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Lessons In Accident Prevention - Madeline Ferguson - A Long Walk With No Return

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The purpose of this paper is, however, Once In Royal Davids City - The Cookham Consort - Christmas Carols From An English Village to speculate about the concrete causes of the Costa Concordia accident, but rather to consider some human and organizational factors that were present in the Costa Concordia accident as well as in the foundering of the Titanic a century ago, and which can be found in many other maritime accidents over the years.

The paper argues that these factors do not work in isolation but in combination and often together with other underlying factors. The paper critically reviews the focus of maritime accident investigations and points out that these factors do not receive sufficient attention. It is argued that the widespread confidence in the efficacy of new or improved technical regulations, that characterizes the recommendations from most maritime accident investigations, has led to a lack of awareness of complex interactions of factors and components in socio-technical systems.

If maritime safety is to be sustainably improved, a systemic focus must be adopted in future accident investigations. It is ironic, and not a little sad, that another remarkable and equally unimaginable maritime accident happened only a few months short of the centenary of the sinking of the Titanic.

Whereas the Titanic collided with an iceberg, the Costa Concordia hit an underwater rock. In both cases the ships were subjected to an unexpected and massive flooding. The Titanic sank to the bottom of the Atlantic Ocean. It was only because the Costa Concordia accident occurred in shallow waters that the ship did not completely founder in the Tyrrhenian Sea.

The purpose of this article is to discuss the extent to which the factors involved in the sinking of the Titanic can also be found in the Costa Concordia accident. We are, of course, not thinking of the physical factors and the immediate causes of the accidents, but rather the underlying factors, sometimes referred to as blunt end factors. In the early s, a growing number of cases Another Night On The Divide - Zatopeks* - Aint Nobody Left But Us that satisfactory explanations of accidents were possible only if the actual events and actions were seen relative to conditions determined by factors that were removed in time or in space cf.

The concepts of sharp end and blunt end factors were introduced to describe the difference between proximal factors working here and now and distal factors working there and thenand how these in combination might lead to an accident. While the maritime technology has changed beyond recognition between andthe human factors—understood as the psychological and physiological characteristics of seafarers—and the organizational factors have not.

More interestingly, the organizational factors also seem to be very much the same then as now. Organizations have, of course, changed in the way they carry out their work, due to increased horizontal and vertical integration made possible by ubiquitous information technology. But the thinking and attitudes of management have changed less and may possibly not have changed at all, at least when it comes to such issues as risk taking and prioritization of issues relating to operational safety.

It is not the purpose of this paper to speculate about the direct causes of the Costa Concordia accident. It is still too early to draw any conclusions or to propose recommendations about the many aspects that undoubtedly will be unraveled during the Lessons In Accident Prevention - Madeline Ferguson - A Long Walk With No Return .

It is remarkable that certain underlying conditions are still the same today as at the time of the Titanic. The Titanic was a state-of-the-art passenger ship on her Luther - Marvin Hamlisch - The Sting (Original Motion Picture Soundtrack) voyage from Southampton to New York in The ship foundered after a collision with an iceberg in the early morning of 15 April.

The events involved in the accident are taken from the official accident report on the basis of the UK Merchant Shipping Acts, to Report on the loss of the SS Titanic As far as the report states, the following facts can be established:. The accident investigation report makes reference to several sailing directions that pointed out the danger resulting from ice in this area. Several other warnings were received before the collision. The master and the officers on watch were aware of the presence of ice in the vicinity of the ship and expected to reach it before midnight the ship collided with the iceberg at The report mentions several conversations on the bridge between officers and the master about the ice and how likely it would be to see it under the given weather conditions.

This means that the iceberg should have been sighted at a distance of approximately meters or yards off the ship pp. The officer on watch had, however, expected that it would be visible from further away, which would have allowed him to decide what to do without time pressure and to execute all manoeuvres with a safety margin.

When he spotted the iceberg, Lessons In Accident Prevention - Madeline Ferguson - A Long Walk With No Return acted instinctively and made two mistakes—he stopped the engine and gave it full astern while operating with the rudder at the same time.

The total capacity of the lifeboats was 1, persons. There were 3, life belts on board p. The report listed 2, persons on board— crew and 1, passengers p. A second investigation was undertaken by the US Senate Although the accident happened in international waters, a large number of passengers were either US citizens or on their way to Lessons In Accident Prevention - Madeline Ferguson - A Long Walk With No Return USA.

As such, the USA had a substantial interest in finding the possible causes of the accident. The two reports differ in scope and detail, but the facts listed in the US report are in line with Lessons In Accident Prevention - Madeline Ferguson - A Long Walk With No Return facts taken from the UK report. There are slight differences as far as some numbers, times, and other minutiae are concerned, just as the interpretations of the facts differ in the two reports.

As already mentioned, the investigation into the sinking of the Costa Concordia has not been concluded at the time of writing. We shall therefore remain with known facts, and refrain from speculating. The consequences of this were loss of watertight integrity of the hull and a subsequent massive flooding so that the engines shut down shortly afterwards. The A Thousand Hours - The Cure - Kiss Me Kiss Me Kiss Me returned intentionally or unintentionally to the island and capsized in shallow water.

The following facts are known:. The master was on the bridge and took command to carry out the course alteration. In order to change the course, the autopilot was switched off and manual steering was done.

The course alteration manoeuvre resulted in a position off the track to pass the island, just about 0. Attempts to change the course of the ship further in order to avoid the charted eastern rock of Le Scole reef with a hard to starboard—hard to port rudder manoeuvre combination failed and the ship hit the eastern rock of Le Scole reef. Evidence from Automatic Identification System AIS records show that a similar close passing of the island was at least made once before, in August Lloyd's List The media have carried numerous discussions and speculations about the maneuvers prior to and after the collision with the rock.

There has also been considerable debate about the evacuation of the ship as well as the timing of the information to the passengers and the emergency response forces ashore. Those aspects can only be reviewed once the accident investigation report has been published and are anyway not germane to the purpose of this paper.

The question debated here is why people—and Sarabanda, Largo - Barthold Kuijken - Wieland Kuijken - Robert Kohnen - French Flute Music Of The Ei to underestimate the risks that exist in operating large ships with many passengers in such dangerous situations.

As already mentioned, the technologies of and are so different that they hardly can be compared. Differences exist in the materials used, the principles of ship's constructions, the equipment available to assist the decision makers, and the technology to support navigation.

A closer look at the two accidents reveals even further similarities:. Both masters were very experienced and had immaculate service records prior to the accidents.

They had spent their entire professional life at sea without larger accidents. Both masters were aware of the potential dangers, but felt that the risks were so small that they could easily be controlled.

In case of the Titanic, no officer on the bridge objected to the navigation of the ship. So far, no information has been published to show that officers on the Costa Concordia disagreed with the manoeuvres of the master.

In both cases, the shipping companies White Star Line and Costa Crociere, respectively either tacitly approved or even encouraged the masters' decisions Lessons In Accident Prevention - Madeline Ferguson - A Long Walk With No Return prioritize performance over safety.

Both accidents resulted into emergency situations for which the ships were not built beyond design-base accidents. Both scenarios were also considered as being highly unlikely. In the case of the Titanic, regulatory follow-up was initiated after the accident International conference on safety at sea This type of response to accidents can be found in most domains. The fact that there are so many similarities between two major maritime accidents a century apart raises the question of why these underlying factors remain when the technology has changed significantly during the same time.

To understand this, it is necessary to look at the human and organizational factors of the accidents. But it is also necessary to consider how accidents are investigated and how the information produced by such investigations is used in the follow-up, by shipping companies and regulatory authorities.

Hollnagel has discussed the extent to which the focus of an accident investigation may influence the results. In both cases, the outcome becomes limited by the unspoken assumptions of the investigation. In order to show the important similarities between the two accidents, we shall evaluate them from several perspectives that broadly can be labeled human factors issues.

The discussion in this paper will limit itself to the accepted role of human factors in safety, and consider the consequences of putting the focus on people at the sharp end and the blunt end, respectively. As previously mentioned, the sharp end refers to the people who are directly involved in a specific activity, in our case the crew on the bridge. People at the sharp end are responsible for the hands-on control of what is going on; they are therefore also the people who directly experience the consequences if and when something goes awry.

The blunt end refers to people who are separated from the activity by time or space, typically as designers, administrators, or managers of the activity in question. The distinction is used because it often is impossible to understand actions at the sharp end without reference to decisions made in the past with regard to, e. To illustrate the need of a human factors perspective, neither the crew on the Titanic nor on the Costa Concordia noticed that the risks increased by how they were sailing.

The failure to notice a changed situation can be explained in terms of individual factors such as complacency, in terms of factors relating to the social nature of the work such as authority gradient, or in terms of organizational influences. The focus of maritime accident investigations has in recent years moved from individual human factors to organizational influences, inspired by Reason Although some classical maritime accident examples, such as the sinking of the Herald Of Free Enterprise in Department of Transport or the fire on the Scandinavian Star in Norwegian Official Reports have a considerable management contribution, the generalization that management responsibility is behind all accidents is misleading and with scarce empirical support.

While the Allegro - Dvořák* / Tchaikovsky* - Leonard Rose, Eugene Ormandy, Philadelphia Orchestra* - Cello Con of management in maritime accidents has been addressed by the International Safety Management ISM Code IMOspecific human factors are still not sufficiently considered. But there are other specific factors, such as the unanticipated side-effects of introducing new technologies on board or the constant struggle to find a balance between safety and economical considerations, the so-called efficiency-thoroughness trade-off ETTO Hollnagel And even when such factors are considered, they are treated as if they were independent, i.

However, these factors depend on each other and usually occur in combination with other factors, resulting in complex interactions. A review of all possible human factors is beyond the scope of this paper. Instead we will concentrate on the issues mentioned above. These factors were involved in the Titanic and the Costa Concordia accidents, and can be found in a great number of other accidents.

They are furthermore not limited to the maritime field, but show up in most other areas including health care, the nuclear industry, and aviation.

Although it is rarely considered by the maritime industry, it plays an important role in, e. It is used to describe how easy or difficult it may be for someone with a lower authority to question or challenge somebody with a higher authority. The authority gradient is itself influenced by a number of other factors, such as education, social background, gender, age, professional roles, and perceived expertise cf.

From the information provided in the accident investigation reports, it appears that the master of the Titanic was not challenged by his subordinates with respect to his assessment of the situation or the conduct of the ship. But the absence of documentation of a disagreement between the master and the officers does not mean that all the officers agreed that the overall risk of a collision with an iceberg was under control and that an iceberg close to the ship could be identified in time.

The authority gradient may nevertheless have prevented individual officers from voicing their concerns. It remains to be seen whether the master of the Costa Concordia was challenged by his bridge team when the ship approached the Island of Giglio. But there are several other maritime accidents where the authority gradient played a role. He thought, he would overtake the vessel, although the ship was on a reciprocal course.


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