The Sewol Ferry Disaster- A Risk Management Nightmare

How a lapse of risk management processes doomed over 300 people

Normally, the waters around Korea are very calm and quite beautiful- such as in the picture of Gwangili Beach, Busan.  However, over 6 weeks ago, Korea experienced a disaster of tremendous consequences that has also had a direct and immediate negative impact on the Korean economy. In the greatest maritime catastrophe South Korea has faced in over 25 years, the culmination of lax risk management processes and procedures became apparent.  Everything that could go wrong went wrong.  In what should have been a relatively easy rescue operation,  over 300 people died because a series of events caused by lax enforcement or risk management protocols conspired to create a deadly and tragic event.  What happened?

On April 16, the Sewol Ferry left Incheon heading to Cheju Island.  Most of the 476 passengers were high school students going on a school trip.  At 8:52 am , a high school student on board the Sewol issued a distress call.  At 8:58 am  the Sewol Ferry finally issued a distress call ( though not though the normal distress channel) on its own.  From 9:00 am  to 9:30 am the Crew issued announcements to the passengers to stay put.  The Jindo VTS informed  the Captain that he needed to make a decision  on whether to evacuate the vessel.   At 9:32 am the first Coast Guard vessel  finally arrives on the scene.  It is too late. By 10:39, the Sewol Ferry sinks leaving more than 300 people trapped inside the vessel.

The  many risk management mistakes and  lapses in judgement  include the following:

1. The ship had been modified to hold more passengers.  The modifications led to a change in the ship’s center of gravity and created a structural imbalance. The imbalance was never fully checked out.
2. The Ferry had been overloaded with cargo. The ship was authorized to carry 987 metric tons of cargo.  On the day of the accident, it was carrying over 3,608 metric tons of cargo.
3.  Apparently, the cargo was not properly secured. Once the ship began listing, the containers and vehicles began sliding and started to fall off the ship. The sliding cargo may have exacerbated the ship's listing.
4. The third mate indicated the ship had a steering mechanism problem that was reported several weeks prior to the disaster. It had not been repaired by the time of the accident.
5. The Third Mate was steering the vessel at the time of the accident though it was her first time to steer the Ferry.  She was steering the vessel through a narrow and dangerous channel when she hit rocks. The Captain was not on the bridge.
6. The Captain was not on the bridge though the Third Mate was steering the vessel through dangerous waters for the first time. The Captain was required by regulations to be on the bridge but he chose to go off to his cabin instead. Failure to be on the bridge at the time of the accident may have led to the disaster.
7. When the ship hit rocks and began to tilt, the Captain ordered the passengers to stay put, which most did. One of the reasons the passengers were told to stay put was that only several of the twenty four life rafts were in fact functional. The Captain was afraid the passengers would be swept away in the dangerous currents if they abandoned ship.
8. The crew contacted the Coast Guard  3 minutes after the boat was in distress.  However, the crew and Coast Guard dithered for at least 30 minutes deciding what to do.
9. Most passengers stayed put per the Captain’s orders . Only after the boat began severally tilting did the Captain decide to inform the passengers to abandon ship.  By then the electricity was no longer working and the ship's intercom no longer was operational. The passengers stayed put, the ship started to sink and it soon became impossible for most passengers to get out.  Most waited for the rescue that never came.
10. The Captain and Crew made no attempt to help the  passengers to safety but decided to abandon ship as soon as the Coast Guard appeared.  They left the passengers to their own devices.

It is clear the emergency response was not well coordinated and the tepid result  was not adequate. Only after the vessel sank ( drowning the 300 passengers who did not abandon the ship) did an adequate size  flotilla show up to handle the evacuation of passengers.  But it was too late   Besides the crew violating a number of laws and safety related procedures as well as maritime regulations such as helping passengers to safety, the crew admitted a complete lack of training.  Somehow,  the crew and vessel had passed inspection despite a complete breakdown in regulations, policies, and procedures; had such policies and procedures been followed the catastrophe would have been avoided.  It became apparent that  the crew had no idea on how to handle an evacuation in the face of such an emergency.

It is obvious, that the Sewol Ferry is an extreme  example of a risk management failure.   But it is a reminder that companies as well as individuals that decide to skirt burdensome risk related processes designed to minimize the exposure of risk may be flirting with disaster. The owners of the Sewol Ferry have been indicted for negligence and failing to comply with the various maritime related laws of Korea.  The owners have  also suffered a complete meltdown of reputation and brand. Individuals will most likely go to jail.  The Captain in fact faces criminal charges which are punishable by death.

This is reminder to all companies and individuals involved in safety related occupations as well as companies in heavily regulated industries that not only should risk management processes be implemented but that such processes need to be strictly followed and enforced. How does your company or organization stack up with regards to enforcement of legal  risk management processes? There is no room for error.