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Exxon Valdez grounding event tree

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MEDIA
Media were alerted
to the spill and
reports went out on
the wire. Images of
oil covered wildlife
went viral Media
descended on
Valdez.
Knew in
advance of ice
in shipping
lanes
Set sail at night
Left the Bridge
before critical
manoeuvre out of
shipping lanes
Set ship to
Autopilot in closed
waters
Left unqualified
3rd mate to
complete difficult
manoeuvre
around ice
Elected to exit the
shipping lane
rather than slow
ship and proceed
through the ice
Ship not operated
to the
requirements of
Condition watch Ctwo officers on the
bridge.
Many official s departments.
EPA, Coastguard NOAA,
Alaskan Government, Alyesko,
Federal Authorities, EXXON,
OFFICIALS Insurers. Lawyers
Did not slow
ship, Set throttle
to power up
mode
Did not seek
permission to
exit
navigation
channel
Media found ample
locals willing to talk. The
early press was
negative.
Exxon
holds press
conference
in Valdez. It
does not go
well.
Frank
Iarossi gives
press
conference
Exxon Execs do
not respond to
the media for 6
days
EXXON
Advised
VTC that he
was slowing
to navigate
ice
No
information
from
Exxon for 6
days
Media
frustrations
on lack of
information
coming out.
Senior
Exec says
Exxon will
raise fuel
prices to
pay for
spill.
Press
become
openly
hostile
towards
exxon
Power struggle
over clean-up,
responsibility,
powers, Authority,
legalities
Exxon officials
are facing a
bloodbath in
the press
Press all
negative
towards
exxon.
Senior Exec says
Exxon will raise fuel
prices to pay for clean
up.
Valdez press
conference
Generally most Official
departments had Powers increased
CEO Lawrence Rawl does
live interview.
Exxon place full
page ads in the
press.
Exxon continues to be
dominant global oil giant
Exxon suffer
huge financial
loss, reputation
COAST GUARD
Increases controls.
Ugrades response
capabilities to be
worlds best
Captain Joseph
Hazelwood
Drank offshore
prior to
departure.
3 years cleanup. 15 years
fighting
compensation
payout.
Overhauls
procedures.
Increased Authority
ALYESKA
Captain was
an Alcoholic
Exxon brand
becomes
synonymous
with the spill.
Brand loyalty is
lost.
CEO does
live
interview. It
does not go
well.
Many workers in
the clean up die
from cancers.
6000 die
waiting for
settlement
LOCALS
Consumed 2
beers on board,
time unknown.
Businesses
lost,
Legally drunk as
Captain
Commands
Helmsman to
turn 10 degrees
right to come
back into
shipping lane.
3 rd mate Pressed Autopilot
button off
After 1 1/2
minutes notices
ship does not
respond.
Gives right
rudder 20
degree order
Ship remained in Autopilot
Helmsman also pressed
Autopilot off
Excessive
workload
Ship does
not
respond in
time
Fatigued
Cousins did not realise
ship on Autopilot. Ship
does not respond to
inputs
Ship
outside of
Navigable
channel
Confirming his own navigation
calculations
Exxon fights
settlement for
15 years
Valdez Fishing
industry
decimated in the
medium term
Did not
successfully
navigate
route
Third Mate Cousins testifies for the
prosecution. Escapes conviction
Third mate
Gregory Cousins
Not licenced to
Navigate channel
AB Maureen
Jones. Escapes
prosecution
Did not comprehend ships
position
Observes red
flashing light to
Starboard. Busby
island light 6. 45
deg ahead to
Starboard flashing
5 seconds.
Informs
Third Mate
Observes
again red
light to
starboard
flashing 4
seconds.
Bligh Reef
Bouy.
Able
Seaman
Maureen
Jones
Reacted late
to
information
Ship was not
slowed
Long term
Kagan most
Junior crew
member
Shipping lanes clearly identified.
Reefs marked
Accelerated retreat
of the Columbia Ice
glacier
Calving of Ice
in Columbia
Bay
21 ice incursions to
shipping channel in
1989 up from 3 in
previous years.
CLIMATE CHANGE?
Night time transit
Heavy Ice in
shipping
channel
Misty
Able Seaman
may become
Helmsman
Helmsman
Kagan
Reduced
visibility
ENVIRONMENT
ENVIRONMENT
Ecosystem
recovering. Oil
persists below
the rocks and
sand receding at
4% a year..
143 million
litres lost
Immediate
Helmsman
Kagan. Escapes
prosecution
Calm weather
opportunity
missed in the
first few days
10% of the spilled oil is
recovered. Over 1
million Gallons
remained
Alyeska- which Exxon is a
member reduced spill
response crew numbers.
Equipment that was
supposed to be in place
to implement a response
within 5 hours was not .
crude oil contaminated
1,990 kilometers of
shoreline. Some 2,000
sea otters, 302 harbor
seals and about
250,000 seabirds died in
the days immediately
following the spill.
Storms spread the
un-contained oil
over a wide area
Visible support
Exxon
Valdez
grounding
Culture
Evidence of crews overworked.
Rules were in place governing
work rosters but practicalities of
manning ships with reduced
workloads meant these were
often not adhered to.
3000 square miles contaminated,250,000
birds killed, thousands of marine animals,
20 species affected, thousands of
fisherman affected, food resource wiped
out for years.
42 million litres
of oil spilled in
30 minutes
Management were aware
Hazlewood was an Alcoholic
Exxon deemed him clean
and fit to Captain a ship.
ORGANISATION
Fatigue
Exxon had excellent training
requirements for Captain and
crew.
Crew numbers
Training
Coast Guard VTC
radar does not
reach the EV.
No tug escort past
Valdez Narrows
Watch Supervisor Added for VTC. Qualifications
upgraded and expanded.
Exxon Valdez not
observed on radar by
Coast Guard VTC
Exxon actively reduced crew numbers. Exxon
Valdez was not under manned however,
Required 15 she had 19 + 1 MED
Supervision
PROCEDURES
25 million to
repair Exxon
Valdez.
Temporary lost
use of asset
Feedback
process
Reduced capacity
at Alyeska spill
response unit
VTC
Regulations
Pilot leaves ship before
EV leaves Prince
William Sound
No requirement
for ship pilots
past Rocky
Point
Pilot plus two licenced deck officers between Bligh Reef
and Seal rocks
Traffic.
One way traffic extended to Bligh reef
Navigation
No Pilot on board for
Ice floe transition.
EQUIPMENT
Differential GPS required.
PROCEDURES
SHIP
Radar coverage upgraded
New repeater towers
EQUIPMENT
Fixed Navigational tower on Bligh Reef
Ships must remain in the traffic lanes
Exxon Valdez banned from Alaska
Alyeska
retrenches spill
response
workers
Alyeska removes
essential spill response
equipment from Valdez
8 of 11 Oil
tanks
ruptured
Spill response
measures
scaled back
Downsizing of actual
workforce. Alyeska
fake worker numbers
to meet minimum
requirements.
Exxon Valdez in good condition.
Confirmed seaworthy prior to
departure.
Double hull ships in all
American ports by
2015
ENGINEERING
INITIAL SPILL
RESPONSE
115,000 barrels18,285,000
litres of oil lost
in the first 30
minutes
Single hull
ship unable to
withstand
grounding
Up to 900,000
barrels, 143
million litres of
oil was lost.
Increased reporting requirements
SHIP
Reduced speed limits
New Weather condition requirements. Port closed at 40
knots
Inadequate
equipment on
hand to contain
spill
Alyeska takes
legal action
Court overturns Alaskan
Authorities ban on single
hull ships in Valdez
System
effective for 12
years, trust
established.
Alyeska establishes spill response teams
Approval
granted June
1973
Alyeska- consortium of 8 oil companies created
Has powerful connections
Delays in
getting
equipment
to the site.
2 tugs now
to escort to
Hinchinbro
ok
entrance
Oil spill barge and
equipment taken out of
service for repairs. No
backup
Increased requirements for spill response and
containment.
Insufficient
quantities of
dispersant
on hand to
disperse
spill
Alyeska make
recommendations on spill
prevention strategies to
Alaskan Authorities
Expert advice
Alaskan Authorities
determine single hull ships
will not operate from Valdez
Alyesco propose spill prevention strategies for Valdez
Authorities set very strict guidelines on requirements to
protect Valdez.
Media interest
Special interest groups
Government pressure
Community engagement
Stakeholder submissions
Wider community concerns
Expert advice
Legal advice
Special interest groups
Alaskan Authorities determine course of action
increased towing equipment requirements for shipping.
ALYESKA SERV vessel worlds best practice.
Alyeska reserves 20 million gallonb cleanup capacity.
Use of ice scouts
Community engagement
Legal requirements
Single hull oil
container ships
permitted in
Valdez
Insufficient spill
response crew
numbers to
contain the
spill
Captain
Hazelwood
30 - 50 years for
oil to dissipate
Cost
pressure to
avoid delays
Exxon was the most prestigious shipping
company to work for, with good work and pay,
highly sought after
Exxon Halved crew
numbers 19771989
PEOPLE
( GROUPS )
PEOPLE
Medium term
ICE
FLOES
IMPACT
SHIPPING
LANES
3 rd mate
Gregory
Cousins
testified for the
prosecution.
CREW
Informs
Third
mate of
Red light
to
Starboard
Seaman
Kagan
promoted
Settlement
inadequate to
cover losses
Fired. Tried in
court. Eventually
had DUI revoked
on technicality
Vilified. Name
becomes
synonymous with the
cause of the
accident. Never
Captains another
ship.
Escapes
prosecution
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