Thursday, April 24, 2014

THE S. KOREAN FERRY DISASTER REVIEW, OUR ENTIRE ANALYSIS IN ONE PLACE

http://www.aol.com/article/2014/04/21/south-korean-president-ferry-crew-actions-murderous/20872548/?icid=maing-grid7%7Cmain5%7Cdl6%7Csec1_lnk3%26pLid%3D466971

EDITORIAL NOTE: Presented below in chronological order are our three analytic posts on the South Korean Ferry disaster, our latest observations, and our final conclusion. We will not address this subject again until the official reports are issued closing the case.

LET'S NOT LET ANGER OVER SOME OF THE CAPTAIN'S BEHAVIOR  CLOUD THE SEARCH FOR THE REAL CAUSES OF THE CAPSIZE AND LOSS OF LIFE


History Teaches Us That Not All Of The News Coming Out Of Such A Disaster Is Accurate. Forensics Tells Us That Accidents Are Usually The Result Of A Causation Matrix Though There May Be A "Proximate Cause. Experience In Accident Investigation Tells Us To Suspect That In This Case The Actions Of The Captain Before And After The Capsize Are Probably In The Realm Of "Contributing Factors" And Not The "Proximate Cause' 


The Captain had the misfortune of surviving the accident and is now the target of angry parents of the school children lost, and some very angry over statements by government officials. South Korea seems to be in a scapegoat search mode, vice a skilled and analytic forensic assessment of what happened, in the hopes of not only punishing anyone guilty of negligence, but also for identifying the causation matrix so that similar mistakes may be avoided in the future. South Korean President Park Geun-hye used terms like "unforgivable murderous behavior " when referring to the Captain and the conning officer who have been arrested. He is using such language at a time when his government is being subjected to a lot of negative criticism over its handling of the rescue. We think that the rescue efforts, to the extent that we know the details have not been manifestly sub par, despite the tremendous loss of life. We suspect that the real and justified criticism of the South Korean Government may come later when the preventative side of ferry regulation is examined. This is likely coming quite some months from now when media interest has died down a bit and public opinion cooled a bit. Who could blame a politician  for wanting to identify a "villain" early on and hopefully have him neatly buried before the real accident causation matrix with its potential for exposing governmental contributions is completed.

 The South Korean Coast Guard  
Is well regarded as a professional and ethical maritime safety, police, and investigative agency and follows the para naval tradition of well organized coast guards world wide. This organization is subordinate to civilian authority but not directly run by politicians. Coast guards around the world are known for forensic analysis into accidents in depth, and publication of forensic analysis that are done in the time required to get to the facts and not one timed to media driven public opinion. These organizations often don't spare themselves scrutiny or criticism in the wake of such accidents. The search for the real proximate cause and all of the contributing factors is rigorous and disciplined.

NOW SOME THINGS ARE OBVIOUS:

 The proximate cause of the accident was the capsize of the vessel. The real forensic question was, what was the proximate cause of the capsize? Regardless of the types of internal or external forces working the hull at the moment of capsize, the "proximate cause " of capsize is pretty much that the ship's center of gravity rises above the center of buoyancy. (We are over simplifying a bit, professionals will note that we do not address mathematical modeling concepts of some of the related variables such as "righting arm". Because of the variables a capsize does not occur each and every time that the center of gravity gets above the center of buoyancy, but in every actual capsize the center of gravity rose above the center of buoyancy by the factor required for the particular vessel under the particular circumstances  necessary to capsize.) SO IN THE SEARCH FOR THE PROXIMATE CAUSE OF THE CAPSIZE WE MUST DETERMINE WHAT CONDITIONS INTERNAL OR EXTERNAL OR COMBINED SENT THE CENTER OF GRAVITY ABOVE THE CENTER OF BUOYANCY. RIGHT NOW WE KNOW VERY LITTLE.

SOME THINGS WE DO KNOW:

 Ferries are designed to be very stable and their conditions of load are very predictable. Tankers  cargo carriers, and semi submersible drill ships often require complex stability calculations to insure that they remain stable during changing conditions of load. The masters of such vessels must be highly skilled and competent in stability calculations. By contrast most ferries are designed to be very stable over their entire range of anticipated load. Where the tanker master may need to recompute stability and counter ballast after taking on cargo, discharging cargo, or fueling, the ferry master may only need to assure that he never violates any of the conditions of his stability letter, which are based on an "incline experiment conducted on the vessel or a sister ship at a ship yard.  The conditions are usually pretty simple and easy to check for before getting under way. Typically they include a requirement to maintain a certain range of fore and aft draft marks. This can be checked by a ship's officer visually before getting under way. Generally no bilges or voids may be flooded, also easy to monitor. 

 But there are potential pitfalls to this simple stability regime. If a ferry is modified, the permission of the national regulating agency such as a coast guard and the classification society must be conferred. Owners sometimes send their passenger vessels to the yards, lay off the crews or send them on vacation and then engage in modifications that profoundly affect stability but improve profit in their minds untutored in any real understanding of the nautical arts and sciences. At such times the non mariner managers often neglect to notify those pesky coast guards and classification societies. When the crew returns the stability dynamics have changed but they still have the same old "stability letter to guide them. It should certainly be understandable that a master who has been subjected to a deliberately deceptive practice may not immediately discover it. That failure may involve some level of "negligence" but it is hardly "murderous". We are not saying that this happened, only that it is among the type of things that have happened in the past in similar cases. No one really knows yet exactly what happened to cause the capsize. We offer this example as simply one of many available where the Master has little or nothing to do with the cause of capsize.

THERE WAS LOSS OF LIFE IN EXCESS OF WHAT WOULD HAVE BEEN THE CASE HAD THE MASTER ORDERED ALL PASSENGERS ON DECK AND IN LIFE JACKETS EARLY.

  A prudent master, under the circumstances of a suspected loss of stability in the ocean around Korea in April, has to be concerned with a hazard to his passengers in addition to drowning. Hypothermia is a killer. Lots of the passengers of the TITANIC got off the ship in very well designed "life jackets" ( personal flotation devices). They did not survive long in the cold water. No one yet knows exactly what the reasoning process of the Captain was in the way that he ordered the eventual abandonment.  Certainly potential time in the water and even standing out in the cool weather out on deck and the dangers of hypothermia were part of his decision matrix. Unfortunately with the South Korean head of government already referring to the decisions as "murderous", and the Captain already under arrest and facing criminal charges, legal defense considerations are pretty much going to drive any discussion of this decision matrix, which may hold much potential for gaining information that could prevent loss of life in any future incident. 

 THE CAPTAIN SURVIVED THE ACCIDENT:

 Captains do sometimes survive accidents that sink their ships and kill some of the people on board. Its not a crime, its the luck of the draw subject to certain required standards . The standards don't require a Captain to go down with his ship. But they do impose some serious actions upon him that often cause him to be the last person off a sinking ship, and very often the last man doesn't make it , hence the old saying a "a good captain goes down with his ship". We observed this issue not that long ago off of Italy and we posted a description of the expected behaviors of the large passenger vessel master penned by an American master. We think this essay provides an interesting model of how the ferry Captain's behavior will ultimately be judged in a dispassionate tribunal.We reprint it below in its entirety:

MERCHANT MARINE INTERESTOpinion

Editor's Note: We ran this guest blog shortly after the COSTA CONCORDIA accident. Since then there have been some other accidents and another recent cruise ship incident that didn't involve sinking, but again there is a lot of professional discussion and not a few formal regulatory inquiries going on over the duties of the master. NOW we learn that the Master of the COSTA CONCORDIA is on trial in Italy on multiple counts of man slaughter. We thought this post is again relevant and worth reexamining.

The COSTA CONCORDIA: Must a Captain Go Down with His Ship?

File:Aivazovsky - Shipwreck.jpg
Public domain image of  19th Century ship wreck in progress
  An old seaman's saying goes "a good captain goes down with his ship". The typical "land lubber" often asks why. It's a legitimate question. My phone has been ringing off the wall and my E-mail stuffed with requests for explanations all day. Why would I have any idea?

 I'm a licensed American Merchant Marine Officer who has served as Master and Pilot on large American registered excursion vessels and ferries ranging from 400 passenger capacity to 1400 passenger capacity. Those who know me know that I've had some job losing disputes with management over passenger safety. In one well known argument, that I actually won, I asked a vessel owner who at first didn't want to order the additional children's life jackets that I asked for to imagine himself in my position if something happened. What kid do I deny a life jacket to? How do I ever leave the sinking craft in an adult sized life jacket if children don't have one? What do I tell their mothers? You might note that in that argument one thing I was trying to preserve was not only the lives of children too small for typical life jackets ("personal flotation devices " in the parlance of the regulations) but my own apparent right to abandon ship. That's right folks the Captain has an inherent right to take action to save his own life if he has fulfilled his duties. The reason that "good captains" often go down with the ship is the nature of the duties.  Let's look at those duties and why they so often lead to a Captain's death.

 The first duty of a Master in a situation likely to result in the total loss of the ship is to decide to either abandon ship or conduct damage control. Depending on the size of the vessel, and the professionalism of the subordinate officers available to him, and the nature of interior ship communications, this duty may require a personal damage survey and assessment.  Some Captains have been lost, trapped in rapidly flooding compartments, or blown away by fire and explosion during the initial damage assessment survey leaving the decision to abandon to a surviving subordinate. If the Captain decides to conduct damage control the decision to abandon ship is deferred but damage control may include a decision for partial abandonment when passengers are involved. The Captain may order everyone not involved in dewatering, counter flooding, or fire fighting to take to the life boats. If the damage control efforts go south it is the Captain's duty or that of the surviving senior officer to order abandonment. Of necessity, the Captain is the last man off, sometimes he doesn't make it.

 Regardless of how soon after discovery of flooding or fire abandonment follows, the Master always has the duty to insure that abandonment is carried out as orderly and safely as possible under the circumstances. This means a maximum effort at accounting for everyone and seeing them safely off the ship. What constitutes a good faith effort? Generally as good of a head count as possible under the circumstances and a diligent search of all unflooded or combustion free compartments for any missing. Under ideal conditions there is a life boat muster roll, orderly embarkation, a head count, a search for anyone not answering muster and an eventual declaration by the Chief Officer to the Captain that all hands are present or accounted for. "Accounted for" means that any missing crew or passengers were seen jumping off the ship, or did not turn up on a search of unflooded compartments. Ship's officers aren't required to enter burning compartments, or flooded, or flooding compartments once an abandonment order is given. Abandonment is ordered when damage is progressive and proceeding at an irreversible rate. Only after the maximum possible effort under the circumstances of the individual case has been made to account for, and evacuate all crew and passengers, may the Captain disembark. Yet under many circumstances he may not be able to disembark yet.

 There was a recent case of a fishing vessel in Alaska where after the crew was in inflatable life craft the Captain became aware that the life craft's emergency alert and locating device was not working. He returned to the pilothouse and successfully got off a radio message to the U.S. Coast Guard with the position of his vessel, its survivors, and the nature of their distress. This radio call is credited with the coast Guard's successful rescue of the crew before they could die of exposure, a not unlikely outcome for a fishing vessel in North Sea if no body knew they were in trouble and where they were at the moment of abandonment. Unfortunately that final trip to the pilot house cost the Captain his life but saved the lives of his crew. He was a "good captain" who went down with his ship. Not because he was obligated to do so on some principle of honor but as he continued "to work the problem" he ran out of time.

  My Uncle, Captain Earnest Douglas, a Master Mariner during World War II survived the sinking of his ship by a German torpedo. Fortunately the ship went down somewhat slowly. He had ordered abandonment and received the Chief Officer's report that all surviving crew were "present or accounted for." He secured the bridge, took the log and other papers not on the destruction bill and embarked the life boat where he checked the roster. One old seaman, with a bit of a drinking habit was not present. Asking questions he learned he had not been on watch in any damaged compartment and was in fact off duty. asking a few more questions he became dissatisfied with the nature of the pre- abandonment compartment check. He climbed back up the Jacob ladder determined to search the sinking ship, and as luck would have it, discovered the old seamen unconscious and un-wakeable in his bunk. He carried the old man down to the life boat. Uncle Ernie did not go down with his ship, nor suffer any recriminations for its loss.

Sometimes after total abandonment, the master still stays aboard due to other duties. When a master orders abandonment out of an abundance of caution on a ship progressive but slow flooding and has gotten off a call for help, he may stay aboard. While the ship's crew may have lacked the equipment to stop the flooding he may be aware of commercial salvers or Coast Guard like forces on the way. When they arrive his presence is needed to assist with the salvage effort and to preserve certain rights of the owner. Sometimes such Captains miscalculate the rapidly changing stability situation and get caught in a violent capsize while the vessel still seems to have ample free board to stay afloat. The "good captain" knows his duties and in an abandonment situation these duties often extend his on board time into unfortunate circumstances.

Those captains who have of late claimed that they abandoned ship before all crew and passengers are off in order to manage rescue and salvage efforts from shore are completely out of touch with reality. Ashore is where we find professional salvage masters and Coast Guard rescue coordinators. These people are far better qualified and connected to move assistance from shore to distressed ship. The Captain is needed on scene, preferably aboard, to help coordinate where his superior knowledge of his own ship and the situation can do the most good. There is no international law that outlines these duties of the Master on a sinking or burning ship. However some national laws, and this is true I understand of Italy recognizing these traditions borne of necessity, do require the Master to stay aboard or on scene until relieved by proper authority or forced off by real necessity. No Captain is bound by any tradition to go down with his ship but honor, tradition, and some law require him to continuously "work the problem." Some times the "problem wins."

 Occasionally, as may have been the case in the TITANIC, a captain works the problem until almost the bitter end and deliberately decides to forego his last chance for survival. The Captain of the TITANIC is mostly remembered as a tragic figure today, an unlucky but brave individual. Suppose he had survived? Would he have been remembered for those he saved or lost? How would the story of his failure of moral courage in not refusing corporate demands to run at high speed through known ice burg infested waters have played out in the media of the day? Because he went down with his ship "working the problem" history has not judged him a villain.  "Good captains go down with their ship" because they either run out of time or make a choice but not out of any tradition or law that requires it. It has cost me a job or two, but I find the moral courage to argue with, or refuse an employer over a safety issue infinitely preferable to having to exercise the physical courage of a "good captain" in an abandonment situation. I believe that such exercise of moral courage, coupled with a little luck, is responsible for my arrival at the safe harbor of 63 and retirement without losing a vessel and facing the "good captain's" unfortunate choices. There were a number of owners who refused to acknowledge me as a "good" captain, but there are no passenger or crew ghosts haunting me.

Capt. Ray Bollinger
American Master and Pilot

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 Well we hope we have given our readers a lot to think about; and maybe our readers won't be among those in the rather obvious rush to judgement going on. At least no one will be waiving our coverage of the event around as "evidence" of why any particular individual ought to punished right now! We can never say never, we've seen some pretty dumb things come out of our own White House at times regardless of who was in office, but generally our presidents have mostly let senior Coast Guard officers directly address the nation under similar circumstances. South Korea has a professional coast guard, but the world is not hearing from them. If we were, we would probably be hearing a lot of cautionary language about how the investigation is in a very preliminary stage and that people shouldn't jump to any conclusions.There are politicians, ferry company managers, safety professionals, perhaps engineers, or classification society surveyors who may be contributors to causation in this case. All would love to see this case closed with the speedy legal conviction of a single "villain" . Well "it ain't over till the fat lady sings" and the fat lady is the full professional forensic examination that eventually will take place. The "fat lady's song will be all about proximate cause and contributory factors and all of the humans who contributed. The complete cast of characters is not on the stage yet.

 Please take a moment and contrast our coverage of the event with the coverage of the situation on scene :


ARTICLE AND VIDEOS AVAILABLE ON AOL
By GILLIAN WONG and HYUNG-JIN KIM

"JINDO, South Korea (AP) - South Korean President Park Geun-hye said Monday that the captain and some crew members of the sunken ferry committed "unforgivable, murderous behavior," while criticism of her own government's handling of the disaster grew".....Read More




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SOME STORIES OF CREW MEMBER HEROICS ARE STARTING TO EMERGE AS THE KOREAN GOVERNMENT AND PUBLIC CONTINUE TO HEAP BLAME ON THE CREW


READ MORE ABOUT CREW ACTIONS AND RECENT RADIO TRANSCRIPT REVELATIONS
http://www.aol.com/article/2014/04/22/acts-of-bravery-emerge-from-pilloried-ship-crew/20873296/?icid=maing-grid7%7Cmain5%7Cdl2%7Csec1_lnk3%26pLid%3D467487


EDITORIAL NOTEThis post follows up on our post of Monday April 21, 2014 where we first examined what we know of this accident and reprinted an article clarifying the master's responsibilities in an accident. To read our original post . To follow our analysis as it unfolds we suggest starting at the beginning with our original post. Our analysis is very different from the official S. Korean government pronouncements put out so far and very different from the media opinions thinly disguised in the reporting so far. We suggest our analysis only to those who can handle fact based maritime forensics if you are simply looking for a scape goat and are willing to allow  everyone else in the "causation matrix" a free ride then stick with the general media. But our analysis concerns itself with the proximate cause and all contributing factors and the responsible parties for both the proximate cause and all contributing factors. 

We believe the above image to be a South Korean Coast Guard photo of S Korean Coast Guard helicopters working the rescue attempt of the capsized ferry SEWOL. It is similar to a number of AP photos which may be viewed at : https://www.google.com/search?q=Korean+Ferry+SEWOL,+photos+official+company&tbm=isch&tbo=u&source=univ&sa=X&ei=tdJWU5nsH-KV8gH1q4DoDg&ved=0CDoQsAQ&biw=1304&bih=707#imgdii=_  you will also find photos from other sources there as well. We have at least studied the photos posted at the above linked site and can find no evidence of inflatable life rafts or rigid life boats. Look carefully at the top most deck , in this photo turned on its port side. The top deck is the typical storage spot for automatically released inflatable life rafts, often the back up system for large cruise ships. We also looked carefully along the sides of the ship in photos taken of it during normal service and could see no evidence of rigid life boats or inflatable evacuation rafts. 

 Yet this ship was operating along an open ocean route in a cold water region. If we are correct in assuming that the ship had no way of evacuating passengers except to put them in life jackets and in the water, the reported repeated discussions between the ship's deck officers and the Korean Coast Guard Vessel Traffic Center about how soon could the ship expect help to arrive makes an awful lot of sense. As we speculated in yesterday's post, the deck officers and the Master were possibly facing a Hobson's Choice expose their passengers to death by hypothermia while awaiting rescue or delay evacuation until rescue was at hand. The warmest we would have expected the water temperature to be at that location, and this is highly optimistic on the side of warmth, would be 55 degrees F or 12.78 degrees C. In water temperatures between 40 and 60 degrees F survival times vary with age, and physical condition and what a person is dressed in when they enter the water but the range is 1 to 6 hours with 1 to 3 hours being more likely, and time to becoming unconscious can be as short as thirty minutes. The colder you are when you enter the water, the shorter the survival time. So standing around on a cold deck a long time waiting to enter the water may extend your over all survival time but not your survival time in the water.

 Now assuming, remember we are just speculating based on photographs; that the ferry did not have life boats or inflatable evacuation rafts so that there was no way to get the passengers off dry shod. Now doesn't the radio transcript between the ferry and the S. Korean Coast Guard Vessel Traffic Center (VTC) make sense? The ferry officers keep asking when they may expect help because they are trying to extend survival times. The VTC never gives them an answer because frankly while the VTC probably knows exactly how long it will take to get the first coast guard helicopters on scene they also know the small number of helicopters they can send won't be able to carry but a handful of people at a time. Behind the scenes the VTC personnel are working with their Search and Rescue counter parts to see what kind of surface vessel response they can put together from both S. Korean Coast Guard assets and "Good Samaritan" commercial vessels". At the moment the VTC is talking with the ferry, the total vessel response possible is not known yet, the transit time of the first vessels to the scene is not known, and their carrying capacity for survivors is not known. This is all "Ops normal" in most any coast guard around the world under similar circumstances. No country has instant rescue resources for hundreds of off shore passengers always ready at hand for immediate deployment. The first asset on scene will likely be a helicopter and it won't be able to carry many people.Put people in the water too soon and when the surface rescue fleet arrives, much like in the Titanic case , they are just collecting bodies floating in life jackets.

 The S. Korean Vessel Traffic Center (VTC)  repeatedly urged the ship's officers to get the passengers dressed as warmly as possible and into "life rings". The ferry replied that their public address system no longer worked . The VTC urged the ferry to send crew members below and to start getting the passengers ready for evacuation even though they could not yet give a time on scene for rescue. If you read the stories of crew heroism linked to at the start of the article you will note that it contains stories of crew members below decks and in interior public spaces doing just that, in some cases giving away their own personal flotation device (life jacket) to passengers when there were more passengers in a space than there were life jackets in storage. Again this would be a normal situation, there must be one personal flotation device per person carried aboard but no maritime nation requires a ship to carry 100% of the requirement in each and every public space aboard. Typically ethical companies carry more than one per person, but storage is always some what spread out. NOW WE HAVE TO ASK AT THIS POINT  IF THE FERRY, IN FACT, AND WE NOW THINK IT MORE PROBABLE THAN NOT ; DID NOT HAVE LIFE BOATS OR EVACUATION INFLATABLE RAFTS WHY NOT?

 We don't know S. Korean passenger vessel safety law but we know the basic trend in such regulations in a lot of nations. We think it more probable than not that the ferry was not required to carry either life boats or inflatable evacuation rafts. The National Transportation Safety Board NTSB in the United States has had a recommendation pending for about a decade for the U.S. Coast Guard to require dry shod evacuation on all passenger carrying vessels. To this date the U.S. Coast Guard has not acted on the recommendation. The U.S. , nearly a century after Titanic , has many exceptions to the life boat rule of one seat per person duplicated on each side of the vessel for some fairly large passenger excursion boats, crew boats and ferries in the warmer climate zones of the U.S. Yet as the NTSB points out despite fairly mild winter air temperatures the water temperatures in winter over most of the United States inland and coastal waters will induce hypothermia in very little time. After a small charter fishing boat with no inflatable raft put its passengers and crew in life jackets into the water and ended up losing most to hypothermia before rescue, the NTSB recommended that there be no exceptions to carrying some form of dry shod evacuation flotation for any passenger carrying vessels. Owners of such vessels on "short route services" ( variously described by different industry interests ) have fought vigorously to avoid the carriage of this type of life saving equipment calling it an unnecessary expense. The U.S. Coast Guard has yet to respond to the NTSB. Usually the U.S. has the highest life safety requirements of any maritime nation, the reason most often cited by owners for registering their vessels outside of the U.S.  So if South Korea had no life boat rule for such a ferry, not only was it's running without life boats or inflatable evacuation rafts technically legal, it was well within discernible international norms. The problem is the international norm is immoral and irresponsible in light of what is known today about hypothermia.

 Now do you begin to see that the Captain's decisions involving delay of getting every one on deck were far from "murderous" but in fact due to circumstances beyond his control including the possible facts that by law and corporate greed he could not get evacuation rafts for his ship if they were not required by regulation and management viewed them thus "an unnecessary expense'? 
Add to that the unforeseen loss of the public address system and a picture emerges when combined with stories of heroic crew members below decks passing out life jackets of a ship trying to comply with the VTC's recommendations, but also trying to guess against a host of unknowns the best moment to put everyone on deck and when to commit the people to the water where upon the slow and varied by individual death process by hypothermia begins. "Murderous decisions", or difficult and dangerous ones with circumstances setting up the potential for disaster far beyond the control of the Captain, or any of the crew. This is what we mean by contributing factors. Who was responsible for the contributing factor of no evacuation rafts and all of the complications that beset the crew with in terms of abandonment timing?  The government failed to pass the necessary law. Out of a lack of foresight, or based on lobbying by the ferry owners?  The owners who are not obligated to run their vessel safety programs on minimal regulatory compliance standards, had the choice of only carrying the minimum the government required or properly equipping their vessels per modern best recommended practices. The Captain may have made the final decisions but his choices were limited by government and management years before the incident happened. Who really showed the callous disregard for human lives the Captain, the government, or the owners. In hind sight the Captain's decisions were not the best. But the decisions by government and the ferry owners managers were made in the cold light of day without the decks listing and the hull flooding and doomed children screaming. The apparent, and again we stress the word apparent; we aren't official investigators, and don't have access to direct evidence; lack of evacuation rafts is, if a fact, a major contributing factor in the death count. The Captain and none of the deck officers were responsible for the lack of of such life saving equipment.

 In America there are big excursion boat companies that have been exempted from a variety of safety regulations including inflatable evacuation rafts by operation of regulations. Yet in some markets you can observe more than one excursion vessel operator; often most are operating on minimal regulatory compliance. But occasionally one will be operating on best recommended practices. Observe the steamboat NATCHEZ in New Orleans


,
Photo by Infrogmation , licensed:  GNU Free Documentation License
 This large passenger day excursion boat operates in a busy river harbor carrying no over night passengers. Potential assist tugs and other potentially helpful craft are always in sight. The banks of the river are only a stone's throw away. They operate in a climate as near to tropical as you can get and still be in a technically temperate latitude.  Because of these conditions their Coast Guard Certificate of Inspection does not require them to employ watchmen ( a sort of junior unlicensed mate), but they do, in fact enough to keep all passenger decks under watchful surveillance when underway. They also aren't required to employ a non navigating mate, a requirement in the over night service, but they do. If ever an argument could be made that people in life jackets wouldn't wait long for rescue their route would qualify for that argument, but the Natchez carries inflatable evacuation rafts. If the company was run by the typical bean counters their safety program would be gutted as over kill. In fact it is simply a program based on best recommended practices, by ethical management and skilled boat officers. Operating on the assumption that putting passengers in the water would be the routine response in an emergency never crossed the New Orleans Steamboat Company's corporate mind. Revenue/ Profit wise they do just fine despite the extra passenger safety overhead. Safety is just as much a mark of quality in the cruise / excursion/ ferry industries as good food and general cleanliness. It is not a money loser except to short sighted management. 

 So as to the contributing factor of a lack of dry shod evacuation equipment, who should the Korean public hold responsible / liable, the Captain and the one mate who has been charged and described as "murderous and negligent", or the government and the owners? The government chose to not update the safety regulations to reflect modern knowledge of in water survival times. The owners chose not to set up their safety and survival equipment in accordance with best recommended practices and instead chose minimal regulatory compliance as their standard. Again this assumes that in fact the ship did not carry such equipment. If it did then the question should revolve around why the equipment was not deployed.

Finally as we noted in yesterday's post, the proximate cause of the loss of life is the capsize.
It would be difficult for a Captain to cause that by his sole error. We note that the S. Korean Coast Guard has detained the Chief Engineer. But that doesn't mean that he is responsible either. There are dozens of potential reasons that could cause sudden flooding and the resultant threats to stability. Some of these conceivably could be caused by manufacture's defect. Some failures may be of equipment subject to third party inspection and certification, classification society surveyors,  or SK Coast Guard inspectors or others may have failed to detect a critical defect, even then failure to detect a defect may not be evidence of negligence.
Our advice to the South Korean public is to with hold judgement until the information starts coming from reliable sources like the RK Coast Guard and any relevant marine transportation investigative body.  

 Generally, you may pretty well accurately presume that anything coming out of the mouths of elected officials or corporate officials right now is self serving and done in anticipation of deflecting liability for contributing factors. By arresting and criminally charging specific persons and attempting to vilify them in the media a defensive legal barrier is now erected around the accused and it becomes unlikely that any useful information that could be used to prevent this sort of thing in the future will  be forth coming as it would be if this thing was being examined in a neutral and forensic manner with judgement being reserved until all of the facts were in. Declarations of murderous intent by the President not with standing, you can bet that there is such an examination starting up within the SK Coast Guard system and that you won't hear much until they have some real verifiable facts available. 



                                                                                                                      
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THE OWNER ADDED AN EXTRA DECK TO INCREASE CAPACITY OF THE FERRY

 


A recent report by the KOREA HERALD names business man  Yoo Byung-eon  as the owner of the ferry SEWOL. A controversial figure you may read about him by following either of the links above. Apparently he is something of a news worthy figure, to put it kindly , in Korea. There may have been something of a scandal behind his original acquisition of businesses licenses to run ferries. However from a maritime accident forensics point of view we find these two facts revealed in the KOREA HERALD article to be most informative. First  the ferry was acquired used from Japan. Few nations allow the purchase of foreign built vessels for domestic service between ports of the nation. This is called cabotage law and is quite common among seafaring states. So now the question must be asked was it against applicable South Korean law at the pertinent time, or did the owner have an exemption, and if so how did he come by it? There are two reasons why most nations frown on the use of foreign built vessels in the domestic ferry trade. First part of the reason for cabotage law is to protect the domestic ship building industry, allowing operators on domestic routes to buy foreign defeats this purpose. Second such equipment is often well used and repair, maintenance, and classification society inspection records sometimes a bit jumbled and confused.

 The second enlightening aspect of the Korea Herald article is that this owner had an additional deck added to increase passenger capacity and revenue. Now here we find another probable contributing factor to the proximate cause of the accident, the capsize. Such an addition changes the location of the center of gravity and in most nations such a modification has to be pre- approved by the Merchant Marine regulating body after a through plans review. After the addition, a new inclining experiment must be conducted and any corrections such as additional solid ballast made to assure that the center gravity has not risen too close to the center of buoyancy, a precondition of a capsize. Any errors or short cuts in this process and you have a probable major contributory factor in the capsize for which government, marine surveyors, the modification design naval architect, and the owner may have joint or several liability or even criminal culpability. It is unlikely the master presently under arrest had much if anything to do with this modification.

 Now keep in mind that there is also evidence of a hard and sudden turn to starboard. The Captain was not on the bridge for that turn, the mate was but both are under arrest and if their attorney is smart, they are probably not talking. There is also evidence of broken straps and lose cargo or automobiles in the main hold. All of these are contributing factors in the proximate cause of the loss of life, the initial capsize. 

As we said before ....it ain't over until the fat lady sings.

                                                                                                                                             

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FINAL NOTES:

 Among the additional factual notes reported since our last post and our observations and comments:

1. REPORTED FACT: The mate on watch made a hard turn at full speed and is accused of thus operating recklessly.

OUR OBSERVATION: Such a turn would not be the norm as it would give the ship , if the ship had proper conditions of stability , a slight and temporary list. Such a list could cause some passengers to lose their footing, and generate a bit of alarm. However, a ships initial stability must be such as to not capsize in such a maneuver as hard turns at speed are sometimes necessary to avert collision or other hazard. While the Captain was not on the bridge at the pertinent moment, we doubt that the new mate was "show boating". The mate  would know that such a sudden maneuver, indeed if there was such, would bring an off duty Captain to the bridge as fast as his legs could carry him. The perception by some, that there was a hard turn at speed just before the capsize may be a function of a rudder malfunction forcing the rudder position over hard without human intervention. With the mate under arrest and already facing criminal charges these questions won't be answered for quite some time. If the observed "turn" was the result of a mechanical malfunction this contributing factor could be the liability or culpability of engineering crew, incomplete survey, or even manufacturer's defect, or some combination of any two, or all of the above. 

2. REPORTED FACT: Cars or other cargo broke loose from their securing devices and were free to move in the direction of the list.

OUR OBSERVATIONS: (1)  If true, free weight movement would be the type of contributing factor that could radically change the position of the hull's center of gravity in response to a sharp turn induced list that would normally not induce capsize.  (2) Another sudden stability destroying factor that may have acted in concert with the contributing factor of free weight movement caused by loose cars or cargo would be "free surface effect", the movement of liquids in the bilge and  / or tanks. Some combination of these types of contributing factors generated the "tripping moment" when the center of gravity of the hull rose vertically above the center of buoyancy. If these prove to be contributing factors and they commonly are in capsize events, not all aspects of these contributing factors are in the hands of the Master, Mate, and Chief Engineer, now under arrest and criminally charged and understandably not likely to be saying a lot. (3)  Regardless of the reason for the sharp turn, we have to keep in mind that there was an addition to the vessel after purchase that deviated from the original design and we don't yet know the effects of this alteration on the vessel's stability or how well the owner communicated those changes to the ship's officers. Moreover, if the alteration as completed made the ship more "tippy"the entire alteration design and regulatory approval process needs examination.

3. REPORTED FACT: Dead children were found inside interior compartments with broken fingers indicating terrible post capsize struggles to get out of the interior. We now know that that the Captain had rightly considered the dangers of hypothermia in delaying evacuation. We also know that after radio discussion with the S.Korean Coast Guard's Vessel Traffic Service there is evidence of an attempt to move the passengers to exterior decks , some quite heroic. by crewmen hampered in this endeavor by a lost public address system. There is a cultural element involved with the number of the trapped children. They were obedient and respectful of their elders and very reluctant to deviate from the last clear instruction received. Western kids would have run right over their teachers and the crew to get out on deck, not because of any superior judgement concerning their own safety , just to see what was going on and to hang out. In this particular situation the Western children would have accidentally enhanced their survival chances, but in most situations the opposite is true. As parents and world travelers ourselves it does not appear to us that there is any happy medium found in any culture in the world. There was definitely a cultural contributory factor at work in this accident in terms of the total casualty count;  but the route to insuring that such a cultural factor never again endangers children on a ferry doesn't involve changing the culture but in improving interior ship's communications with redundant and less failure prone equipment. This again is a task for the marine safety regulators.

CONCLUSION: We have done our best to try and inform our readers of the type of analysis that goes into a professional ship wreck forensic examination using media reports for assumed facts. The reader must keep in mind that all of this has been based on assumed facts not in evidence. We assumed certain reported elements as facts to demonstrate the analytic process. The people of S. Korea have to now let their Coast Guard and Transportation authority professionals do their work. We know from experience that it is painstaking, detailed investigative and analytic work that takes time, months. One of the aspects of modern life that makes the work of marine forensic professionals exceptionally difficult is the modern day rush to criminalize marine and other transportation accidents. This human tendency has been enshrined in law by very human and politically motivated legislators all over the world of late including the United States. rarely are such accidents the sole result of actual misbehavior of one officer or a small group of officers. There is almost always a complex causation matrix. The causation matrix may or may not include elements of negligence. The contributory factors closest to the proximate cause may be by desk bound managers or regulators ashore. It takes time and skills to sort these things out. The last thing that is needed under such circumstances is a national chief executive who doesn't know port from starboard mucking about hurling charges of "murderous negligence"before any facts are in and while the proper experts have barely started work. But of course such laws imposing early criminal liability of certain obvious targets with few proof requirements work to the advantage of all of the desk bound managers, third party inspectors, and regulators who often have been as negligent or far more negligent than the ship's officers. 

 "It ain't over till the fat lady sings". We think the "fat lady" when she appears will be in a South Korean Coast Guard Officer's Uniform and the chorus of the closing song will be a far cry from "The Captain did it, let us hang him and go home." No we think when the matter is finally addressed by the S. Korean Coast Guard there will be a few "fat cats" squirming. These will be people as yet mostly unnamed and not being called "murderous" by elected politicians. Politicians want to make electoral capital out of everything. Coast Guardsmen want the truth, and the information needed to prevent this from happening again. The South Korean Coast Guard is a professional and credible organization of marine professionals, give them the time to do their job. The lives of future ferry passengers depend on their performance. Professionally, the SK CG knows this and cares more about being able to retire without pangs of conscience over failure to speak the truth to power, no matter how personally painful, than politicians care about reelection. There may be some hard feelings over the rescue effort, but we can tell you that we saw nothing  negligent in the effort. No nation can afford to provide instant massive air borne massive maritime evacuation services, or post rescue boats every half mile along the coast. Rescue boat design is always a compromise between speed, stability, sea keeping capacity, on scene endurance, and towing power. It is because rescue can rarely be instant, that prevention is so important. To the Coast Guardsman this accident was a "failure of prevention". The South Korean Coast Guard can and will get to the real answers. Now that hopefully we have provided some insight into what is involved in that process we are going to take our own advice and stop talking and await their report. 

Johnas Presbyter,  Editor

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