REFLECTIONS UPON A CASUALTY The Loss of M/V Costa Concordia by Geoffrey W. Gill, Esq.

Whatever one's point of view may be, there appears unanimous agreement that the Friday 13 January 2012 casualty to the passenger liner Costa Concordia will be an "industry changing event." Remaining to be seen is the direction and magnitude of that change, though the change can be expected to be significant in view of other publicly notorious maritime casualties and their consequences: Titanic, triggering the Saving of Life at Sea convention; Herald of Free Enterprise, triggering the International Safety Management Code and concept of a maritime safety culture; Exxon Valdez, triggering Oil Pollution Act 1990; and Erika, triggering a European Union ban against single hull tankers, being examples. However, for all the shock and incredulity inspired by the casualty, it was but one of a number occurring over roughly the past month: on Christmas Day, the loaded Vietnamese bulk carrier Vinalines Queen sank in rough weather with the loss of 22 of 23 crewmen; the South Korean tanker Doola No. 3 was almost split in two by an explosion, with 11 seafarers missing; and, a bulk carrier and ferry collided off Morocco, to name but a few. The sea remains a dangerous place and seafaring a dangerous occupation. Indeed, maritime insurance data reflect that over a recent 10year period, claims cost the P&I industry on average USD 4 million a day, with more than 65% of this pay-out attributable to incidents in which human error played a dominant part and, further, the average number of incidents involving serious or total loss of vessels over 500 grt had risen steadily over the 15-year period to 2008. As for Costa Concordia, while much remains unknown or subject to speculation, what is known is that this 4,800 person capacity modern passenger liner struck a rock, part of a charted outcropping, while engaged in some form of "tourist navigation" allowing her to be seen by inhibitants of and visitors to the Island of Giglio off Italy's Tuscan coast. With 17 dead and 16 still missing, this casualty remains subject of a media feeding frenzy with editorial stigmatization of the ship's master and speculation as to underlying circumstances. The following comments rely, in part, upon analysis provided by g-Captain of AIS information from the vessel, generalized information from Lloyd's List, and the comment author's recent book Maritime Error Management and his many years as a licensed deck officer and maritime attorney, and only minimally upon coverage by the popular media. While specific details have yet to be agreed upon, a fair observation is that the vessel was much closer to land &endash; certainly to the rock outcropping &endash; than anyone had intended. The vessel's owner has stated that a deviation from the expected voyage passage plan to come close to the island of Giglio was "unauthorized, unapproved and unknown" to owner's shoreside management. Perhaps unrelated, there is evidence that last summer one of the company' passenger vessels made an authorized "sail by" close by the island, during which that vessel passed considerably closer than the minimum 500 meters expected, and perhaps as close as 200 meters to the rock subsequently struck by Costa Concordia. Perhaps more relevant is evidence that prior to the casualty voyage, there were

several other "sail bys" of the owner's vessels by the island. To the extent other formally unauthorized sail bys may have occurred &endash; recognizing that such events would have been common knowledge on board within at least the bridge navigation team &endash; suggests a "normalization of deviance," where a deviant organizational or shipboard experience gains a level of acceptance because there is neither a bad outcome nor punitive response nor peer disapproval. What may once have been idiosyncratic tends to become accepted. An example of normalization of deviance was NASA's Challenger tragedy. Another, perhaps more alarming, scenario presents if Costa Concordia's captain Shettino did in fact violate a company rule prohibiting such or similar deviations [and, in any event, deliberate sailing so close to a charted outcropping violates multiple rules of good seamanship]. Deliberate violation of formal rules, regulations, policies and procedures [RRPP] is more common than may be expected. A study of aviation pilots found an approximate 20% of the study pilots violated RRPP (violators being referred to as "drongos," a species of Australian bird purportedly noted for regularly defecating upon the heads of passers-by) while another study of North Sea oil field workers found a 29.6% rate. Interestingly, violators violate not usually for personal benefit but rather, among other factors, generally to benefit their employer. Not surprisingly, the violation of RRPP is of great concern within the maritime industry, due in part to the traditional on board authoritarian command structure as well as to the geographic remoteness of the vessels and their personnel from shoreside management. This remoteness also contributes to frequent erosion of the ISM Code inspired company safety culture into a vessel peculiar safety climate. Captain Shettino's actual motivation for deviating from the original voyage passage plan is unlikely to be known until there is a Vessel Data Recorder transcript of the discussions that occurred on the bridge. However, AIS data from the vessel suggests the vessel did so deviate. The circumstances of the deviation and subsequent navigation implicate little-studied cognitive issues related to maritime watch-standing. Presumably the decision to approach the island was announced by captain Shettino, with or without explanation, to his bridge team then on watch. While he purportedly claims that navigation close to the island was "by eye," information has not yet been disclosed regarding whether or to what extent courses were laid down on a chart or the scale of such chart. At a minimum, appropriate Bridge resource Management would have required timely discussion of the contemplated deviation, with all relevant aspects carefully and jointly evaluated by the navigation team. Consideration should have been given to whether the deviation and its execution was consistent with prevailing company operating procedures. Any dissenting opinions should have been expressed, heard and evaluated. The failure of subordinate officers to question the master's decision if inconsistent with RRPP or otherwise in any way alarming would have constituted what may be referred to as "destructive obedience," an abdication of professional resp0nsibility involving deliberate or slavish acquiescence to orders or practices recognized as unsafe or contrary to standing orders or procedures. Such destructive obedience was demonstrated by the submarine USS Greeneville's OOD failing to question the commanding officer's abbreviated surface search by periscope minutes before the surfacing submarine struck and sank the Japanese fishing training vessel Ehime Maru.

The anticipated sail by should have been plotted against navigational hazards and a danger zone determined, marked and avoided. All means available, presumably numerous and functioning, for ascertaining the vessel's position and progress should have been utilized to maintain constant situational awareness at all three levels: perception, comprehension and projection. Certainly, as had been proven previously, a successful sail by was possible to achieve, albeit with diminished safety margins. The casualty occurring despite the availability of technologically advanced navigational equipment is likely to precipitate further discussion and argument whether such equipment de-skills traditional navigational knowledge and practice, a corollary to the general belief that mariners are allowing technology to do their thinking. Analysis of Costa Concordia AIS information assessed from ashore suggests several executory deficiencies. Costa Concordia appears to have approached the island at an over the ground speed of 15.5 knots &endash; fast under the circumstances. While maneuverability at speed is improved, a faster speed compresses the time available for analysis and assessment of the evolving situation &endash; especially critical when the evolution is accompanied by stress, as would be a relatively sudden decision to pass close by a rocky island outside any marked channel. The degree of the starboard turn to parallel the island and clear the outcropping appears to have been made later than would have been intended and certainly later than necessary for safety. The danger, as the vessel proceeded parallel to the island, presented by the rock appears to have been recognized at the proverbial "last minute," as a turn to starboard appears to have been initiated almost at the rock, but with the ship's pivot point about one third the ship's length abaft the bow and the momentum of her forward motion, Costa Concordia still tended toward the rock so a hard turn to port seems to have been started in an effort to swing the midships and stern areas away from the rock. Following contact, the ship suffered a blackout, though how extensive is unclear. Certainly emergency electrical power would be expected to have kicked in. Propulsion and steering were lost or minimized, thereby adversely affecting an initial attempt to bring the ship closer to the port beyond the rock for assistance. With the vessel's speed reduced to less than three knots but with her heading taking her away from land, the bow thruster was engaged to push the bow to starboard so she was brought about and with wind and current working on the vessel's starboard side she was set down toward a sandy area where she grounded, laying on her starboard side with an approximate 80 degree list. Certainly the event had an immediate traumatic effect upon the command and navigating team &endash; just how severe remains to be seen. While much criticism has been directed relative to post-strike decisions and behavior, not all relevant information has come to light. At least for the moment, perspective may be gained from considering the question posed in Joseph Conrad's Lord Jim: "Do you know what you would have done? Do you?" Overall, proper evaluation of the vessel's handling and individuals' performance cannot fairly be made until the "bounded reality" of Captain Shettino and his

navigating team is known. "Bounded reality" refers to the notion that in decision making, individuals' rationality is limited by the information they possess and otherwise is available, the cognitive restrictions of their minds relative to that information, and the limited period of time available within which decisions must be made. Once the bounded reality of the personnel of Costa Concordia and other relevant information is known, hopefully then informed decisions may be made by politicians and regulators in a direction to minimize maritime casualties. Geoffrey Gill, Esq. Law Offices of Countryman & McDaniel