At least 11 people have been killed – with 24 still missing – after the cruise ship Costa Concordia ran aground on rocks near the island of Giglio, Italy. The ship was taken manually up to 4 miles off course on a route not authorized by the company.
This incident can be thoroughly examined in a visual root cause analysis built as a Cause Map. First, we examine the impacts to the goals for this incident. The confirmed deaths and missing people are a significant impact to the safety goal. Additionally, the environmental goal is impacted because of the potential for a spill of the 500,000 gallons of fuel still onboard. The required evacuation of the ship can be considered a customer impact goal. The loss of use of the ship – estimated to be $85 to $95 million for lost usage in the next year and the decrease in bookings due to concern over the incident can be considered an impact to the production/schedule goal. The damage to the ship, which was recently built and insured for approximately $575 million, is an impact to the property goal and the rescue and recovery efforts are an impact to the labor goal.
Once we have these impacts to the goals, we can begin an analysis by asking “why” questions. The impact to the safety goal – dead and missing passengers and crew – were caused by the ship running aground on rocks and some issues with the evacuation process. The ship ran aground on rocks because it got too close to the island in a manually programmed unauthorized deviation of the ship’s route, potentially to provide passengers with a better view. This deviation in route, sometimes called a “fly by”, had been previously authorized by the company. No crew members questioned the change in route by the Captain, noting that onboard he is solely responsible for the ship. (Note that with great power comes great responsibility, and the Captain has been charged with manslaughter.) Although the ship contains alarms meant to warn the crew when the ship goes off-course, these alarms are deactivated when the ship route is manually altered.
There were some issues with the evacuation of the ship, though as the company notes, not due to the evacuation procedure, which was externally reviewed in November. Rather the issues were caused by the severe list of the ship (it was leaning almost completely to one side), which affects the ability to use the lifeboats. Additionally, some of the passengers (who had just come aboard) had not yet completed a lifeboat drill. The drill is required to be performed within 24 hours of boarding the ship and was scheduled for the morning after departure. The grounding occurred just 3.5 hours after departure.
Currently, rescue and recovery efforts continue. Attempts are being made to remove fuel from the ship, which is in a protected area. Concern about cruise ships in the area have previously been raised, with some wanting to limit ships that are allowed in the area. Additionally, both the cruise ship company and the government are reconsidering the timing of lifeboat drills in order to ensure the best results for passengers in issues like these.
To view the Root Cause Analysis investigation, please click “Download PDF” above