You may have noticed from photographs, that the hole in the Costa Concordia is on the “wrong” side of the hull. That is to say that it is NOT on the side nearest to land but on the opposite “sea-side”. That means that this really COULD have been no more than bad luck and the ship was steered into an uncharted rock., followed by the skipper doing exactly the right thing and, knowing that the boat was about to sink, steered it towards land in an attempt to “beach” it.

Whatever the cause, there will be  a structured investigation roughly along the lines of that of 25 years ago when the Herald of Free Enterprise sank. You may notice the similarity between the photograph above and that of the Costa Concordia

In 1987, which was 75 years after the Titanic disaster, the Herald of Free Enterprise sank in Zeebrugge Harbour and 193 people died. There appeared to be a very simple explanation for the “accident”.   The loading doors at the front of the boat (through which cars entered the boat) had been left open.

However, a proper structured  investigation  designed to identify the Root Cause of the disaster was needed. This is exactly what will happen with the Costa Concordia.

In order to carry out such an investigation , it is helpful to understand the theory of Business Controls.

The following controls are fundamental and through them, every single problem which involves systems and people can be solved. There are only FOUR such controls. They are Policy, Organisation, Procedures and Supervision: POPS. (There is ONE additional control which applies to all of the four basic controls which is Review and Appraisal. That simply means that the other four controls need to be regularly checked and if necessary modified so that they continue to be fit for purpose).

Policy and Organisation are called High-level Controls and Procedures and Supervision are the low-level or day-to-day controls. When carrying out what is called a Management Audit, one starts with the low-level controls and works UP to the High-level (Policy and Organisation).

So, back to the Herald of Free Enterprise.

The doors were left open because one man was asleep when he should have pressed the button to close the doors. Therefore, the PROCEDURES control had broken down. The procedure was that when the boat was about to move, a button would be pressed on the bridge. That would trigger the man to press the button to close the doors.

The direct SUPERVISION control was  was non-existent because the man who should have pressed the button was supervised by a senior man in charge of ferry car-parking  and who wasn’t even in the loop as far as closing the loading-doors was concerned.

In addition, there was no PROCEDURE for anyone to confirm to the bridge whether the doors were closed or not. It was assumed that once the “close the doors”  button had been pressed that the doors were closed.

The ORGANISATION control is about the people involved in the process. In this case, the organisation consisted of just ONE lowly manual worker who, on this occasion, was asleep. The  First Officer who pressed his button, immediately assumed that once he had pressed it, his job was over.

The last Control is the highest-level  - POLICY. This control is administered right at the top of an organisation –  by the Senior Management and the Board of Directors.

One may be forgiven for thinking that there is absolutely no way that such a high-level control could possibly have anything at all to do with someone forgetting to close the loading-doors on a ferry.

However, the Root Cause of the Herald Of Free Enterprise disaster WAS a breakdown in the POLICY control.

The Company’s POLICY was to turn the ferry around in 15 minutes.Consequently, the man who should have pushed the button was tired because he had not slept properly for two days and was already asleep when the boat had docked.

So in this case, Controls at every level had broken down and because the final Control (REVIEW and APPRAISAL) had never been applied, ALL of the existing controls had become “unfit-for-purpose”.

POPS is a very simple but effective method of structured management thinking. For instance, if the POLICY, ORGANISATION, PROCEDURES, SUPERVISION as well as the  REVIEW and APPRAISAL  Business Controls had been applied to the Banking Industry, we would never have had a financial crisis.

The banking industry was  (and still is) working with business controls which may have been appropriate in the 1960s but  because (in most cases), bankers did not understand the “business” of BUSINESS CONTROL, more and more complicated products were being managed by outdated and irrelevant controls.

Hopefully, the owners of Costa Concordia do have all of the correct controls in place.

However, the name-calling , guesswork and blame-game is already in full-swing.

This should be a very interesting few months.