The nation of South Korea was devastated after a ferry capsized off Byungpoong on April 16, 2014. While the ferry tipped over and sank quickly (within two hours), the evacuation orders came slowly (a half-hour after the first distress call.) The combination resulted in over 300 being trapped within the ship and killed. The Captain and much of the crew were able to escape.
There are a multitude of causes involved in this tragedy, which can be captured within a Cause Map. A Cause Map visually develops the cause-and-effect relationships that led to organizational goals that were impacted.
Clearly, the safety goal in this case was impacted, due to the large number of deaths (at the time of this blog, 226 bodies had been found and 73 people are still missing). In addition, legal action is being taken against the captain and members of the crew responsible for navigation for negligence and failure to assist passengers. The Captain has also been arrested for “undertaking an excessive change of course without slowing down”. The loss of the ship can be considered an impact to the property goal, and the massive rescue and recovery operations are an impact to the labor/ time goal.
By asking why questions, the cause-and-effect relationships are developed. Most of the deaths resulted from passengers drowning when they were trapped in the ship as it capsized and sank. The ferry capsized because of a sharp turn and stability issues. The ship was turned too quickly at excess speed, possibly because the third mate in charge of navigation was inexperienced (this was her first time) and of steering gear issues, reported two weeks prior to the accident and apparently not fixed. The ship had been recently modified to add more passenger cabins, which made it top heavy. As a result of the modifications, the recommended cargo weight was reduced. The ship was carrying three times the cargo weight recommended at the time of the accident.
Passengers became trapped in the ferry prior to the evacuation order, which was issued thirty minutes after the first distress call (and which it appears not all passengers were able to hear). During this time, the ship had listed to a point that made it impossible to get out. The Captain was concerned about the safety of his passengers in the water and appears to have called the parent company to request permission to evacuate. Additionally, the ship’s life rafts were unable to be used. Photos show crew members being unable to release life rafts. Only 2 of the 46 on the ship were successfully deployed. Lastly, the crew provided insufficient assistance, abandoning ship without making necessary efforts to free the passengers.
This tragic incident has been compared to the Titanic (due to the insufficient number of lifeboats and people being unable to leave the ship), the Valdez oil spill (because an inexperienced third mate was performing navigation while the Captain was in his cabin), and the Costa Concordia (when the Captain left the ship without supervising the evacuation effort). As long as lessons from other organizations (and even industries) are not understood by those performing similar work, these tragedies will continue to happen.
To view the Outline and Cause Map, please click “Download PDF” above. Or click here to read more.