Wednesday, April 23, 2014

Captain Lee Joon-Seok's leadership dilemma in the sinking of the Sewol

Damned if he had done. Damned far worse because he didn't.

The Sewol ferry tragedy of April 16, 2014 is subject matter for Seconds from Disaster. Early indications from the official investigation are the passenger-cargo ferry was an accident waiting to happen until, finally, a critical chain of events set off a rapidly ballooning emergency in which standard operating procedures were inadequate, capabilities were negated, decision trees collapsed, and instant decisions were forced in a chaotic situation where every alternative carried mortal risks, information was incomplete and murky, and the stakes were life or death.

The Sewol's captain, Lee Joon-Seok, wanted an orderly evacuation to save all of his passengers and crew and knew he needed outside help to accomplish that. His decision to wait for rescue craft instead of hastily abandoning ship made sense given the sea conditions and the incapacitation of the shipboard emergency response. The story of Jung Cha-Woong, a student who died after abandoning ship because he gave his life jacket to a friend, validates the captain's risk assessment of a chaotic ditching in the strong current of the cold sea. It's likely more passengers would have died like Jung did if Captain Lee had ordered his passengers and crew to ditch the Sewol at the outset.

However, when the listing ship rendered the life boats unusable, Captain Lee's choices became bad or worse: the likely death of some of his passengers if he hastily ordered an abandon ship versus the growing possibility of many deaths if rescuers did not arrive in time to conduct an orderly evacuation of the Sewol. When a single fatality is intolerable, but the option of saving everyone is growing remote, how does a leader choose between the likely death of some of his charges due to an improvised leadership action versus the possible death of many of his charges due to deferring to the system's emergency response?

Captain Lee chose to rely on the system's emergency response to save everyone on his ship while that option was turning impossible.

His decision to wait for rescue craft implies he believed - or hoped - the Sewol would stay afloat and upright longer than it did. But shouldn't Captain Lee have known his listing ship was fast becoming a death trap for his passengers and crew below? Were his only choices to ditch or wait inside? While hoping for the best, shouldn't he have prepared for the worst? Rather than tell his passengers to remain inside and even return to their cabins, shouldn't Captain Lee have ordered his passengers and crew to assemble outside, in position for a fast evacuation or to ditch the sinking ship if necessary?

Perhaps Captain Lee deemed that assembling outside for rescue was too dangerous with the ship canting, the port side submerging, and his crew immobilized and incapable of controlling the evacuation. Perhaps there simply wasn't enough space on the outer decks of the starboard side to safely hold all 476 passengers and crew.

In any case, Captain Lee should not have abdicated his command and departed the Sewol until it sank at the earliest - not while so many souls were still aboard his ship.

The Sewol ferry tragedy reminds us that system authorities can be trusted only so much to control an evolving, complex emergency. They're only human. The disaster exposed the inadequacy of the shipboard emergency procedure, and it's been reported the crew's emergency training was minimal. According to surviving crewmen, the listing of the ship made deployment of the life boats impossible. Apparently, despite that listing is a common happening for sinking ships, the Sewol had no contingency for it, reminiscent of emergency procedures on airliners that only fit a narrow range of possible emergencies. The listing ship overwhelmed the shipboard emergency procedure, such as it was, and paralyzed Captain Lee's chain of command. After the fleeting chance to evacuate the Sewol was gone, the first-responding coast guard and civilian ships had neither the time nor means to effect a rescue of the hundreds drowning inside the ship.

Beside Captain Lee's leadership dilemma, the passengers and crew faced their own survival dilemma in the quickly deteriorating crisis. It's easy to say they should have made their own risk assessments and exercised their own judgement to abandon ship while escape was still possible, but it's not that simple. The current was strong, the sea was cold, and the life boats were stuck. Every alternative was risky and the information was poor, so the passengers and crew reasonably relied on procedure and the captain's oversight and expertise. When the captain ordered them to stay put, they likely assumed the worst was over and the Sewol would stay afloat until rescuers arrived to conduct an orderly evacuation. Some passengers and crew were lucky enough to be in position to escape once it became clear that waiting for rescue was untenable. For the rest, once the Sewol fell on its side on its way to turning turtle, escape would have become impossible for anyone trapped in cabins, corridors, and even open communal spaces like the canteen. The port side turned floor would have flooded and clogged with debris and bodies, while the usable exits shifted high above and out of reach on the fore, aft, and starboard sides turned walls and ceiling. As the capsizing Sewol became inescapable, there was no backing up for a do-over by the trapped passengers and crew; their reasonable decision made at the beginning to obey the captain, stay put, and wait for rescue sealed their fate.

If his passengers and crew had ditched with no life boats in an uncontrolled evacuation that resulted in some deaths, Captain Lee might have been excoriated for panicking when help was on the way and punished for plunging his charges into the strong current of the cold sea. Hindsight tells us Captain Lee should have traded some deaths to save many more lives. Instead, he chose to wait for outside assistance to conduct an orderly evacuation of all of his passengers and crew, which resulted in many deaths.

Captain Lee would have been damned if he had hastily ordered an abandon ship but is damned far worse because he didn't. Forced to choose on the spot between a likely bad outcome versus a possibly worse outcome that's bundled with hope for the best outcome based on incomplete, murky information with life-or-death stakes is the classic leadership dilemma.



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