A while ago Wayne Thomas forwarded the “Costa Concordia Report on the Safety Technical Investigation” to everybody in the office and only just now did I have a chance to read it.
While the report is not dated or specifically identified as “final” it appears this is an English language version of the last word by the Italian Ministry of Infrastructure and Transports on the Costa Concordia and closely resembles an NTSB final report in its technical thoroughness.
There have been various press and web discussions regarding the recommendations in the report, but a few less obvious paragraphs struck me as particularly interesting with regard to emergency human factors issues as have been discussed in the women and children first and OODA Loop blogs and in some of our papers such as the QESTH paper.
First the report makes mention of a language issue (page 75). The report notes that the vessel’s language was Italian, but that there were a total of 38 nationalities aboard the vessel. The report goes on to provide a number of examples of serious communications failures. It is interesting to note that while English is the universal language for airplane transportation, English has not quite found universality in maritime transportation. At the risk of being called Anglo centric (even though I am a native Dutch speaker and not a native English speaker), it really is time for everybody to realize that there is no better choice than making English the “de facto” maritime language. Undoubtedly, a tight focus on English as the ship’s language would have reduced confusion, helped OODA behavior and possibly saved lives. Learning a different language may appear to be a hurdle, but once committed, it truly strengthens a person, makes her more valuable as a mariner, and will undoubtedly increase safety in the long run. Most of all, a person’s English ability is so easy to test that it can serve as a ready measure of a person’s commitment towards training and individual improvement. (Obviously, this will not work for native English speakers, but nothing keeps us from testing them for their ability to train others in English with clarity, generosity, commitment and cultural sensitivity) The English translation of the report is an interesting lesson with regard to the maritime language. Quite possible the Italian original was quite elegantly and accurately written, but the English translation will be read by orders of magnitude more readers than the Italian version. Unfortunately, the generally poor quality of the English translation will undoubtedly result in confusions in the long run.
The poor quality of the translation becomes more evident on page 82 where, only after a close study of the fractured English, it becomes evident that the investigators complimented the vessel engineering crew and electricians on their performance during the emergency. It turns out that these mariners stayed below deck and kept Observing, Orientating, Deciding and Acting until the last moment and, at risk to their own lives, provided the best possible support to their shipmates and the vessel until the very last moment. This behavior closely follows what occurred on the Titanic where not one engineer survived, but the lights stayed on until the last moment. In the first instance this would indicate that the engineering types are made of sterner stuff than the deck department. I would hate to dispel such a first impression, being the son of a son of a ship’s engineer, but I doubt that, as a whole, engineering types are more courageous than deck officers (and will happily point at many instances of truly heroic behavior by many non-engineering mariners and shipmates). Instead I suspect that engineering types are trained differently than other shipboard personnel. Really what happens is that when the water is rushing into the lower ship compartments they see an engineering problem; something they deal with every day and have been trained to deal with all their lives. They see a problem that needs solving and will probably become so involved in trying to solve it that they will only realize until it is too late that the problem is unsolvable. But meanwhile, their attempts serve the system, and, as such, maybe we need to focus more on training people to become problem solvers rather than procedure followers.
On a purely technical level, the recommendation to significantly increase emergency generator capacity for emergency pumping on page 171 is also interesting. Pumping against massive flooding tends to be a losing battle, but then again, very occasionally, may make the difference. However, when the main plant is down and when there is no massive flooding, and the vessel is drifting for a few days with a few thousand crew and passengers, that extra emergency generator capacity sure would make a difference with keeping the ventilation and sanitary systems running. While the engineers may not be able to play with the big plant, at least it would keep them busy with making quick fixes and making use of the extra power to keep everybody more comfortable. Not a bad systems approach.