We should be incredulous that an almost new, state-of-the-art, luxury mega-liner could have so disasterous a mis-adventure in modern times. It seems that mistake was piled upon mistake and the wonder is that even more lives were not lost in the face of such incompetence. The buck seemingly stops with the captain, Francesco Schettino, however who put in place the oversight and governance that allowed him to be there?
He clearly did not have an adequate grasp of risk manangement, the error inherent in many hydrographic charts and the need to test and enforce procedures. Had he been required to do bridge simulator training that requires executive crew to regularly rehearse all manner of disaster just as flight crew must?
I can only surmise that the answer is no – otherwise so many errors would not have been made:
a. Taking the ship out of auto-pilot in confined waters without good cause
b. Over reliance on the accuracy of charts (the age and technology used to make them influence the expected accuracy)
c. Inadequate lateral sensor data and decision support software to predict and correct for navigation hazards
d. Not having software/procedures that automatically announced to passengers and radioed authorities when hull integrity was breached
e. Not having smart-card locks on cabins that failed safe – i.e. unlocked in event of power failure rather than stayed locked
f. Not making sure all crew members had a defined role, knew their role in emergencies and fulfilled it
g. Not having prompt procedures for damage reports, rapid analysis with mathematical models on hand to predict consequences & best responses
h. The delay in evacuation until a tilted ship made that ever so much harder and prevent launch of some lifeboats
i. Not having rolled out ladders to deploy if a ship listed too far to launch boats
j. Not having contingencies in procedures for loss of lighting, a listed ship, changing PA announcements as a situation evolved, and changing lifeboats.
k. Not prioritising evacuation of elderly, the infirm and children
LINE MANAGEMENT MUST TAKE RESPONSIBILITY FOR A POOR QUALITY SYSTEM THAT ALLOWED THAT CAPTAIN & HIS TEAM TO BE SELECTED
FURTHERMORE FOR NOT MONITORING THAT THE SYSTEMS, PROCEDURES, TRAINING WERE IN PLACE & PERFORMING PROPERLY!
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