1. Introduction Costa Concordia as organizational accident, a comment

Costa Concordia as organizational accident, a comment
Hans J.W.G.M. Houtmani
1. Introduction
An organizational accident, that is what the article of captain Di Lieto describes of the unfortunate
accident of the cruise vessel Costa Concordia in January 2012 (Di Lieto, 2012)1. Di Lieto uses Reasons’
model of an organizational accident, which was published in 1997 (Reason, 1997).
Having followed after the accident what happened I had read several open access articles in order to
understand what has happened. This article is based on those open articles (see references), the article of
Di Lieto as well as knowledge of human factors in safety critical systems and aviation knowledge. This
article is not based on any court deposition that might have been used by Di Lieto, as these are in Italian
and not for widespread use, as might articles in the English language be.
The approach used in this article is to widen the ideas presented by Di Lieto. The basis used for this
widening is that no person comes to work to do a bad job and that behind every part of human behaviour
there might be an explanation. This explanation is used to make progress: they will lead to problems inside
the system.
2. Organizational accident, what is that?
Let’s first return to the definition of “organizational accident”. It is a comparatively rare but often
catastrophic event that occurs within complex modern technology, such as nuclear power plants,
commercial aviation, the petrochemical industry, chemical process plants, marine and rail transport, banks
and stadiums. Organisational accidents have multiple causes involving many people operating at different
levels of their respective companies. Organisational accidents can have devastating effects on uninvolved
populations, assets and the environment. Organisational accidents are a product of technological
innovations which have radically altered the relationship between systems and their human elements
(Reason, 1997, page 1). In the footnote related to the description of “organizational accident” Reason
mentions that it is not always easy to draw a hard and fast line between individual and organizational
accidents and that his book argues that it is useful to treat them as distinct kinds of event (Reason, 1997, p
20, note 1).
Summarizing the elements of an organizational accident leads to the following elements:
1. Rare but catastrophic
2. Occurring within complex modern technology
This article can be found at http://www.enavinternational.com/wosmedia/273/costaconcordiaanatomyofanorganisationalaccident.pdf
Pagina 1 van 13
3. With multiple causes
4. Involving many people at different levels inside a company
5. With possible devastating effects on uninvolved populations, assets and the environment.
Reason mentions some interesting issues related to an “organizational accident”:
They are difficult events to understand and control
They are hard to predict or foresee
They happen ‘out of the blue’ for people on the spot (all Reason, 1997, p. 1).
3. What was the accident again?
On January 13th 2012 around 20.45 hrs UTC the cruise ship Costa Concordia hit a rock in the sea near the
island “Isola de Giglio”, leading to a grounding, 32 fatalities, 64 injuries and an emergency evacuation of
more than 4.000 persons on board. The rock was hit on the port side of the ship, after which the ship
listed, turned around towards the port of Giglio and grounded close to the harbour. A rescue operation
started. The place where the accident happened, was in a specially protected area of Mediterranean
The captain later stated that the order to turn the ship was given too late by him (BBC News Europe,
2012b). And he also stated that the reason for deviating from the passage plan and to pass closer by to
Giglio was that he was told to do so by an unnamed manager, while shipping closer to the shores was
widespread practice in Italian industry (Cinelli, 2012). This can be seen as a practical drift: step by step the
norms are changed without people in the industry noticing after a longer period that there has been a drift
from the norm. The statement that he was told by management stands in contrast to the statement of the
CEO of Costa Crocieres that it is possible that ships deviate from prescribed routes but that this is done
without company consent (Dinmore & Gainsbury, 2012).
Within days after the accident the company gave a statement that the captain had deviated from the
planned route “due solely to a manoeuvre by the commander that was unapproved, unauthorized and
unknown to Costa. He wanted to show the ship, to [go] nearby this island of Giglio, so he decided to
change the course of the ship to go closer to the island", the Costa Crocieres boss Pier Luigi Foschi stated.
The first explanations from the captain of the ship indicated that he had stated that he denied any
wrongdoing, saying the rocks his ship had hit were not marked on his nautical chart (BBC News, 2012a).
Within days after the accident the company distanced itself from the captain when the company
mentioned that the captain had made serious mistakes with very severe consequences (Mesters, 2012).
Other sources indicate that the evacuation was chaotic. Some passengers mentioned that there was panic
and that it was as if all passengers were on one deck to get into the life boats, but that the life boats
sometimes could not be lowered while the Italian crew was expressing itself in Italian also to those who
did not understand Italian (Schravesande, 2012). It was also mentioned that many of the 1.100 crew
members on board were not able to express themselves in English (Mesters, 2012) (BBC News Europe,
Prof. Niko Wijnolst, stated that the survival equipment on board of cruise ships is still the same as a
hundred years ago when the Titanic went down. Cruise ships are growing to a size where an evacuation
leads to chaos and can no longer be handled (Derix, 2012). The same article mentioned the opinion of the
Cruise Lines International Association that stated that life rafts are central in the safety procedures
because of the international rules. New survival equipment requires quite some training to use them and
there is no time available for training. Personal life suits have been evaluated and rejected as these suits are
too hot on board a life raft.
Pagina 2 van 13
4. Previous trips
Was this trip the first one to pass Isola de Giglio close by? No, it was not. Data from August 14 th 2011
showed the ship followed a similar course close to the shoreline, according to Lloyd's List Intelligence and
Safety at Sea and on January 6th 2012, it passed through the same strait but sailed much further from the
island (BBC News Europe, 2012a). Costa Concordia also had made a similar voyage near Isola de Giglio
in 2008. And based on AIS data it became known that two sister ships, the Costa Pacifica and the Costa
Allegra, made three passages in 2009 and 2010 (Editorial staff of SafetyatSea, 2012).
Was there a policy? Certainly there was (or should I say is) a policy. Costa Crocieres’ CEO stated that the
policy is that ships follow the standard route away from the island, but that the captain has the legal
authority to decide on a route change (Editorial staff of SafetyatSea, 2012).
And the captain told investigators during a hearing in January that he made a mistake on the approach,
navigating by sight and because he knew the depths well. He had done this manoeuvre three or four times
before this trip. This time he ordered the turn too late and came into shallow waters, hitting the rock
(Editorial staff of SafetyatSea, 2012).
Is this a drift into failure? Drift is described as the slow, incremental movement of systems operations
toward the edge of their safety envelope (Dekker, 2005). The previous trips when the island was passed,
were successful, so why not do it again? The hazards of coming closer to shore were no longer seen.
5. Criminal investigation and prosecution
On January 16th 2012 the captain of the Costa Concordia was put under house arrest after the public
prosecutor made a request to the magistrate in charge of preliminary inquiries. The prosecutor requested
the detention of the captain and the officer of the watch based on the fact that they had shown culpable
behaviour consisting of imprudence, negligence and incompetence and in violation of the regulations for
having maintained a speed over 15 knots, even though in the proximity of obstacles, in a way such as not
to be able to act in an appropriate and efficient manner so as to avoid collisions and to halt the craft
within a distance appropriate to the circumstances and to the conditions of the moment, caused the
shipwreck of the said Costa Concordia, at the same time thus causing the death of (at that time) two
passengers. He was furthermore charged for not having been the last to leave the motor ship Costa
Concordia of which he was captain, during the abandonment of the same (in danger, being in the process
of shipwreck) (Montesarchio, 2012).
The captain was ordered to go back on the ship by the Coast Guard while some hundred persons were
still on board. The captain stated that it was impossible for him to go back (Montesarchio, 2012) (BBC
News Magazine, 2012).
Being the last to leave is one of the issues of Italian maritime law (seen as part of the duty of care) but no
longer a part of the Safety of Life at Sea Convention since 1974 (BBC News Magazine, 2012).
Within days after the accident the captain was seen as the culprit, condemned in public for his behaviour
that was seen as irresponsible, negligent, and it is his behaviour that is mentioned as “the focus of the
world's ghoulish fascination with this disaster” (Editor of the Times, 2012).
It is questionable whether the captain is criminally the sole person responsible for the accident. As
mentioned in The Times: “More and more, sophisticated industrial societies attempt to regulate out the
possibility of accidental disaster. They set rules and standards, draw up codes of practice, appoint
supervisory bodies and institute inspections. The aim is to ensure that a single individual does not, by
Pagina 3 van 13
malice or bad judgment, endanger those beneath him. But the fact remains that the responsibility
ultimately lies with the individual in charge.” (Editor of the Times, 2012).
Will the captain get a fair trial? He has his question about this, as expressed by his brother-in-law in March
before evidence was to be given during a court hearing (BBC News, 2012b). Ahead of this trial the captain
was said by his family to be depressed and afraid, where his lawyers stated that he was scapegoated
(Johnston, 2012).
But if we want to make real progress investigators have to dig deeper and look into the backgrounds of
the accident: the culture of the organization in which the accident happened. The chief prosecutor of
Tuscany told reporters that his organisation was not only looking for the captain and his responsibilities,
but also to the organisation that made the man the captain of the ship (Hooper, 2012). A month later the
media reported that the investigation had widened to other persons in the cruise company (Fearis &
McNeill.Linsey, 2012), specifically also some executives on shore during the accident (Ognibene, 2012).
Executives of Costa Crocieres were also put under investigation. Apart from the captain and four officers
who were on board, three managers of Costa Crocieres were formally put under investigation with charges
of manslaughter, causing a shipwreck and not communicating with the maritime authorities about what
was happening (Thuburn, 2012).
6. Safety investigation
There is also another investigation running which ought to head for the safety related issues in the
maritime world, as it is performed by the Italian maritime investigative body on marine accidents. This
investigation ought to take precedence over criminal investigation in order to address the safety needs of
our global society. On May 18th 2012 the maritime investigative body gave an update of the investigation
and derived from the presentation during the update the following issues can be derived (Italian Maritime
Investigative Body on Marine Accidents, 2012):
The criminal investigation has precedence over the safety investigation;
The ship has had such a course towards the island of Giglio that it came in a position much more
close to the coast than was to be done according to the planned course;
When the ship is sailing too close to the coast the course is altered twice but the ship hits a rock
of “Le Scole”, reduces speed instantly (from 16 to 8.3 knots) and the two main electrical engines
lose power;
The ship sails towards more open (and deeper) sea, turns over starboard and returns to the island
where it runs aground;
Investigations that were finished at the time of the presentation were:
o The delay in sounding the alarm and taking the timely steps to abandon ship
o The organisation of the abandonment of the ship (it was appropriate to manage an
emergency like this one)
Investigations that were still performed at the time of the presentation were:
o Crew manning (recruitment, muster list arrangements, familiarization with emergency
o The voyage (navigation planning, bridge assets, master com procedure)
o Stability (leak assessment, flooding dynamics, ship response capacity, watertight
compartment systems)
o Black out (loss of electric power, loss of power distribution, emergency electric sources)
o General emergency management (internal communication, emergency timing, bridge
team crisis response)
Pagina 4 van 13
Safety equipment (survival crafts and rescue boats, effects of ship assets on evacuation
procedure, ship evacuation timing)
o Ship devices/capability to put in place an adequate response to the emergency (device
arrangements, device vulnerability, device interoperability, redundancies).
Why so much place in this article for the open parts of the investigation? Because the tools that people
have to work with, are not their choice but are chosen by others, higher up in the organisation. It will
therefore be difficult to hold the crew or the captain responsible for the outcome, when issues like crew
manning, stability and safety equipment are issues of importance for the outcome of the event.
7. Discretionary space
The discretionary space is the space a front line operator has while performing his or her job, doing those
things that have not been specifically written down in rules and regulations or procedures and that finds
its basis in knowledge, skills and experience gained while doing the job. This discretionary space can only
be filled by the human doing the job but is full of ambiguity, uncertainty and moral choices. The
discretionary space motivates people to do their work to the best of their abilities. This space, filled by an
operator, in turn leads to the possibility of being prosecuted and blamed when incidents or accidents
happen: in hindsight it is stated that the operator did the wrong thing. Discretionary space is therefore
directly related to the choices operators make: the free will to act or not to act (Houtman, 2009).
What was the statement of the organization? Costa Crocieres’ CEO stated that the policy is that ships
follow the standard route away from the island, but that the captain has the legal authority to decide on a
route change. And what happened during several previous trips with different ships (not implying that this
also means with different crews)? During previous voyages (see above in paragraph 4) several ships
deviated from the procedures and headed towards the island. But the outcome was different: no accident,
only an organizational issue (or not) to show the ship to people on the island.
8. A Reasonesk’ view of the accident?
The view that Di Lieto shows in his article (Di Lieto, 2012) is based on the almost two decades old view
of prof. Reason. Are the ideas of 20 years ago the last ones in science around safety? Let’s first see how Di
Lieto describes what happened on board, based on errors that were made by humans:
Error 1 is that the captain decided to change his original voyage plan without the agreement of the
Company and local authorities. The former mentor of the captain described this as a company practice
which in other occasions was included in the travel program.
Error 2 is a shortfall in voyage planning: the original route was, according to the safety officer, drawn on a
paper chart and was a few miles off the island, where he most likely had seen the chart with scale 1 :
100.000, apparently being the chart used to plot the deviation towards Isola del Giglio.
Error 3 is the error related to route monitoring, the task of the Officer of the Watch (OOW), with the
senior OOW in charge of the conduct of navigation amongst which is collision avoidance, with the
assistance of the junior OOW. No routes were drawn on the larger scale charts so the junior OOW could
not monitor the route and on top of that she had to assist the helmsman when the captain took the
command of the navigation.
Error 4 is using the INS on the bridge by the senior OOW when the radar distances was used from the
furthermost radar echo of the rock (“Le Scole”) and not from the limit of the no-go area which in this
Pagina 5 van 13
case was the 10 meter bathymetric line, while the INS could also produce a chart alarm in relation to the
warning zone ahead of the ship.
Error 5 is lying in the area of Bridge Resource Management (BRM) and attributed to the captain as a team
leader. Items mentioned are a lack of team briefing, a lack of handover, and they are related to the captain.
Error 6 is a failure to maintain the newly established safety margin of about 0.25 NM which would have
been far enough away from the rock to not hit that rock, despite the fact that this was below a previous
set safety margin.
The disadvantages of using this Reasonesk’ view towards an accident can be described as follows. Let’s dig
deeper in some of the errors mentioned here.
Why is error 1 the first error? If it was company practice to change the voyage plan without the agreement
of the Company, the error (as far as one can speak of an error) lies earlier in time and is related to other
issues e.g. the supervision over the day-to-day operations from the side of the company, a gap in the
procedures, a drift into failure, of even the discretionary space of the captain. So the first error was not the
first error.
If error 2 is the second to be mentioned, one might raise the question whether a previous error may lie in
a decision or a habit about using charts for a certain part of the passage plan. If it is a decision, it is done
by some person on the bridge, not corrected by others on the bridge. If it is a habit, one can say that is has
grown over a period of time (a drift into failure) not corrected by other persons on the bridge, or maybe
even wide spread by these crew members or the fleet. Other charts (1 : 20.000 and 1 : 5.000) were also
available and appeared to be more suitable for navigation in shallow waters. Which decision or habit is
lying behind the choice for this 1 : 100.000 chart? Was this just the captain’s choice and directives
followed by the officer preparing the voyage plan? And if so, why did the captain choose this chart?
Error 3 is about the charts: no route drawn on the charts, no possibility to monitor progress. But why did
nobody draw a route on the chart? Navigation is partly knowing where you are and partly knowing where
you are heading to, taking into consideration what lies in between. But was not drawing a line on the chart
a common practice for a route deviation? Customary behaviour on the bridge or inside the organization?
A habit in the organization? Of just a way of working of some person(s)?
Error 4 is an interesting one, especially because the statement is that the INS and radar echoes were used.
A question is whether the chart alarm was set correctly in relation to the horizontal distance from the
biggest hazards visible on more detailed charts. Lots of question and even the answers lead to new
questions because they are related to the way humans worked on the bridge, checked each other,
questioned and challenged the work being done. So not just “error 4” but a bunch of errors.
Error 5 puts the error square on the shoulders of the captain, but I have my serious doubts whether this is
correct. When talking about BRM, it involves all crew members on the bridge. BRM is irrespective of rank
and position as even the youngest crew member on board has to be as assertive to attend others to
possible errors by questioning decisions, habits and behaviour. Questions about this error are stated later
in this article.
My comments on the mentioned error 6 are an extension of my comment on error 5 here above. Was
nobody in a position to challenge what was going on? Did nobody mention the overshooting of the safety
margin? And if so, why?
Pagina 6 van 13
The biggest disadvantage of the Reasonesk approach is that it is linear: it looks like all errors are put in one
line, with a specific starting point and an end point. But the only thing that is correct is the accident: the
rest is constructed in the eyes of the person using the model. The linearity is very questionable as the
errors all have a basis in a certain environment, leading to certain decisions and coming together in one
point, the accident, but the angles from where they come are different.
It must be realized that all errors mentioned in Di Lieto’s article assume that there is a certain starting
point in finding the errors, which is set here in error 1 (changing the voyage plan without approval). But as
can be seen in my comments and as will be explained later in this article, there are only more questions.
The errors, as brought in the article, assume a certain starting point but do not lead to the deeper
problems and better safety improvements. I do not have all the answers, just a lot of questions.
9. Old View and New View
In the several ways to approach an accident there are two possibilities that can (and oftentimes are) used
for safety investigations. The first one of these is what is being known as the “Old View”. The Old View
states that:
complex systems would be fine, were it not for the erratic behaviour of unreliable people in it
human error causes accidents: humans are the dominant contributors to errors;
failures come as unpleasant surprises
- complex systems are basically safe
- they need to be protected from unreliable people (Dekker, 2002).
The Old View is easy to handle after the accident: all information that is gathered heads in the directions
mentioned above, available for an investigator who has enough time to gather it all and explain it in the
way that the investigator seems appropriate to the investigator.
The New View holds a different point of view about the behaviour of humans. The New View states that:
human error is not the cause of failure, it is the effect or symptom of deeper trouble;
human error is not random, it is systematically connected to features of people’s tools, tasks and
operating environment;
- human error is not the conclusion of an investigation, it is the starting point,
- complex systems are not basically safe;
- people have to create safety while negotiating multiple system goals (Dekker, 2002).
The basic point of departure is in fact that nobody comes to work to do a lousy job and that, if things turn
out wrong, we have to investigate the environment as well and ask the questions that are related to this
issue: why did people decide in a certain way? How could it happen?
But if a person comes to work to do a lousy job, he should no longer be allowed on the premises of an
organization as he is a big hazard for the safety in that organization.
The accident in the Old View
If the accident is approached with the Old View in mind, we can see the following issues that can be used
to explain what happened:
it is known that ships can (and have) run aground in shallow waters;
navigating in shallow waters should lead to more attention on the bridge;
Pagina 7 van 13
there was no or no proper passage plan to pass the island at a distance of 500 meters or less;
there was no or no proper risk assessment for the part in shallow waters;
the briefing of this part of the voyage was not or not properly done;
the ship navigated at a speed of 16 knots directly towards the rock;
the radius of the turn in relation to the speed at the time, needed to avoid the rocks in this
shallow waters was not established;
All in all, the system was safe as long as the captain and the rest of the crew had not decided to pass under
the coast of the island in shallow waters. The human was the cause of the accident. In order to avoid an
accident like this one to happen again, and to protect the system against these people there is only one
solution: fire them and it will not happen again. They will be gone from that organization. Whether the
deeper problems themselves are solved, can be questioned.
The accident in the New View
It is for certain that the accident will not happen again with these people, but it is questionable whether
they need to be fired to not have the accident happen again. The circumstances around accidents are never
100% identical and these crew members have an experience, which will be with them for their lifetime.
They will never ever act in the same way again.
Within the New View it is necessary to see the accident as a symptom of deeper trouble, connected to
features of people’s tools, tasks and operating environment. So I went back to the article of Di Lieto and
framed questions in order to go deeper into the system, deeper into the environment where this crew has
been working. I must stress that the answers cannot be given, but just as the article of Di Lieto, they
should be of help for future investigations, to come the answers that will lead to safety improvements, and
they should lead to a better understanding of safety on board for crew members.
In the New View the errors stated her above in the previous paragraph lead to more questions. The
questions that are stated here below are the questions that came to mind while reading the article and can
be used to come to the deeper systemic problems.
In relation to error 1:
How did the idea grew inside Costa Crocieres that “touristic navigation” was doable?
What did management do with this, assuming that it must have been known at management
If nothing was done, was this felt as an approval to continue with “touristic navigation”?
Was there a (formal or informal) norm for low speed touristic navigation along the island?
If the deviation from the passage plan was functional to organizational goals (page 8 of Di Lieto),
the organization must have known about this and seen the advantage. Was this communicated in
some way? What was “the organizational goal”?
Was there a limit no to do it in wintertime? Was this known to crew members? And if so, why
was it still done then?
The safety margin was set at 0.5 NM but there was hardly room for manoeuvring or, as Di Lieto
states: “given the intrinsic limitations of the ship in term of list (as a function of course alterations
with high rate of turns), the approach almost perpendicular to the coast would have not left room
to recover from ship handling errors”. Did nobody react to this approach? Was this the course of
handling the navigation as set by the captain? Was this a normal approach inside the Costa
Crocieres concern? Or is this an issue related to cruises?
Pagina 8 van 13
In relation to error 2:
Why was a less detailed chart used for navigation in these shallow waters?
The safety officer “noticed an isolated position fix placed well south of that route, which
confirms the improperly planned navigation towards Giglio Island”, but did he react on this
information? If he did not do so, why? Was this the culture on this bridge? Or is this the culture
in the organization?
- “The voyage plan had to be reported with priority on all relevant paper charts” and “the planning
officer …. followed the Captain’s directives” but “but the intentions were not translated into a
formal route planning on all available paper charts”. Almost the same type of questions as above:
why why why?
- “The events demonstrated that the safety margin was not established from the limit of the no-go
area - the 10 meters bathymetric line – and not even from the furthermost emerged rock, but
from a generic point of Le Scole Islands, barely visible on the 1:100.000 scale chart”. Why does a
captain and/or a planning officer (and later) a OOW not use a more detailed chart? It can hardly
be an issue of time that the other charts could not be reached.
- De Lieto then states “But was the lack of planning on all relevant paper charts a routine practice?
If so, the error would be at the rule based level of performance”. The error, if it is a routine
practice, is not so much at rule based level, but must be seen as an organizational problem: people
are able to come to different practices than described by the company and nobody is there to
check and correct for the right standards.
In relation to error 3:
Why did nobody draw a route on the chart?
Navigation is partly knowing where you are and partly knowing where you are heading to, taking
into consideration what lies in between. But was not drawing a line on the chart a common
practice for a route deviation?
- Was this customary behaviour on the bridge or inside the organization?
In relation to error 4:
Errors here pile up on each other: after the error 2 and the questions posed there, a question here
is whether the chart alarm was set correctly in relation to the horizontal distance from the biggest
hazards visible on more detailed charts?
- Who sets what?
- Who checks what is being set?
- What is the basic material (e.g. a chart) to see what the threshold for the alarm must be?
In relation to error 5:
BRM involves all crew members on the bridge. Was nobody assertive enough to approach the
captain when he entered the bridge and do the formal handover and team briefing?
What were the senior OOW and/or the junior OOW doing at that moment in time for them to
not come to the formalities necessary at that moment in time?
Did other crew members on the bridge not dare to speak up?
Was the captain a person who showed “autocratic leadership”, as is suggested on page 11 of the
article of Di Lieto?
And if so, why wasn’t this detected in all the years that he was inside the organization?
Speculative as it might be, but another question can be whether the captain was a “bully” who
could not be approached, where BRM did not work, where the organization Costa Crocieres kept
the captain on his position, even when BRM did not work?
Pagina 9 van 13
- Were visitors on the bridge a normal way of working when deviating from the passage plan?
- Were visitors on the bridge seen as a distraction?
- Or is it common practice to accept visitors, any visitor, at any moment in time on the bridge?
- Or is the BRM course itself not developed enough to really work in practice?
In relation to error 6:
The question that arises is how the ship, given the safety margin of 0.5 NM from the furthermost
point of the group of islands called Le Scole, got as close as 100 meters from the furthermost
point striking an underwater rock with a charted depth of 7,3 meters (page 7 and 11).
- How could the ship approach the obstacles within the safety margin with a speed of 16 knots,
leading to less time and space to intervene?
- Did anybody mention this on the bridge?
- What was being done with this information?
- The question stated by Di Lieto around the company procedures and training of crew members
are valid to come to the deeper problems.
It is hard to believe that all crew members were standing on the bridge, “dumb, fat and happy”, heading
towards disaster. And these question might all sound as if it is a criminal investigation, but it should be
remembered that these question are directed to try to explain human behaviour and to not incriminate the
9.3 Rasmussen and the modelling problem
Rasmussen wrote about risk management in a dynamic society and in his article he also mentions the
deviation from normative work instructions and rules (Rasmussen, 1997). He mentioned that there is an
“interaction of the effects of decisions made by several actors in their normal work context, all very likely
to be subject to the same kind of competitive stress”. He built a causal tree from the Zeebrugge accident
where the Herald of Free Enterprise capsized just outside the harbour, showing the different decisions by
different persons at different times in different parts of the shipping company. In the end these all
together resulted in the accident.
One can only hope that the accident investigation will dig deeper than just the technical issues that have
been mentioned up to today, and that due attention is given to the human factors. The expectation at this
moment is that those involved might (an most probably will) incriminate themselves when they open talk
about what has happened on the evening of January 13th 2012.
It should be remembered:
What you look for is what you find
What you find is what you fix
10. So is this an organizational accident?
Summarizing the elements of an organizational accident leads to the following elements:
rare but catastrophic
occurring within complex modern technology
Pagina 10 van 13
with multiple causes
involving many people at different levels inside a company
with possible devastating effects on uninvolved populations, assets and the environment
The appearance is there that this is an organizational accident, but more and deeper investigation is
needed to come to a funded statement that the accident on January 13th 2012 with the Costa Concordia is
indeed an organizational accident.
Then, if you use the interesting issues related to an “organizational accident” that Reason mentions, ie.:
they are difficult events to understand and control
they are hard to predict or foresee
they happen ‘out of the blue’ for people on the spot
I would say: no, it is not an organizational accident. It could be foreseen that, heading towards to coast at
a speed of 16 knots and the alarms switched off, with the safety margins decreased from 0.5 NM to less
than 0.25 NM that this ship would hit the sea bottom (be it a rock protruding a meter above the water or a
rock hidden in the water). So the accident was not a difficult event to understand and control, although it
did happened “out of the blue” for people on the spot.
But then: this is a really abbreviated version of what happened and does not dig deep due to a lack
information of what happened in the bridge of Costa Concordia on the evening of January 13th 2012.
It is my hope that the safety investigation will show that not just the crew made mistakes, but that they
closed the last gaps. Prosecution of people will not be of help.
Reference List
BBC News (16-1-2012a). Costa Concordia cruise ship captain 'went off course'. Retrieved 17-12012a, from http://www.bbc.co.uk/news/world-europe-16576979
BBC News (3-3-2012b). Costa Concordia hearing to be given evidence.
BBC News Europe (24-1-2012a). Costa Concordia disaster.
BBC News Europe (18-1-2012b). Costa Concordia: Captain Schettino 'turned too late'. Retrieved
26-8-2012b, from http://www.bbc.co.uk/news/world-europe-16620807
BBC News Magazine (18-1-2012). Must a captain be the last one off a sinking ship?
Cinelli, Antonella (25-1-2012). Costa Concordia captain claims ship managers told him to take
cruise liner close to shore, transcript shows. Retrieved 26-8-2012, from
Pagina 11 van 13
Dekker, S. W. A. (2002). The Field Guide to Human Error Investigations. Ashgate Publishing Ltd.,
Aldershot, Hants GU11 3HR, England.
Dekker, S. W. A. (2005). Ten Questions about Human Error. Lawrence Erlbaum Associates Inc.,
Mahwah, New Jersey 07430, USA.
Derix, Steven (2012, January 17). 'Reders leren onvoldoende van rampen'. NRC Handelsblad.
Di Lieto, Antonio (2012). Costa Concordia Anatomy of an organisational accident. Retrieved 208-2012, from http://www.enavinternational.com/wosmedia/273/costaconcordiaanatomyofanorganisationalaccident.pdf
Dinmore, Guy and Gainsbury, Sally (21-1-2012). Concordia'not first to deviate from routes'.
Retrieved 26-8-2012, from http://www.webcitation.org/65O0ailMo
Editor of the Times (2012, January 21). The Man on Watch. Should regulation ever replace
individual responsibility and accountability? The Times.
Editorial staff of SafetyatSea (2012, March). Recriminations follow Concordia capsizing. Safety at
Sea, 46, 6-7.
Fearis, Bev and McNeill.Linsey (23-2-2012). Concordia investigation widens beyond ship's
Captain. http://www.travelmole.com/news_feature_P.php?news_id=2000457
Hooper, John (2012, January 24). Costa Concordia captain not solely to blame, says prosecutor.
Investigators urged to consider role of ship's owners in incident as salvage experts begin pumping out fuel
from wreck. The Guardian.
Houtman, J. W. G. M. (2009). What is the relationship between the increased use of the Penal Code and
Safety Reporting.
Italian Maritime Investigative Body on Marine Accidents. (18-5-2012). Marine Accident
Investigation c/s Costa Concordia 13th January 2012.
Ref Type: Case
Johnston, Alan (3-3-2012). Concordia hearing: Scapegoat fears for captain Schettino.
Mesters, Bas (2012, January 16). Zeemansgroet werd kapiteit noodlottig. NRC Handelsblad.
Montesarchio, V. (17-1-2012). Court order of the magistrate in charge of preliminary inquiries of
the Court of Grosseto (Republic of Italy). No. 12/285 N.R. and No. 12/117 Magistrate in Charge of
Preliminary Inquiries.
Ref Type: Bill/Resolution
Ognibene, Silvia (23-2-2012). Prosecutors target cruise ship captain, Costa executives. Retrieved
26-8-2012, from http://www.webcitation.org/65mQ7BysG
Rasmussen, Jens (1997). Risk Management in a Dynamic Society: a Modelling Problem. Safety
Science, 27, 183-213.
Reason, J. (1997). Managing the risks of organizational accidents. (2000 ed.) Ashgate Publishing Ltd.,
Aldershot, Hampshire GU11 3HR, England.
Schravesande, Freek (2012, January 16). Don't worry, alles onder controle, klinkt het over de
intercom. NRC Handelsblad.
Pagina 12 van 13
Hans J.W.G.M. Houtman is the owner of “Just Culture Human Factors in Safety Critical Operations” in
Amstelveen (the Netherlands). He did a M.Sc. “Human Factors and Safety Systems” at Lund University (Sweden)
and has a background in aviation. He can be contacted via [email protected]
Pagina 13 van 13