqed,ScheSnoadmitsthecircumstancebutthengoesontodescribethephaseoftheemergencymanoeuvrewhich,atthatpoint,asstated,atleastformedpartofhisdu@es.Buttothisthoughtlessnessalsomustbeaddedthetotalincapacitytomanagethesubsequentphasesoftheemergencycreated,thusdelayingtherescueopera@onsfromland.

Finally,thenega@veevalua@onoftheindividual’spersonalityincludesthefactofhavingabandonedtheshipaheadofallthepassengersonboardandofhavingremainedoveranhouronthereefwherehehaddisembarkedinasitua@onofcompleteinac@vity.Inthefinalanalysistheseriousincompetence,imprudenceandnegligencethatmarkthebehaviourofthecaptainmakerealandpresentthedangerofrepe@@onofoffencesofthesamesortasthoseforwhichweproceed,i.e.ofseriouslyculpableoffencescommiqedtothedetrimentofthirdpar@esentrusted,owingtotheac@vityengagedin,totheresponsibilityofthesuspect.Thisconvic@onofthemagistratecannotbeinvalidatedbytheuniquenessintermsofdimensionsoftheeventcaused.AndinfactwhatwasdeclaredbyScheSnohimselfduringhisstayattheCarabinieriBarracksofOrbetelloabouthisinten@ontoturnoveranewleafandnolongerboardships,concretelyopensthescenariooftheexistenceofthepossibilityofrepe@@onofthetypeofoffencesthesuspectischargedwith.ScheSnoengagesintheprofessionalac@vityofcaptainofshipsandheisnotforbiddenintheimmediatefuturetocon@nueinhisac@vity.Inanycasespecificdangerofrepe@@onofculpableoffencestakesshapeconcretelyforanykindofac@vitythatentailstheentrustmentofthirdpar@estothecareandtotheresponsibilityofthesuspect.

Themagistratethereforebelievesthatprecau@onaryrequirementpursuanttoleqerc)ofArt.274oftheCodeofCriminalProcedureapplieswithreferencetotheoffencesFrancescoScheSnoischargedwith.

Comingtothecriteriaforthechoiceofprecau@onarymeasurepursuanttoArt.275oftheCodeofCriminalProcedure,itmustbepointedoutthatthenatureofcustodyinprisonisconfiguredbythelawasanextremeremedytobeappliedonlywheneveryothermeasureprovidedforistobeconsideredunsuitableformee@ngtheprecau@onaryneedsthatpresentthemselvesinthecaseinpoint.Itisthoughtthat,includinginconsidera@onofthecircumstancesstatedinthedefensiveinstance,theaforesaidandrecalledprecau@onary

circumstancesstatedinthedefensiveinstance,theaforesaidandrecalledprecau@onaryneedscanadequatelybesa@sfiedwithameasurelessharshthanthatrequestedbythePublicProsecutorandsignallywiththemeasureofhousearrest.

Ifoneactuallyconsidersthesocialinclusionofthesuspect,thefactthathehasastablefamilywithwhichhecohabits,theabsenceofthedangerofflight,thecircumstancerecalledbythedefenceundertheprofileoftheprofessionaltrainingreceivedandconfirmedbythebehaviourengagedinwiththeworkersatthe@meofthedeten@on,heisinanycaseaccustomedinordinarylifetotheobservanceofhierarchiesandrules,whichiswhyitisunreasonabletothinkthathemayeludethecontrolsprovidedfor.Themeasureofhousearrest,withprohibi@ontocommunicatewithpersonsotherthanthosewithwhomhecohabits,thereforeappearsfullysuitableforsa@sfyingtheprecau@onaryneedsinconnec@onwithrecidivisminvolvingengaginginseriouslyculpablecriminalbehaviourbythesuspect.

FORTHESEREASONS

Havingreadar@cles273,274and284oftheCodeofCriminalProcedure.,SheappliestoFrancescoScheSno,underinves@ga@onfortheoffencespursuanttoar@cles113,449(2),inreferencetoArt.428,589(3),81(1)and591ofthePenalCode,themeasureofhousearresttobeexecutedathisresidencelocatedinMetadiSorrento(NA)atViaVitoSanCristoforo10,withabsoluteprohibi@onagainstgoingawayorcommunica@ngbyanymeanswithpersonsotherthanhiscohabitants.

SheorderstheimmediatereleasefromprisonofFrancescoScheSnounlessdetainedforanotherreason.

SheauthorizesFrancescoScheSnotoreachunescorted,withhisownmeans,takingtheshortestrouteandintheshortest@mepossible,theplaceofthehousearrest.

Sheordersthatuponarrivalattheplaceofhousearrestthesuspectshallpromptlyno@fythepoliceforcescompetentforthecontrols,tobeiden@fiedastheCarabinieri,Sta@onofPianodiSorrento(NA).

ShetaskstheOfficeoftheCourt’sClerkwiththemaqerofdischargingobliga@onsandcommunica@ons.

Grosseto,17January2012THEMAGISTRATEINCHARGEOFPRELININARYINQUIRIESDrValeriaMontesarchioCOURTOFGROSSETOOfficeoftheMagistrateforPreliminaryInquiriesFiledwiththeOfficeoftheCourt’sClerkTODAY17Jan.20127:35PMTheCourt’sClerk(DrSandraZANELLI)

Thisini5alinquirysetthegroundsfortheeventualtrialproceedingsThis preliminaryinvestigation was compiled from evidenceimmediatelyaQertheevent,includingthefirstreportofthecoastguardofPortoSantoStefanoof14January2012,thesummarytes5monialinforma5ongivenbythemembersoftheship'screw,thechronologyofeventsoftheHarbourOfficeofthePortofLivorno,theautoma5cIden5fica5onsystemrecording,andtheevidenceoftheHarbourOfficeofthePortofLivorno. Amongstthis’evidence’aconsiderableamountofthemagistrate’sfindingsisaresultofhearsayratherthandirectevidence,eventojudgementsoftheSchetno’scharacterwhicharestrangetofindinanofficiallegalhearing.

arestrangetofindinanofficiallegalhearing. Onthe2February2012theprosecutor'sofficeinParis,France,openedapreliminaryinquirytoques5onsurvivorstoestablishanycriminalliabilityand"assesspsychologicaldamage".". On22February2012,fourofficerswhowereonboardandthreemanagersofCostaCruiseswereplacedformally"underinves5ga5on" TheMagistrate’sInquiry On3March2012,inGrosseto,judgesbeganaclosedhearingopentoallsurvivorsandother"injuredpar5es",andtheirlawyers. On9thofMarchaninves5ga5vetribunal,consis5ngoftwoAdmiralsandtwoprofessorswasconvenedinGrossetotoassistthecriminalinves5ga5ondecideonanyprosecu5onsandthepar5estobeprosecuted.

Tuscany'sProsecutorGeneralsaidthattheinves5ga5onwillseektofindcausesforvariousaspectsoftheevent,andbeyondCaptainSchetnotootherpersonsandcompanies,However,theItaliancourtfailedtoprovidethestatutoryindependentsafetyinves5ga5on,asrequiredbyboththeIMOandtheEUdirec5ve2009/18/ECasItalyhadnotimplementedthisintoItalianLawatthe5meoftheincident.

TheItalianprac5cethatcriminalinves5ga5onoverrulesthestatutorysafetyinves5ga5onisnotacceptedbytheEuropeanUnion.Nocriminalcourtac5onsagainstthecaptainoranycrewmembershouldhavebeentakenbyanycourtwithoutthestatutoryinves5ga5onprovidingfullknowledgeofwhathappenedandwhyithappened.

MrDeiddagoesfurtherandexplicitlyreferstoCosta’stopexecu5veswhenheliststheoffencescommiTed.Theprosecutorgeneralsays:“Magistratesseekcauseandeffectlinksforevents.Up5llnow,aTen5onhasfocusedonthenegligenceofthecaptain,whowastragicallyinadequate.Butwhoselectsthecaptain?Decisionsmadeupstreambyhisemployer,theshippingcompany,needtobescru5nised.Thereisalsothefundamentalissueofsafetyorganisa5on–lifeboatsthatcouldnotbelowered,crewwithnoideaofwhattodo,pooremergencymanagementtrainingandincompetentordersliketheabsurdinstruc5ontoreturntothecabins.Theconfusionshowsincrediblenegligenceinapplyingsafetyregula5ons.Thisisanareathatshouldbeorganisedinadvancewithexercisesandsimula5ons.Actualemergencymanagementcomeslater”.Overthepastfewdays,theprocuratorgeneralhaspointedoutthatrescueopera5onsshowedthat“crewmembersassignedtothetaskwereunpreparedandbereQofanyspecialistknowledge.PassengersleQtotheirowndevicesreceivedconflic5ngmessagesfromthecaptainandotherofficers”.

TheInterna)onalManagementCodefortheSafeOpera)onofShipsandforPollu)onPreven)on(ISMCode) Thiswasintroducedasaresultofthesinkingofthe‘HeraldofFreeEnterprise’onMarch6th,1987,withthelossof193lives.Strangely,theMasterinthiscasewasthrownfromthebridgewingintothewater.ThepublicinquiryledbyJus5ceSheenrevealedthatwhilecrewnegligencewasamajorfactor,theinquiryrevealedthattheshoremanagement,TownsendCarFerriesLtd.,wasjustasmuchtoblame.Thereportsummedupthemanagement'sattudetowardssafetyinthefollowingstatement:'Fromtoptoboqomthebodycorporatewasinfectedwiththediseaseofsloppiness'(Sheen,1987). Itisintendedtoprovideaninterna5onalstandardforthesafemanagementandopera5onofshipsatsea. AsamemberofboththeIMOandtheEU,ItalyisobligatedtoincorporatetheISMCodeinto

itsdomes5clegisla5onand,therefore,itsjudicialsystem.However,ithasfailedtodoso.becauseofthisfailure,lawyerswereunabletopresent,andthusthecourtsunabletoconsider,thetechnicalISMandnau5calissuesthatledtothedisaster.AsthiscodehasbeenimplementedbytheIMOinLegisla5onandallshipshavetofollowit,howcananytrialcourtmakelegaldecisionsontheliabilityandaccountabilitybetweenthecompanyandthecrewwithregardstomari5mesafety?WhydocompanieschoosetoregistertheirshipswithflagsthateitherdelayordonotimplementEUorIMO?

EventhesafetyinquiryignoredtheveryIMOguidelinesfortheimplementa5onoftheISMsystemregardingresponsibility,asthesewouldhavesupportedtheProsecutorGeneral’sinten5ons.

TheCodeisveryclearonthefactthatthecaptainofashipcannotbedelegatedthesoleresponsibilityforthetotalopera5onoftheshipasitisthecompanythathasthisul5materesponsibility.Possibly,apartfromthetwomilitaryofficersonthetribunalhavingliTleknowledgeofsuchmaTers,itcouldhavebeenthatthiscouldhavecausedanoutcomenotacceptabletothepowersbehindthecourtsandthesafetyinquiry.“Iftheen@tywhoisresponsiblefortheopera@onoftheshipisotherthantheowner,

theownermustreportthefullnameanddetailsofsuchen@tytotheAdministra@on.

TheISMCode,chapter3.1 IftheCaptainisnotnamed,thentheCarnivalcruisegroupisresponsiblefortheopera5onoftheship.HowthencantheybeallowedapleabargainallowingthemtoabsolvethemselvesfromthisresponsibilityandplaceitontheCaptainwhoisnotnamed? “Inthefinalanalysis,whilethemasterisclearlyresponsibleforthesafetyoftheshipand

hercrew,thefinalresponsibilityfortheadministra@onandsafeopera@onofeachship

restwiththeCompany”

TheInterna5onalChamberofShipping“Guidelinesontheapplica5onoftheISMCode”,Introduc5on

“EveryCompanyshalldevelop,implementandmaintainaSafetyManagementSystem

(SMS)whichincludesthefollowingfunc@onalrequirements:

“1.3:definelevelsofauthorityandlinesofcommunica@onbetween,andamongst,

shoreandshipboardpersonnel.”

TheISMCode,chapter1.4,Func5onalrequirements.

FromtheaboveitisclearthattheISMcodeconfersontheMastertheul5materesponsibilityonboardtheship,whiletheCompanyhavetheoverallandfinalresponsibilityfortheadministra5onandsafeopera5onoftheship. In supportof theapplica5onof the ISMCode, theEU ruleson safetyopera5onson shipsapply to all passenger ships opera5ng in EU waters and make mandatory theimplementa5onoftheIMOInterna5onalSafetyManagement(ISM)Codeforallpassengerships in regular service to or from EU ports (Regula5on 336/2006). One objec5ve is toensure that the crew is trained for all safety and emergency procedures including theevacua5onofpassengers,andthatitcarriesoutperiodicdrills.TheEUappliedtheISMCodein1996,evenbeforeitenteredintoforce.The inspec5on and cer5fica5on of equipment including life-saving appliances is alsogovernedbyEUlawforallshipsflyingtheflagofanEUmemberState(Direc5ve96/98).

Itisimportantthatitisclarifiedwhatthisreportwasandthatitwasissuedtoproveguiltypar5estobeprosecutedratherthantofindoutthetruthofwhatwentwrong.Itthus

par5estobeprosecutedratherthantofindoutthetruthofwhatwentwrong.Itthusstartedoutwithalistofnamesandthengatheredevidenceagainstthem.ApreliminaryreportwaspresentedtotheCriminalcourtonthe13thofSeptemberandfollowednowtheusualpaTernofbeingleakedtotheworldmedia.

Thereportthereforeisamixoftechnicalinquirycloudedbythecriminalsidewhichlooksforblameandindividualsforprosecu5on.Intherequirementforacriminalfinding,thereportconcentratesonthisandthereforetheinves5ga5onoftheCaptaintoooQeninfluencesthereport.Itseemsasifthereportisfollowingaprearrangedscriptwithadefinedconclusionofblameononeperson,theCaptain.Todothisrequiredconsiderableandessen5alpartsoftheinquirytobeomiTed.

Thisinves5ga5onthereforemissedsomanyfactsofseamanshipandsafetythatwouldhavechangedsuchchargesifpreparedandpresentedtoamarinecourtbutthatchancewasnowover.Thereportwasofficiallyhandedoveronthe15thofOctober.

Thedecisionofthecriminalinquiry. The preliminary investigations about the COSTA CONCORDIACOSTA CONCORDIA shipwreck (that) occurredon the 13th (?) of January 2012 in front of Giglio Island have been concluded and a requestfor committing the responsible persons for trial has been lodged. The Public Prosecutor's Office in the court of Grosseto informs all the people offended aboutthe demand sent to the Judge of preliminary investigations to place on file: - the crime of cooperation in unintentional shipwreck unintentional shipwreck against:Salvatore URSINO, born in Messina on the 16th of July 1985. - the crime of cooperation in unintentional manslaughter crime of cooperation in unintentional manslaughter and unintentionalpersonal injuries against:Salvatore URSINO, born in Messina on the 16th of July 1985;Roberto BOSIO, born in Sanremo (Imperia) on the 26th of October 1966;Manfred URSPRUNGER, born in Enns (Austria) on the 12th of May 1958;Paolo Giacomo PARODI, born in Genoa on the 26th of February 1953.

- the infraction of lack of cooperation with the maritime Authoritiesinfraction of lack of cooperation with the maritime Authorities against:Andrea BONGIOVANNI, born in Sanremo (Imperia) on the 25th of January 1981;Simone CANESSA, born in Rome on the 24th of November 1985;Manfred URSPRUNGER, born in Enns (Austria) on the 12th of may 1958. - the infraction of cooperation in destruction or deterioration of a protectedinfraction of cooperation in destruction or deterioration of a protectedhabitathabitat inside a natural site against:Francesco SCHETTINO, born in Naples on the 14th of November 1960;Ciro AMBROSIO, born in Torre del Greco (Naples) on the 29th of October 1983;Salvatore URSINO, born in Messina on the 16th of July 1985;Silvia CORONICA, born in Trieste on the 5th of January 1983;Jacob RUSLI BIN, born in Jakarta (Indonesia) on the 11th of December 1963. - the administrative offense resulting from the crime of destruction or deterioration of aprotected habitat inside a natural site against:COSTA CROCIERE Spa, Headquarters in Genoa, Piazza COSTA CROCIERE Spa, Headquarters in Genoa, Piazza PiccapietraPiccapietra n. 48. n. 48.The offended people have the faculty, within ten days from this notice, to examine thereasoned application of placing on file as well as all the deeds concerning the investigationsand for the above-mentioned crimes, to lodge objection, explaining the reasons why theinvestigations should continue.

It is reported that the Indonesian Union representing Jacob Rusli Bin was not going to acceptthat he should be held responsible.No comment was made by the Italian maritime Unions other than to express theircondolences, possibly because of their close relationship with the company, Costa CrociereSpa.October 15th. The Criminal Court reconvened

October19th.Thehearingsended.Nodecisionregardingwhowastobeprosecutedandwhatforwasnotannounced.

WhoreallycausedthecapsizeoftheshiponJanuary14thremainedunclearbecausethecapsizeandthekillingofpeopleonboardwasnotdiscussed.Thejudgewoulddecideiftherewereenoughevidencetowarrantatrialbytheendoftheyear.

TheshipownersCostaCrociere,surprisinglywasnotevencalledtogiveevidence.However,theyavoidedpoten5alcriminalchargesbymakingaPleaBargain,accep5ngpar5alresponsibilityandagreedtopayafineof1millionEuro,andthatasimilararrangementwasdoneforfiveofitsemployeesincludingthreeoftheofficersinthebridgeteamandthehelmsman.TheonlypersonnotaffectedbythePleaBargainwasCaptainSchetnoandanyaTemptbyhiscounciltoarrangethesamewasrefused.

November30thTheItalianMari5meInves5ga5onAuthoritypresenteditsini5alfindingsattheInterna5onalMari5meOrganiza5on’s91stMari5meSafetyCommiTee.ItissixmonthsexactlysinceItalyreportedtotheMSCinMay.However,theauthoritysaidthesitua5onhadchanged.

Atthefirstpresenta5on,thespokeswomanfortheinves5ga5onsaiditcouldonlyprovideanoverviewofini5alstagesofac5vityastheinves5ga5ngprosecutorshadseizedkeydocumentsanddatanecessaryforthetechnicalinves5ga5on.

Theadministra5ve,criminalandtechnicalinves5ga5onscon5nuebutthespokeswomansaidtherewasanewimportantelementtoreport.

OnOctober15,thefirstcriminalhearingtookplaceandthismeantthatthedataretrievedfromthevoyagedatarecorderandotherrelevantdocumentsseizedbyprosecutorswasdisclosedforthefirst5me.

Thedatawass5llunderscru5ny,buttheauthorityhasmadesomepreliminaryrecommenda5onsbasedonthreemainareas:naviga5on,safetymanagementandstability.

Theinquiryconcerningthenaviga5onalphasefocusesonwhathappenedbeforetheimpactandinpar5cularthebehaviourofthemasterandhisdecisiontotakethevesselsoclosetotheshoreline.

Theinves5ga5onsimulatedthelastnaviga5onphaseusingCarnival’scruisesimulatortrainingcentreC-SmartinAlmere,consideredthemanoeuvringbeforeimpactandtheship’sbehaviouraQertheevent.Itreconstructedtheac5onusingwitnessstatements,thesurveyreportandvideodata.

Theauthorityshowedthesimula5onattheIMOtodemonstratehowcloseCostaConcordiasailedtotheshoreline.Theonlychangemadewastosimulatetheac5oninday5mesothatthecoastlinecouldbemorevisible.

Thespokeswomansaid:“Thereconstruc5onallowsanalysisofevidencefromthecri5calpointfornaviga5onandthepreliminaryfactorswhichcontributedtotheaccident.Firstofall,theshiQingfromaperpendiculartoaparallelcourseextremelyclosetothecoast.

“Asecondcri5calpointisthatthereferencepointforstar5ngturningwasnotthemostexternallandmark,insteadtheshipproceededtosailsouthwardtowardstheinnercoastline.Anothercri5calpointisthehighspeedatnightsoclosetotheshoreline.”

Thespokeswomanalsohighlightedtheinappropriateuseofcartography,astheshipwasusingchartno6insteadofchart122.

Themaster’sinaTen5onduetopeoplepresentwhowereextraneoustothebridgewatch

Themaster’sinaTen5onduetopeoplepresentwhowereextraneoustothebridgewatchandtomakingaphonecallnotrelatedtoopera5onsalsocontributedtotheaccident,theItalianbodysaid.

Thesimula5onalsoshowedthatthemaster’sorderstothehelmsmanaimedtoensurethatthecompasscoursewasfollowedratherthantherudderangle.

Finally,theinves5ga5onhighlightedtheattudeofthebridgeteam.“Althoughthestaffweremorethansuitableintermsofnumber,theywerenotpayingthedueaTen5ontosteeringandtheshipposi5on,”thespokeswomansaid.

Onthesubjectofsafetymanagement,thespokeswomansaidthealarmonCostaConcordiawasnotimmediatelyac5vatedaQertheimpactandthisdelayedthemanagementoftheemergencyphasesandabandon-shipprocedure.

“Ananalysisofthecrewcer5fica5on,musterlist,trainingandcer5fica5onhighlightssomeinconsistenciesintheassignmentofdu5estosomemembersofcrew,”shesaid.

“Thelackofdirectordersfromthebridgetothecrewonsafetyissueshinderedanefficientmanagementofthegeneralemergencyabandonshipphase.Theexistenceofdifferentbackgroundsandtrainingofcrewwithoutcompleteco-ordina5onhinderedopera5onalmanagement.”

AlthoughItalynotedthattheseissueswerewellregulatedbySOLAS,thespokeswomanaddedthatregula5onregardingsafemanningandmusterlistscouldbereconsidered.

Onthesubjectofmusterlists,sheexplainedthatinves5ga5onscarriedoutbytheItaliancoastguardonmorethan50cruiseshipsflyingdifferentflagsfoundthatmusterlistsareoQenconfusedwiththeminimumsafemanningdocument.

Ontheissueofstability,thespokeswomansaidacombina5onoffactorscausedimmediateandirreversiblefloodingoftheshipbeyondanymanageablelevel.

Shesaidthefloodingofthecompartmentswascausedbythegashinthehull.

“Itisnowpossibletoprovideexactmeasurements.Thegashwas53mfromframe52-125withavariablewidthupto7.3m.Water@ghtcompartmentsfiveandsixfloodedinaveryshort@meaVercollisionandrepresentalreadyalimitcondi@onforgivingtheabandon-shiporderallowingforasafeevacua@on,”shesaid.

Astabilitysimula5onwasalsoconductedbySafetyatSeaCompanyinGlasgow,usingalltheinforma5onavailable,especiallyVDR.

“Itwasfoundthatacri@calfactorcausedbythefloodingwastheimmediatelossofpropulsionandgeneralserviceslocatedinwater@ghtcompartmentsfiveandsix.Oneoftheconsequenceswasthatthehigh-capacityseawaterservicepumpswereunavailableastheycouldonlybesuppliedbythemainswitchboard.”

Theinves5ga5onalsonotedthatthelackofawirelesstelecomsystemcouldbeconsideredafactorindelayingtheexchangesbetweenkeypersonsduringtheemergency.

Althoughthespokeswomansaidthefloodingofwater5ghtcompartmentswheremostofthevitalequipmentwasstoredmadethecasualtyunique,italsodemonstratedthevalidityofsomeamendmentstoSOLASsetngfurtherrequirementsfornewbuildingsorexis5ngships,suchasrequirementsforsegrega5ngvitalequipment.

Shesaid:“Improvementscanbeseeninconjunc@onwiththeSafeReturntoPortrequirements,suchas:providingdoubleskintoprotectthewater@ghtcompartmentscontainingequipmentvitalforthepropulsionoftheship;morepar@@oningandsub-par@@oningofthewater@ghtcompartmentstolimittheeffectofflooding;discon@nuitybetweenthecompartmentscontainingtheship’sessen@alsystems;moredetailedcriteriafordistribu@onofbilgepumpsalongthelengthoftheshipandpossiblearrangementofatleastonehighcapacitypumptodrainlargequan@@esofwaterfromanisolatedcompartment.”

Italyhasrecommendedcentralsystemsfortheemergencydieselgeneratorincasesofemergencysuchasredundancyofsteeringtocounteractfloodingandheeling.

emergencysuchasredundancyofsteeringtocounteractfloodingandheeling.

Italsosaiditshouldbepossibletosupplythebowthrusterstomaintainthebowatseaevenwithlossofpropulsionandmainsteeringfailure.

Aprogrammeoftestssimula5ngtheemergencycondi5onstookplaceonNovember16and17.Theresultsareunderevalua5onandwillhelptoverifyandbeTerunderstandtheemergencydieselgeneratorandrelatedswitchboard.

20thDecember,Prosecutorsconcludedthecriminalinves5ga5onintotheshipwreckoftheCostaConcordiacruiselinerandwerepreparingtoseekatrialforitscaptainandeightotherpeople.

CaptainFrancescoSchetnowasaccusedof(A)manslaughter,(B)causingashipwreckand(C)abandoningtheship,whenthevesselfirstcontactedrocksandthencapsizedaQerhebroughtittooclosetotheislandofGiglio.

OnFebruary23,2013thenamesof10personsandacompanychargedwithcrimesandinfrac5onsoftheCostaConcordiaincidentJanuary13,2012weremadepublicasfollows;

The preliminary investigations about the COSTA CONCORDIA shipwreck (that) occurred onthe 13th (?) of January 2012 in front of Giglio Island have been concluded and a request forcommitting the responsible persons for trial has been lodged. The Public Prosecutor's Office in the court of Grosseto informs all the people offended aboutthe demand sent to the Judge of preliminary investigations to place on file: - the crime of cooperation in unintentional shipwreck against:Salvatore URSINO, born in Messina on the 16th of July 1985. - the crime of cooperation in unintentional manslaughter and unintentional personalinjuries against:Salvatore URSINO, born in Messina on the 16th of July 1985;Roberto BOSIO, born in Sanremo (Imperia) on the 26th of October 1966;Manfred URSPRUNGER, born in Enns (Austria) on the 12th of May 1958;Paolo Giacomo PARODI, born in Genoa on the 26th of February 1953.

- the infraction of lack of cooperation with the maritime Authoritiesinfraction of lack of cooperation with the maritime Authorities against:Andrea BONGIOVANNI, born in Sanremo (Imperia) on the 25th of January 1981;Simone CANESSA, born in Rome on the 24th of November 1985;Manfred URSPRUNGER, born in Enns (Austria) on the 12th of may 1958. - the infraction of cooperation in destruction or deterioration of a protectedinfraction of cooperation in destruction or deterioration of a protectedhabitathabitat inside a natural site against:Francesco SCHETTINO, born in Naples on the 14th of November 1960;Ciro AMBROSIO, born in Torre del Greco (Naples) on the 29th of October 1983;Salvatore URSINO, born in Messina on the 16th of July 1985;Silvia CORONICA, born in Trieste on the 5th of January 1983;Jacob RUSLI BIN, born in Jakarta (Indonesia) on the 11th of December 1963. - the administrative offense resulting from the crime of destruction or deterioration of aprotected habitat inside a natural site against:COSTA CROCIERE Spa, Headquarters in Genoa, Piazza Piccapietra n. 48.25thFebruary2013,On25February2013theChiefProsecutorsaidaQerasophis5catedscien5ficandothertechnologicalinves5ga5onwascarriedout:

"thedeterminingcauseoftheeventsoftheshipwreck,deathsandinjuries,is,unfortunately,

"thedeterminingcauseoftheeventsoftheshipwreck,deathsandinjuries,is,unfortunately,drama@callyduetothehumanfactor."

HealsosaidCostaCrociereSpA,theItaliancruisecompanyandshipowner,hasaskedforapleabargainagreementwhich,ifitwasaccepted,couldseeCostapaya€1million($1.35million)fine.

Thetrialwassupposedtotakeplace15-24April,2013atGrosseto,apparentlybehindcloseddoors,sothepublicandmediacouldnotaTend.OnApril17thepresidingjudgepostponedthehearingsun5lMay14. 25February2013–ItalianprosecutorsseekindictmentofCostaConcordiacaptainFrancescoSchetnoandfiveotherCostaemployees(fourcrew,oneshoreside)

PHASE6THECOSTACROCIEREPLEABARGAIN

10thApril2013.CostaCrocierereachedaPleaBargainwiththeprosecu5on.Inthis,CostaCrociereacceptedaEuroOneMillionfineinordertoseTlepoten5alcriminalchargesagainstit.Thispreventsthecompanyfromeverbeingprosecutedinacriminalcourtforitsroleinthedisaster.Thiseffec5velyleavestheMasterasthesoleagentresponsibleforthedisaster.ItalsocompletelyignorestheTheInterna5onalSafetyManagement(ISM)Codethatisaninterna5onalstandardforthesafeopera5onofshipsandforpollu5onpreven5onrequiredforshipstobeoperatedbytheIMO. CommentsonthePleaBargains. TheIMO,underwhoseauspicestheISMCodewasins5tutedandeffec5velyareresponsibleforitsgovernance,saidnothing.

Takingpar5cularexcep5ontothecourt’sdecisiontopermitpleabargainingarrangementsinsuchaseriousmari5meincident,IFSMAsecretarygeneralCommodoreJimScorersaidthatthecriminalisa5onandvic5misa5onofthemaster“isbeyondbeliefandneedsexposingandcondemningatthehighestlevel”.

‘LearningfrommistakesidenJfiedduringtheprocessofanaccidentinvesJgaJonisanimportant,ifnotvital,partoftheinternaJonalMariJmeCommunity’ssafetyculture.’

H.P.Berg.HumanFactorsandSafetyCultureinMari@meSafety(2013)

ThiswasacknowledgedbytheBundesstelleFurSeeunfalluntersuchung(BSU,TheGermanFederalBureauofMari5meCasualtyinves5ga5on,whenitpubliclycri5cisedthePleabargainingandthedecisionnottoinves5gateCostaCrociere’sroleinthedisaster.

Ref;2014BundesstelleFurSeeunfalluntersuchungannualreport.

May22,2013,itwasannouncedthatthetrialwillbeginonJuly9andthatonlyCaptainSchetnowillbetriedforcausingtheshipwreckbynaviga5ngtooclosetoshoreproducingacontactwitharockonJanuary13,2012.

Theotherpersonsaccusedofassis5ngtheCaptainwillonlybejudgedlater.

24May2013–ItalyreleasesfullaccidentreportonCostaConcordiacasualty

Theconsiderabledelayinpublishingthisreportwasthesubjectofextensivecri5cism.

OnApril262013theInterna5onalChamberofShipping(ICS)andtheInterna5onalTransportWorkers’Federa5on(ITF)madeajointsubmissiontotheIMOcommen5ngontheapparentfailureofsomeflagstatestosubmitmari5mecasualtyreportstotheorganiza5on,obviouslydirectedattheItalianAccidentreport.

“Thelackofinves@ga@onandaccidentreportshindersthedevelopmentofappropriatemeasuresbyIMOtoaddressthecauseofseriousincidentsinwhichseafarersmayhavelosttheirlives”

ITFac5nggeneralsecretary,StephenCoTon.

“Italsofrustrateseffortsbyshipoperatorstolearnfromthereportsandtoamendordevelopnewprocedures,orimplementothermeasurestopreventormi@gatesimilarfutureincidents”

ICSsecretarygeneral,PeterHinchliffe.

ICSsecretarygeneral,PeterHinchliffe.

ICSandITFhavethereforesuggestedthatfurtherconsidera5onmightbegivenbyIMOtotheextenttowhichflagstatesshouldretainthela5tudewhichtheycurrentlyenjoywhendeterminingwhethertheresultsofanyinves5ga5onshouldbesubmiTedtoIMO.

theItalianMarineCasualtyInves5ga5onCentralBoard,MCICB,submiTedmonths16monthsaQertheaccident,givingthereasonforthedelaythatthecriminalcourtandtheprosecutorshadconfiscatedtheVDRfor9months.

ItcouldbethattheICS/ITFhavemisunderstoodthesitua5on.FlagStatesareonlyrequiredtoreportwherethereisaregulatoryimportance.Whentheydoreport,itistheflagstatethatgivespermissiontotheIMOtorelease.

7THPHASE.THESAFETYREPORT

Belowfollowsthecompleteunalteredtransla@onoftheSafetyreportconclusion.Itisdisappoin@ngthatthetransla@onhasbeendonesopoorly. The EU Direc5ve 2009/18/EC establishes the fundamental principles governing theinves5ga5onofmari5meaccidentsinordertodeterminetheircause.

ThisDirec5ve,whichenteredintoforceon17June2011,introducesamongotherstheobliga5onforMemberStatestohaveinplaceanindependentaccidentinves5ga5onbodyandtheinves5ga5onitselfisdoneonthebasisofacommonmethodologyandtheaccidentreportshouldbemadepublicwithin12monthsfromthedateofthecasualty.However,Italydidnothavesuchaunit,whichleQtheresponsibility,inthecaseofCostaConcordia,withtheFlagStateadministra5on. Owingtothelengthofthereportonlytheconclusionshavebeenincluded. CONCLUSIONS Foreword ItisworthtosummarizethatthehumanelementistherootcauseintheCostaConcordiacasualty,bothforthefirstphaseofit,whichmeanstheunconven5onalac5onwhichcausedthecontactwiththerocks,andforthegeneralemergencymanagement.ItshouldbealsonotedthattheCostaConcordiais,firstofall,atragedy,andthatthe32deadpeopleandthe157injured,dependedonlybytheabovemen5onedhumanelement,whichshowspoorcompetencebykeycrewmembers.Accordingwiththeevidencesfoundattheendofthepresentinves5ga5on,itisnecessarytoputinevidencethatCostaConcordiaresultedinfullcompliancewithalltheSOLASapplicableregula5ons,matchingthereforealltherelatedrequirementsoncesheleQtheCivitavecchiaPortontheeveningofthe13January2013.

5.1NavigaJonbeforetheimpactphase Thisisthephaseoftheincidentistobeconsideredcrucialtotheinves@ga@on,asitisthecauseofac@onoriginatedtheseriousConcordiacasualty,andinthatsenseisduefirstlytohighlighttheconductoftheMastergearedwilfullytopasstheshipinrestrictedwatersandtheninasmallspace,byarouteparalleltoandperpendiculartoanexcessivelyclosetotheshore,interveninginaverylightwayonthecourse(thenwithbowswhichgavethehelmsmanfacultyofself-management)togenerateasweetturn,butatthesame@meverywide. Itisworthtohighlightalsothefollowingproblemsintermsoforganiza@on:-inthemean@me,althoughtheshipwasproceedingquicklytowardtheshore,takingcommandwellinadvance,s@llin@metocorrectthedangerousroute,representsfortheMasteranaggrava@nginhisnau@calbehaviour;-thedifficul@esoftheMasterinreadingtheradarscreen(accordingto1stDeckOfficer,waswithoutglassesfornearvision);-theuseofcartographytotallyinadequate-aninappropriateapplica@onofsystemsnaviga@on(EcdisandRadarinappropriatescaleofapproaching);-however,thedistrac@onoftheMasterbytheconductduebothtothepeopleinthehotelbusinessdepartmentthatwerealreadyonthebridgewhenhearrived,andtothecallengagedbyoneofthemwithacolleagueontheground;-theordersoftheMastertothehelmsmangivenbyassigningthebowtofollow,ratherthanorderingtherudderangle. 5.1NavigaJonbeforetheimpactphase Thisisthephaseoftheincidentistobeconsideredcrucialtotheinves@ga@on,asitisthecauseofac@onoriginatedtheseriousConcordiacasualty,andinthatsenseisduefirstlytohighlighttheconductoftheMastergearedwilfullytopasstheshipinrestricted watersandtheninasmallspace,byarouteparalleltoandperpendiculartoanexcessivelyclosetotheshore,interveninginaverylightwayonthecourse(thenwithbowswhichgavethehelmsmanfacultyofself-management)togenerateasweetturn,butatthesame@meverywide.Itisworthtohighlightalsothefollowingproblemsintermsoforganiza@on:-inthemean@me,althoughtheshipwasproceedingquicklytowardtheshore,takingcommandwellinadvance,s@llin@metocorrectthedangerousroute,representsfortheMasteranaggrava@nginhisnau@calbehaviour;-thedifficul@esoftheMasterinreadingtheradarscreen(accordingto1stDeckOfficer,waswithoutglassesfornearvision);-theuseofcartographytotallyinadequate-aninappropriateapplica@onofsystemsnaviga@on(EcdisandRadarinappropriatescaleofapproaching);-however,thedistrac@onoftheMasterbytheconductduebothtothepeopleinthehotelbusinessdepartmentthatwerealreadyonthebridgewhenhearrived,andtothecallengagedbyoneofthemwithacolleagueontheshore;-theordersoftheMastertothehelmsmangivenbyassigningthecoursetosteer,ratherthanorderingtherudderangle.Regarding the specific direc@ves collected within the ISM procedures, emerge precisecri@cality that can be found in watch-keeping on the bridge, both with regard to thedistrac@on of service personnel due to the presence of strangers, but also about theverifica@on of the ship posi@on, which in this case has never been (at least from audiorecordings)ascertained.AndinthiscontextitisclearthearbitraryaStudeoftheMasterinreviewing theoriginalwaters.Thecomputersimula@onsomewhatconfirmeddelays in theship’s manoeuvring in that par@cular circumstance. In this respect, the following cri@calpointscanbepreliminarilyindicatedascontribu@ngfactorstotheaccident:

-shiVingfromaperpendiculartoaparallelcourseextremelyclosetothecoastbyinterveningsoVlyforaccomplishingasmoothandbroadturn;

-insteadofchoosing,asreferencepointforturning,themostextremelandmark(Scolereef,closetoGigliotownlights)theshipproceededtowardtheinnercoastline(PuntadelFaro,southernandalmostuninhabitedarea,withscarceillumina@on);

-keepingahighspeed(16kts)innightcondi@onsistooclosetotheshoreline(breakers/reef);

-usinganinappropriatecartography,i.e.useofItalianHydrographicalIns@tute.chartnr.6(1/100.000sizescale),insteadofatleastnr.122(1/50.000sizescale)andfailingtousenau@calpublica@ons;

-handoverbetweentheMasterandtheChiefMatedidnotconcretelyoccur;

- bridge (full closed by glass windows) did not allow verifying physically outside, a clearsoutlookinnight-@me(whichinsteadcouldhavemadeeasiertheMaster

eyesadapta@ontowardsthedarkscenario),catchingmoreovernoisebyseaslammingtotherocks/beach;

-Master’sinaqen@on/distrac@onduetothepresenceofpersonsextraneoustoBridgewatchandaphonecallnotrelatedtothenaviga@onopera@ons;

-Master’sorderstothehelmsmanaimedatprovidingthecompasscoursetobefollowedinsteadoftherudderangle.

-BridgeTeam,althoughmorethansuitableintermsofnumberofcrewmembers,notpayingtherequiredaqen@on(e.g.shipsteering,acquisi@onoftheshipposi@on,lookout);

-Master’sarbitraryaStudeinreviewingtheini@alnaviga@onplan(makingitquitehazardousinincludingapassage0,5mileoffthecoastbyusinganinappropriatenau@calchart),disregardingtoproperlyconsiderthedistancefromthecoastandnotrelyingonthesupportoftheBridgeTeam;

-overallpassiveaStudeoftheBridgeStaff.NobodyseemedtohaveurgedtheMastertoacceleratetheturnortogivewarningontheloomingdanger.Thepresentcasedemonstratestheinadequacy,intermsoforganiza@onandthenabout"whodoeswhat"oftheBridgeTeam.ThisincidentcanbeusefulasawarningforarevisionoftheguidelinesnowtakenbythevariousConven@ons(SOLAS,STCW,ISMCode),andincludedwiththeISMproceduresonboard.Thisinpar@culartoexploretheareaswhereinterveninginordertoensurethatthemanagementstructureofthebridgerespondtoeachsitua@onandcondi@on(ordinary,cri@cal,emergency)thatmayoccuratsea,providingalsoinstrumentsforadapta@ontodifferenttypesofvessels/sailing/quan@tyandqualityofthecrew(amongtheothersacorrectadop@onofthetradi@onalnaviga@ontoolsandrelatedcriteria,theadapta@onoftheoutlookandradio-naviga@on). Onepar@cularareacanbe,ofcourse,thedivisionofdu@esofeveryonewhichisinservice,togetherwiththeconsulta@onforsharingofdataandriskanalysis(inConcordianobodyhasverifiedexactlyhowtheshipwasproceedingregardtothedanger,withtheexactposi@oninrela@ontotheseabedandthecoastandwiththekinema@csitwastakingwhilesailing).Thesetasks,ifcoded,canbe(regardlesswhowasthewatch-keeper)amodelofsupporttoavoidrisksintheeventcondi@ons: -closenaviga@on;

-narrowpassages;

-possibledangers. Finally,itcouldbealsocodedinabeqerwayacompletebanofthepresenceonthebridgeduringthevoyageandmanoeuvresofpersonnelwhichisnotpartofthecommanding/conduc@ngstaff(DeckOfficersandsailors/lookouts),andtheresul@ngpenal@es[seeonthereferencetherelatedchapter@tledrecommenda@ons(opera@onalmaqers)].Onthewhole,theaccidentmayleadtoanoveralldiscussionontheadequacy,intermsoforganiza@onandrolesofBridgeTeams. 5.2Breachandmanagementofdynamicstabilityduringflooding

5.2Breachandmanagementofdynamicstabilityduringflooding Acri@calfactorconcurrenttotheflooding,causedalsobytheviolentandsuddenfloodingandverydecisive,wastheimmediatelossofpropulsionandservicesingeneral,shortcircuitsoccurringinthechainofthetwoWCmoreviolentlyaffected,i.e.thesamePEMroom(No.5)andtheWC6(aVDD.GG.),wherever@cally-butundertheBridge0-insistrespec@velytheelectricproduc@onpanelandthedistribu@onone(inPEMarepresent,belowtheproduc@onpanel,eventhetransformers).Theblack-outwasrecordedonly50secondsaVerthecontact.Althoughtheprotec@onspresentbeforethepowerdistribu@onhaveintervenedtopreventthetransmissionofshort-circuitsontheelectricalpanelfromemergencyDG,lossofpropulsionduetothecollapseofthesixmainDD.GG.andtheconsequentloss ofproduc@onanddistribu@onofelectricityhit,crucially,produc@onfacili@esandoverallgovernanceoftheship. Oncelosttheproduc@onofelectricalpower,theconsequentcri@calitywas,infact,theinabilitytohaveavailablethepumpsofexhaus@onlargemasses(approximately1,000m3perhourflowrate,requiringalargepowerconsump@onwhichisinsurableonlybythenetworkproduc@on/primarydistribu@on),asonlyadequateaidstocontrol(3pumpsshouldhaveoperatedatthesame@me),deple@ngthem,thefreeliquidsurfacesimmediatelyproducedinWC4,7and8. Theemergencypump(250mcflow/h)hasnotbeenac@vated,alsoforthediscon@nuousopera@onofemergencyu@li@esevidently(especiallyinthecrucialphaseoffailure,i.e.from3minsto20mins).It,however,couldnotprovideanysignificantcontribu@ontothereduc@onoffreeliquidsurfaces. Afurtherelectricallinesupplyingtheemergency,andthenaffectedbythesameproblemsofcon@nuityinopera@ng,isthebalancingpump.Regardless,andtakingintoaccounttheseverityofthelist,theuseofthatpump,possibleonlyintanksattheextremebow,couldnotsurelyhaveanimpactontheimprovementofcondi@onsofstability. Takingintoaccounttheexcep@onalityandtherapidityoftheevent,theSOLASrulesreferabletoConcordiadonotestablishthattheshipisequippedwithanautomatedsystemofwaterdetec@oninthefreecompartmentsand,consequentlyofacomputerizedfailurecontrolsystembydirectinforma@onnecessarytocalculatetheresidualdynamicstability. Withregarditshouldbenoted,infact,themerefunc@onofsupportperformedbythecomputerizedstabilitysystem(i.e.NAPA),whichrespondstoRule8ofChapterII/1ofSOLAStoprovide,beforeandaVerfailure,theparametersofsta@cstabilityandthecondi@onoffinalfloodingdeterminedwiththehelpoftheoperatorwhomanuallyenterthenecessarydata.TheNAPAispoweredbyoneofthebaqerygroups(UPS)onboard,andaVersomeini@altechnicaldifficul@es,appearstohavebeenusedregularlybytheOfficersincharge. Thestabilityofthevesselresul@nginthe10stepsanalysedinthefloodingsequencehavebeendeterminedusingNAPA,asthesoVwareusedforthefloodingsimula@ondoesnotperformstabilitycalcula@ons;thestabilityresultsareavailableinAnnex1bApp3. Thestabilityofthevesselisfoundsa@sfactoryintermsofGMatequilibriumheelingangle,rangeandareaunderrigh@nglevercurve(represen@ngtheresidualrigh@ngenergyofthevessel)fromstep1(represen@ngthevesselsitua@onat9.45p.m.of13January2013)tostep9(represen@ngthevesselsitua@onat10.31p.m.),whereasatstep10(represen@ngthevesselsitua@onat10.54p.m)therigh@nglevercurveisalmostneglectablemeaningthatthevesselhaslosthercapabilityofopposingtohealingcauses. Furthermore,star@ngfromstep8(represen@ngthevesselsitua@onat10.26p.m)irreversibleprogressivefloodingoftheintactspacesaVerwardthebreachoccurscausingtheprogressivelossofstabilityandthelossoftheshipherself.Fortherelateddiagram,seethepicturesreportedintheAnnex1baqachedtothemainAppendixNo.3(howevertherelatedtechnicalgraphsarereportedatpageno.117and119).

119). Basedonthesequenceofevents,evenintheabsenceatthe@meofacompletepictureoftheevidence-andgiventheexcep@onalnatureoftheevent[itreferstoanextremecaseofacontactforhighspeedwhilesailingatshortdistancefromthecoastandfortheincidentroute(couldbequalifiedasboarding)followed@llafewminutesbeforeimpact]–itcanbeassumedthatanintegratedsystemofdefence(passiveandac@ve)canhandleasimilarcaseinthefuture,reducing: theconsequencesandship’sfloodingreac@onevenintermsofresistanceagainstsinking,shouldbebasedoncriteriaofsafety/construc@on/arrangementsofdifferentsystems,otherthanthoseexis@ngtoday.

Excludinginthelong-termthereplica@onofaneventsodrama@candsevereasthatwhichoccurred to the Costa Concordia, should be considered in the future a similar incident(consequen@aldamages)theeventualcontactbetweentwoshipsathighspeed,withacute/obtuse angle of impact that would affect, therefore, more than two adjacent water@ghtcompartments.

Theabovemaqersareexaminedlaterinthecorrespondingrecommenda@onschapter,bothintermsofvitalequipmentandredundancy. 5.3FuncJonalityoftheEmergencyDieselGenerator. Theopera@onoftheEDGshowedsignificantcri@cali@es,whichrequireprudentconsidera@onsintheround. Itisacri@calissuethatboththeviolentimpact,theconsequentlycollapseandthemassiveamountofwaterthatfloodedthevitalpartsoftheship,causinguncontrollableconsequencesanddamage,eveninvisible,properlyimponderable.Wepointoutthatthepoweremergencygridwentintoautoma@copera@on,despitethefastpathfollowedbythewaterwithinthecomplexsystemofproduc@on/distribu@onofelectricity,par@cularlyintheWTC6(sternDDGGroomandElectricalPanelofthemaindistribu@on).Itishoweverknown,asshowedbythisIB,thattherelatedequipmentweretheninvestedbyacollapse,andthegridworkedonlyinaforcingway. Beingunderstood,theconclusionofthedeeptechnicalinves@ga@ondraVedinthefollowingsentences,somecri@calelementscanbefoundintheaspectsbelowmen@oned:-limitedavailabilityofemergencylinesincaseoffailureforfloodinganddirectconsequencesonmanagementofresidualdynamicstability;

-absoluteabsenceofredundancyintheproduc@onofemergencypower;

-lackoflinesavailableinemergency,inpar@cularthosealsothatcouldbeusedforanalterna@vegovernmentoftheship. Inviewoftheaforemen@onedresults,carriedoutwiththeaidofboardCostaFavolosasistershipac@vi@es,theconclusionsareherebelowsubmiqed: ThestatementinEnclosureno.1tothemainEnclosurenr.(….)providesevidenceofEEPefficiencycondi@onsatthedepartureofthem/vCostaConcordiafromCivitavecchiaon13thJanuary,2012(itistoemphasizetheposi@veresults–withthebreaker901closure–duringthemonthlytestwithnoload,carriedoutintheportofToulonon8thJanuary,2012). Asitcanbenotedfromtheeventschronologyreportedinthenarra@veofthisreport,thecontactoccurredat21.45.07andtheblack-outwasrecordedat21.45.57.At21.46.03theEEPautoma@callystarted,asshownbythesteeringgearpumpspowersignal.

Thelargeandsuddenfloodingofthecompartmentsledtoacri@calsitua@onforthebreaker901thatat21.46.44trippedcausingapowerlosstotheES.Asthebreaker901wassuppor@ngasitua@onofcontemporaneousshortcircuits(thoseofthelinespoweringthecompartmentsinvolvedintheprogressiveflooding)itstrippingmayhavecausedthetotal

compartmentsinvolvedintheprogressiveflooding)itstrippingmayhavecausedthetotalblack-out.DuetotheabovetheconcurrencyoftheshortcircuitsoccurringtothelinespoweredbytheESwouldseemthemostprobablecauseofthebreaker901malfunc@oning.

Wecannotruleoutthatthe"ship-to-shore"commutatorsubmersionmayhavecontributedtothebreaker901malfunc@oning,s@llbearinginmindthatitisnotpossibletoactuallyascertainthefloodingrealsequence,alsoduetothefactthatthemainswitchboardroomswereboundedbyclassA(steel)bulkheads,doorsanddeckpla@ng,i.e.fire-resistantandalthoughthelaqerwerenotwaterprooftoheadpressuretheywereanywayanobstacletothefloodingprogress. Ontheotherhand,shouldweconsiderthesuddenfloodingofthemainswitchboardroomfeasible,thelaqercircumstancecouldnotbeconsideredasacontributorycausetotheEEPmalfunc@oning(breaker901).Asamaqeroffact,theEDGs@llkeptonworkingautoma@callysupplyingpowertotheship’selectricplantupto21.46.44.

Thetestno.6showedthatitispossibletomanuallyclosethebreaker901,manuallydisconnec@ngtheauxiliarytensiontotheclosing/openingcoilwithoutemployingascrewdriver,providedthattheminimumtensioncoilispowered.Shouldtheminimumtensioncoilnotbepoweredorresul@ngfaultytheswitchcannotbeoperated,evenmanuallyopera@ngthemechanicalclosurepushbuqons.Thatmeansthatwecannotruleoutthatafaultorapowerlossmayhaveinvolvedtheminimumtensioncoilofthebreaker901,thereforejus@fyingtheFirstElectricianforcedinterven@on.

LaterontheEEPresumedworking,asdeclaredbytheFirstElectrician,andasresul@ngfromtheVDRrecordsrelevanttotheliVsdoors. Summarizing,theEEPdiscon@nuousworkingdependedonthebreaker901intermiqentfunc@oning,thelaqercausedbytheexcep@onaleventinprogressandbytheunexpectedconsequencesoccurringduetotheheavywaterprogressiveflooding.In fact the evidences resulting from the witnessesand the records relevant to the m/v Costa Concordia casualty - as verified during the checkscarried out on board the sister ship m/v Costa Favolosa - demonstrated the EEP adequateintervention when the black-out occurred and its full compliance with the applicable rules.

Redundancy of electric power is one the main target drafted in the following chapter titledrecommendations (emergency power generation), as suggested by the present lessonslearnt. 5.4OnboardorganizaJon–emergencymanagement TheGeneralEmergencyAlarmwasnotac@vatedimmediatelyaVertheimpact.Thisfacthasledtoadelayintheorganiza@onofthesubsequentphasesofemergency(flooding-abandonshipprocess).Withregardtotheorganiza@ononboard,theanalysisofcrewcer@fica@on,oftheMusterList(ML)andoftheproceduresoffamiliariza@onandtrainingonboardhighlightedsomeinconsistenciesintheassignmentofdu@estosomemembersofthecrew.Theproceduresimplementedforthefamiliariza@onandtrainingofthecrew,requiredfortheirinclusionintheML,werenotfullyresponsivetotheneed.Somecommunica@onproblemsbetweenthecrewmembersandbetweenthemandthepassengerssomehowhinderedthemanagementofthegeneralemergency-abandonshipphaseandcontributedtoini@a@vesbeingtakenbyindividuals.Itisdeemedthatsuchflawsareaqributablealsotothedifferentbackgroundsandtrainingofcrews.Itappears,therefore,thattherecruitmentofcrewmembers,carriedoutbyexternalagenciesworldwide,playsafundamentalroleinthemanagementofemergencies. It isalsonecessarytoemphasizethedifferentscopeoftheMinimumSafeManning(MSM)documentandtheMusterList(ML).SOLASregula@onV/14.1requiresthattheshipshallbesufficientlyandefficientlymanned,fromthepointofviewoftheprotec@onofthesafetyoflifeatsea.Thisregula@onmakesreference,butnotinamandatoryway,tothePrinciplesofSafeManningadoptedbytheOrganiza@onbyResolu@onA.1047(27).TheAdministra@onshould,therefore,issueaMSMdocumentappropriatewiththeabovemen@onedprovisions.SOLASregula@onsIII/8and37providedetailsfortheprepara@onandpos@ngoftheML.Inpar@cular,regula@onIII/37requiresthatthecrewshouldbeorganizedinaMLshowingtheir

par@cular,regula@onIII/37requiresthatthecrewshouldbeorganizedinaMLshowingtheirassignedtasksinthemanagementofvariousemergencies.

Inthelightoftheabove,itshouldbeunderlinedthat,inourexperience,toooVenthescopeoftheMLisconfusedwiththatoftheMSM(andthiswasalsofoundoutonpassengershipsflyingaFlagotherthantheItalianone).Infact,thecrewindicatedintheMSMdocumentshallbeproperlytrained,beinpossessionofthecer@ficatesandtrainingprovidedinaccordancewiththeSTCWConven@onandthenholdingthe"minimumstandard"required.However,personsonboardwhoareassignedtosafety du@es, as per theM.L., some@mes lack the necessary skill or simply are unfamiliarwith the ship lay-out and procedures. It is believed that this aspect merits a focusedaqen@onanddiscussion.

Thegeneralemergencyandtheabandonshipsignalswereac@vatedwithdelayinrespecttothemomentwhentheawarenessthatatleastthreecon@guousWTCoftheshipwereflooded;thismeantthattheseriousnesswasevident,andthisinforma@onreachedthebridgeat22.01butthefirstlifeboatswereloweredintheseaonlyat22.55.TheMaster,whoselastvoiceinthebridgewasrecordedat231930,firstofallabandonedverysoonthebridge(leavingoftheretheStaffMaster,whoremained@llthe233230)andleVtheshipbeforeherevacua@onwascompleted;at01.11(contactedbytheSARtelephonenumber1530).TheMasterdeclaredtobeonshore,whileseveralpassengersandcrewmembersweres@llonboard;andhowever,mostoftheOfficerswerealreadyonshore,togethertheirMaster. ItisevidentthattheMasteroftheConcordia: -notpromptlydeclaringthegeneralemergency,despitethepremisesoccurred;thusseriouslydelayingthegatheringofthepassengersandcrewintheMusterSta@ons;

-notac@va@ngtheMusterList;

-abandoningtheshipwhilepassengersandcrewweres@llonboard, couldhavecausedasaconsequenceoftheabovefindingsthe32decedentsinthecasualty,asalreadyshowedindetailbythestatementreportedinthepreviouschapter4,accordingwith the findingwhich reconstructs the dynamic of the causality and the only prac@cablealterna@vewaytoavoidthosevic@ms,whichwas,instead,ignoredbytheMaster.

Withintheshipreports(Annexes59-60)regardingthetwolastgeneraldrillscarriedoutonboardduringDecember2011,althoughsimula@nganabandonshipaVeraseriousfireonboard,itwaspointedout-despitetheMasterwasthesame–acorrectapproachofthebothemergencies.Inpar@cularwithinthe14thDecemberone,theMaster,justaVertheawarenessthatpassengerswereindanger,launchedimmediatelythegeneralemergencyalarmandjustaVer25minutes,whentheHotelDirectorconfirmedtotheMasterthatallpassengershadbeenevacuatedfromthelivingspaces,heraisedtheabandonshiporder. Thereforetheabovemen@oneddelayingplayedthemainrootcauseonthereference,becausemostlyofthosepersons(atleast18onthewholeaspassengersandcrewmembers)delayed,desperatelyaqemptedtocrosstheshipfromstarboardtoleV,slippingtothestarboardsidewhentheshiplistedbecausetheheelinggraduallyincreasedfrom30degreesto80degrees.Thisisconfirmedbytheanalysiscarriedoutaccordingtotheposi@onwherethosevic@mswerebeenfound.Meanwhile,theothersdesperatepeoplewerethrownintothesea. Itisclear,accordingwiththeanalysisalreadydraVed,thatseveralOfficersbelongtothedeckstaffcontributedtocausethecasualty.Moreover,someofthedeckstaffofficersandthehoteldirector,sincetheyfailedtheirdutyduringthemanagementoftheemergency,couldhavecontributedtocausethedeadpersons.TheDPA,indirectly,couldhavecontributedtocauseofthedeadpersonsaswell(atleastintermsofmoralobliga@on,takingintoaccountthatherealizedtheseriousdangertoolate). 5.5SummaryOfTheHumanFactorsAnalysisAndRelatedFinalConclusions

Onthewhole,humanfactorscharacterizedthiscasualty,asalreadystatedindetailbothinthepreviousanalysisandinthepresentconclusions. Now,however,itisworthwhiletoputinevidenceinwhattermsthismainelementcanbestated,matchingitwitheachofthesingleac@ons,orwiththerespec@vecrewmemberswhocommiqedtheac@on. Firstofall,analyzingthebackgroundofthecrewmembers(Officersmainly)involvedinallthedifferentphasesoftheevent(evenbeforethecontact),thisIBexcludesthatthecasualtyandtheconsequenthandlingoftheemergencyisdue,intermsofhumanperformance,tothelackofcompetency. Itislikewiseevident-alsobecausewehavenoelementstosaytheopposite-thatthecasualtyandtherelatedfailureintermsofemergencyhandlingwascharacterizedbythelackofalertness.Inreferencetothis,thisIBexcludes,inaccordancewiththepreviousanalysis,thattherewereproblemsrelatedtofa@gueandrelatedrestandthehealthofthecrewmembers(theyhadcer@ficatesoffitness).Insteadwithreferencetostress,whilemostfactorswhichcouldhaveinfluencedthiselement,ithastobeexcludedaswell.ThisIBcannotsaythesamefortheindividualfactorssuchas:personally,healthproblemsoccurredduringtheseagoingserviceonConcordia,personalrela@onships,mo@va@on,senseofdanger.ThisIBhasnotelementstoestablish,foreachcrewmemberinvolved,ifhe/shefelt“op@mumperformance”(linkingittothestresslevel)ontheday13thJanuary2012andexactlyduringtheoccurrenceofthecasualty.Therefore,distrac@ons,errorsandviola@onscanbeestablishedastheelementswhichcharacterizedthehumanfactorsasrootcausesintheCostaConcordiacasualty. Bothdistrac@onsanderrors(inalltermsofslips,lapsesandmistakes)hadbeenmadeduringtheMaster’sperformancebeforethecontact,accordingtothepreviousdetailedanalysis.Distrac@onsanderrors(inalltermsasslips,lapsesandmistakes,aswell)hadbeenmadeduringtheBridgeTeamperformance(alltheBridgeTeaminvolved)beforethecontact,accordingtothepreviousdetailedanalysis. Notwithstanding the above preamble, regarding the competency, not having aqended atraining course on Bridge Resources Management course - BRM, (not mandatory at thisstage) could have represented aweakness in terms of competency (human factor as badhumanperformance)inthiscasualty.InfactnoneofthosedeckOfficersondutybeforethecontact (Masterandall theBridgeTeam)hadaqendaBRMcourse.Regardingtheac@onscarried out by the Master during the naviga@on before the contact, some errors andviola@onsoccurred(asthisIBsupposes),respec@velydueto:

-abouterrors,as“falsehypothesis”[accordingwithhisconvincementtooperateinafamiliarsurroundings,despitetheexternalenvironmentchanged(shipwasnotinmanoeuvringbutshesailedlikeinanusuallynaviga@onlikeinhighsea,darkness)],“pressure”(promisetoacrewmemberforsailingtooclose),“decision”(insis@ngtochangetheoriginalvoyageplan),“mistake”(heappliedabadruletomanoeuvre),“lapse”(heomiqedthehandover); Aboutviola@ons,as“shortcuts”[twoISMprocedureswere,infact,notapplied,thefirstinorderthescheduledhandoverandtheconsequentwatch-keeping,thesecondregardsthewatch-keepingincaseofclosesailingwithothersships(keepadistancenotlessthan1mile–seeAnnex25).Inthisreference,despiteitisapplicableforothershipsapproaching,therelatedcriteriashouldbeextendedaswell,bytheMaster,totheGiglioapproaching,consideringtheexternalenvironmentandthespeed],“op@mizing”(hetriedtomatchthepleasuretowardsacrewmemberwiththeonlypurposeofthesailing,whichwastoproceedinsafetymannerforapproachingthenextscheduledport). Itisworthtopointoutthattheaboveerror(thelapse)andviola@ons(thetwoshortcuts)regardalsotheFirstMate(indutybeforethecontact).WhilealltheBridgeTeamcarriedoutbothlapseandmistake/failureofaqen@on,respec@velynotmakingthelookoutandtheadequatesupport/warningtotheMasterduringthemostdangerousphaseofapproaching

adequatesupport/warningtotheMasterduringthemostdangerousphaseofapproaching(notan@cipa@ngthemanoeuvrestocorrectthewrongcourse). Abouttheemergency,theperformanceoftheMasterwasaffectedbyerrors.Thesecanstatedintermsoflapses(omissionsofproceduressuchas,mainly,theDecisionSupportSystem;moreover,heleVthebridgeasfirstandaVerleVtheshipverysoon),failureofaqen@on(heseemedsuchasabsentbythecontextoftheemergencyanddisorientedbothhisStaffandDPA),mistake(lackofknowledgeaboutthevitalequipmentslocatedineachcompartmentbelowthebulkhead). Onceagainabouttheemergency,itisworthtopointoutthefollowing:-bothdelayandmistakeregardingtheHotelDirector(hedidnotcoverhisdutyscheduledbytheprocedures,omiSngfirstlyhisfundamentalroleonboard);-delayandmistakebysomeDeckOfficersbelongingtotheemergencyStaffaVerthecontact(theydidnotcovertheirexactlyrole,despitetheywereac@veinsuppor@ngtheemergencyhandling;however,theirac@ons/reac@onswereinfluencedbytheabsenceoftheMasterwho,carryingouttheaboveerrors,didnotcoordinateandgoverned-atallasresultedbytheVDRconversa@ons-theemergency). 5.6SAROperaJons Summarizing,SARAuthoritywhichintervenedtocoordinatetherescueopera@onswas,ofcourse,notinformedinasuitablewayrespecttotherealscenariooccurredonboard,bothbytheMaster/BridgestaffandtheCompany.Fortunately,theincidenthappenedneartheshoreline(thearea,however,iss@llnotcoveredbytheVTSsystem),andthat’swaythedelaycausedbytheShip,firstofall,didn’tcompromisetherescueopera@on.Just15minutesaVertheevent,thankstosomepassengers,LeghornMRSCwaswarnedaboutsomefailureonboard,andaVerfewminutes(2214),thevesseltrackwasfoundbyLeghornAIS.ThePatrolBoatintheareawastasked,at2216,toreachtheConcordiaposi@on,approachingherat2239.Themainlessonlearntis,therefore,thedelayandthemissinginforma@onbytheship. SARopera@onscanbeconsideredoverallsuccessful,takingintoaccountthatinfewhoursallthepersonsonboardhadbeenevacuated.Itisneedtotakeintoaccountthat,aVer5hoursbytheabandonship,remainedonly40/50personsonboard.1.270persons(athirdofthetotal)were,attheend,savedbytheshoreSARresources,whiletheothersweresavedbytheship,whowerebeensupportedbythesameSARresourcesbythe@mewhenthefirstlifeboattouchedthesea.Despitethecasualtyisatragedy,thenumberofvic@mswasconstricted,andallofthemdeadmainlyforthedelayingoftheonboardemergencyprocedures. Theabovemen@onedsuccesswasachievedalsowiththecontribu@onoftwosignificantelements:-specialpatrolboatsdeployedbytheCoastGuard(22meterslengthandabletoloadmorethan100passengers)providedwithaspecialfender,knownas“balmoral”,whichallowedtoapproachthehullandthelifeboatswithoutcrea@nganydamagetobothshipsandpeopletorescue;

-special rescuers, who were divers with a proficiency as speleologist, able to climb andbreak the structures, to rescue, even in dark condition, persons standing in the ravines. 6.SAFETYRECOMMENDATIONS FOREWORD Thefollowingrecommenda@onshavebeenmade,despitethehumanelementbeingtherootcauseintheCostaConcordiacasualty.Hereiswhy,aVerthisinves@ga@on,wewouldliketodeliveryinthehandsoftheInterna@onalMari@meCommunityoursugges@onsregardingasthenavalgigan@sm,representedbytheVeryLargeCruiseShips,tofacethisactuallyandrisingwonder.

Webelievethatwecanonlyinves@gateto:-mi@gatethehumancontribu@onfactorwitheduca@on,trainingandtechnology;

-improvedaybydaythebuilding,throughthemoderntechnology;

-stressallthemari@mefieldclustertomakethemaximumcontributefortherelatedstudyandconsequenttechnicalresearch. The following recommendations must be considered the starting point of the actions takenconsequently to this extraordinary tragedy, since we believe that many other issues could berisen, reflecting on the deep and taking time to react more, among others, with the threesuggestions fore mentioned. 6.1AcJonstaken 6.1.1WhatFlagAdministraJonalreadymade: Itshouldberecalledthatintheinterimperiodfromthebeginningoftheinves@ga@onandthepublica@onofthisreport,someoftheissuesiden@fiedbythisInves@ga@onBody,andalreadyimplementedonItalianFlyingFlagships,wasbroughtbytheFlagAdministra@ontotheIMO(refertodocumentsMSC90/Inf.19,MSC91/7/7)andtakenonboardbysuchanOrganiza@on(refertoMSC.1/Circ1446/rev1,Long-termac@onplanonpassengershipsafetyandamendmentstoSOLASconven@onassetoutinMSC91/22Annex14).Theproposalsoriginallymadearesummarizedinthefollowing:1.Informa@ononpassengers:theinforma@onrequiredbySOLASregula@onIII/27andEuropeanDirec@ve98/41/ECshouldbeintegratedwiththeindica@onofthena@onalityofeachpassenger.Thiswouldhelpcommunica@ons,incaseofaccident,betweenSARCentresandAdministra@onswhoseci@zensareonboard; 2.Voyageplan:thevoyageplanrequestedbySOLASregula@onV/34shouldbemadeavailablebythemastertotheCompanypriortotheship'sdepartureandbekeptavailableun@lthenextDOCaudit;3.Instruc@onstopassengers:thefollowingmeasuresshouldbeimplemented: a)attheirembarka@on,passengersaretobeprovidedwithabrochurecontainingalltheessen@alemergencyinforma@on;thesebrochuresaretobeavailableintheFlaglanguageandinthelanguagesspokenbythepassengersonboard; b)inaddi@ontowhatisprescribedbySOLASregula@onIII/19.2.2,safetyinforma@onistobeavailablethroughtheship'sTVsystem,bothincabinsandinconspicuouspointsinthepublicareas,attheembarka@onandthroughoutthevoyage; 4.musterofpassengers:themusterofpassengersasperSOLASregula@onIII/19.2.2,iscarriedoutattheship'sdeparturefromthehomeport;whereembarka@ontakesplaceindifferentports,separateanddedicatedmustersaretobeperformedforpassengersembarkinginthoseports. 6.1.2HowtheMLCConvenJon(inthefinalrushtoenterinforce)couldcontribute,intermsofrecruitment,placementandmanningtowardsthehumanfactor: AssessmentnecessarytorecognizetheprivateManningAgencywhichmanageinthemari@mefieldtorecruitandfindemploymentforseafarersandotherpersonnelwhosupplytheshipssailundertheItalianflagshouldbetaken;

-periodiccontrolsontheac@vi@esofsuchAgenciesshouldbeestablished;

-amoredetailedcriteriaforemployingRecruitmentandJobAgencies.Organizeprocedures,throughtheSMSManual,tocarryoutsystema@cauditsoftheabovemen@onedAgenciesshouldbeestablished;

-theregula@onpertainingtotheMLC2006ILOConven@oneventotheCountrieswhicharenotMemberStatesoftherelatedOrganiza@ons/Agenciesshouldbeextended;

notMemberStatesoftherelatedOrganiza@ons/Agenciesshouldbeextended;

-improvingtheguidelinestocontroltheac@vitycarriedoutbytheManningAgenciesfortherecruitmentandfindemploymentcouldbedeliveredwithintheMLCworkinggroup. 6.1.3WhattheCompanyalreadydid(beforeanda_ertheMarch2012auditbytheFlagState) 1.CompanyAuditfollow-upasaconsequenceofthecasualty: FollowingtheCostaConcordiaeventandaVertheevalua@onofini@alinforma@onandelementsofinves@ga@onacquired,theFlagAdministra@onconsiderednecessarytoperformanauditrelatedtothesafetymanagementsystemoftheCompany"CostaCrociereSpA". Inthisregard,theFlagAdministra@onprovidedaDOCaddi@onalverifica@onthatwasperformedon6and7March2012byfourITCGOfficersandaRecognizedOrganiza@onauditor(RinaServicesSpA).7"NonConformi@es"and5"Observa@ons"werefound.Notwithstandingtheneedtoconductanaddi@onalaudit,within6months,theCompanyDOCcer@ficatewasendorsed.Thenon-conformi@escontrolandcorrec@veac@onsweremonitoredbytheFlagStateAdministra@onanddefini@velyclosedon5June2012.On3October2012theabovemen@onedDOCaddi@onalauditwascarriedoutbyITCGpersonnelinconjunc@onwithRecognizedOrganiza@onauditors(RinaServicesSpA)withoutanyfinding.2.Regardingtheorganiza@onalchangesimplementedbytheCompanyfollowingtheCostaConcordiacase,themostrelevantwiththesubjectare: a.AmendingP12.04IO01SMSProcedure“ManagementoftheEmergencyInstruc@onforPassengers(Annex61):

ForwardingtheCircularLeqerGEN.SER.N°97/2012–implementa@onofac@onsinfavourofcruiseshipsiden@fiedinresponsetotheaccidentof“CostConcordia”,whichamendedtheaboveprocedureestablishinganewpolicyonpassengeremergencyinstruc@ons,bythe1stofFebruary2012(thisshouldbeadoptedoneweekbeforethatthesamepolicywasadoptedbytherestofthewholeCruiseIndustry).Accordingwiththisnewpolicy,theaboveprocedure(Annex62)pointsoutthatguest’ssafetydrillisperformednowbeforethedepartureoftheshipfromtheembarka@onport,andthoseguestsiden@fiedasnotpar@cipantsarere-invitedtoanothereventorganizedon-purpose.b.AmendingP12.04IO02SMSProcedure“DecisionSupportSystemforMaster”(Annex63):

Reviewing,bythe2ndofJune2012,therelatedfundamentalrule,implemen@ngeachac@ontobetakenincaseofemergency.Therelatedworkflowisamendedfor:

-Contact/Leaking,enforcingtheassessmentoftheWTCandthelinked,consequent,ac@ons,alsorelatedtotheDamagecontrolPlan;

-Aground,implemen@ngtheprocedurefortheVDRdischarge;

FireinEngineRoom,enforcingtheassessmentandtheconfinementoftherelatedver@calzone,andimplemen@ngtheprocedurefortheVDRdischarge;

FireoutsideEngineRoom,implemen@ngtheprocedurefortheVDRdischarge;

EmergenciesrelatedwithPollu@on,stressingtheac@onoftheMasteralreadyestablished,toemphasizethatheisobligedtofollowtherelatedplanforfigh@ngthepollu@on. Itresults,moreoverthattheCompanymade:

Crea@nganewMari@meDevelopment&ComplianceDept,whichreportsdirectlytotheCEOandmanagesalltheHESS[Health-Environmental-Safety-Security]maqersrelatedwiththeCOSTA-IBERO-AIDAbrands(Annex64).

Implemen@nganadvancedsystemtomanageandmonitorfleetroutethe"HighTechSafetyMonitoringSystem"(HT-SMS),involvingbothonboardandgroundstaff.ThesystemenablestheCompanytomonitorposi@onandcourseoftheen@refleetinreal@me(Annex65),toverify:

-Thesafetylevelofrouteplans,comparingtherouteplannedbytheMaster(PassageVoyagePlanorVPP)withthestandardroute;

-Actualposi@onofeachvesselcomparedwiththerouteplannedbytheMaster(VPP)andthestandardroute;

-quicklyandautoma@callyiden@fyunexpectedchangesofdirec@on.

Crea@ngadedicated"F.O.C."FleetOpera@onsCentreinGenoaHQtomonitorandmanageanyalarmgeneratedbythesystem(therelatedprocedureisaqached);

‘IsabouttobeofficiallyreplacedtheP15.6IO01“CrisisManagementPreparednessPlanOpera@onal&Repor@ngProcedure”byabrandnewE.S.U.[EmergencySupportUnit]Manual,preparedbyaworkingteamledbyanothernewrolecreated:theCrisisManagementDirector,repor@ngdirectlytothePresident.TheCrisisManagementDirector’sorganiza@onisabouttobefullydeployedwhenevercrisislevelsaresuchastoposerisksforpassengers,crewandcorporatestructuresingeneralandinvolvesnewanddedicatedGenoaHQinfrastructures.

d.Implemen@ngthetrainingtowardstheDeckOfficers,throughamandatorypolicyadoptedbyCarnivalCorpora@onon1stSeptember2012(seeAnnex50),whichestablishes,asdraVedinthepreviouschapter4,thefollowingac@ontakenaboutsuchthefollowingsummarizedmandatorycourses,whichamendedinconcretetheprocedureP5.03SMS(Annex66):

-BridgeResourcesManagement(BRM-twolevels);

-ECDIS-NACOS(twolevels);

-ShipHandling;

-Stability.Furthermore:MasterandStaffMasterhavetoaqendalltheabovecourses;

SeniorOfficeronWatchthetwolevelsofbothBRMandECDIS;

JuniorOfficeronwatchBRMandECDIS1stLevel;

CourseforInstructorisrecommendedfortheMaster;

TheCarnivalCorpora@onnewSafetyStandardaddressestheproficiencyindetailsaswell. 6.2RECOMMENDATIONS PREAMBLE Theimmediatefloodingoffivewater@ghtcompartments,wheremostofthevitalequipmentoftheshipwaslocated,makestheCostaConcordiacasualtyquiteauniqueevent.Theextent

ofdamageiswellbeyondthesurvivabilitystandardapplicabletotheshipaccordingtoherkeellayingdate.However,theinves@ga@onhasallowedtheiden@fica@onofsomerecommenda@onstheadop@onofwhichcouldcons@tuteanimprovementofthecurrentrequirements.Theaimofsomerecommenda@onsisalreadytakenintoaccountbytheSOLASConven@onfornewbuildingsorexis@ngships,throughvariousamendmentstotheConven@onincluding:1.requirementsforsegrega@onandredundancyofvitalequipmentforpropulsion,steeringandnaviga@on,i.e.SOLASregula@onsII-1/8-1,II-2/21andII-2/22onthesafereturntoport,applicabletoshipsbuiltonoraVer1July2010;

2.onboardstabilitycomputer(orshore-basedsupport),applicabletopassengershipssubjecttothesafereturntoportrequirementsandbuiltonoraVer1January2014,i.eregula@onII-1/8-1.3ascontainedinresolu@onMSC.325(90);

3.floodingdetec@onsystem,forshipsbuiltonoraVer1July2010asperSOLASregula@onII-1/22-1;and

4.useofElectronicChartDisplaySystem(ECDIS),SOLASregula@onV/19.2.2.3.2applicabletoallpassengerships(forthoseconstructedbefore1July2011,therequirementshallbemetnotlaterthanthefirstsurvey*aVer1July2012). However,therecommenda@onsgivenbelowmayemphasizethenecessityforhavingsomeoftheaboverequirementsreconsidered.

Itmustbepointedoutthattheadop@onoftheserecommenda@onsmaypermitanimprovementintheship'ssurvivabilityduringacasualtyastheoneinvolvingtheCostaConcordia;althoughtheymaynotbesufficienttorendertheshipunsinkablewhenmorethantwowater@ghtcompartmentsareflooded. 6.2.1STABILITYForwhatconcernthestabilityrelatedissues,itisrecommendedthatthefollowingitemsareconsideredwiththeaimofimprovingtheexis@ngrequirements:1.double-skinforprotec@ngtheWTCscontainingequipmentvitalforthepropulsionandelectricalproduc@on;

2.limi@ngofthedownfloodingpointsonthebulkheaddecktobediscussedinthelightofPartB-2ofChapterII-1ofSOLAS74,asamended 3.provisionofacomputerizedstabilitysupportforthemasterincaseofflooding;and

4.interfacebetweenthefloodingdetec@onandmonitoringsystemandtheonboardstabilitycomputer,takingintoconsidera@onregula@onsII-1/8-1and22-1ofChapterII-1ofSOLAS74asamended. Ini@a@vesin1.and2.,above,aremeanttobeaddressedtonewshipswhilethediscussiononthecontentof3.and4.shouldbeextendedtobothnewandexis@ngships. 6.2.2VITALEQUIPMENTANDELECTRICDISTRIBUTION Thefollowingissuesneedtobediscussedforpossibleimprovementsoftheexis@ngrequirements:1.discon@nuitybetweencompartmentscontainingship'sessen@alsystems(suchaspropulsionsetsormaingeneratorssets)inordertopreservetheirfunc@onalintegrity(referenceshouldbedonetoregula@onII-2/21,SOLAS74asamended);

2.moredetailedcriteriaforthedistribu@on,alongthelengthoftheship,ofbilgepumpsandrequirementfortheavailabilityofatleastonepumphavingthecapacitytodrainhugequan@@esofwater(referenceshouldbedonetoregula@onII-1/35-1,SOLAS74asamended);

amended);

3.reloca@onofthemainswitchboardroomsabovethebulkheaddeck(referenceshouldbedonetoregula@onII-1/41,SOLAS74asamended); Theabovemen@onedrecommenda@onsnumber1,2and3aremeanttobeaddressedtonewshipsonly.4.reloca@onoftheUHFradioswitchboardabovethebulkheaddeck,forallexistentshipswhichareprovidedwiththisequipmentbelowthisdeck,andforthenewships,itshouldbelocatedabovethebulkheaddeck. 6.2.3EMERGENCYPOWERGENERATIONRegardingtheemergencysourceofelectricalpower(ref.regula@onII-1/42,SOLAS74asamended),thefollowingshouldbeconsidered: 1.increasingtheemergencygeneratorcapacitytofeedalsothehighcapacitypump(s)men@onedinthepreviousparagraph“VITALEQUIPMENTANDELECTRICDISTRIBUTION”;

2.provisionofasecondemergencydieselgeneratorlocatedinanothermainver@calzoneinrespecttothefirstemergencygeneratorandabovethemostcon@nuousdeck.Inthisrespect,thedefini@onof"mostcon@nuousdeck"inthelightofSOLASregula@onII-1/42.1.2seemstobenecessary.Thissecondgeneratorcouldbedimensionedonthebasisofselectedservices.Therelatedmanufacturingandhandlingshouldbeasfollows:.

a)newemergencydieselgeneratorsaremadeaccordingtoaimedandspecificbuildingtechniquesinordertoguaranteeaunfailingandlong-las@ngfunc@oning;

b)regulateinanop@malwaythefunc@oningtests,planningthemonceaweek,underasignificantload(atleast50%)andofatleasttwohoursdura@onforboththeemergencydieselgenerators. 3.provisionofanemergencylight(bothbyUPSandemergencygenerator)inallcabinsinordertodirectlyhighlightthelifejacketloca@on. Althoughtheaboverecommenda@onsaremeanttoaddressnewships,considera@onsontheapplicabilityofitems2.and3.alsotoexis@ngshipsissuggested. 6.3.4OPERATIONALMATTERS Theeventdemonstratedthatthereistheneedforverifyingtheactualityofprovisionscontainedininterna@onalinstruments,suchasSOLAS,STCWandISMCoderelatedtodifferentissuessuchas: 1.bridgemanagement,consideringaspectssuchasthedefini@onofamoreflexibleuseoftheresources(thatmaybetailoredforrespondingtoordinary,cri@cal,emergencycondi@ons),anenhancedcollec@vedecisionmakingprocessand"thinkingaloud"aStude;

2.BridgeTeamManagementcourseforcer@fica@onsrenewalshouldbemandatorybythe1stJanuary2015;

3.PrinciplesofMinimumSafeManning(resolu@onA.1047(27)asamendedbyresolu@onA.955(23))thatshouldbeupdatedtobeqersuittolargepassengerships.Amandatoryapplica@onoftheseprinciplesisalsoconsidereddesirable; 4.musterlist,showingthepropercer@fica@on/documentaryevidencenecessaryforcrewmembershavingsafetytasks;

5.inclusionoftheinclinometermeasurementsintheVDR.Theaboveitemscouldbeapplicabletobothnewandexis@ngships.

6.3.4EVACUATIONANALYSIS 1.Fornewships,itwouldbeusefultorequireanevacua@onanalysistobecarriedoutattheearlystageofaproject(ref.regula@onII-2/13-7.4,SOLAS74asamended),extendinginmandatorywaytheaboveregula@on,actuallylimitedtoro-ropassengerships. 2.Regardingtheembarka@onladders:withtheshiplistedatanangleexceeding20°,itwasdemonstratedthattradi@onalembarka@onladdersweremoreuseful.Therefore,inthelightoftheabovemen@oneddetailsdraVedinPara4.6.1.4,itmaybenecessarytoconsiderwhethertheminimumnumberofembarka@onladders(one)oneachsideshouldbeincreased(SOLAS74asamendedreg.III/11.7) 6.3.5SAR ThiscasualtygivesusspeciallessonsalsointermsofSARexperience.Despitethemain,unbelievablelessonlearntis,thedelayandthemissinginforma@onbytheship,wewouldwarntheIMOaboutotherissues,torecommendeachSAROrganiza@onforprovidingitsresourcesbythefollowingtools: -SARpatrolboatsuppliedwithfixfenders,blockedintheuppersideofthehull,toapproachsafeotherships/boatsincaseofextraordinaryevacua@onofpersons.Thisshouldbeabletoloadatleast100passengersintheirdeck;

-Diversspeleologist,abletorescue,evenindarkcondi@on,personsstandingintotheravinesofships/wrecks. AllthelessonslearnedandtheconsequentabovemenJonedrecommendaJonshavebeensharedwiththerelevantFlagStateOffice.

7THPHASE.THETRIALS

ItalyhasbeenconsistentlyrankedasthemostcorruptcountrywithintheEurozone,accordingtoTransparencyInterna5onal’sannualsurveys.IntheWTO’sGlobalCompe55veIndexitranks49thoutof144.Forbusinesscompe55veness,itsranked106th,nestledbetweenHondurasandSierraLeone. ITALIANCRIMINALLAW Italian criminal law is divided into two parts: there are the rules describing the types ofcrimescodifiedbothintheCriminalCodeandinspeciallegisla5on,andtherearetheotherrules,contained intheCodeofCriminalProcedure,governingthe inves5ga5onsofcrimes,thearrest,charging,trialofaccusedetc.,uptothefinaldecision.

The preliminary investigations phase Once thePublic Prosecutor’sofficehas receiveda crime report, he is obliged to start thepreliminaryinves5ga5onsandhehasamaximumofsixmonthstoayear(dependingonthenature of the crime) to carry out a systema5c examina5on of the personwhomay havecommiTedthecrimeandtheques5oningofwitnesses.

therequestforatrialmustcontainsomeformalrequirementsand,amongthem,themostimportantisastatementoftheallegedcriminalact,theaggrava5ngcircumstances,togetherwithanindica5onofsourcesofevidenceacquired. Atthehearing,theJudgecaneitherclosethecasewithoutthenecessityofatrialororderthecasegototrial,bymeansofa“decreeorderingatrial”

TheTrialTrialhearingsarenormallypublic.Forunexplainedreasons,thiscasewasnot,eventhoughitwasheldinanauditoriumcapableofholding1000personswithonly200seatsoccupied.

Thetrial istheheartoftheprocess:firstofall,preliminaryand introductory issueswillbeverified and discussed, then the witnesses and consultants will be heard both for theprosecu5onand/orthedefence.

Thedefendant,athisrequest,hastherighttohavethelastword.AQeralltheevidencehasbeen heard and once the Public Prosecutor and the defence lawyers have argued theircases,theJudgere5restomakehisdecision.

Appeals

AQerbeingfoundguilty,thedefendant,butalsothePublicProsecutorifheisnotsa5sfiedwith the decision, can bring an ac5on. The former to clear his name or to reduce theprevious sentence, the laTer to get the convic5on of the accused or an increase in thepenalty.Judgmentisnormallybasedontheverbalevidenceheardduringthetrial,sothatthedefendantdoesnothavetoappearagain.

Appealbefore theSupremeCourt isprovidedonly for someques5onsof lawas the factsalreadyheardinthelowercourt,arenolongerques5onable.

Pleabargaining

Plea-bargainingiswidelyusedintheItaliansystem.Ithastobegrantedbythecompetentjudge,furthertotheagreementoftheoffenderwiththeprosecu5ngauthori5es,oncondi5onthatthepunishmentagreedisnothigherthanfiveyears’imprisonment.Thelawconsidersapleabargaintobesubstan5allyequivalenttoaconvic5onsentence(Ar5cle444oftheItalianCodeofCriminalProcedure),butaccordingtocaselawtheaffirma5onofguilthasalowervaluebecausecriminalresponsibilitywasnotproveninthecourseofacriminaltrial.

ItisacceptedasanagreementbetweentheaccusedandtheProsecutorontheextentofthepenalty to be applied and, implicitly, on the affirma5onof guilt. This proceeding allows adefendant to take advantageof a discount of up to one-third of the original penalty. TheagreementmustbepresentedtotheJudgewhocanacceptorrejectit.IftheJudgeacceptsthe agreement, the judgment becomes final rapidly. Otherwise the decision can only bechallengedintheSupremeCourt.

Fromthisitcanbeseen,regardlessofthepleabargainagreed,theimplica5oncouldbethatthose named, either in Italy or abroad, by admitng to a criminal charge, could find thattheyhaveacriminalrecord.

TheTrial.

Italianmagistrateswillbeaskedtoinves5gateclaimsthatCostaCruises,owneroftheConcordiaoceanlinerwhichranagroundofftheItaliancoast11daysago,triedtocoverupasimilarincidentin2005,whentheirFortunavesselallegedlystruckrocksnearSorrento.

RobertoCappello,whowasworkingasanofficialphotographerforthecompanyatthe5me,saidthattheFortunaappearedtohitrocksduringacloseapproachtothecoastnearthesouthernportinMay2005.Hesaidphotographshetookshowingthelis5ngcabinsanddamagetothevesselwereconfiscatedbycompanyofficials.Hisallega5onswillthisweekbepassedtomagistratesinves5ga5ngtheConcordiadisaster,inwhich32peoplearefearedtohavedied.

MrCappello'sclaimscameasdiversrecoveredthebodiesoftwowomenfromthecapsizedcruiseliner,whichisres5nghalf-submergedneartheportofGiglioisland.Thatbringsthenumberofbodiesfoundto15,with17otherss5llmissing.Expertsarealsoexpectedtobeginpumpingfuelfromtheshiptodayinanefforttopreventanenvironmentaldisasterinthearea.

CostaCruiseshasinsistedthatclosesail-bysofthetypethatendedintragedyatGiglioon13Januaryhaveneverbeenendorsedbythecompany.ButtheConcordiacaptain,FrancescoSchetno,whoisaccusedofabandoningshipaheadofhispassengersandcouldbechargedwithmanslaughter,hastoldthepreliminaryinves5ga5onsjudge,ValeriaMontesarchio,thatCostaCruisesencouragedpassenger-pleasingcloseapproaches"atSorrento,Capriandeverywhere"to"createpublicity".ItwouldappearthatnotonlydidthecompanyendorsetheseregularsailbysbutthiswasalsoknowntotheCoastguard.

The2005incidentissaidtohaveoccurredontheCostaFortunalinerthatleQSavonaforPalermoonthe24April."TheincidenthappenedonthefirstFridayofMay,"saidMrCappello."Itwasearlyintheevening,about7pm.Iwasinmycabin.Wewereclose,veryclosetotheshore–about200metres–whenwehit.Therewasaloudbang.AtfirstIdidn'tknowthattheshiphadhitrocks.Thefirstthingwewereawareofwastheshiplis5ngfromleQtoright.ElsewhereontheshipIsawthatplateshadfallenfromtables.Peoplewereobviouslyawarethatsomethinghadhappenedandtheywerefrightenedbuttherewasn'tanimmediateexplana5onfromofficials."

Hesaidtheshipappearedtozig-zaginthewater"likeasnake",butcarriedonataslowerpaceanddockedinPalermo."Wewerelatertoldthattheshiphadhitawhale–really.You'dhavelaughedifthewholethingwasn'tsoseriousandfrightening,"hesaid.MrCappellosaidthathewentdownintothekeelwherehesawandphotographedagashintheship"thedepthofarmandtensofmetreslong".HealsosawthatapropellerbladeonetheleQsidewasbroken.

wasbroken.

"Butwhenwedisembarked,CostaCrociere(Cruises)officialsmademehandoverthefilesonmycamera.Iwasbasicallythreatened.TheysaidthatassomeoneonacontractwiththemIwasobligedtohandoveralltheimagesinthecameraortherewouldbetrouble,"hesaid,adding:"Ibelievethecompanyknewabouttheseclosesail-bysandevenencouragedthem.Butit'stakenthedeathsofmanypeopleforittoreallybeexposed."

CarloRienzi,presidentofthena5onalconsumergroupCodacons,whichisleadingaclassac5onagainstCostaCruises,issendingMrCappello'sclaimstoFrancescoVerusio,theGrossetoprosecu5ngmagistratewhoisheadingthecriminalinves5ga5on.

AspokesmanforCostaCruisessaidthatthecompanywouldnotcommentonanydevelopmentsrela5ngtothedisasterduringthejudicialinves5ga5on.

April15,2013,CostaCrociereSPA,declaredthatthecompanywasa,‘damagedparty’.

"AVerthepoorvic@ms,Costaisthemostdamagedpartyhavinglosta500millioneuroship,"CostaaqorneyMarcoDeLucasaid.HesaidheisseekingdamagesfromScheSnoandtheotherdefendants"asthepenalcodesays'whoisguiltyofacrimehastopayforit.'" However,ithasbeensuggestedthatinfacttheCompany,aQeralltheseTlements,hadgainedratherthanlost.Withregardtocompensa5on,the protocol of 2002 to the Athens Convention relating to thecarriage of passengers and their luggage by sea, 1974 was not mentioned. This was probablybecause it did not come into force un5l23April2014. Itsubstan5allyincreasestheship’slimitsofliabilitycomparedtothe1974AthensConven5on,bothasconcernsdeathoforpersonalinjurytopassengers,aswellaslossofordamagetopassengers’vehiclesandluggage.

May22,2013.TheItalianjudgePietroMolino,ataclosed-doorhearinginthetownofGrosseto,agreedtoprosecutors'requestthatonlyCaptainFrancescoSchetnobetriedonchargesofmanslaughter,causingtheshipwreckandabandoningthevesselwhilemanyofits4252passengersandcrewweres5llaboard.

"ItmustbereiteratedthattheaccusedScheSnoalmostexclusively(sic)carriestheweightforthestrikingchainoferrorscommiqed," Thisisverystrangeasatthefirstinquiry,ProsecutorGeneralDeiddawasadamantthattheCompanyshouldalsobeprosecutedforitsmanagementfailingssta5ng; “problemsandincredibleactsofirresponsibilityregardingsafetyandorganisa@on”andnotes:“Theemployerisguarantorandhasresponsibility.Decisionstakenbytheshippingcompanyshouldbeunderclosescru@ny”.

July16th.2013.Thetrialthatwassupposedtotakeplaceonthe15thApril,2013,atGroseTo,commencedwithonlyCaptainScheenoaccused.Theotheraccusedpersonswhohadacceptedpleabargainsweresentencedtoprisonwithatermof5meservedwithouttrial.

February11th2015.CaptainSchetnowassentencedbythecourtatGroseToto16yearsonemonthinjailandtopay,jointlywiththeshipowner,€30.000:-toeachof110civilianpar5es,€5.000:-toeachofanother50civilianpar5es,€300.000:-totwocivilianpar5es,€500.000:-tofourothercivilianpar5es,€1.500.000:-tofurthertwocivilianpar5esandothersumsto100'sofothercivilianpar5es.

TheAppeal

12thMay2017.CaptainSchetnoappealedbutlostinallinstancesandisnowininjail.

FINALANALYSIS

FirstPhase;TheCollision. Ifweacceptthattheini5a5onofthiscloseapproachtotheIslandofGigliocamefromtheCaptain,thenwemustalsoacceptthatthecompanyaccededtothisaspartofthepassengerentertainmentpackagenotjustonthisshipbutotherswithinthefleet.However,theques5onremainsastowhythiswasdoneatnightwithoutanyannouncementoftheapproachtothepassengersandthereforefewpassengerstowatch.Forsomereason,theinquiryseemedtoques5onthepresenceofotherpersonnelonthebridge.Thisagainisverycommonandshouldnotinterferewiththenaviga5onoftheshipwhichcarriesonregardless.ThereisnorecordoftheOfficeroftheWatchengagingwiththesepeoplethereforewemustassumethatthefunc5onsofthewatchcarriedonasnormal. Italwayshasbeenthepreroga5veoftheCaptaintoinviteselectedguestsontothebridgebutwiththepermissionoftheOfficeroftheWatch,whoisinchargeofthebridgeun5ltheCaptainassumesthatresponsibility.Inotethatoneofthekneejerkreac5onsoftheentertainmentmanagementsistobanallnon-opera5onalpersonsfromthebridge. Bythestrictinterpreta5onoftherulesofnaviga5onthedistanceofflandwasunsafeatthespeedtheshipwasmakingthroughthewater,butthenthesamecouldbesaidforthevast

speedtheshipwasmakingthroughthewater,butthenthesamecouldbesaidforthevastmajorityofshipswhospeedinfog,makepassageofriversand�ords,andpassthroughnarrowstraitsnoneofwhich,shouldthesteeringfail,couldavoidcollisionwithlandorgrounding.ThecruiseshipsthatventureintoicewaterssailingclosetoicebergsforpassengeramusementareoQenaconsiderabledistanceawayfromanyrescueservicesshouldtheybeneeded.Thisisnottocondonetheprac5cebutsimplytostatethatsuchspeedanddistancesfromlandisnotuncommon.Withreferencetospeed,oneconsidera5onisthattheslowerashipproceeds,thesloweritreactstothehelmorders.Thusonlargeships,atslowspeeds,thenaviga5oninconfinesareasbecomesmoredifficultandrequiresconsiderableskillandIspeakfromexperiencehavingcommandedshipsfarlargerthantheCostaConcordia.Whatthiscasedealswithisacloseapproachpurelyforentertainment.Afardifferentcasethanthatofshipsrequiredbythenatureoftheirbusinesstomakesuchnaviga5on. TheCaptaindisobeyedthecompany’srulesontheuseofthephoneonthebridge,howeverIwonderifthatruleappliesifthecompanycallstheCaptainonthephonewhileheisonthebridge? Toaskastothedepthofwaterofftheislandisastrangerequest.IftheCaptainhadanydoubt,thenheshouldnotbethere. Iconcludethathewasremissinhisprimeduty,thatofthecareofthoseonboardandhisship. IdonotconcurwiththeremarksontheCaptainseyesightnotbeingadjustedorhisfailuretowearhisglasses.Onamodernshipsbridge,especiallyacruiseshiptherearemanyscreensallemitnglightthatthebridgescannotbecompletelydarkened.Hiseyesightwasprovenbythefactthathewasthefirstpersononthebridgetoseethefoamfromthewavesontherocks.Furtherastheshipwasapproachingthelandwheretheonlylightswouldcomefromisolateddwellings,therewasnothingtoseeahead. Thechartwaswrongforthenaviga5onalpurposeofcloseapproachtoland.Shipsoccasionallyhavetousesuchchartsinemergencycasesforcloseapproachorenteringaportorevendosowithoutachartatall,usingtheexcellentpilotbooksforreference.Whenthisisdone,itiswithconsiderablecare,especiallyconstantnaviga5onaloversightandreducingspeed.Idonotfindthatthespeedforthisshiptobeexcep5onal,butinthecircumstancesofthechartinuse,thenthespeedshouldhavebeenreduced. Hedidnotknowtheposi5onofhisship.Ifinditstrangethananycaptaincangoonhisbridgewithoutcheckingtheshipposi5onasthisisastandardprocedureonanyshipbyacompetentMaster.Insteadheplacedtotalrelianceonthebridgeofficerswhoprovedtobeincompetentfortheposi5onstheyheld. MakinganysuchcloseapproachshouldrequiretheMastertoorderallW/Tdoorsclosed,regardlessoftheiruse.Itwouldagainseemthatinthisfleet,theleavingofthesedoorsopenwascommonplacethereforethefaultisalsointheguidancefromtheCompanytothefleetingeneralastotheW/TdoorpolicytoconformwiththeIMOlegisla5onandrecommenda5ons. TheSeniorOfficerofthewatchfailedtoaltercoursein5metomaketheturncorrectly,thusplacingtheship.28cablesinsidetheintendedcourseline.Therewasnoposi5ontakenbeforethealtera5onoronedirectlyaQer.Thiswouldhaveshowntheshipwasnowheadingforthereef. ItwouldseemthattheymadenoreferencetotheirradarsandtherewasnoaTempttouseparallelindexingassis5ngtheminkeepingtheirdistanceofftheland.TheydidnotadvisetheMasterofthefailuretoaltercourseatthedesignated5meortheshipsposi5on.Asthesecondofficerofthewatchwasresponsibleforfixingtheshipsposi5on,Iques5onwhathewasdoingthroughoutthisapproachandwhyhealsoremainedsilent. ItisstatedinthesafetyreportthatthehandoverbetweentheOOWandtheCaptaindidnot

ItisstatedinthesafetyreportthatthehandoverbetweentheOOWandtheCaptaindidnotcorrectlyoccur.Ofcourse,whenpossiblethehandovershouldbecarriedoutproperlywiththeposi5onoftheshipbeingverifiedandagreedtogetherwiththecourseandspeed.Thetrafficsitua5onshouldbeclarifiedandofcoursethehandovershouldnotoccurduringorjustpriortoachangeofcourse.Finally,thehandovershouldnottakeplaceun5ltheofficerassumingnaviga5onalcontroloftheshipisfullysa5sfiedastothesitua5on.Thisisthenormalexpecta5on.However,inanemergencysitua5on,whichmostCaptainshaveexperiencedatsome5me,thecaptainhastheabsoluterightandindeedmustassumeimmediatecommand.Ontheseoccasionsthereisusuallyinsufficient5metofortheformali5esandthesimple,‘IhavetheCon’isenough.Inthisoccasion,thereforethatCaptain’stakeoverwasnecessaryandappropriateforthesitua5on.However,theCaptainhadnotascertainedtheposi5onoftheshiporthatthealtera5onofcoursehadtobemorerobustandthatthenewcourseshouldbechangedtoplacetheshipbackontheintendedcourselinethatwouldtaketheshipclearoftherocks. AmajorcontributortotheaccidentwasthefailureoftheFirstOfficertounderstandthecorrectprocedurefortheMastertakingcommandofthebridge.HeassumedthatastheCaptainwaspresentatthefrontofthebridgethentheMasterwasnowincommand.HethenshouldhaveapproachedtheMasterandadvisedhimattheveryleast,ofthepresentcourseandspeedandthattheshipshouldbealteringcourse. Itisdifficulttounderstandthat,whentheCaptaindidaltercoursehedidnotalterontothecorrectcoursebutinsteadreducedthealtera5on,takingtheshipcloserinsidethecourseline.Thisagaindemonstratesthathedidnotknowtheposi5onoftheshipbutwasrelyingonins5nctandvisual.Againthebridgeofficersremainedsilent. Hismethodofalteringcoursewasunusualinthefactthathegavecoursestosteerratherthanhelmordersfollowedbythecoursetosteer.Thisstyleofordergivestheindica5onastohowmuchwheelthecommandrequiresandinwhichdirec5onbeforethehelmsmanadjuststhehelmasthecourseapproaches.TheMaster’sapproachcouldbeconfusingtoahelmsmanwhoseEnglishwaspoorandItaliannon-existent.Whileunusual,thereisnoorderedorsetruleastohowthisisgiven. OntheCaptainseeingthefoamfromthewavesontherocks,hegavetheordertoaltercoursebut,insteadofalargecoursealtera5onthatwouldhavetakentheshipclear,chosetomakeamoderatealtera5on.Therewasnoques5oningofthereasonwhythiswasdoneunlessitwasanassocia5onintheCaptainsmindwiththepoorstabilityoftheseshipswhenmakinglargealtera5onsofcourseandtheresultantaccidentoccurringfromtheheel. Bythis5methe3rdofficerwassta5onedbytheHelmsmanashehaddemonstratedbyapreviousmistakehispoorunderstandingofEnglish.Wenowhaveasitua5onwheretheshipisclosingwithrocks,s5llnoaccurateposi5onoftheship,water5ghtdoorsnotclosedandthehelmsmannotfullyunderstandingtheordersbuts5llleQonthewheel.Whydidthe3rd

officernottakethewheelorordertheCadettodoso?Justonemistakebyahelmsmanshouldhavebeencausetoreplacehimimmediatelyinsucha5ghtnaviga5onalsitua5on. Anyreduc5onofspeedatthisstagewouldbepointless.Ifanythinganincreasewouldhaveimprovedthespeedofturn.IntheselastmomentstheCaptainwasaTemp5ngtomakethecorrectac5on.Byputngthewheelhardtostarboard,thebowwasfallingclearoftherocksbutthiswasalsoswingingthesterntowardsthem.OncetheheadwasclearhewasaTemp5ngtostabilisetheturnwhichwouldhavestoppedthesternswingtowardstherockandthiswouldhavetakentheshipclear.AsshownbythestudyoftheUniversi5esofBresciaandPisa,ifthismistakehadnotoccurredtheshipwouldhaveclearedtherocks.Thiswasatheoryatthe5meofthesafetyinquirybutinsteadofbeingthoroughlyinves5gatedwassummarilydismissedas‘theshipwouldhavehittherocksregardless’,statedbytheheadoftheinquirywithoutanyaccompanyingcalcula5ons.Neitherwasitin5meforthetrialwhereitwasagaindismissed.Itwasavailableandofferedfortheappealbutit’sadmissionwasrefusedagainwithnoreasongiven.

reasongiven. Thehelmsmannowmadethefinalmistakeandputthewheelthewrongway,althoughimmediatelypickedupandcorrected.Thiswastoolateandtheshipcollidedwiththereef.AswiththeTitanic,thedamageoccurredduringanavoidingac5onandtoredowntheship’sside.Itwastheworstplacetocollide. Responsibili)es. Despitetheincorrectinforma5ongivenini5allybytheCompanyCEO,headmiTedtotheSenateinquirythatthisentertainment’naviga5onwasknownandencouragedbythecompanynotjustonthisshipbutthroughoutthefleet.Ifthecompanyhadnotencouragedthis,theincidentwouldnothavehappened.TheCompanyknewthatthisshipandprobablyalltheothersweremakingsuchpassengerentertainmentsailbys.Theycertainlyknewthatthisshiphadmadethispar5cularmanoeuverbeforeunderthesameMasterandothers.Thesafetyreportfailedtoexaminethisproperlytogetherwiththefactthecompanyini5allydeniedthis.Therewasnomen5onorexamina5onofthepreviousaccidentinsimilarcircumstancesin2010andwhythecompanydidnotstopsuchnaviga5onalamusementsaQerthatoccasion. TheCaptainhadlimitedexperienceincommandandhisofficersandcrewwereincompetentfortheposi5onstheyheld.ItistheCompanywhopromoteandappointofficersandcrewtoaship. Thecaptainhadallowedhisperceivedcelebrityposi5ontoencouragehisbehaviourtotheextentthatitinterferedwithhisprofessionaldu5es.Hefailedinhisnaviga5onoftheship,hisdutyofcaretothoseonboardandhisleadershipofhisofficersinhisexpecta5onoftheperformanceoftheirdu5eswithduediligence. Theques5onofthechartswasnotpursuedbytheinquiry.Theshiphadbeenmakingsuch‘sailbys’beforesothismusthavebeendoneagainwithoutthecorrectchart.Wasthechartindentedforandifsowhywasitnotsuppled?Ifitwasnot,theywhydidthenaviga5ngofficernotadvisetheCaptain? ThefirstOfficer,astheseniorwatchkeeper,failedinhisdu5estocon5nuehiswatchun5lproperlyrelieved.Hefailedtoaltercourseproperlyplacingtheshipontoadangerouscourse.Hefailedtoorderthefixingoftheshipsposi5onbeforeandaQertheturn.HefailedtoobservetherocksaheadandwarntheCaptain. Thelanguagedifficulty,whichwillalsobeheardoflater,isamostseriousand,aswehaveshown,dangerousproblemespeciallyamongsttheopera5onalstaffoftheseships.Itwouldbe,tothosenotofthemarineindustry,unbelievablethatthoseonthebridgehavedifficultyincommunica5ngwitheachotherandthatevenaseniorengineeradmiTedthathehaddifficul5esunderstandingordersinEnglishandItalian.Thereisnoofficialtes5ngstandardrequiredbySOLASandalthoughthishasbeenraisedwiththeIMOmany5mes,theyhavefailedtoenactlegisla5onforthis.Canyouimaginetheairlineindustrybehavinginsuchafashion?Iftheydid,noonewouldfly,buttheyhaveastrictstandardwhichisappliedwithrigour. Insteadweleavetheexis5ngSOLASrequirementstothecompaniestotest.Itisobviousthiswasnotdone.Strangely,justpriortothis,theCompanyappliedtotheFlagStatetochangetheopera5ngLanguageonboardtheshiptoItalian.Onthisship,thecrewwascomposedof46differentna5onali5es,withtheonlycommonlanguage,evenifpoor,English.Thismeantthatorderswerebeinggiveninbothlanguagestotheconfusionofmany. Thecompanyfailedinitsresponsibilitytoensurethatthecrewcouldcommunicate,especiallytheopera5ngstaff.FurtheritchangeditslanguagetoItalianandboththeFlagStateandcompanyareguiltyoffailingtoensurethatItaliancouldbeunderstoodbytheopera5ngstaff.TheIMOfailedtoensurethatthepropertes5ngcriterionforlanguageproficiencyisadoptedatseabylegisla5on.

adoptedatseabylegisla5on. TheCompany,TheFlagStateandtheIMOmustbearresponsibilityforthisfailurewhichcontributedconsiderablytothedeathsonboard. Theques5onastowhytheCaptainfailedtomakealargealtera5onofcoursewhenfirstseeingthefoamfromtherockscouldbeansweredbytheaccidentsthathaveoccurredpreviously. TheCrown Princess, another Carnival Cruise shipwas leaving Florida in calmweather forNew York. Twice the ship suddenly and violently listed starboard injuring Nearly 300passengerswere injured, someseriously. Strangely, itwasagainapassengerwhono5fiedthecoastguard,not the ship.TheCoastGuardmadecontactwith the shipand theywereadvisedthattheshipwouldreturntotheport.Thisreturnwasdelayedbythecoastguardun5l they were assured that the ship was manageable by inspec5on. the CrownPrincess docked. The accident, according to the inves5ga5on report,wasdue to incorrectopera5onbythecaptainandhiscrewoftheautopilotsystemcausingahighdegreeofhelmtobeused. In2010,anotherlargeCarnivalcruiseshipnaviga5ngthemiddleoftheGulfofMexicohadtomakeanemergencymanoeuvretoavoidan“obstacle”that,whilenothavingbeeniden5fiedfromthebridgepassengersclaimedtohavespoTeditandfoundthattheshipwasheadingstraightforit.60passengerswereinjured.TheseincidentswerediscussedwithinCarnivalandthesediscussionsmaywellhaveinfluencedtheCaptainoftheCostaConcordiainhisreluctancetousehardhelmtoavoidtherocks. TheCaptainhadnothingtodowiththedesignoftheshipwhichisen5relyinthehandsofthebuildingyard,theownersandClasswithliTleinvolvementbytheFlagState.Iftheyarebuildingshipsthatcannottakeavoidingac5oninaccordancewithSOLASlegisla5onandwithoutinjuringhundredsofpassengers,thenIsuggestwehavetoexamineclassastowhytheyareapprovingsuchdesigns.Againtheinquiryfailedtoinves5gatethis. TheDamage Thedamagewassuchthatallonboardfelttheblowfromcontactwiththerocksandtheimmediatelistoftheship.ShortlyaQertheengineroomlostpowerandtheemergencygeneratorfailedshortlyaQerthat.Thesafetyinquirymadeextensiveinquiriesastothisfailurewhichhadsuchaneffectontheforthcomingevents. ItmustbenotedthattheEngineeringofficerskeptthebridgeadvisedastothesitua5onandcon5nuedintheirendeavourstocorrecttheemergencygeneratorfault.TheshipwasthenonemergencybaTerypowerwhichregreTablydidnotsupplypowertothepumpsorthesteeringmotors. Therewereanumberofreportedemergencycabinlightfailingsleavingtheoccupantsinthedark. Thepassengersandcrewwereadvisedthattheonlydamagewastothegeneratorsandthatthepowerwouldberestoredshortly.Thenadvicecon5nuedandpassengerswereadvisedtogototheircabins.Asitwasobvioustoeveryonethatthesitua5onwasfarmoreserious,thiscauseddistrustintheinforma5onbeinggivenandaddedtotheearlystagesofapanicsitua5on.ThiswasenhancedbymanyofthecrewnotbeingabletocommunicateproperlyeitherinEnglishorItalian,includingaseniorengineerofficer. Whilethefloodingoftheshipwasputdowntothenumberofwater5ghtcompartmentsbeingbreached,despitewitnesses’statementsadmitngtoclosingandopeningofwater5ghtdoorsandtheconsiderablenumberofW/Tdoorsontheship,thiswasnotproperlyinves5gatedbythesafetyinquiry. TheshiphadauthoritytoopencertainW/Tdoorsforworkingpurposeshowever,fromstatementsitwouldseemthatcrewcouldopendoorsastheyrequired.Despitetheship

statementsitwouldseemthatcrewcouldopendoorsastheyrequired.Despitetheshipmakingapassageclosetoland,thesedoorswerenotorderedtobeclosedun5laQertheaccident. TheCaptain,knowingthecloseapproachthattheshipwasabouttomakeshouldhaveorderedallW/TdoorswellbeforearrivaloffthecoastofGiglio.ThiswastheCaptain’sresponsibility. Itisdifficulttounderstandwhytheshiphadbeenapprovedfor25W/Tdoors.ThesafetyinquirymadenoaTempttoinves5gatethisalthough,asthecompanywouldhavehadtosubmitdocumenta5ontoboththeClassandtheFlagstateauthori5estosupportthisrequirementasitwasagainsttheprincipleoftheSOLASlegisla5onforW/Tdoors,allsuchdocumenta5onwouldhavebeeneasilyavailabletotheinquiry. TheresponsibilityforthislieswiththeCompany,RINAandtheItalianCGandthisshouldhavebeeninves5gated.Iftheyhaveallowedsuchopeningsinthebulkheadsthereisagoodpossibilitytheyhavedonethesamewithotherships. Phase3TheAbandonment Fromtheculminatedandoverwhelmingevidenceofthosewhowerethereandtheanalysisbyexpertopinionitisobviousthatimmediatelyfollowingtheaccident,theCaptainsufferedseveretrauma5cshockwhichleadtoacutestressdisorder,enhancedbyguiltcomplex.Thisisrecognisedbythearmedforces,thepolice,thefirebrigadesandevenindustryashoresowhynotatsea?Whywasthisnotinves5gated?Icannotimagineamoretrauma5ceventforaCaptaintoexperience.TheCaptainwaspoorlyrepresentedashisdefenceteamshouldimmediatelyhaveraisedthisatthetrialbutfailedtodoso.Evenso,theinquiryshouldhaverecognisedwhathadhappenedandinves5gatedthisespeciallyasmanypassengersares5llclassifiedass5llsufferingfromthis! TheCaptainwasinnomentalcondi5ontoissueanysensibleordersaQerthiseventandthisshouldalsohavebeenrecognisedbythenextincommand,the2ndCaptainwhowaspresentonthebridge,andheshouldhaveimmediatelytakencommand.Hefailedtodoso.Thiswasthecauseofthedelayinorderingthemusterandcommencingthedisembarka5on.TheinquiriesandthetrialsconcentratedonthisdelayasthisbeingthemaincauseofthedeathsofthepassengerseventhoughthiswasbeyondthecontroloftheCaptain,hewasfoundguiltyandsentenced. Fromthiscomesamostimportantques5on.Canyouprosecutesomeoneforac5onscarriedoutwhilesufferingfromamentalcondi5onthathastheclassicsymptomsofdenial? AnotherfailureoftheSafetyreportwastheproperexamina5onofthereasonswhythelife-raQswerenotloweredandthatthreelifeboatsfailedtolower.Thelife-raQfailurehasveryseriousimplica5onsforallthecruiseshipindustryas25%ofallthoseonboardtheseshipshavetousethesefortheirsurvival. Canwebelievethat66liferaQsof69onboardfailedtolaunch,orwasthereanotherreason?Isuggestthatthemajorityofthecrewmadeadecisionnottousetheseandinsteadusedthelifeboatswhichwerereservedforthepassengers.Ifthisindeedoccurred,thenthedeathswhichoccurredaQerthemajorityoftheboatshadbeenlaunchedaretheresponsibilityofthosecrewtakingthepassengerplacestotheextentthathundredsofthemwereleQbehind.Itismostimportantthatthisbeinves5gatedandthisshouldbeanIMOinves5ga5on,notleQtotheflagstate.ItisregreTablethattheScandinavianmanufacturersofthelife-raQs,whocertainlyknowthetruth,werenotcalledtogiveevidenceandhaverefusedtoanswerrepeatedinquiriesintothismaTer. Regardingthelifeboats,thefailureofthetelescopicdavits,causingthefailureoflaunchingofthreelifeboatsreleasedbypressurizedgasboTles,shouldhavebeenproperlyinves5gated,especiallyasworkhadrecentlybeencarriedoutbythemanufacturersto

inves5gated,especiallyasworkhadrecentlybeencarriedoutbythemanufacturerstomodifythesebyextrapowerpackstopushthedavitsout.Whatwaswrongwiththedavitstorequirethis?wasthemodifica5oncarriedoutcorrectly?Consideringthat450passengerseatswerelostbecauseofthisfailure,andthiscouldbeareasonforsomelossoflifeorinjuries,whywastheFinnishCompanyconcernednotinves5gatedandcalledtogiveevidence? Furthertothiswehaveevidencethatevenatanangleof15degrees,5degreeslessthattherequiredlaunchingangle,lifeboatsdidnotlowercorrectly.Again,noinves5ga5on,bytheItalianInves5ga5onboard,CLIA,TheIMO,andEMSA.Wherewerethecallsforinves5ga5onbytheInterna5onalChamberofshippingandtheITF?isunbelievablethatsuchamajoraccidentwiththepoten5alofsuchdisasteronlyavertedbythedirec5onofthewind,couldoccurwithsoliTleconcernbythoseagenciesthatarepurportedlydedicatedtothesafetyoflifeatsea. Theshipwassailingwithmanyofthosecrewresponsiblefortheopera5onoftheselifesavingcraQbeinguncer5ficatedorwiththeircer5fica5onexpired,completelyagainsttheSOLASregula5ons.Thismeantthatanumberofthesecouldnotbelaunchedasnooneknewhowtolaunchthembutthatistooeasyanexplana5onforsuchalargenumbernottobelaunched. Whywasthecruisedirector,whohasnopartinthesafetymanagementsystemorthecommandaspectoftheshiporderingpassengersawayfromtheirmustersta5onintoadangeroustaskofcrossingtheshiptotheoppositeside?Wastherenotadeckofficerpresent?Iftherewerenoordersemana5ngfromtheexecu5veofficers,thenleadershiphastocomefromsomewhereandhisfrustra5oncouldbeunderstood.Ifhewastryingtoplacethepassengersintowhatheconsideredsafetythanhecannotbecri5cisedfordoinghisbest.Thisshowsacompletefailureinleadershipandarobustcommandstructureonthisshipandtheeaseinwhichitfailedwhenunderpressure. Whilethisistheimmediatefaultofthoseonboard,itistheCompanythatmustdemandsuchastructureandsupportthosewhoexercisethis.Againtherewasnoinves5ga5on. WiththeCaptainsufferingfromtrauma5cstressdisorder,whydidthoseotherofficersaroundhimnottakeimmediateac5ontocallamusterandpreparetheboatsforlaunch?Apartfromtheirlackofleadershipandfailuretocarryouttheirdu5es,couldtherebeanotherreason?LetusnotforgetthatforyearstheIMO,despitewarningsfromprofessionalseamen,hadbeenpermea5ngthemarineindustrywiththedangerousconceptthattheshipisthebestlifeboat.Translatedthatmeanskeepeveryoneonboardun5lyouarecertaintheshipisabouttosink,asmodernshipsaredesignednottosink.Thisnonsensehasbeenpickedupbycrewsaroundtheworld,asthosewhowarnedtheIMOknewitwouldandIsuggestthatthisaffectedthedecisiontoimmediatelygotomusterandbeginlaunchingtheboats,thuscausingafurtherdelay.Therewasnootherreason.Theshipwasveryclosetolandandevenaharbour.Theweatherwasfineandnodangertotheboats. TheIMOmustacceptadegreeofresponsibilityforperpetua5ngthisabsurdtheorywhichhadalreadybeendiscreditedbytheTitanicsinking,andforthedeathsthatoccurred. Chaos Themind-setforthechaoswasalreadysetinmo5onbytheobviousdecep5oninthepreliminaryannouncementsmaderegardingthecollisionbeingapowerfailure.Thiscauseddistrust. CrewwalkingroundwiththeirlifejacketsonwiththefewwhocouldspeakEnglishtellingpassengersitwasnothingdidnothelpasdidthefactthatveryfewcouldspeakEnglishandtellthemwhatwashappening. Theincreasinglistoftheshipagainwithnoexplana5on.Thiscausedanumberofpassengersandcrewtoheadforthelifeboatsregardlessofanymuster.Thisinturnmeantthatwhenthemusterwasannouncedandthosepassengersremainingwenttotheirsta5onsthey

foundthattheirplaceswerealreadybeingtakenbythosewhoarrivedbeforeanddisregardedanysetboat,oQenbecausetheydidnotknowtheirboatnumber. Asthelistandcrowdincreasedthenarrowboardingareabecamepackedwithpersonstryingtoboardtheboats.Thelackofproperlytrainedcrewsupervisedbyresponsibleofficersagainaddedtothegrowingpanic.Nowmanycrewwerealsotryingtoboardtheboatsandfigh5ngwasbreakingout. Manywerewithoutlifejacketsastheywereontheupperdeckswhentheshipbegantolistandwerereluctanttogototheircabinslowerdowninthedimlighttoretrievetheirlifejackets.Figh5ngoverlifejacketsalsobrokeout.Therewasnocontrolordisciplinebeingimposedbythoseoftheshipss5llonboard.Passengersnowbegantotakecontrolthemselves,insomecaseseventakingcontroloftheboatsasthecrewwhenloweredothewaterwereincapableofcontrollingtheboatsproperly.InsteadofusingtheirownliferaQstheywereassignedto,crewwenttothelifeboatsaddingtothecrush. Nowpassengerswerebeinginjuredinthecrushandstruggles.Somepeoplebegantofallorjumpoverthesidetoswimtothenearbyrocks.Asthelistneared20degrees,thebridgeandcommandhadbeenabandonedanditbecameeveryoneforthemselves.IntheaTempttofindboatspaceorsafetywithintheship,passengersbegantodie.Crewpushedpassengersasidetotakeplacesintheremainingboats.Theabandonmenthadnowchangedintoarescue.Bythisstagetherewereover1000peopleleQonboard,ascountedbytheshorerescueserviceswhohadnowtakenchargeoftherescue. Therewereexcep5onstothegenerallypoorand,inmanycases,disgracefulbehaviourofthecrew.Incredibly,thedeputymayorofGiglio,MarioPellegrini,boardedtheshipwhentheCaptainandhisofficershadleQ,andtookchargeofsomeoftherescueopera5ons.AccordingtoMarioPellegrini,whowasmiredinthechaosabove,twoofficersworkedwithhimtosupervisetheescapeaTempt:thedoctor,SandroCinquini,andespeciallyyoungSimoneCanessa,thesameofficerwhoearlierintheeveningtoldtheCoastGuardtheshiphadsufferedonlyablackout.Canessa’sroleintheevacua5onhasnotbeenmen5onedpublicly;yetaccordingtoPellegrini,hewasthesinglemosteffec5vecrewmans5llworkingtoevacuatetheshipduringthelongnight’smostharrowinghours.“WhenIgotupthereandsawSimone,hewastheboss,hewastheonlyoneuptherereallyhelping,”saysPellegrini.“WhenherealizedIwastheretohelp;hesawwecouldworktogether.Hewasfantas5c.Simone,Ithink,createdawholeescaperoute.Hewasatthetop.Ididmybesttohelphim.”

Men5onmustalsobemadeofanumberoftheengineeringstaffwhoresolutelyperseveredwiththeemergencygenerator.Eventhecruisedirectorcon5nuedtoassistpassengersun5lhefellandbecameinjured.Unfortunately,thesewerefewinnumbercomparedtothosewhoabandonedtheirsta5onsandplacedthemselvesbeforethosewhotheyweresupposedtoprotect.

Responsibility. WhiletheCaptainwasresponsibleforthegroundingofthevessel,hedidnotkillorinjureofthesepeople.Withtheshipincalmwaterssoclosetolandandwithreadilyavailableshoreassistance,everyoneshouldhavebeenrecoveredwithoutlossorinjury.TheCaptainwasmentallyincapableofanydecisiveactofleadership.Itwasthe2ndCaptainandtheotherdeckofficerswhofailedduringtheabandonmentphase. ItwastheCompanywhofailedtoensurethatthecommonlanguageshouldbeEnglishasthemajorityofthemixedna5onalitycrew,especiallytheopera5onalcrewandtheirpassengerscouldunderstandthisbeTerthananyotherna5onallanguage. ItwasalsotheCompanythatfailedtoensurethatallkeypersonnelcouldspeakandunderstandEnglishand,asItalianwasnowtheopera5onallanguage,Italianaswell. ItwastheCompanythatfailedtoensurethatthelifeboatandliferaQcrewshadtrainingand

ItwastheCompanythatfailedtoensurethatthelifeboatandliferaQcrewshadtrainingandcer5fica5on. ItwastheCompanythatbrokeSOLASlegisla5onoverthetraining,thefailuretorequirewarmclothingtobebroughtbythepassengers. ItwastheCompanythatfailedtoactonthecaptainscomplainsastothepoortrainingandabilityofthecrew. TheninturnitwastheFlagStateMarineAdministra5onthatfailedtoensurethatthelanguagespokenbythekeypersonnelwasthatthattheyallcouldspeakandunderstand. ItwastheIMOthatfailedtoenactlegisla5ontoensurethatlanguagecapability,especiallyforopera5onalandkeypersonnelinanemergencycanbeclearlyspokenandunderstood.Theyhaveknownthisformanyyearsandfailedtotakeac5on.Againpeoplehavediedbecauseofthisorganisa5on. Codacons,whichisanon-profitorganiza5oninvolvingassocia5onsworkingforconsumer’srightsprotec5onandisoneofthemostimportantandrepresenta5veconsumer’sassocia5oninItalyisclaimingthatelectricalproblemsmayhavecontributeddirectlytothedeathsofseveralpassengerswhoarethoughttohavediedinthestrickenvessel’sliQs.Theorganisa5on’slawyerGiulianoLeuzzi,saiditwasfearedthatfourvic5msmayhavedrownedwhiletrappedintheelevators.

Thesafetyreportshouldmakemen5onthatthereisnoIMOlegisla5onregardingtheliQs.Thisisurgentlyneededinorderthattheyshouldreturntoadeckinorderthatthoseinsidecanescape.Furtherthatwhenthemainpowerfailsonboard,thentheseliQscannotbeused. Asiscommoninthemarineindustrytoday,muchworkisdelegatedbytheflagstatetoaresponsibleorganisa5on,whichistheclassifica5onsocie5es.Wherethisisdonetheremustbeadequateoversight.Withoutthis,becauseofthecompe55onbetweenclasssocie5esandtheinfluenceoflargefleetshippingcompanies,bothcrewandpassengerswillcon5nuetosufferfromadequatesafetyprovision. TheMasterdeclaredthatheneverwouldhaveevacuated4.000persononboardun5lhewasquitesurethattheshipwouldhavesunk.HelistenedtotheIMOregardingtheshipbeingalifeboat. TheCaptainandthebridgeofficerswereincompetentandtheirinexcusableerrorsofjudgementweretheini5alcauseofthegrounding.Thereisnoques5onthattheCaptainwastherootcauseofthegroundingandwithhisbehaviourandthatofhisofficers,theshipwasanaccidentwai5ngtohappen.Butwithregardtoresponsibility,hewasnotaloneinthis.TheseniorOfficerofthewatchbearsconsiderableresponsibilityforhisfailuretocommencethealtera5onofcoursein5metoplacetheshipcorrectlyonthelineofthenextcourse,hisfailuretorequireanimmediateposi5onaQerthealtera5onascompleted,hisfailuretofollowthecorrectprocedurefortheCaptainspresenceonthebridgeandhisfailuretoadvisetheCaptainoftheshipbeinginthewrongposi5onandthedangerahead.Heshouldnothavebeengrantedapleabargainconsideringhisimplica5oninthecollision. SeaworthyandSafe. Avesselownerhasadutytoensurethathisvesselisseaworthyandcouldfaceliabilityforinjurieswhenthisdutyisbreached.legallydefined,aseaworthyshipisonethatisfitforanynormalperilsofthesea,includingthefitnessofthevesselitselfaswellasanyequipmentonitandtheskillsandhealthofitscrew. TheHague/Hague-VisbyRules,whichapplyeitherbylaworbyagreement,tothemajorityofcontractsforthecarriageofgoodsbyseaalsocontainanobliga5onastoseaworthiness.Ar5cle3.1oftheseRulesprovidesthat:

“Thecarriershallbeboundbeforeandatthebeginningofthevoyagetoexercisedue

“Thecarriershallbeboundbeforeandatthebeginningofthevoyagetoexerciseduediligencetomaketheshipseaworthy,properlyman,equip,andsupplytheship,maketheholds,refrigera@ngandcoolchambers,andallotherpartsoftheshipinwhichgoodsarecarried,fitandsafefortheirrecep@on,carriageandpreserva@on.”

Ifpassengerscouldbeconsideredascargo,thenthewordpreserva5onwouldseemtoapplyandthefailureofthesafetyequipmentandemergencygenerator,allofwhichcontributedtothedeathsofthepassengerscouldbearguedasafailureoftheseaworthinessofthevesselforthecarriageofpassengers.

Safetyontheotherhandisdifferentandwhilstseaworthinessandsafetyoverlap,compliancewithonedoesnotnecessarilymeancompliancewiththeother.MostminimumsafetyrequirementsareincorporatedinSOLAS,MARPOLandSTCWConven5onsandthroughtheseintothelawsofthemajorityofmari5mestates. InthecaseoftheCostaConcordia,therequirementsforthecorrectcer5fica5onofthoseinchargeofthelife-raQsandlifeboatswerenotobserved.Thisnon-compliancenotjustputallthoseonboardatrisk,butcontributedtothedeathsandinjuryofthoseonboard.Itisthereforedifficulttounderstandthecriminalprosecu5onformanslaughteroftheCaptainforamomentaryactofincompetence,whiletheCompanyandthosewithinthatcompanywerenotequallychargedoverthisactofnon-compliancethatmusthavebeenknowntothoseinthemanagementandthereforecouldbeconsideredapre-meditatedact.

EPILOGUE

ThishasbeenlikeputngaJigsawtogetherwithmanypiecess5llmissing.Wehaveapicture,butnotthewholestoryandunlessthosewhoknowwherethesepiecesareandarewillingtocomeforward,Idoubtifthecompletestorywilleverbetold. Ashort5meago,thecruise/passengershiperawastransformedbytheentryoftheentertainmentindustry.Sincethen,themarineandentertainmentindustrieshavebeenuneasybedfellows,muchlikeanewlymarriedcouplewhomarriedforconvenienceratherthanlove. TheMarineindustryformanyyearshashadoneabidingpriorityandthathasbeenthesafetyofthoseonboardandtheship,althoughtemperedbycostconsidera5on.Thisresultedinthefactthatwhileitwasimportantthatthepassengersenjoyedtheir5meonboard,thiswasnotattheexpenseofsafetyandallaspectsoftheshipbothdesign,opera5onandlegisla5onwasformulatedtocopewiththis.ProfitcamefromthecarriageofthepassengersandtheauthorityoftheMasterandhisexecu5veofficerswasunques5oned.Theirprofessionalismandabilitycamebeforeallelsewithleadershipimbuedinthemfromtheirbeginningsoftheirtrade. TheEntertainmentIndustry,ontheotherhand,existstoprovideentertainmentandthegreatertheentertainmentthegreatertheprofit.Thecomfortoftheirguestswasparamount.LeadershipwasrarelyamaTerofconcernaswasoverallsafety.Legisla5onwasjustahindrancethatcouldbeovercomebywhatpolitelycouldbetermedas‘persuasion’whichprobablyaccountsforthefactthatCLIA,theirrepresenta5vebody,gaveover10milliondollarsoverthelast10yearstoUSpoli5ciansalone. Thisisnottosaythatsafetyisignored,however,itdoesnothavethesamepriorityasthemarineindustry.Equally,thecommandandleadershipoftheshipdoesnothavethesamepriority.Theentertainmentsidefeelsmorecomfortablewiththeirownpersonnelinchargeofmostoftheshipfunc5onsthanthatofthetradi5onalexecu5veorbridgebranchthusgraduallytheircommandposi5onhasbeendiminished. Thisisunderstandableandprobablyinnormalsitua5onsenhancestheopera5onoftheshipsasawhole.Neitherdoesitmeanthatthenewstyleofopera5onisdisinterestedintheoverallsafety.However,bothindustriesares5lllearninghowtoworktogetherandmistakesinevitablyoccurduringthisprocess.Whentheseoccur,whatisessen5alisthatweadmittothemandbyinves5ga5onandopendiscussion,welearnfromthemtoavoidrepe55on.ThisoQenmeansthatthereisaneedtocurbtheuseofPublicRela5onsandMarke5ngdepartmentsthathaveinevitablygrownwiththeseships.Bytheirnature,disclosureoracceptanceoffaultisthelastop5oninanyincidentandofcourse,thishindersanyinves5ga5on,especiallyinanenvironmentthat,withtheIMO’sconstantfailuretoactonsafetymaTersandtheflagstatesheadingtheirowninves5ga5ons,allowsaliberalscopeforobstruc5onandworse,interference.

InthecaseofCostaConcordia,theuseof‘smokeandmirrors’beganfromtheverystartoftheincidentun5ltheCaptainwaswellandtrulybehindbarsbearingthefullblamefortheaffair. OnemustwonderattheinterferencethatwasmadewiththefinalsafetyreportwhichleQsomanyunansweredques5ons,exceptwheretheCaptainwasconcerned.ItishardtobelievethatmarineprofessionalscouldhavewriTensuchasoQreportleavingsomuchun-inves5gatedandques5onsunanswered.TheycompletelyavoidedtheISMCodewhichwouldhavepointeddirectlyatthemanagementashoreand,whilemakingpointsregardingtheirac5ons,failedtofollowtheseup.Consideringthelongdelayinpublica5on,andignoringtheratherfoolishexplana5onthattheprosecu5onhadtakenevidencethattheycouldnotgetback,IsuggestthatthebeTerexplana5onwasthat,consideringtheverycloserela5onshipbetweenGovernmentandCompanyandtheseeminglyverypoorstandardofthereport,certaininterestedpar5esheldbackthereleaseun5lthereportwassani5sedtotheirsa5sfac5on. Thesafetyreportshouldmakemen5onthatIMOlegisla5onisurgentlyneededregardingthesafetyofthosetrappedintheseliQsandthattheyshouldreturntoadeckinorderthatthoseinsidecanescape.Furtherthatwhenthemainpowerfailsonboard,thentheseliQscannotbeused. TheIMOmustconsidertheimplica5onsoftheirpropaga5onofthe‘shipisalifeboat’theory.Certainlythepresent‘hotel’shipscannotbeconsideredthat.IdonotdiscountthepossibilityofdesigningshipsthathaveafarbeTerchanceofthisthanthepresentgenera5onbutconsideringthereluctanceofmanyofthesecompaniestoevenplaceadequatelifejacketsonboard,Ihaveafeelingthatitwillbealong5mebeforeweseethechangesindesignandmanagementattuderequired.Inthemean5me,allshipsmustbepreparedforabandonmentandthereshouldbenodelayinpassengersbeingmusteredbytheirassignedboatsandevenbeingorderedintothemtoawaitthefinaldecision.Discomfortisfarpreferabletoaworsealterna5ve.TheshipabandonmentcriteriaaspresentedbytheIMO,canbeseenasdeeplyflawed.IsuggestthatthefactorsIhaveshownwillatleastdoubletheevacua5on5me,whichwouldmeanthatnoneoftheexis5nghotelshipscanpassthe5mecriteria.theCriteriaforevacua5onmustbebasedonworstcasescenarioratherthanthepresentbestcaseandabandonmentbemadetakingintoaccountallfactorsofweather,heelandlist,darkness,distancefromthemusterpointtotheboatembarka5onposi5on,numberofelderly,infirmandhandicappedpersonsonboard,possiblefireandsmokeandes5matednumberofintoxicatedpersonsonboard.Butthenthishasbeenknowninthemarineindustryforyearswithnothingdonetocorrectit. Theshipsshouldbedesignedtoensurethatthemustersta5onsarebytheboatswithamplespaceforassemblyandevensitngarrangementsforpassengerstoawaitanyembarka5onorder.Eachboatmustersta5onshouldbesuppliedwithafirstaidandtriagetrainedcrewmember,afirstaidpackandadefibrillator.Havingsuchaplacetoawaitabandonmentwouldassistinremovingaconsiderableamountoftheprobablepanicsitua5onfromtheabandonmentequa5onandenablethosewithminorinjuriestobeassessedandtreated.InthecaseoftheConcordia,many,bothpassengersandcrewwereinjuredintheabandonmentandchaosphaseands5llleQonboard. Thatthemustersta5onbewherepassengersaresuppliedwiththeirlifejackets.Atthesame5me,lifejacketsbealsostoredinthepublicroomsincaseofinabilitytousethemusterpoints.Thereshouldalsobeastudyastowhypassengersshouldembarkenclosedlifeboatswearinglifejackets.Ifanythingdidgowrong,veryfewofthemwouldbeabletoevacuatethelifeboat. Cruiseshipsshouldberequiredtoadopteitherdoublehulls/doublesideskinsexactlythesameastheoilandchemicalcarriers,bulkcarriersandcontainerships,especiallythosegoingintoicywaters,ortwolongitudinalbulkheadsextendingfromthecollisionbulkheadtotheaQermostbulkhead.

theaQermostbulkhead. Thatthenewre-evalua5onlifeboatandlife-raQspacesberequiredforallcruiseshipsregardlessofdateofbuild. ThatcruiseshipsshouldcarrysufficientlifeboatsforALLonboard. Thatanumberoflifeboatsspecificallydesignedfordisabledorinfirmpassengersbecarried.Thatthecabinsfordisabledpassengersberequiredtobeonthesameornexttotheembarka5ondeck.Un5lthiscanbeappliedthattherebealimita5ononthenumberofdisabledpassengerscarried,especiallythoseinwheelchairs. ThatmanoverboardsystemsbefiTed. Thatalllifejacketsbereplacedforatypethatincorporatesahood,facemaskandcrotchstrap.Thatthehoodbecapableforuseinsmoke. Thatno5cesbeplacedonallopenupperdecksabove4.5meterssta5ngthatitisdangeroustojumpfromthesedeckswithlifejacketson. Thattheprocedureforjumpingintothewaterwithlifejacketsonbestatedanddemonstratedatthejoiningmustersandano5cebepostedineachcabin. Thatpassengersareadvisedofthewarmclothingrequirementbeforejoiningandthatthewearingofthisclothingatthemusterbestrictlyenforcedespeciallyonshipssailinginwintermonthsandinicecondi5ons. Thateitherallforwardfacingexternalligh5ngexceptforthenaviga5onlightsbeex5nguishedorwindowscurtained,orthatthenaviga5onlightsfiTedbeincreasedinsizeandbrightness. Thatoncruisesofovertwoweeks’dura5on,everytwoweeks,allpassengersbemusteredattheirmusterpointandthatalllifeboatsareloweredtotheembarka5onposi5on.Thatifthetheini5almusterplaceisawayfromtheboardingmusterposi5on,themusterdrillincludesthepassengersbeingconductedfromthemusterpointtotheirlifeboat. Thattheuniformsonboardreflectthecommandresponsibilityandthattheopera5onalofficerscanbewelldefinedfromthehotelstaff.Thiswillavoidconfusionwiththeopera5onalofficersandcrewoftheshipwhowillbegivingthecommandordersduringanyemergency. Thatsufficienttrainedseamenareemployedtoenableeachlifeboattocarry3andeachlife-raQhave1.Theseshouldnotbehotelorentertainmentstaff. OfcourseIdonotexpectagreementwithallIhavesaid,nordoIclaimthatIamcorrectinallmyassump5onsbutthisisintendedaspointsfordiscussion.Itmightseemthatallthisisaskingtoomuchbutastheprimeconsidera5onofseamenisthesafetyofthoseonboard,ourfunc5onasseamenprofessionalsistoconsideralltheproblemsanddealwiththembeforetheeventratherthanthereac5veapproachcurrentlyused.WerelyontheIMOandSOLASregula5onforleadershipbutwhenthatdoesn’thappen,arewetostandbackandwaitforthenextaccidentandthenthenext? Thisisexactlywhatwearedoingandeach5mewepointourfingeratSOLASandsay,‘Theequipmentconformed,’‘Thedesignconformed’or‘Theshipwasmannedaccordingtothesafemanningcer@ficate,’asifthatcanexonerateusfromresponsibilityforthoseinjuredorkilled.WehaveaprofessionalvoiceandIsuggestifweusedthismoreoQen,itwouldbetothebenefitofallthoseatsea. Hopefullywecanlearnfromthisaccidentasitcouldbethelastchancewehavetogetitright.AccordingtoChris5neDuffyoftheCruiseLinesInterna5onalAssocia5on‘Wearewhollycommiqedtoexaminingwhathappenedandtoiden@fylessonsthatcanbelearnt.’

whollycommiqedtoexaminingwhathappenedandtoiden@fylessonsthatcanbelearnt.’ CLIAthencompletelyignoredtheevidenceofmanyfailuresofthecruisecompanyandtheequipmentandmachineryonboardtheship. Possiblyoneofthestrangesteventstookplaceafewmonthslater,buts5ll,evenbythen,ratherdisturbingallega5onswerecomingthroughregardingthebehaviourofthecrew.InSeptember2012,Lloyd'sListofLondonawardedthe5tleofSeafarersoftheYearrecognisingthebestprofessionalsailingandshiptotheCostaConcordiacrewfortheirexemplarybehaviourduringtheshipwreckwhichhassavedmostoftheship'spassengers.Manyrepresenta5vesoftheleadingmarineins5tu5onsaTendedthepresenta5onandapplaudedwhatcanonlybetermedasthemostbizarrepresenta5onforyears.Onemustwonderastotheinducementthatini5atedsuchanawardwhichinsultedthosewhodied,wereinjuredandtrauma5sedbytheeventsthattranspiredonthatnight. Itmightseemstrangeforthosewhowereinjuredortrauma5sedtounderstand,buttheywereverylucky.Thewrongwinddirec5on,andthisshipwouldhavedriQedintodeepwaterandcapsizedtakingprobablythousandswithherprovidingadisasterencompassingthoseoftheTitanicandgivingusthegreatestpeace5memarinedisasterinhistory.Thefinalfortunewasthattheshipgroundedsoclosetothelandandaharbourandimmediatelytheshorerescueservicesworkedsoadmirablyandunceasinglyun5lallthosealivewerefoundandbroughttosafety. Withallthefaults,bothashoreandonboard,thefailureofthesafetyequipmentandmachinery,boatsandlife-raQs,theuntrainedandinexperiencedcrew,thelackofSOLASlegislatedcer5fica5on,thelanguageproblems,thelackofbasicnaviga5onalskills,thelackofleadershipandchainofcommand,itisimpossibletoclaimthatthisshipwasseaworthyforitsprimeduty,thecarriageofpassengersinsafety. IwillleavethefinalcommenttoanunknownpassengerwhohasobviouslybeenaroundthemarineIndustry. “At the end of all this,” he predicted, “it will all be for nothing. You wait and see.” HowTrue. References Aharonian,AniA.andBornstein,BrianH.,"StressandEyewitnessMemory"(2008).FacultyPublica5ons,DepartmentofPsychology.UniversityofNebrasca-Lincoln. Asle Hoffart & Tomas Formo Langkaas, Oslo University. Castro, Luciano. Concordiagate - The cruise ship tragedy as told by two reporters on board(Futurebook Book 2) . CUEC Editrice. Corriere della Sera. Concordia. The true story. Corriere della Sera. ‘CostaConcordiacaptainhandshimselfintoprison’TheGuardian(12May2017)

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