Monday, April 21, 2014



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.


 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.


 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.


  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. 


 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:


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

 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 :


"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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