It could be pretentious to try to already withdraw an experience feedback of a perhaps spectacular but too recent accident and without unspecified result of the nautical or penal investigations. Nevertheless some tracks of analysis can be already advanced:

• The initial error of navigation
• The bad management of the situation after the accident
• Language of the crew versus language of the passengers
• The « behavior » of the ship
• The behavior of the ship’s Master
• The behavior of the crew in the process of evacuation
• The behavior of the Company
• Means of evacuation
• The information of the passengers in general
• The communication with the passengers in crisis
• The lessons which could be learned from the accident
• Conclusion

The initial error of navigation

       Using the recordings of AIS positions which reached us, we clearly see the error of navigation carried out by the officers of the ship. It is not a question of an accident following a breakdown, but a single catastrophic error of navigation! Even if Captain SCHETTINO had taken the responsability for navigation, it seems that the officer on watch (OOW) who could be the chief officer, let done.With the instruments present on the bridge today, the bad route taken by the ship at a speed of almost 15 nds should have challenged the other officers on bridge.It is able to all the masters "to flirt with the rocks" would be only in narrow channels, in port entries or passing the jetties! But in these cases, speed is reduced at the safety speed (to be able to stop at a distance pre-measured during the ship's trials but near a length and half for a ferry or a cruise liner) and this, to be able to rectify the position or an erroneous route without delay. This safety speed is thus automatically related to a safety distance specific to the ship: we must be able to stop the ship and to make half-turn or sail astern without danger. Commonly, we will multiply by two the distance obtained plus one length of the ship as the pilot's foot. So, roughly the safety distance to pass is 4 times the overall length of the ship!

       While taking as assumption that for CONCORDIA the calculation above remains valid, we can find the following safety distance for this ship: 1200m (0,7 mile)! On January the 13th, the COSTA CONCORDIA did not keep the safety distance which would have made it possible to avoid the rocks even in the event of a badly committed turning manoeuvre (she was definitely too close!) NB :At her safety speed (10 nds), the car-ferry NORMANDIE (Brittany Ferries 160m/2200 pax/24.000 cv/2 prop/crossing Ouistreham-Portsmouth) stops within 250 meters with 60% of the power astern).To circumvent an obstacle at sea where along the coast at a minimum distance of 0,5 mile either 900 meters or nearly 4 times the length of the ship remains "good sailor practice" for this ship.

       En conclusion :Captain SCHETTINO sailed certainly with his flair! However he had a plotting table (or equivalent) connected to the GPS and coupled with the electronic chart! Even he had a practice of the area nobody does not allow that with a ship whatever she is! Remember the « flirting with the rocks » accidents with wounded persons on the one hand (HSC SAINT MALO) and with casualties of the other (HSC SLEIPNER) or same accidents without human damage (car-ferry MONTE STELLO, aircraft carrier FOCH, tanker ELORN, frigate DUPERRE, Car-ferry ARMORIQUE, Cargo WASHINGTON, Car-ferry SOLIDOR, Cruise liner GAUGUIN, Gaz tanker EL PASO and much more)…where again it should finally be noted that they were big human errors! Human errors, no cruise or ferry company is protected, but when it causes neither casualty nor wounded persons, the accident provoke little noise and is quickly forgotten if not occulted! Only the person responsible for the accident and the insurer keep really a bad memory of it!

       Consequence of an inadequate risk taking, the company has the right to draw its experience feedback and sanction its masters if necessary. Sometimes the possibilities of a dangerous behavior of a Master can be detected before…he cause an accident! In that case, the company takes preventive measures while analyzing for example that certain chief officers, having to go up to seniority, could present a too great danger for its ship, its crew, their passengers and the Company! We know all of us colleagues prevented from being in command but in a politically correct way (place within the shore management, voluntary separation or forced resignation). No one is infallible but sometimes the discharge from the master's position is carried out soon after the beginning of his command or even after a few years, it is a prevention action nevertheless. Sometimes this is never done and… a stupid accident as COSTA CONCORDIA can happen!

The poor management of the situation after the accident

       This ship was built in 2005/2006, it profits from the provisions of SOLAS Chapter II-1 "stability after damage" but not yet of the more strict criteria "safe return to the port" applicable only to ships built after the 1st of July 2010 i.e. after invasion of two contiguous compartments (For CONCORDIA it seems that it is the case on port side after hitting the top of the rock) the ship takes a maximum heel of 7° by using the cross-balance valves which will allow evacuation on the two sides of the ship! The SOLAS chapter specifies that the flag (Italian maritime Administration and or the classification society acting on behalf the flag) can allow a list going up to 12°.

       I consider that 12° is still possible for a controllable evacuation! Moreover the rightness lever of the ship must remain sufficient the ship does not capsize (SOLAS II-1 reg 8) which is very logical.

       The COSTA CONCORDIA ran up against the rock at 15 nds assuring therefore heavy noise and strong vibrations. Everyone on board knew that the ship had hit the bottom! The first reflex was certainly to slow down quickly and evaluate the damages; but the loss of propulsion was may be instantaneous.The ship is at this time at good distance from the coast (see chart); it takes already some list this mean the ship's hull is open, the depths are between 30 and 100 meters… he can try to be across the initial route to reduce the speed by all means (rudders, bow thrusters, stern anchor) for a better condition of evaluation of the situation and especially to already begin gathering passengers via an announcement to muster them for a possible evacuation. In fact it seems that he had to undergo a blackout little time after the shock with the rock, the investigation will clarify!

NB : An error is often made in the merchant navy on the emergency signals. The only obligatory signal is the general alarm composed of at least seven short blasts and a longuer one. It is in general a question of ordering to the crew members to gather the passengers in the "ASSEMBLY POINTS" known theoretically by all on board (broad information as coming on board + information everywhere onboard (in public areas and cabins) for a possible evacuation!

       On a car-ferry or cruise liner, the problems start with gathering passengers wearing their life jacket. Notwithstanding the real situation, gathering passengers with their life jacket on is always difficult and undoubtibily if the majority of the passengers are on decks because... their life jackets are in their cabins!…on a cruise ship ALL passengers have a berth in cabin spred on numerous decks. On a car-ferry at least half of passengers are in reclining seats concentrated on only one deck with life jackets stored close to them! Easier no ?

       When calling passengers during the boat drill carried out after the departure (it is in reality an assembly drill), this exercise is also presented as a ludic moment for the passengers "you can bring your cameras" ! It is true that the spectacle is photogenic with all these life jackets of a bright orange color! It is true that to transform this mandatory exercise into a show is brilliant and it is arranged to be carried out if the weather is not very good on the open sea!

       If the weather is bad and obviously the ship is not well (continuous alarm, abnormal noises, abnormal list, crew overworked and appearing anxious, reduction or absence of lighting etc…), gathering and keeping some organization become difficult from the disordered behavior of passengers nevermind they are 1000 or 5000 ! The only difference between these two numbers is passengers are gathered over a bigger length of ship which allows may be more flexibility to muster (at this occasion what will be the length of the future 6.500 pax ships ?).

Training of sefarers for crowd and crisis management as well as human behaviour

       All crew members assigned to help passengers in emergencies are in theory trained to manage crowds. Catering and hotel personnel moreover is trained to ensure a communication with the passengers under these conditions: they are elementary English vocabulary and movements with hands and arms to draw attention of passangers to see instructions, escapes, assembly points, life rafts etc…. Officers and petty officers are moreover trained to manage crisis and human behavior (behavior of passengers and also their own behavior in crisis). It is today the special training V/2 of STCW (the preceding V2 and V3 were strangely reduced to only one in STCW 2010 in force since January 1st, 2012!)

       This kind of training courses are delivered in centers approved by IMO members (so then valid for the rest of the world) but even if the contents are complete, the reality and the effectiveness of this training remain random in certain centers and not only in the Philippines! Many members of the hotel/catering personnel are titular of the corresponding certificate, but seem to be unaware of about what it is as soon as you check a little bit their competence during boat drills or during ISM internal audits. During these drills, it is rare to see this personnel worried or even conscious of the diversity of possible reactions of passengers or other members of crew in crisis.The good trainers for this specific training are unfortunately rare and the assistance of simulation is quite insufficient. The maritime industry will certainly quickly invest in simulation and the regulation will evolve also to a certain requirement of simulation I guess.

       A training on human resource management (CRM- Crew Resource Management) obligatory in the commercial aviation industry for a long time, was introduced into the mandatory part of STCW 2010 (also called Manila amendments) in its minimal form of BRM (Bridge Resource Management) or ERM (Engine Room Resource Management). It thus seems seafarers are still considered, by the members of the IMO, as incompetent to really understand this management of human element because the contents of training was reduced to its simpler expression (from a 30 hours course in aviation, it passed to a content of hardly a few hours in the maritime world! 5 times less !)

       If the tendency of the ship-owners is too often to make the minimum of what is mandatory, it should be recognized that certain European ship-owners of cruise liners and ferries are good on this matter…I saw entire crews from the Master to the chief cook coming to follow the complete crisis managemnt course! Bravo… if everyone could do it like that!

       In conclusion, sailors are able to assimilate this kind of training related to human reactions or resources… these courses can be carried out onboard by Company specialized officers or by a specialized trainer from an approved center.The best ship-owners are doing that already!

Language of the crew versus language of passengers

       On all ships today a working language must be fixed by the Company or the master. Each crew member must be capable to understand and, for those which are in charge of the safety of others, to give orders and instructions and to submit a report in the same language (SOLAS regulation).With a crew of more than 30 nationalities and 6 or more mother tongues languages, English is necessary for the crew but to give orders to passengers of 6 other different languages and who do not speak obligatorily English!… how to manage?

       Don't worry, to gather and or to embark passengers in noisy atmosphere of alarms, gust of winds, cries of ones and others, the body language is still the best means… we ask the crewmembers to behave like semaphores (well-known technique)!

The behavior of the damaged ship        It seems that the ship continued on its way as far as the North area of the port of Giglio and then she tried to return in front of the entry… this was very clever ! It appears unfortunately that the ship was unable to avoid the Northern rocks of the small port, even she had her engines, it could not apparently avoid them. Apparently the solution was to anchor as soon as possible after the accident or to come for grounding in the entry of the small port.Being late to decide, in fact the master did not have any other solutions!        The fact of coming on the rocks caused other damage on starboard side thus placing the ship without any possibility of righting and certainly causing her total loss. Opened as she is, the ship should not capsize, it will certainly slip along the rocks because of the weight of seawater inside and will be posed completely or partly on the bottom half-immerged, it should not sink nor capsize at first approximation.

The behavior of the ship's master

       A ship's master is somewhere, as any manager, a specialist in risk management. An obligatory passage plan is always worked out, validated by himself, where the risks of navigation were taken into account.Any modification of this plan is then possible according to the decision of the ship's master or his representative on the bridge ie the OOW (to avoid a collision for example) but must be accompanied by an automatic new risk analysis. To carry out the traditional "inchino" (which is not planned apparently on the passage plan), Captain SCHETTINO apparently based his behavior on his knowledge of the area! Are we dreaming! To flirt with the rocks without a particular procedure not using all the resources (human and technical) of the ship is completely crazy! If the ship's master wants nevertheless, navigate at sight or with his flair only, the distance from the coast should for example have been announced every 10 seconds by the OOW to ensure a proper turn!

       Then, after the accident, I consider that Captain SHETTINO tried to save his passengers while approaching the entrance of the small port! Had the ship two anchors dropped? Another possibility could have been to drop the stern anchor but by misfortune… she did not have any!

       In addition the Master is critized for having left the ship and the evacuation behind. He defends himself , as far as I know, and I approve when he says that on a bridgte listing 40° where nothing works any more, he could not do anything and it was better to be ashore trying to coordinate the rescue teams. It could nevertheless have coordinated the rescue since a port service boat with means of communication provided by this same port!

       What happen to him ? Too much stress certainly and probably a physical or mental sideration on the consequences of his error? Any captain even of a splendid ship, remains a man with his qualities and his weaknesses also, unfortunately!

The behavior of the Company

       Captain SCHETTINO, it should be admitted, was nevertheless one "kamikazé" whose tendencies would have been detected by COSTA COMPANY. Apparently the practice to come to flirt with the rocks was in the practices of COSTA CRUISE ships… and nothing never appeared on the passage plan and I guess in the bridge logbook! To approach the rocks is like to fly between the sky-scrappers for a captain of an Airbus 380!

       In addition, to be close to shore at night is not for the benefit of passengers as some persons believe (at night we does not see manything ashore only some lights here and there!) but only for the joy of shore viewers ! It is true, a completely illuminated large ship, very close, this is very impressive! In fact we can do that… by respecting the safety distance (see above)! In addition it could have been a competition between masters or between ships, causing unreasoned behaviors in many disasters; this is case of Snekkar-Artic capsizing for example.

       Today, these inadmissible behaviors should have been analyzed earlier during the ISM audits and been treated like major nonconformities and thus prohibited! If the management of COSTA CROISIERE in charge of the SMS as accepted that, there is complicity! And the Italian Administration also because they should have immediately withdrawn the DOC of the Company! For some colleagues - the survivors of the ISM skepticism for example - still say to me that the ISM is phony! In its application, yes often, and not only under exotic flags…here is the proof!

       In conclusion, in this case the responsibilities are to be also searched in the management of the Company and the controls from the flag or class (acting on behalf the flag).

The behavior of the crew members during the evacuation

We already spoke above about the special trainings of all passenger ships personnel in charge of assembling passengers in the event of emergency.To be trained it is right, but to remain qualified and able to deal with the others it is not easy when you are stressed yourself beyond your own physical and mental capacities. The preparation for evacuation is carried out regularly by all crew members during exercises and drills. They are not operations without any risk (ref. Accident on the CMA CGM containership « Christophe Colomb » a short time ago). For testing boat drills it is out of question of taking more risks than necessary. As soldiers we do comprehensive risks assessment before any operation with the lifeboats and/or the MES (the last time I tested them, in real deployment ship alongside, evacuation by slides, I should have called the ambulance two times!). It is thus out of question to consider a real simulation to evacuate passengers and moreless with a tremendous 12° list! How many I'm going to kill this time?        What remains to us? Simulation is strongly criticized by colleagues but it will be our only possibility to study the mustering of all passengers with, in addition, the possibility to simulate bad weather (rolling), a collateral emergency situation like a fire (cf the loss of the cruise liner ANTILLES), the SOLAS list or more! I do not know if the EXODUS V 30 software of Greenwich University, which simulates the evacuation, has the possibility to simulate an excessive list!        You must know that before accepting the MES (toboggans or chutes) and in particular, checking that crew and passengers can be evacuated in 30 minutes, the flag Administration can ask for a real evacuation test. For reasons mentioned above and perhaps also for insurance cover, the Company and the shipyard generally find an agreement with a local military academy (or a maritime college) which can provide 200 persons who will evacuate for example through a « 400 persons MES ».We measure the time taken for the deployment and the evacuation of these 200 guys and… we multiply by two! It is indeed understood that all the means of evacuation are used at the same time! But…these" guinea-pigs" were informed on the procedure before the exercise and also this was not a competition to see who will be the first down below! In addition they are all of them 20 years old and are in full physical condition (the old colonels are not there believe me!). Good, that passes… but how to do it differently? NB : PS As far as I know there was only one death among the COSTA CONCORDIA’s crew! What that means? …the crew members perhaps left the ship first by leaving the passengers behind them? I think that they were certainly well involved to launch the boats but they also did think of saving their own life first? I often noted that the Filipinos know their role in the event of emergency, on the other hand the catering and hotel personnel still did not assimilate the service which it owes to passengers… at the time of assembly drills, this personnel appears well dressed at the stations with their life jacket very well doned and…they wait for evacuation among the others… helping the passengers does not come to their mind apparently.

In conclusion for a good evacuation as much as close to reality, the only solution remains "simulation" and the effort of the originators for realistic scenarii will be very much appreciated… then go to your your machines and can the best wins… I feel a market which will open rapidly! In addition, it should be noted that the special training is not mandatory for ship's personnel not having responsibilities in safety of passengers… still seeking the error! The SMS auditors would have tested the knowledge, understanding and proficiency of the catering/hotel personnel and I suggest training and training again !

Means of evacuation

       The SOLAS convention allows mixing different types of evacuation appliances: life boats, MES and liferafts.The choice of mixing is given to the ship-owners within nevertheless the strict framework of the number of passengers which can be evacuated on each side of the ship (Not 100% on one side as you know) and with the agreement of the Flag Administration at the beginning of the construction..

       Today we can have a large cruiseship like COSTA CONCORDIA with the majority of the means in the form of rigid lifeboats of 150 persons max but no MES at all (toboggans or chutes) but nevertheless some mandatory liferafts. With 4 MES (2 on each side fore and aft as on NORMANDY or others), I think sincerely that Captain Francesco SCHETTINO could have evacuated his passengers more easily earlier and perhaps avoiding wounds and casualties. Today large ferries have been just launched into service with several MES but… without boats (SPIRIT OF BRITAIN and SPIRIT OF FRANCE)! The risk analysis carried out should have been very convincing because the British Administration has accepted!

The information of the passengers in general

       Because of the different language between passengers and the working language of the ship, the international regulation (SOLAS III reg 8) requires that clear instructions have to be communicated in the language or the languages required by the flag Administration and also in English.

       This is in general well ensured by all the ferries and crusie companies. Indeed it is easy and not very expensive. We can find in all cabins, assembly stations and other public spaces, suitable information in the form of wall bilingual posters in language of the flag and in English.Two languages on a panel it is ok, but more would become "unredable" for passengers and also completely unaesthetic in some deco. Indeed to allow verybody able to read in situation of intense stress it is necessary that the letters are sufficiently large while the drawings are recommended because always readable.The problem seems solved for IMO but not for us! When we have Spanish, Italian, Portuguese, German, Arab or Russian passengers, the problem is not solved at all. We cannot require that all the passengers speak a minimum safety English like the crew members!!! Good, to add Spanish information in the garage of the ferry of the line of Spain it is easy! But for the others?

       Many companies have invested - even it is not obligatory - in bilingual small folders on safety and emergency information according to the line and hold at the disposal of passengers. The same information in other current languages on the line is also available on demand.An adequate information will be made in the passengers areas on several occasions at the beginning of the voyage. Even if these folders given to all the passengers when embarking include a small commercial part, the effectiveness is recognized but the price is quite high… think of million of passengers carried!

These small folders are well studied but still suffer from a defect in my opinion: if the assembly points appear, on the other hand the means of evacuation do not appear in it! However it would not be very complicated and not expensive to add it! On the aircraft you have in front of you the equivalent "safety card" where appear the deployed toboggans! Moreover, and this time in a lawful way, a safety annoncement must be carried out for the passengers - as from the moment there is only a new passenger - before or immediately after the departure (it is made in general during the departure). NB : the small folders do not replace this mandatory annoncement!

       What can we say? To have very often observed the passengers during this announcement, I can say even if the annoncement is well made, the great majority of passengers do not listen. As on the aircraft, how many "captive" passengers listen to the briefing and look at the hostess who move her arms in front of them… I guess not many? To counter this disinterest about this safety annoncement carried out among many others, terminals were installed in the public places and videos are shown continuously

       Effectiveness : Even with that, I am not sure that every passenger have recorded the message… interviewed after an accident, you always have a certain percentage of passengers who did not hear anything!

Communications in crisis

       It is most difficult part undoubtedly.The question is simple: how to communicate in crisis? The master, who has really another thing to do, must he communicate on the tannoy system every fifteen minutes? He is, and it is normal, stressed by the situation: is he going to communicate his own stress to everyone via a voice not easy to control? It will be necessary for him moreover to do it in two languages at least one is not his mother tongue! However the voice of the Master is essential in emergency and if the communication carried out is well controlled, it will be a significant element of prevention of the dreaded panic.

       Are the ship's masters well prepared to do this? Many companies of passenger ships, apart from any obligation, but by pure good action, send its masters and chief officers for that kind of training. But is this sufficient? I always advise these masters and chief officers to involve themselves by speaking in this "bloody" microphone… believe me this is not easy…you are quite alone in front of your microphone on the bridge of your ship! It is necessary to be prepared but how?… quite simply while announcing, after the departure when the conditions of navigation allow it, a warm welcome to the passengers and announcing a superb or a little shopping crossing to them! This procedure has been in force for P&O ferries for example, for more than 20 years and in almost all airline companies! When you hear the "Captain speaking"a little time after takeoff, it is not because the flight captain is sympathetic but because he is training himself to be freely speaking and in at least 2 languages… in case of!

       Dans le cas du COSTA CONCORDIA, il a été rapporté que les annonces étaient enregistrées. Ce doit être vrai du moins pour les premières annonces d'urgence. En effet, au début de la situation d'urgence, on privilégie la diffusion d'une annonce pré-enregistrée car le capitaine ou son adjoint sont bien trop occupés par ailleurs. L'idéal est un appareil de diffusion contenant l'annonce correspondant aux 3 ou 4 scénarii majeurs à savoir incendie, collision, échouement/talonnage et homme à la mer ! Je vous passe les détails de la méthode et du texte mais il est important que les annonces soient faites par la voix du ou des capitaines assurant à tour de rôle le commandement du navire et donc enregistrées d'une manière professionnelle …chaque capitaine embarquera donc avec sa clé USB !

The lessons which we could get

       Without awaiting the results of the enquiry, the first experience feedback is obvious:

• Inadequate behaviors of certain companies, as well as on board or ashore; the Company safety management system should have stopped the bad habits.The system is thus to be re-examined and I believe that CARNIVAL (owner of COSTA CROISIERE) have decided a complete review of it and in its other branches. It is really the least it can carried out but it will have to reinforce or add a possible evaluation of risks of dangerous behaviors of its ship's masters (nearly 100 cruise liners in service nevertheless!) and, at the same time, to better train these masters in management of these risks (CRM, leadership etc…);the literature exists, the courses also, then?
• The simulation of the evacuations will have to be improved and will have to be made compulsory as well as the corresponding course including for all the crew members. At this occasion a new targeted visit of the EMSA (Maritime European Safety Agency) in certain countries which are big sailors suppliers would be very beneficial (IMO unfortunately still does not have real power as in many other matters!).
• To maintain the authorization of coastal channels for ships until a certain length, but to set up an obligatory pilotage licence with obviously the possibility for the masters to acquire this renewable licence like the other port licences.
• For the cruise ships, the mixing of life boats (which are also used to go to the beach!) and MES/toboggans (I have less confidence in the chutes!) should enter in SOLAS ie become obligatory for the new ships.
• A new amendment to STCW should be prepared to amplify the management oh human resources on board (CRM) and linked with an improved crisis and human behaviors training and extended to all members of the crew.A fast application should be decided.
• To require in SOLAS a special training for masters and chief officers of passenger ships for crisis communications and a practice of the "Captain speaking" is strongly advised.

En conclusion

An investigation is going on as per the requirement of SOLAS convention.It is conducted in the regular manner by the Italian maritime administration and its equivalent of our French BEA.I do not know if this last were invited to take part in it… there is nevertheless some French citizen who died in this shipwreck! We will be able to only make comments (code of practice in force since January 1, 2010!).I hope that the report of investigation will be exhaustive, but I am not really sure that all the Members of the Commissions have all necessary independence. Personally, I remain orphan of a survey unit within the IMO, made up of truths specialists in the whole world recruited by IMO itself… as NORWAY proposes it for a long time! Capt. Bertrand APPERRY Marine surveyor and consultant ISO/ISM/ISPS mars 2012