Be Perfect, or Else

Be Perfect, or Else

But Lot’s wife, behind him, looked back, and she became a pillar of salt.

– Genesis 19:26, English Standard Version

We’ve talked a fair bit about risk management in matters of employment, contracting, baseball, and insurance. We’ve talked about communication, getting buy-in from stakeholders, properly training and vetting employees, and checking our assumptions. We’ve harped on ounces of prevention and on measuring twice. You’ve probably got the point by now.

But sometimes we get a bit too … academic. So today’s discussion is going to veer down a more serious avenue, and we’re going to talk about what happens when risk management fails. Below, we’ll discuss seven disasters, each of which was preventable. Indeed, they all teach us the same lesson that Lot’s wife learned the hard way – one second, or one decision, is sometimes all that stands between you and disaster.

The Moby Prince ferry disaster

On March 10, 1991, the Moby Prince ferry collided with the oil tanker Agip Abruzzo in the Tyrrhenian Sea off the coast of Livorno, Italy. The collision caused a fire that killed 140 people on board the Moby Prince.

The Moby Prince was a relatively new ferry, and it was equipped with the latest safety features. However, the disaster was caused by a number of factors, including:

Poor communication: The two ships did not communicate effectively before the collision. The Moby Prince was sailing in very poor visibility, and the crew was not aware of the oil tanker until it was too late. Even worse, both the crew of the oil tanker and the Italian coast guard erroneously communicated that the tanker had struck a small tugboat. As a result, first responders were not even aware of the Moby Prince’s involvement until an hour after the collision.

Inadequate safety procedures: The Moby Prince had inadequate safety procedures in place for dealing with a fire. The crew was not properly trained, and the lifeboats were not accessible.

The Costa Concordia cruise ship disaster

On January 13, 2012, the Costa Concordia cruise ship ran aground on the island of Giglio off the coast of Tuscany, Italy. The grounding caused a hull breach and the ship capsized, killing 32 people.

What doomed the Costa Concordia? Many things, all of which could have been remedied or should never have happened:

Human error: The captain of the ship, Francesco Schettino, made a number of mistakes that contributed to the disaster. He sailed too close to the shore, he failed to follow emergency procedures, and he abandoned ship before all of the passengers and crew had been evacuated.

Inadequate safety procedures: The Costa Concordia had inadequate safety procedures in place for dealing with a grounding. Passengers that had only recently embarked never received a safety briefing, and consequently did not know where their muster stations were located.

Poor hiring decisions: The ship’s helmsman, an Indonesian, could speak neither Italian nor English and was unable to execute the captain’s orders immediately prior to impact.

The Los Alfaques campsite disaster

On July 3, 1978, a propane gas tanker exploded at the Los Alfaques campsite in Alcanar, Spain. The explosion killed 217 people and injured over 2,000 people.

The disaster was caused by a number of factors, including:

Corporate malfeasance: The tanker was traveling through a populated area because its owners did not want to pay tolls on the national highways.

Poor resource management: The tanker had previously been used to transport highly corrosive gases (which eroded the seals) and did not contain a safety release valve.

Poor training: The tanker had been overloaded, and the driver was never trained to transport hazardous materials.

The Hyatt Regency walkway collapse

On July 17, 1981, two walkways collapsed at the Hyatt Regency Hotel in Kansas City, Missouri. The collapse killed 114 people and injured over 200 people.

The Hyatt Regency walkway collapse was ultimately caused by a design flaw in the walkways, but the collapse could have been prevented had it not been for:

Communication failures: A design change was inadequately communicated between the design firm and the manufacturer, leading to improperly distributed weight.

Groupthink: Later investigation showed that none of the architects and engineers objected to plans that, in hindsight, were obviously flawed.

Lack of buy-in from employees: Onsite workers ignored the bowing and bending beams and failed to report them up the chain of command.

The Cocoanut Grove fire

On November 28, 1942, a fire broke out at the Cocoanut Grove nightclub in Boston, Massachusetts. The fire killed 492 people and injured over 160 people.

The Cocoanut Grove fire was caused by a number of factors, including:

Safety planning: The nightclub was overcrowded on the night of the fire.

Lack of fire safety precautions: The nightclub did not have adequate fire exits or sprinkler systems.

Design oversights: The club was constructed with highly flammable material, and its maze-like design was hard to navigate in the dark.

Thunder River Rapids Incident

On October 25, 2016, four people were killed in an accident on the Thunder River Rapids ride at Dreamworld amusement park in Queensland, Australia. The victims were trapped in a water channel when two rafts collided. The Thunder River Rapids ride was a popular attraction at Dreamworld, and it had been operating for over 30 years. Its failure was caused by:

Lack of contingency planning: Prior to the accident, one of the two large water pumps critical for the ride’s operation failed. The remaining pump was unable to maintain the water level necessary for safe operation.

Risk assessment failures: The ride lacked a water level safety sensor that could have automatically stopped the ride, even though such a sensor would have been relatively inexpensive.

Training failures: Investigation showed that the broken pump had malfunctioned three times that day, but staff did not halt operations for repairs.

Haunted Castle Fire

On May 11, 1984, a fire in an amusement park attraction in Jackson, New Jersey killed eight teenagers. Contributing to the disaster were:

Design flaws and willful neglect: The attraction, originally designed to be temporary, was never outfitted with safety equipment (including smoke detectors) and never submitted for a fire inspection.

Oversight failures: Management knew that the building was in disrepair, that exit lights were not working, and that visitors commonly lit matches in the attraction’s dark corners.

Putting it all Together

Now, please don’t think we expect you or your company to be responsible for an accident of this magnitude. But consider that all of the parties involved in these incidents thought the same thing. Your job, as a business owner that wants to do right by your employees and customers, is to take the little steps necessary to avoid all accidents. Even small actions can have big consequences.

With that, we leave you with our favorite risk management recommendations, to implement or ignore at your peril:

Communication is essential: All parties involved in an activity must be able to communicate effectively with each other. This is especially important in high-risk activities, such as ferry crossings and cruise ship voyages.

Safety procedures must be comprehensive and up-to-date: Safety procedures must be in place for all potential hazards. These procedures must be regularly reviewed and tested to ensure that they are effective.

Safety equipment must be adequate: Life-saving equipment must be available in sufficient quantities to meet the needs of all people involved in an activity. This equipment must be properly maintained and readily accessible.

Hazards must be identified and assessed: It is important to identify and assess all potential hazards before engaging in any activity. This will help to identify risks and implement control measures to mitigate them.

Risk control measures must be in place: Once hazards have been identified and assessed, risk control measures must be implemented to reduce the risk of accidents and disasters.

A strong safety culture is essential: A strong safety culture is essential for preventing disasters. This culture must be instilled in all employees and stakeholders.

If you would like assistance in designing a safety program or auditing your current procedures, please contact Steve Setliff ( at 804-377-1261.

To learn more about what disasters can teach us, check out Fascinating Horror on YouTube.

Photo credit: EU Civil Protection and Humanitarian Aid,; used under Creative Commons License.