The cruise ship Costa Concordia tragedy should never have happened. The Masters and Captains commanding these magnificent passenger vessels are among the most trained, experienced and seasoned maritime professionals afloat. They are hand- picked to represent the best of the sea going professions to sail the capital investments of the leading shipping lines of the world. Likewise, the crews assigned to vessels such as the Costa Concordia receive the best training that is on the market. The qualification processes in every phase of ship board operations, from navigation to engineering, is rigorous, demanding and unforgiving. Moreover, the systems installed onboard to guide and operates the Costa-Concordia were at the cutting edge of navigational and engineering technologies.
Yet, the ship ran aground. In well charted waters. In waters that were known to be rife with navigational hazards and, at worst, with hazards potentially fatal to the ship itself. The ship and Captain had navigated these waters on numerous occasions as part of a standard routing and navigation plan. The threats were known. Yet on the night of January 13, 2012, the Costa Concordia committed the most egregious of maritime sins by steaming into shoal water with seemingly with little or no concern for the risks involved.
Certainly, this is not the first time a prominent commercial vessel has gone aground. Sadly, it will not be the last. This, then, begs the question: Why?
The prudent mariner, prior to departure from a port or anchorage, will “lay down” a navigational track on charts of areas that it expects to transit on its journey. Starting with “large scale charts” (small area with greater definition for hazards associated with inland/ near coastal navigation and to aid visual navigation), the ship’s navigation team deliberately “plots its course” out of harbor or anchorage areas. Tides, depths, obstructions, navigational aids are all considered to ensure the ship’s safe navigation out of “restricted waters.” Once clear of inland navigational hazards, the ship’s track then shifts to a “small scale” chart (large area) for its “lower risk” open water transit.
This navigational planning process is deliberate, focused and intended to mitigate risk to the integrity of the vessel while in its most vulnerable (and high risk) environment. Add the variables of weather (wind, fog, visibility, sharpness and crispness of radar and visual navigational aids) and other maritime traffic in the vicinity and the risk factor to ship safety increases exponentially. The navigational plan is then briefed, critiqued and “challenged” by all members of the bridge and navigational teams to insure that the plan has addressed all key factors as well as ensuring that each member of the “ship control team” understands where, when and how the ship will maneuver. This last process is deliberate and perhaps the most critical phase. Nothing is left to chance when it concerns the ship’s navigational safety.
Why then, after all of the preparation, all of the planning and all of the briefings, did the Costa Concordia “run aground” on Friday, 13 January, 2012 with the resultant tragic loss of life? Some will say “human error.” Some, particularly those closely vested with the ship’s safety, will cite “systems failure.” Others will even go as far to lay blame on the navigational charts (given that mariners have plied these waters for the past 3000 years, it is somewhat doubtful at best).
The answer, I submit, lies deep within the human conditions of hubris, ego and arrogance. Each of these elements, when taken individually, are fatal flaws unto themselves. When combined in total in the singular being of the lead decision maker (Captain/Master of the vessel in this case), the results are, predictably, tragic. The Captain’s decision to navigate extraordinarily close to the shore on the evening of the 13th of January was prompted by nothing more than a “spur of the moment decision” to thrill the passengers with a close “fly by” of Isola del Giglio.
Hubris, ego and arrogance, as embodied by the Captain, intervened so thoroughly and completely that even the most experienced mariner (and qualified) onboard utterly failed to consider the fundamental principle of considering operational risk management (ORM) into his decision to deviate from the established navigational track. All of the navigational planning and preparations became subordinate to his own hubris. Moreover, the Captain’s own persona created an environment whereby subordinate staff members either failed (out of negligence) or were so intimidated by his authoritarian style of leadership that nothing was said (out of fear for their own careers). Had there been even a scintilla of consideration for the extraordinary risk that was being assumed by the Costa Concordia in this capricious, spur of the moment decision, this disaster most certainly would have been averted. The fact that the Captain was not even posted on the bridge but cavorting with his passengers during this most risky of maneuvers is evidence enough to point to his embedded fatal flaws. Sadly, it is only through the loss of life that these personal (and professional) shortcomings came to light.
The loss of life and the suffering of the survivors is tragedy enough. The tragedy will be compounded, however, if simple lessons learned are not taken from this incident and applied across the board and amongst all manner of disciplines that require planning and preparation to mitigate risk in dynamic operational environments. First and foremost amongst these lessons is that any decision contains its own inherent risk. This risk must be recognized, considered and assessed in the context of ongoing operations and within the risk framework established by organizational leadership. Secondly, operational risk management must be conducted by leadership in light of previous planning considerations and risk mitigation efforts. This alone should act as a brake mechanism that stops the “sequence of bad decision making” or, at the very least, serves as an impetus to challenge any contemplated deviation from an established plan. Thirdly, and most important, is the recognition of the human condition (ego, arrogance and hubris) when inserted into organizational decision making processes. Specifically, the examining of any change in a plan in order to flesh out the root cause for the change. Is the decision to affect a change operationally imperative or is leadership decision making compromised by the dominance of hubris, arrogance or ego. If it is the latter, the organizational climate must be such that it permits, without prejudice, the leader to be professionally challenged by those who see the decision for what it is or isn’t.
Written by John Kunert CBRM CBRA
Senior Planner
Circumspex LLC
