“I will make sure that all this sacrifice was not for nothing by removing the layer after layer of corruption that has accumulated over the years, and by making South Korea a safe country,” vowed the president at the time, Park Geun-hye.
On April 16, 2014, a tragic disaster occurred in South Korea when a passenger ferry ship carrying 476 people including 325 students from a high school, sank off the coast of Jindo, resulting in the deaths of 304 people which included mostly high school students.
With advancements in technology, transport services over rail, land, air, and sea have seen a remarkable improvement in safety measures, which brings us to this fundamental question in the blog, why did this happen? Why did so many people have to lose their lives?
In this blog, we shall delve deep into the ferry disaster that struck South Korea and understand the key reasons, why this happened.
WHY FERRY SANK?
"I am haunted day and night by the thought of the children who lost their lives in the cold waters." – Survivor's parent
The passenger ferry did not sink due to natural causes but due to entirely human causes as per reports on the incident.
Following were some of the factors that were majorly responsible for the sinking of the ferry
The owner of the ship made some renovations to improve the profitability of the ship, however, the ship became more dangerous, and surprisingly these renovations were approved by the regulators
The load of the cargo on the ship was twice more than the permissible limit
The cargo on the ship was not properly secured
So, when the ferry made a sharp turn fighting a strong current, the ferry which was already unbalanced began to tilt over the other side and the poorly secured cargo began to slide accelerating the tilting.
Ultimately the ship capsized resulting in this massive tragedy with the loss of so many lives.
ORGANIZATIONAL AND SYSTEMIC FAILURE THEORY
"Systemic failure is not about blaming individuals; it’s about recognizing the interconnectedness of actions and consequences." – W. Edwards Deming, American Engineer
Let us now touch upon Organizational and Systemic Failure Theory to better understand why such disasters happen.
Organizational and Systemic Failure Theory refers to the idea that large-scale accidents or disasters are often the result of multiple, interconnected failures within organizations and systems, rather than a single catastrophic event or human error.
This theory emphasizes how complex organizations—such as governments, corporations, or regulatory bodies—can suffer from structural weaknesses, poor communication, inadequate training, and dysfunctional decision-making processes that accumulate over time and contribute to accidents.
One key aspect of Organizational and Systemic Failure Theory includes:
Multiple Layers of Failure:
Accidents are rarely caused by a single failure or human error. Instead, they result from a combination of smaller, seemingly minor issues that, when combined, lead to major disasters. These can include management failures, safety lapses, inadequate risk assessments, and flawed decision-making processes.
Now based on the facts on what we are aware of, we shall try to explain via theory how this disaster happened.
HOW ORGANIZATIONAL AND SYSTEMIC FAILURE THEORY EXPLAINS THE SEWOL FERRY DISASTER
"In complex organizations, a single failure often signals deeper systemic problems that must be addressed holistically." – David Woods, Systems Engineer
It is clear from the facts available that a single reason was not possible for a disaster of this magnitude to happen.
A multiple-level breakdown has happened and let’s see in detail the factors responsible for it.
1. Leniency by Courts
Courts do not give stricter punishments in such cases where life safety incidents have happened in South Korea.
For instance:
In 1970, following the sinking of a ferry that claimed 326 lives, the ship's captain received a 3-year prison sentence, while the owner of the ferry company was sentenced to 18 months in jail. A similar tragedy occurred in 1993 when 292 people died in another ferry accident. Port authority inspectors, deemed responsible, were given prison sentences ranging from 6 to 8 months. Source: Reuters
The above instance clearly shows that even in instances of life and death, situations were not taken seriously, and had people who committed lapses been given stricter punishments this tragedy may not have happened.
2. Inadequate money on safety training
According to Korean media reports, Chonghaejin Marine Co, the company that operated the ferry, spent 60 million won ($58,000) on lobbying and entertainment last year, while only allocating 514,000 won ($500) for safety training. Source: The Guardian.
If you are going to spend just 500 USD on safety training, then it is adequately clear that your employees are not equipped to handle the situation on the ground in case an emergency happens. Then it is not surprising that this level of disaster happened.
3. Competency
South Korea’s National Assembly voted to dissolve the Coast Guard post the ferry disaster as they were heavily criticized for their ineffective role in the rescue operations. Coast Guard officials themselves admitted that they did not have the proper equipment or training to conduct the rescue operations. Source: The BBC
4. Ballast Water
The ferry had 580 tonnes of ballast water on board, only 37% of the legally required amount, leaving it dangerously unbalanced, according to investigators cited by the South Korean news agency Yonhap.
If the ballast water was not meeting the required amount, then who let the ship sail?
How come this was allowed to happen? Was no inspection done, how were so many lives put at risk?
Note: Ballast water refers to water that is taken on board a ship to maintain stability and balance, especially when the vessel is not carrying cargo or when it needs to compensate for uneven loading. It helps ensure the ship's stability, trim, and structural integrity during a voyage.
5. Leadership failure
There was a leadership failure at many levels as reports indicate that the owner of the ship was given warnings about the ship's stability however it was disregarded as per prosecutors.
Further during the disaster, a catastrophic leadership failure occurred when the captain abandoned the ship despite passengers still on board. A clear violation of maritime protocol. When the captain abandons the ship, then there is no one left to guide the passengers on board, and is a serious catastrophe during the disaster. Source: The BBC
6. No lifeboats
While international regulations mandate lifeboats for passenger ships, the ferry was licensed solely for Korean coastal trade and therefore only had to meet local standards. This seemingly meant it was only required to have inflatable life rafts, which are significantly more difficult to deploy and board than lifeboats, according to SWZ Maritime.
When we have seen clear-cut examples of the sinking of the Titanic how many lives could have been saved had lifeboats been there why were there no lifeboats?? Read our previous blog on this topic here.
These above instances indicate multiple-level failures resulting in a disaster of this magnitude.
CONCLUSION
This tragic sinking of the ferry serves as a stark reminder that life safety issues should be taken seriously. Organizations must consider Organizational and Systemic failure theory to better understand the various threats their operations face. Organizations must consider that one simple reason cannot be the cause for a failure to achieve the target, but a multi-level failure consideration shall ensure organizations avoid such disasters and be better prepared in the future by conducting efficient root causes of the incidents and implementing effective corrective actions.
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Image credit: 대한민국 국군 Republic of Korea Armed Forces, CC BY-SA 2.0 <https://creativecommons.org/licenses/by-sa/2.0>, via Wikimedia Commons
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