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Errors in judgment

Responsibility for several recent tragedies rests not only with the captains, but also with the systems that put them in place

Three recent maritime accidents made most of us aware, once again, that going to sea can be a risky business. In fact, the most recent passenger ship accident, in April off South Korea, was the 100th passenger vessel lost since 2002.

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Acts of God are acceptable risks in maritime law and tradition. Acts of man, however, are another matter. The sinking of the tall ship Bounty and the capsizes of the passenger liner Costa Concordia and the South Korean ferry Sewol were compounded and directly caused by human error, afloat and ashore.

These incidents have much in common. They involve unnecessary loss of life stemming from errors in judgment made well before the incident itself. And despite what most of us have been led to think, the captains were not solely to blame. Responsibility also resides elsewhere — ashore, in the owners and advancement systems that put these captains in command in the first place. Before getting to the principal underlying cause of these tragedies, let’s look at the facts as they are known.

Costa Concordia

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On Jan. 13, 2012, the Italian cruise liner M/V Costa Concordia grounded at 2145 local time at high speed on Le Scole Rocks, near Giglio Island off Italy. The ship’s master was on the bridge at the time of the grounding. The vessel carried 2,306 passengers and 1,023 crewmembers. Twenty-eight passengers and four crewmen lost their lives; 157 people were injured. Significant mistakes were made before and after the grounding.

The ship, under the master’s command, intended to make a flyby of the island at high speed (15.5 knots), as the master had done numerous times in the past to impress the islanders and his passengers. A small-scale chart of the island was used for navigation because a more appropriate large-scale chart was not carried aboard the vessel.

The grounding — attributable to miscalculating the location of the shoal and initiating a turn too late — ruptured five contiguous bulkheads on the port side. Both engine rooms immediately flooded, rendering the ship without propulsion. Both emergency generators failed to keep up with the demand load. The ship continued northward under her own momentum and became adrift a mile or so past the island. With favorable wind and current, the ship drifted back toward the island and grounded at 2300, about 75 minutes after her initial allision with Le Scole Rocks.

Local search-and-rescue authorities were initially notified of the incident by someone ashore. Authorities attempted to contact the ship at 2200; however, the ship informed them of the extent of the damage at 2226. According to one investigative report, the master reported at 2225 that the “hull has a breach on the left side that is causing a gradual heel, that on board there are dead or injured people, and he only requires the assistance of a tug.” He only requires the assistance of a tug?

At 2236, the ship declared a distress, and at 2254, the abandon ship order was given over the public address system. The master abandoned the bridge at 2320, and SAR authorities were informed at 0034 that the master and other officers were now in a lifeboat. At the time, passengers and possibly crew were still on board.

The Italian Ministry of Infrastructures and Transports, which conducted the investigation, concluded: “On the whole, human factors characterized this casualty.” The decisions of the master, before and after the grounding, were cited over and over. Nonetheless, the investigating board never questioned the competence of the master to be in command or investigated the process that put him there.


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Bounty — the wood-hulled 180-foot (sparred length) square-rigger launched in 1960 — sank in the wind and waves from Hurricane Sandy off North Carolina in October 2012. Coast Guard Air Station Elizabeth City rescued 14 survivors in harrowing conditions. Two were lost. One deceased crewmember was located. The master, reported to be in a survival suit, was never found after an exhaustive search, likely entangled in his own ship when she sank.

The Bounty was built in Nova Scotia for the 1962 film Mutiny on the Bounty at a cost of about $750,000. One might assume a long service life was not a design or construction requirement, as her original cost would suggest, even by 1960s prices. After her movie career, she was used primarily as a tourist attraction; she was acquired by her present owner in 2001. The vessel underwent numerous renovations to her hull, masts and rigging over the years, including the addition of ballast to improve stability.

On Oct. 25, 2012, Bounty concluded an event with the Navy in New London, Connecticut, at 1700. On board were the master and 15 crewmembers. The 63-year-old master had spent his career at sea and had command of the Bounty for the past 17 years. Only four other crewmembers had more than two years of experience on tall ships.

Sandy had reached hurricane strength Oct. 24. The forecast was for the storm to move up the East Coast and stay offshore until it was abreast of Cape Hatteras, North Carolina, then turn northwestward, making landfall between the Delmarva Peninsula and New York City.

After the Navy event concluded, the master assembled the crew to advise them that the ship was getting under way in about one hour. He told the crew that her exact course would depend on the hurricane. Bounty’s normal crew size was 20 to 25. The master explained that those who wanted to get off could, but they would have to pay their own way to St. Petersburg, Florida, the ship’s next destination. And because the ship was already short-handed, those who remained aboard would have to double-up for those who left. None did.

The master had utmost confidence in his vessel, even bragging a few months before how he “chased hurricanes” to his advantage in a local TV station interview. He frequently said ships were safer at sea than in port during a hurricane.

In the post mortem, few of us would affirm that Bounty was seaworthy when she departed New London for St. Petersburg on the evening of Oct. 25. More than normal rot was discovered in her planking but not replaced during her last dry dock, a month earlier. Her machinery and dewatering pumps were unreliable, even though the ship was a “leaker.” (All wooden vessels leak to some degree, either through the hull, deck or through-hull fittings. Bounty’s was beyond normal.)

Perhaps more significant, the majority of her crew was inexperienced in terms of tall ships, particularly in handling heavy sails in a hurricane. Nonetheless, the master departed, running both her sails and two 375-hp diesels.

The master’s intentions for avoiding Hurricane Sandy are unknown; he failed to share his voyage plans with any of his crew before sailing, including his first mate. The National Transportation Safety Board report shows that the vessel initially headed south-southeast for about 36 hours, then changed course to the south-southwest. The captain’s rationale might be found in an email he sent Oct. 26, in which he wrote to his director of portside operations: “Thanks for the [weather] update, because of it I feel OK about trying to sneak to the west of Sandy, new course 225T. It looks like it will stay offshore enough [for] us to sneak by. Thx.”

On Sunday, Oct. 28, 200 nautical miles north of the eye of the hurricane, things aboard Bounty began to deteriorate. Flooding progressed, dewatering pumps began to fail, the now injured chief engineer was incapacitated and the crew was fatigued from battling 30-foot seas and 90-knot winds, according to the NTSB report. Nonetheless, the master pressed on, bypassing Morehead City, North Carolina. By 1800, the NTSB reported that the chief mate advised the master to call the Coast Guard. He declined and instead decided to press on and concentrate on handling his ship. The rest is history.

The NTSB concluded “that the probable cause of the sinking of tall ship Bounty was the captain’s reckless decision to sail the vessel into the well-forecasted path of Hurricane Sandy, which subjected the aging vessel and the inexperienced crew to conditions from which the vessel could not recover. Contributing to the sinking was the lack of effective safety oversight by the vessel organization.” The NTSB never raised the issue of the master’s fitness for command or the system and organization that put him there.


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On April 16, the South Korean-registered M/V Sewol, a 481-foot, 6,835-gross-ton “roll on-roll off” ferry, capsized off the southwest tip of the Korean Peninsula, with 281 people confirmed dead as of mid-May, mostly high school students. The acting master and several crewmembers were immediately detained on suspicion of negligence and abandoning people in need. The CEO of the company that owns the vessel was arrested.

The facts known to date are as sketchy as they are difficult to fathom. The capsize occurred in coastal waters in calm conditions. The vessel heeled and stayed over for a considerable period of time before fully capsizing less than three hours later. The ship reported that the heeling began about 0848. Passengers were directed to remain in their rooms and told repeatedly not to move. At 0914, the ship reported that the angle of heel made evacuation impossible, and four minutes later that the vessel was now heeling 50 degrees to port.

Although the local vessel traffic system told the ship to direct the passengers to don life jackets, it could not be verified whether or when that order was carried out by the crew. The response from the vessel was that the ship’s public address system was now out of order. About 0930, the captain ordered the ship evacuated. His explanation for delaying the evacuation was his concern for passengers being subject to the cold water and swift currents before rescuers could arrive. Yet, in a well-viewed video, he was seen leaving the ship with several crewmembers while many passengers still remained on board.

The AIS evidence shows that the vessel took a sudden turn to port, coincidental with the sudden heel. It was known that the ship carried three times the amount of authorized cargo. Overloading this ship apparently had been a common practice. Much of the deck cargo, including vehicles and sea containers, became adrift, which would help explain the sudden loss of stability. In a recent renovation to add additional cargo-carrying capacity topside, seawater ballast tanks of about 2,000 tons were installed. It is not known whether these tanks were, in fact, ballasted when she lost stability.

On May 15, it was reported that the master, chief engineer, and first and second mates were charged with murder and could face the death penalty upon conviction “because they didn’t use the ship’s facilities at their disposal — such as life rafts, life vests and announcements to evacuate passengers.”

Indictments alleging violation of a ship safety act were handed down against 11 other crewmembers. The most fundamental element in a judicial system is educational. In the aftermath of this tragic and preventable marine catastrophe, the South Korean government has certainly sent a message.


Clearly, none of these tragedies resulted from a simple mistake in judgment, such as when coming to a fork in the road. Rather, the errors were cumulative. Two incidents involved captains who abandoned ship while their passengers were in peril. Two involved going to sea with vessels that were manifestly unseaworthy. The decisions these masters made that resulted in people dying were calculated and deliberate. Not only was their judgment an issue, but unfortunately their character was, as well.

Judgment and character are attributes that develop over a lifetime and are essential for those charged with the responsibility of being a ship’s captain. Eventually all of us become an open book for all who care to see. None of these captains was a pirate. None put a gun to the vessel owner’s head. Each came up through the ranks, so to speak, with many years of seagoing experience. They did not steal command; they were willingly given it by the owners or their representatives.

Perhaps these owners relied too heavily on the fact that these masters were duly licensed. In the United States, maritime credentialing is predicated solely on sea experience and knowledge that can be tested in a classroom. Unfortunately, evaluating an individual’s navigational standards or judgment and character is not something that can be determined by a government agency.

The two investigating boards also failed us by not questioning these masters’ fitness for command and the systems that put them in place. There is little doubt that the investigation of the Sewol tragedy will do otherwise.

It should be remembered that the master is not required to go down with the ship. However, let’s hope if it’s our ship that’s sinking that the master is the last one off. Merely going to jail or the gallows won’t help very much.

See related article -

- Questions of Character

Richard Dein has more than 50 years of commercial and recreational maritime experience, including 24 years of active duty in the Coast Guard. Since 1979, he has served as a maritime expert in federal and state court for marine accident reconstruction, navigation rules, seamanship, search-and-rescue, and towing. Dein, who resides in Annapolis, Maryland, has held a Coast Guard master’s license continuously since 1962.

July 2014 issue