Tag Archives: cruise ship

Root Cause Analysis - Incident Investigation

The Salvage Process of Costa Concordia

By ThinkReliability Staff

On September 16, 2013, the fatally stricken Costa Concordia was lifted upright (known as “parbuckling”) after salvage operations that were the most expensive and involved the largest ship ever. The ship ran aground off the coast of Italy January 13, 2012 (see our previous blog about the causes of the ship running aground) and has been lying on its side for the 20 months since.

The ship grounding had immediate, catastrophic impacts, including the death of 32 people. However, it also had longer term impacts, mainly pollution from the fuel, sewage and other hazardous materials stored aboard the ship. It was determined that the best way to minimize the leakage from the ship would be to return it upright and tow it to port, where it the onboard waste could be emptied and disposed of, then the ship broken up for scrap.

Because a salvage operation of this magnitude (due to the size and location of the ship) had never been attempted, careful planning was necessary. Processes like this salvage operation can be described in a Process Map, which visually diagrams the steps that need to be taken for a process to be completed successfully. A Process Map differs from a Cause Map, which visually diagrams cause-and-effect relationships to show the causes that led to the impacts (such as the deaths and pollution). Whereas a Cause Map reads backwards in time (the impacted goals result from the causes, which generally must precede those impacts), a Process Map reads from left to right along with time. (Step 1 is to the left of, and must be performed before, Step 2.) In both cases, arrows indicate the direction of time.

Like a Cause Map, Process Maps can be built in varying levels of detail. In a complex process, many individual steps will consist of more detailed steps. Both a high level overview of a process, as a well as a more detailed breakdown, can be useful when developing a process. Processes can be used as part of the analysis step of an incident investigation – to show which steps in a process did not go well – or as part of the solutions – to show how a process developed as a solution should be implemented.

In the example of the salvaging of the Costa Concordia, we use the Process Map for the latter. The salvaging process is part of the solutions – how to remove the ship while minimizing further damage and pollution. This task was not easy – uprighting the ship (only the first step in the salvage process) took 19 hours, involved 500 crewmembers from 26 countries and cost nearly $800 million. Other options used for similar situations included blowing up the ship or taking it apart on-site. Because of the hazardous substances onboard – and the belief that two bodies are still trapped under or inside the ship – these options were considered unacceptable.

Instead, a detailed plan was developed to prepare for leakage with oil booms that held sponges and skirts, then installed an underwater platform and 12 turrets to aid in the parbuckling and hold the ship upright. The ship was winched upright using 36 cables and is being held steady on the platform with computer-controlled chains until Spring, when the ship will be floated off the platform and delivered to Sicily to be taken apart.

To view the Process Map in varying levels of detail, please click “Download PDF” above. Or, see the Cause Map about the grounding of the ship in our previous blog.

Root Cause Analysis - Incident Investigation

Engine Room Fire Results in Cruise Ship Nightmare

By Kim Smiley

On February 10, 2013, an engine room fire on the Carnival Triumph cruise ship knocked out a significant portion of the ship’s electricity and crippled the propulsion system.  Passenger descriptions of the rest of their “vacation” have included the words hellish and nightmare.

This incident can be reviewed by building a Cause Map, a visual format for preparing a root cause analysis.  A Cause Map intuitively lays out the causes that contributed to an issue to visually show cause-and-effect relationships.  The first step in building a Cause Map is to fill in an Outline which includes the basic background information for an issue as well as the ways that the problem impacts the goals.  In this example, a number of goals are impacted such as the customer service because of the many unhappy passengers and negative media coverage; the schedule goal because the delay of the return of the ship; and the safety goal because of there was a potential for illness.    Once the impacts to the goals are determined, the Cause Map is built by asking “why” questions.

Starting with the safety goal, the first step would be to ask “why” there was a potential for illness.  Illness was a very real possibility because of the unsanitary conditions that existed onboard the ship.  The toilets in the aft portion of the ship couldn’t be flushed because the sewage system was inoperable after the fire.  Full toilets and the rolling motion of the ship made a disgusting and unhealthy combination.  There have been many reports of human waste on floors and even leaking between levels onboard the ship which is probably not anybody’s idea of an ideal vacation setting.  Add in the limited electricity available after the fire and passengers faced filthy cabins without lighting or air conditioning.  Food also became an issue because the limited electricity made preparation of hot meals difficult and the supplies diminishing as the ship remained at sea longer than planned.  The ship’s return was delayed because it had to be towed back to port after the fire wiped out its propulsion.

Investigators are working to determine what caused the fire that started this mess.  They have determined that a leak in a fuel oil return line was part of the problem, but it may be months before the details are known.

What is known is that cruise ship fires aren’t as rare as might be expected.  There were reports of 79 fires onboard cruise ships from 1990 to 2011.   While more information is needed to understand the details of this particular fire, there has been speculation that lack of adequate preventative maintenance may contribute to this issue across the cruise industry.  Keeping a cruise ship in port for a week’s worth of maintenance costs tens of millions of dollars and companies have to try to balance this cost with the risk of an issue during operation.  And the risk is big.  If something goes wrong during operation, like it did in this example,  it can be very expensive.   The total cost of the fire onboard Carnival Triumph is estimated to be $80 billion, including 12 cruises that have already been canceled to allow time for repairs.  In addition the negative press isn’t exactly helping entice potential customers into booking a cruise.  Balancing the cost of maintenance with the risk of not performing it is an issue that many industries face.  No one wants to spend money on unnecessary maintenance, but no company wants to make headlines that have the word nightmare in them either.

To view a high level Cause Map of this issue, click on “Download PDF” above.

Check out our previous blog about  the Costa Allegra , another cruise ship that lost power.

Root Cause Analysis - Incident Investigation

Cruise Ship Loses Power

By Kim Smiley

Part of the excitement involved in passenger cruises is access to remote areas of the world.  However, when a ship runs in to trouble, that remoteness can result in extremely difficult conditions.  This was the case on the Costa Allegra, which suffered an engine room fire in the Indian Ocean.

Passengers aboard the Costa Allegra experienced sub-standard conditions when the ship lost power and propulsion due to an engine room fire.  During the three days while the ship was being towed to land, there was no air conditioning, lighting, or running water.  Food and drinking water were provided by helicopter.

We can examine the causes and effects of this issue in a Cause Map, or visual root cause analysis.  With the Cause Mapping process, we begin by examining the impact to the goals.  Namely, when the incident occurred, which of the organization’s goals were not met?  In this case, although there appeared to be no injuries resulting from the fire itself (although some passengers may have become ill during the resulting conditions) there was the potential for severe injury resulting from the fire and then the lack of power that resulted.   Additionally, the customer service goal was impacted by the lack of running water, air conditioning, and lighting.  The schedule goal was impacted because the ship needed to be towed for 3 days.  The property goal was impacted due to the damage to the ship from the fire, and the labor goal was impacted due to the need for the ship’s crew to stand guard against pirate attack.

Once we’ve determined the goals that were impacted, we can use them as a basis for our map, and ask “Why” questions to add more detail.   Here, an engine room fire on the ship resulted in the loss of ship power, causing the loss of air conditioning, lighting and running water, and the loss of ability for the ship to propel itself, necessitating a tow.  The length of the tow is also affected by the type of ship doing the towing.  In this case, the first ship to arrive to the aid of the Costa Allegra was a fishing vessel.   Although tugboats later arrived, the Costa Allegra requested that the fishing vessel continue the tow, although it is believed that the tugboats would have been able to speed up the tow, possibly resulting in the ship arriving as much as 12 hours earlier.  The cruise ship company has stated that the tow was not changed in consideration of the consistency of the voyage for the passengers but there are also potentially financial considerations.  Assistance to people at sea is not paid, but assistance to ships is.  Thus, the fishing vessel actually entered into a contract with the cruise ship for the tow.

Part of the reason that a fishing vessel was the first to arrive is that there is little maritime traffic in the area.  This is due to the remoteness of the area in which the cruise ship was traveling, as well as the risk of piracy.  This, of course, led to a constant armed guard on the disabled ship to protect from potential pirate attack.

The location to which the ship was towed also impacts the length of the tow.  It was determined that smaller ports closer to the location of the disabled Costa Allegra could not accommodate the large number of passengers on the ship, so the ship was towed to an island of Seychelles.

The cause of the fire itself is still under investigation, although it is believed that an electrical fault is a likely cause and that arson is not likely.  As more information becomes available, we can add that information to the Cause Map as well.

To view the Outline and Cause Map, please click “Download PDF” above.