Tag Archives: ferry

Hundreds Saved by Arduous Helicopter Rescue From Ferry Fire

By Kim Smiley

In a grueling rescue effort, 427 people were saved from a passenger ferry, Norman Atlantic, which caught fire December 28, 2014 off the coast of Greece.  About 150 people managed to escape the fire in lifeboats, but the remaining passengers were lifted to safety via helicopter.  Gale force winds, heavy rain and darkness all combined to make a difficult rescue operation even more daunting. Ten people died as a result of the accident with few details known about what caused the fatalities.

A Cause Map, a visual root cause analysis, can be built to analyze this incident.  The investigation is just beginning and there are still many unknowns, but an initial Cause Map can be begun that can easily be expanded to incorporate new information as it becomes available.  Even the exact number of people onboard has been difficult to determine because there were several stowaways discovered during the rescue operations that weren’t listed on the ship’s manifest.

What is known is that the fire began early in the morning of December 28th and 427 people were rescued off the ferry. Early reports are that the fire started on the parking deck where there were tanker trucks filled with oil.  Witness accounts indicate that the fire spread fairly quickly, leading to speculation that the fire doors failed.  As the fire progressed, the ship lost power.  Once power was gone, the lifeboats were useless because they require electricity to be lowered.  The heat from the fire drove passengers to the top deck and bridge where they were bombarded by cold, rain and thick smoke for many miserable and likely terrifying hours.  Helicopters pulled passengers to safety one by one, working through the windy night with night vision goggles.

In a stark contrast to the South Korea ferry that capsized off Byungpoong in April, the captain was the last person to leave the Norman Atlantic. The rescue effort was truly impressive.  As Greek Prime Minister Antonis Samaras said, the “massive and unprecedented operation saved the lives of hundreds of passengers following the fire on the ship in the Adriatic Sea under the most difficult circumstances.”

The Italian Transport Ministry has seized the vessel pending an investigation into the fire and thorough inspection of the ship.  Whenever a disaster of this magnitude occurs, it is worth understanding exactly what happened and reviewing what could be done better in the future.  There will be many lessons to learn from this incident, both in how to prevent and fight shipboard fires and how to perform helicopter rescues at sea.

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

Commuter Ferry Crash in NYC Injures 85

By ThinkReliability Staff

A commuter ferry struck a pier in Lower Manhattan, NY during the morning commute on January 9, 2013, injuring at least 85 people – some critically .  According  to US Coast Guard Captain Gordon Loebl, “We know that they hit the pier at a relatively high rate of speed.”

We can examine this issue in a Cause Map, a form of root cause analysis which provides a visual “map” of cause-and-effect relationships.  We begin by determining the impacts to the goals resulting from this incident.  The safety goal was impacted due to the large number of people who were injured.  (No fatalities have been reported as a result of the crash.)   The customer service goal was impacted because the ferry slammed into a pier (nobody expects that on their morning commute!).  The ferry was damaged, impacting the property goal.  Presumably the ferry will be out of service for some time, impacting the production goal, and will require repairs, impacting the labor goal.  Any time required for the response can also be considered an impact to the labor goal.

A Cause Map can begin as simply as beginning with an impacted goal and asking a couple of why questions.  In this case, the safety goal is impacted by the injuries, which were caused by the ferry striking the pier.  More detail can be added to the Cause Map by asking more “Why” questions.

In this case, it’s not clear what caused the crash, though drug or alcohol use by the captain has been ruled out.  There have been some recent complaints about maneuverability due to a recent overhaul replacing the engine and propulsion system but it’s not clear if this played a role in the crash.  It’s also unclear why the ship was traveling at 14 knots when it was about to dock.  Because the ship was about to dock, people had gotten up from their seats and were standing in hallways and on or near stairways, increasing the rate of injury.  It does not appear that there are any regulations requiring commuters to remain seated until the ferry has stopped moving.

The ferry company, as well as the appropriate transportation authorities, will continue their investigations to determine the causes of the ferry incident.  Once they do, they will provide recommendations or requirements to ensure a safer morning commute.

To view the Outline and Cause Map, please click “Download PDF” above.  Or click here to read more.