After a major event, allow people to keep their dignity, speak their truth and understand that there is no ‘right perspective’ on what happened. These were my key takeaways from Nippin Anand’s NZISM Masterclass. Here, he introduced the ‘diversity of perspectives’ concept, the background of the ship’s captain, and a brief overview of happened to the Costa Concordia on the night of the 13th January 2012.
Who is Nippin Anand?
I first came across Nippin’s work thanks to Todd Conklin’s Pre-Accident Investigation podcast. See: PAPod 218 – The Costa Concordia – “We were the first to talk to the Captain about what he was thinking.” – Nippin Anand.
I was hooked and immediately wanted to know more. It turns out Nippin was once a ship’s captain (Master Mariner) and has also collected half an alphabet behind his name (PhD, MSc, FNI and CSci). He’s spent the last two decades working in both the oil and gas and maritime sectors and has focused on social science, systems engineering and human factors in the workplace.
What Happened to the Costa Concordia on the 13th January 2012?
The Costa Concordia was approximately 290 metres long, 35 metres wide and had 13 decks. It’s planned cruise schedule around the Mediterranean Sea included stops in seven ports over seven days. On the day that it ran aground, there were 4,882 passengers and crew on board.
At 9:45 pm she struck a rock on the eastern shore of Isola del Giglio, Italy. Nippin shared a re-creation video where a ‘shiplike’ icon was slowly pirouetting around a hydrographic chart. Having spent some time at sea with the RNZVR, watching a ship that size completing ‘uncontrolled manoeuvres’ made me feel queasy. After the initial grounding, the ship lost power, ran aground for a second time and began to list (heel over).
Although thousands of people were evacuated by lifeboat, the remaining 1,270 passengers and crew were stranded. The lifeboats couldn’t be deployed due to the angle that the ship was heeling over at. Maritime search and rescue teams made a superhuman effort to evacuate everyone, and despite their extraordinary efforts, thirty-two people lost their lives.
Timeline:
- 21:45 Initial grounding
- 22:36 Call to abandon ship
- 22:39 Second grounding
- 22:50 Successfully deployed lifeboats were ordered ashore. At the same time, the ship’s list exceeded the evacuation system capability, and the remaining lifeboats were unusable
- 00:15 Ship’s List exceeds 50 degrees
- 00:36 Master left the ship.
Introducing the Ship’s Captain: Francesco Schettino
In 2015, Francesco Schettino was formally labelled a criminal and sentenced to 16 years in prison. Yet, Nippin introduced him as a man who was deeply passionate about the sea and his profession.
Schettino was born in Meta, Italy and grew up in a seafaring family where he was constantly on, in and around boats. I did some research and discovered that he studied at a Nautical Institute and initially worked for a ferry company. He joined a subsidiary of Carnival Corporation in 2002 and reached the rank of Captain in 2006. This means he had done his time, earned his rank and was by no means ‘stupido’.
Despite Schettino being a part of the seafaring community all his life, Nippin was the first member of his profession to reach out and really talk to him, some five years after the Costa Concordia event.
Accident Investigation ‘First Story’ and ‘Second Story’
Nippin presented the idea that there are two stories surrounding any major event. The first focuses on traditional safety and quickly finding the ‘cause’ of what happened (even when you don’t understand the context or complexity of the situation). It’s a world where everything is ‘obvious’ and ‘preventable’, with the aid of hindsight and a liberal dose of biased assumptions.
After this process has finished, we then move on to the ‘exacting a pound of flesh’ process by apportioning blame, exacting punishment and feeding a media frenzy. This is the story that allowed the wrecking of the Costa Concordia to be blamed entirely on one person.
The second story is not so sensational. This is the story that investigates system vulnerabilities and the entire ecosystem (context) that the event occurred in. Nothing is obvious, it’s a slow, methodical process, and the outcomes often reveal no easy solutions or remedies. It’s also not that newsworthy as there are no magic bullets loaded into smoking guns.
Challenging the World of Accident Investigation.
Nippin describes the traditional accident investigation processes as either a ‘hero narrative, based on outcomes’ or a ‘witch hunt’. To illustrate this, he compared and contrasted the story of Captain “Sully” Sullenberger and the landing of US Airways Flight 1549 on the Hudson River, with the grounding of the Costa Concordia.
For me, this was the most challenging part of the day. What if Flight 1549’s story had been different? What if people had died and the plane had been destroyed? Captain Sullenberger’s actions would almost certainly have been vilified. It demonstrates how a few random changes in a sequence of events can mean one captain becomes a criminal and another a hero.
What Does All This Mean?
Since I began my HSE career in 2002, I’ve sat through multiple accident investigation courses, ranging from Taproot and root cause analysis, through to the ‘fishbone method’ and ‘full monty’ ICAM investigation. As a law school survivor, I also have a whole swag of biases and mental impediments that won’t easily go away.
I’m now feeling decidedly uncomfortable because none of these accident investigation processes focused on treating people with the dignity that they deserve. Although, I like to think that I at least try to be polite when in investigation mode.
I stumbled across Safety-II in 2017 and since then have started learning about pre-accident investigations and learning teams. Nippin assures us that he will cover these topics over the next few workshops and I can’t wait. Don’t forget, if you are a member of NZISM, you can access these for free. Simply go to the website and register now.
As always, if you have any thoughts on the Costa Concordia investigation or anything to add to this blog, please call me on 0272 007 680 or email sarah@employmenow.co.nz.