VOICES FROM THE COSTA CONCORDIA (PART 2) HOW AND WHY

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

The catalyst of the Costa Concordia incident was the impact of the ship with the Scole rocks on the coast of the island of Giglio while engaged in, what the CEO of the Company Costa Crociere describes as ‘tourist navigation’.

While the Italian investigation and safety report mentioned a number of aspects to this accident, many points were missed and errors were made. Nether was any investigation made as to the reasons for the failures leading to the collision. The importance of a number of these cannot be overemphasised as there are vital lessons for us to learn from the course of events that led to the disaster. 

Planning

The Costa Concordia was nearing the end of weekly weekly cruise tour round the Mediterranean and preparing to sail from Civitavecchia, the port of Rome. Prior to sailing, Captain Shettino ordered Simone Canessa, the ship’s navigator, to change the ship’s routejust before sailing. Canessa stated that she was not given any reason, although that would have been obvious, but that she heard it was to give the island a salute for those crew on board from the island.

Amongst the various charges against Captain Shettino was the fact that he did not notify the marine authorities of this deviation however, Italy’s Automated Search and Rescue System (ARES) states that notification of a deviation from the planned route needs to be made to the port authorities only if the new route deviates from the planned one by 15 nautical miles or more.  As the Concordia’s deviation was less than this, it did not need to be notified to, or approved by, the port authorities.

The Company, as previously shown, denied that it knew about their ships deviating to sail close to land, but then admitted they knew and encouraged such actions.

On 13 January 2012, only the original route was drawn on a paper chart (with a scale of 1:100,000).  The chart was used to plan the deviation, but it was not actually plotted on the chart. Instead, the planned deviation was uploaded to the ship’s automated navigation system (the Integrated Navigation System (INS)), which, according to international law, could only be used as an aid to navigation when sailing close to land; not the primary means.

The deviation ordered by Captain Schettino.

The report on the Safety and Technical Investigation of the casualty cites The first officer's testimony that despite being required to sail close to Giglio, the ship did not have accurate nautical charts for doing so. The Costa Concordia had a 1:100,000 scale map for open seas, not the 1:20,000 scale map for coastal sailing, on which the rocks that the ship hit are marked. Thus the Captain was correct, in an oblique way, in stating that the rocks were not marked on the chart.

As the ship had made this kind of close passage previously, then the same scale of chart must have been used on those occasions as well. Either the ship had not indented for the correct chart to be supplied or it had been refused. Even though this had considerable bearing on the accident, the inquiry never investigated this.

At 21:19:02 the Senior OOW, the 1st Officer, contacted by phone the Master, as per the instructions given after the departure from Civitavecchia, informing him that the ship was 6 miles from the Giglio island and that will be abeam at 21:44.

The Bridge Organisation.

The modern word adopted by our profession for this is ‘Bridge Team’. The Captain is not part of the team unless he directly assumes the navigation of the vessel. Only at that point does he becomes the leader of the team.  As a generalisation, a confident Captain will discuss his intentions with whoever is directed to carry them out prior to their initiation, otherwise he imparts his wishes to the senior officer present who then directs the ‘Bridge team’. Prior to the ship sailing, the navigating officer of the ship will prepare the courses to the next port and these will be approved by the Captain. Once under way, short deviations to the plan will be initiated by the Captain through the Officer of the Watch, unless the navigating officer is not a watch keeper, in which case he could be called for this task. It is for the OOW or the navigator, to advise the Captain of any impediment or dangers to the ship caused by the deviation. The problem of ‘teams’ is they tend to separate the head from the body, the larger the number involved, the greater the distance of separation. 

Thus the Captain of a cargo ship the same size or even larger that the Costa Concordia, with few bridge personnel, will have a greater ‘hands on’ approach than the Captain of a large cruise ship, who will, if he is not careful, become more remote from the prime task of navigation, leaving this to the bridge team, much as he leaves the engineering to the Engineering team and the catering to the Hotel team. Now, instead of guiding the progress of the functions of his ship, he becomes a decision maker based on his direction to others and dependant on their compliance and what he is told, rather than what he sees.

He is thus dependant on the abilities of his officers more than his own. Captain Shettino placed complete trust in officers that were not competent enough for this trust.

 The helmsman, or any helmsman for that matter, while being considered part of the bridge team is an important functionary responsible for the physical steering of the ship under the direction of the Captain or OOW, whoever has the con, and required to carry out the orders given to him. He is not management, nor is he any part of the decision making process on the bridge. It is essential that not only does he have the ability and experience to steer a ship but has an excellent understanding of the language of the ship. As an aside, all helmsmen make mistakes, especially when given in different languages to their own and even more so in situations of urgency, when their experience and training is essential to the correct compliance with the orders given.

The Navigation

The Captain arrived on the bridge at 21.34.36. The First Officer,Ciro Ambrosio, as the Senior Officer of the watch, was in charge of the bridge team. The First Officer was assisted by the Third Officer, Silvia Coronica, who was plotting the position of the ship.

On his arrival on the bridge, Schettino noticed the use of the Inertia Navigation System (INS) being used as the primary means of navigation and the ship in autopilot. 

He asked, “Don’t we normally use paper charts and manual manoeuvring when we are this close to shore?”  

In order to use the Electronic Computerised Display system (ECDIS) it is required that the officers using such system have specific training.

None of the navigators, not even the Captain, had the IMO required ECDIS training in accordance with the STCW requirement (by STCW Manila Amendment 2010) 

From this, the Captain was correct in requiring the use of paper chart as the prime navigation procedure. This rendered the ECDIS, along with any radar use, as only navigational aids. On this ship at that time, The ECDIS could only be regarded as a training module as if it had been used as the prime navigation method, this would have been illegal. The lack of training was the responsibility of the Company. 

The Company bridge procedure "P.14-MAN 01 SMS - Procedures for the bridge" (Para 4.7.1) states that the charts and nautical publications to be used for navigation are those published by the Admiralty; vessels operating in Italian ports must also use the charts published by the Hydrographic authority and, in particular, the charts for the harbour and the first 2 charts of entry / exit used for arriving in the port must be kept. From this it is required that paper charts are used as the prime method of navigation plotting.

The First Officer then ordered the switch to paper charts for the main navigation and the helmsman to take the wheel. (Manual steering was also a requirement of the company when navigating in perceived hazardous waters.) This action should have been taken before the Captain had to remind the OOW

Excerpt of the navigation chart in use on the bridge. The scale on this chart is 1: 100,000 instead of the correct chart 119 scale 1:20,000.

The second officer, as the ships navigation officer, would be responsible to the Captain for the correct charts being available. It should be noticed that there is no position fixed after the alteration of course.

At 2139.14. the Captain assumed the con of the ship. 

He had been on the bridge less than 5 minutes. Allowing for the time it would take for him to adjust his eyesight to night conditions this was insufficient time for him to absorb the information required to assume command of the bridge and the bridge team even if they had appraised him. The course at this time was 290 and the ship was almost at the next course alteration marked on the chart.  It is also a recognised procedure that handovers are not carried out until any alteration of course is made or in good time to make a safe handover before such alteration. Also that the position of the ship be established to the satisfaction of both the officer handing over and the officer taking over. This was not done.

The Captain was criticised for having guests on the bridge, however there is no evidence of their presence affecting the navigation. However, the Captain was using his mobile phone and that was against the Company’s procedures.

There appears to be a discrepancy at this point as to the function of the leader of the bridge team. If it is the Captain, then he should at least check the position of the ship. Alternatively, if he is reliant on the First officer for navigational duties, then, at least require a position check to be made. 

The alteration of course should have begun before the Captain assumed the con or the Captain should have waited until this was completed.

First Officer Ciro Ambrosio was in charge on the bridge, when the planned turn was going to be executed away from Giglio Island. Ambrosio gave the following reason for this not being done;

"But he (Schettino) did not immediately speak the phrase 'I'm taking control,' which signals a change in command. However, given the way he positioned himself, I assumed he had taken command and I thought I was no longer in charge. Then, since the captain was distracted, and we were getting closer to Giglio, I (Ambrosio) gave orders to the helmsman. He (Schettino)was on the telephone with (retired Costa Capt. Mario) Palombo. Even though I (Ambrosio) had finished my shift, I felt I had to retake command in order to give orders to the helmsman to start our approach to Giglio Island, which was getting closer."

Because of this the 1st officer had passed the point at which he should have begun to alter course and this proved to be the catalyst for the accident. Again this was missed by the accident inquiry.

It is most surprising that the 1st officer did not know a primary rule for bridge control and that is that, even if the Captain is present, if he has not formally assumed control, the OOW continues exactly as if the Captain is not present. I recognise that there are times when the Captain does not have time to go through all the generally required formalities of handover, especially in an emergency situation. I coped with this in my standing orders by stating that as well as formally assuming navigational control, I could state ‘I have the Con’. Also if I gave any order affecting the course or speed of the ship it must be assumed I have control. Sometimes, especially when you hit the bridge flying, there is no time for formalities. 

At the time of handover, the ship was almost at the next plotted course alteration which was intended to bring the ship to a route taking it along the coast of the island. 30 seconds before arrival at this position the Captain orders a course of 300. Again this demonstrates that the Captain did not know the position of the ship as even if he had ordered the next course of 334 as marked on the chart, he would still be inside the course line (closer to land). 

This was confirmed in the inquiry by a comparison of the planned route on the chart no. IIM 6, recovered on board the Costa Concordia (rebuilt also by the Mate, with a good approximation, during the testimony of March 1, 2012), and the layouts AIS / VDR ship, it is clear that the Master has passed the point of turn planned to pass the Giglio island thus placing the ship into position much closer to the coast than that laid down on the chart.

Course Alteration

Course alteration combines all the principals of navigation. First the position must be established, then the alteration must be made in sufficient time and with a degree of wheel commensurate with the speed, draft, current and weather conditions, in order that the ship arrives on her new heading exactly on the course line. The closer the ship is to any potential hazard, the more accurate the alteration must be. In the case of the Costa Concordia, at the speed the ship was proceeding, the weather prevailing would not have effected any alteration. Being a cruise ship with little variation of draft, this again, once established, would not cause any appreciable variation of degree of turn. Therefore, in this case, consideration can be confined to speed of ship and degree of turn. Proximity to land enables the position to be fixed with complete accuracy, especially when using paper charts that the company required in the situation of close approach to land.

There are three types of change of course manoeuver;

The first is by arriving at or close to the alteration position and then to give the helm order or use the autopilot to bring the ship onto the next course. Once on that course, then establish the position and adjust the course to bring the ship back onto the required course line or if the open sea situation allows, then a new course can be made to bring the ship to the next alteration position. While this can be used on open seas away from land, it is not suitable for close coastal navigation.

The second is by visual and gradual changes of course together with the use of other position aids such as parallel indexing to watch the progress through the alteration to achieve the next course on the line. To achieve this requires a good knowledge of the manoeuvrability of the ship and considerable experience, especially when in close coastal waters.

Wheel Over

The third and most accurate is one based on the ships manoeuvring data sheet and is referred to as a ‘Wheel Over’. 

The altering of course prior to arriving at the alteration position is a well-known and established procedure. Prior to the dawn of the larger ships existing today, this was generally done by the officer of the watch from his experience and knowledge of the ship, although even on passenger ships of the 50’s, a marked wheel over position based on the degree of alteration required was used. With the size of ship today, often with cruise ships restricted in the degree of helm that can be used, this should be standard practice on large vessels, whether passenger or cargo, especially when near land. Experienced navigators usually make out a graph based on the manoeuvring data and graduated for speed and degree of change of course.

Immediately after any alteration of course it is a basic professional requirement that a position be established to ensure that the ship is on the required track. In this case, this wasnot done, neither was there any evidence of parallel indexing or even visual or radar observation, even though the Captain had ordered the radar to be set for 5 cables distance off the land. No member of the bridge team seemed to be aware of the safe navigation of the vessel, possibly each expecting the others to do this. It should be pointed out that the duty of the 3rd Officer, within the bridge team, was the plotting of the ships position.

Over the next three minutes the Captain orders three more course alterations all turning the ship to the next course finally settling on a course of 330 at 2142.07 and a speed increase to 16 knots. Even now the ship is still not steering the course laid down and no one has yet noticed that the ship is well inside the course line. 

During these course changes, it is apparent that there is general confusion as to the courses being ordered with both the helmsman and the First officer misinterpreting the orders given.

At 21:43, Schettino noticed the white foam of the waves breaking against the rocks in the distance and realised the immediate danger the Concordiawas in. He gave the order to turn “350 degrees to starboard”, but the helmsman did not understand and said back, “340 degrees”.  Both Schettino and the first officer shouted back, “350 degrees!”  It was at this point that the third officer had to leave her post to assist the helmsman.

The fact that he was the only person on the bridge to see this would refute any argument that his eyesight or failure to wear glasses had any bearing on the case.  No member of the bridge team seemed to be aware of the safe navigation of the vessel, possibly each expecting the others to do this. It should be pointed out that the duty of the 3rd officer, within the bridge team, was the plotting of the ships position.

Over the next three minutes the Captain orders three more course alterations all turning the ship to the next course finally settling on a course of 330 at 2142.07 and a speed increase to 16 knots.

During these course changes, it is apparent that there is general confusion as to the courses being ordered with both the helmsman and the First officer misinterpreting the orders given. On the approach to the grounding point, there are three steering incidents where the helmsman appears confused as to the course or helm orders and one case where the OOW is momentarily confused.

As will be shown in the abandonment phase, the language problems on board affected the operational command of the ship as well as the safety of the passengers.

SOLAS Chapter V – Regulation 14, and ISM Code paragraph 6.6.

Each crewmember must have suitable skill to understand the work language and, for some activities, to give orders and instructions, and consequently to answer using the language of work. 

The language of work must assure an effective skill of communication suitable to: 

1.    1) to warrantee adequate performance of the crew in the actions related to the safety; 

2.    2) receive the information related to the application of the SMS procedures. 

The Company “Management Company System Manual” (MAN 01SMS – Annex- 15), has established, in the paragraph 5-5-3, that the language of work on board of its ships is the Italian language.

 Proficiency of the English language was internationally mandated for those at sea nearly 10 years ago, although performance standards with a system of testing protocols to verify that mariners can speak, read and write English in accordance with the STCW and SOLAS regulations have never been formally established by the IMO. While some ship registries such as the United Kingdom and Marshall Islands have their own specific English language testing requirements for mariners, the international regulations do not. It should also be pointed out that although these countries have issued a testing requirement, that testing is in the hands of the shipping company or management employing them. Flag State Inspections and Port State Controls have the powers to check on language used and it’s understanding by the crew. This rarely occurs.

AN ISM audit was carried out by the Flag State (Italy)  on March 6/7th2011 during which the following non conformity was recorded; 

1.    The procedure for the evaluation related to the recruitment of the deck and engine personnel does not provide for the assessment of the work language. 

2.    The procedure related to the recruitment of the personnel assigned to the complementary services does not provide for the assessment of the work language, when these personnel are engaged to be assigned in a task linked with the Muster List. 

The following statements from officers and crew on board support this;

The helmsman, Jacob Rusli Bin, of Indonesian nationality, testified  ( reference paper n. 0267 of the Judicial Authority of Grosseto), that he did not at times understand the Master's orders, even though they were in English.

 The 1st Engineer, responsible for engine management, (interview on 20 March 2012 – Enc. 384), of Bulgarian nationality, testified he does not fully understand the orders given in the Italian language (the working language), during the emergencies situations.  Italian was now spoken as the Company had recently changed from English to Italian with the approval of the Italian marine authorities without any check as to whether the crew, particularly the operating crews could understand Italian.

After noticing the white foam breaking on the rocks, Captain Shettion realised the immediate danger the Concordia was in. He gave the order to turn “350 degrees to starboard”, but the helmsman did not understand and said back, “340 degrees”.  Both Schettino and the first officer shouted back, “350 degrees!”  It was at this point that the third officer had to leave his post to assist the helmsman.

21 43 46. the the ship is heading 327° 

21 44 11 the Captain orders Starboard 10 

21 44 15 The Captain orders Starboard 20 

21 44 20 The Captain orders hard to starboard 

21 44 36 The Captain orders amidships.

 At this time and  position, the bow is less than 150 meters from Scola rocks, while the ship is off the planned course line by more than 809 meters 

21 44 43 port ten, but the helmsman reaches only 5 degrees to port before the next order at  21 44 45 of port twenty.

By this the Captain, having cleared the rock with the bow, was intending to clear the stern which was now swinging towards the rock. There also seems to be a reluctance to order hard wheel movements. This could be because these ships are not designed for such wheel movements with the result that hard wheel movements often cause injuries and damage

It was here that the helmsman went to starboard, then corrected himself and went to port as requested. The delay caused by the error was 8 seconds. 

This 8 seconds delay was critical although dismissed by the Italian courts.

At the trial, The Judge, based on his consultant’s opinions, using qualitative arguments, stated that the helmsman’s error had been inconsequential on the impact.

In November 2015, at the 2nd International Conference on information and communication Technologies for disaster management, a conference paper was presented by  Paolo Gubian and Mario Piccinelli Dept. of Information Engineering University of Brescia Brescia, Italy, and  Bruno Neri and Francesco Giurlanda both of the University of Pisa. Their studies are based on a reconstruction of black box and automation system data.

 In the figure below, the blue outline represents the actual ship position at impact time  while the green outline represents the simulated ship position, without the helmsman’s error. The black ellipse represents the rock’s position. As can be seen, in this case the left bulkhead of the ships is about 10m from the rock. One could safely state that, according to the simulator, the ship would have passed close to the rock without impacting or, considering the worst case for the simulation error and model approximations, the impact could have occurred about 18mbehind. 

“For a correct reconstruction of the facts, it was very important to evaluate the exact time at which the hull hit the rocks, as well as the exact contact point with the shallows, in the coordinate system of the ship’sGPS. In fact, an accurate time-reconstruction is crucial, due to the short time elapsed between the error and the impact. The Judge’s consultants had previously performed an evaluation of the ship’s position at the estimated impact time (21.45’.07’’). This reconstruction, in our opinion, was not consistent with cartographic data: at 21.45’.07’’, the position of the breach on the ship’s bulkhead was about 40m behind the shallows. To investigate this point in more depth, we performed anaccurate analysis of position, heading and time data of the ship. From these data, it was possible to calculate the instantaneous (linear and angular) velocity and acceleration………….. The Judge’s consultants, using qualitative arguments, stated that the helmsman’s error had been inconsequential on the impact. This conclusion in our opinion should be re-examined using a quantitative approach and taking into account the aforementioned facts.”

Gubian, Paolo & Piccinelli, Mario & Neri, Bruno & Neri, Paolo & Giurlanda, Francesco. (2015). The Disaster of Costa Concordia Cruise Ship: An Accurate Reconstruction Based on Black Box and Automation System Data. 10.13140/RG.2.1.1912.5522.

21 45 05 hard to port 

21 45 07 the ship collides into the rocks. The speed decreases to 8.3 knots, loses propulsion of the two engines, and adrift in the direction of 350 °. 5 compartments are breached. the ship can survive with only three breached.

While the appalling navigation and bridge discipline was mainly responsible for the events that night, the language problem undoubtedly was critical to the collision. The continued use of a small scale chart was not investigated and one is left with a feeling of casual familiarity with the close approach to the island. 

However, this is just the start of the problems. Part 3 to follow.