Friday, February 15, 2013

Carnival Triumph: Evidence of Lack of Control.

Safety Management System Quality Assurance could have Triumphed in this event:


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. 

Some questions come to mind while reading about this event : Why didn’t they seek to dock or tender the ship as soon as possible to reduce impact on the passengers. The cost of that would certainly be less then the fallout now. The ship passed several ports in Mexico in those 5 extra days. Also, the passengers had a hard time in getting meals. There was no procedure that could have formalized that processes to ease stress. Also, could there have been a contingency plan to mitigate the sewage problem in a more sanitized way then bags and buckets? Just a few thoughts that come to mind. 

Of course the best scenario is to PREVENT the incident from happening to begin with. Process Identification, then Analysis followed by Process Improvement. All of this could have been prioritized through Risk Assessment. 



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




2 comments:

  1. I totally agree with the comment that the incident will impact on the company's financial health. There are organizations who do not see the value of one dollar, and there are organizations who do not see that the value of of a dollar is in quality assurance. When hitting the fork in the road one must be prepared to take the road which leads to zero tolerance to compromise safety. Safety and risk management is to manage the triggers which activate hazards.

    farnorthaviation

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  2. Thank you farnothaviation for that comment. I have learned since I posted this that Carnival has had a track record of leaking fuel in the engine compartments. There leaks were the cause of the fires as was the case with the Triumph. You are so right! a dollar saved in not Assuring Quality will cost the company 100 fold when an incident happens. The law suits have begun and I am sure will go on for years on this event. "You can not begin to calculate the cost of Lack of Control."

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