As I hear about events, like BP Oil rig, Batteries in the 787, Newtown...etc. Now the Carnival cruise ship Triumph. My Quality Assurance mind automatically goes back to the same thoughts. What will the Root Cause Analysis show of this event. Yes there was an engine fire. I researched Carnival incident history and guess what. This is not the first time Carnival had problems with fires in the engine area.
According to the processes in SMS, which we are all very familiar with, analysis of all incidents, hazards and accidents must be done in order to come up with elimination or mitigation of the root causes to prevent these from happening again. Well, here we have another case of ignoring the “Variations” that have occurred in order to continually improve the system to prevent these incidents from reoccurring.
In addition, in performing a bow-tie diagram, you could have figured out what would be the best decision to make after the fire and power outages to reduce the impact to the passengers and crew. What do we do if the bathrooms don’t work? How do we feed everybody in an orderly manner? How to we handle special need customers? Do we have a plan to get the passengers off the ship as soon as possible? These and many other questions should have been resolved BEFORE the incident takes place.
THE LESSON: Unfortunately Carnival Cruise lines will know what the cost of this event will be. You can guess it will not be cheap and deeply impact on the company’s financial health. Not to mention the loss in future customer loyalty. That will be the biggest fallout from this incident. ..........Your thoughts