The results of an independent investigation instigated by Hurtigruten with Oslo law firm Wiersholm and DNV GL on the COVID-19 outbreak at the end of July, were released around 10 days ago.
While confirming many of the details outlined in the previous investigation by the Norwegian Maritime Authority (NMA), the report provided additional information pointing to mistakes that were made in connection with the preparation for the voyages and the handling of the outbreak.
“The outbreak on ‘Roald Amundsen’ was not due to a single incident or an individual’s actions. The situation arose as a result of a series of events and actions,” said Jan Fougner a Wiersholm lawyer at a news conference in Oslo who led the investigation assisted by DNV GL. ”The report provides several recommendations to prevent such a situation from happening again.”
The publication of the report along with the Oslo news conference was claimed to be part of Hurtigruten’s commitment to provide transparency by the Norwegian media.
During the second expedition cruise in July on board ‘Roald Amundsen’, a suspected outbreak of COVID-19 appeared with several crew members starting to feel ill and one passenger from the previous week’s cruise testing positive for the virus.
Hurtigruten came under intense scrutiny for its actions during the three days from when the first suspicions were raised until the company alerted passengers and issued public statements, the media said.
Passengers were permitted to disembark and begin their travels home across Norway before they were informed of the potential exposure. A total of 70 cases of the virus were ultimately reported among passengers and crew.
“The outbreak of infection in ‘Roald Amundsen’ was a serious incident,” said Hurtigruten CEO, Daniel Skjeldam as the report was released. “What the report describes is not good enough. This is not how Hurtigruten should be. I want to apologise for these failings.”
Wiersholm’s report looked at four elements starting with the preparation for the return to service, the enlistment of crew, steps before the outbreak, and how the outbreak was handled.
As with the NMA report, this investigation also called into question Hurtigruten’s risk management steps and culture around risk management. Acknowledging that the preparations for the cruises were undertaken in difficult situations and over a short period of time, the report concluded, “Hurtigruten’s risk management process was not sufficient.”
The report highlighted that an overall risk assessment was not carried out for COVID-19 and that affected the selection and implementation of risk management measures. Among the examples cited was a lack of training for the crew and a lack of a systematic approach to monitoring and reviewing the COVID-19 risk.
Crew recruitment was also highlighted saying that Hurtigruten failed to implement sufficient risk-reduction measures, including testing of the foreign crew members. Again pointing to the lack of training, the investigation found that once on board, quarantine protocols were not observed, practised incorrectly, or differently in part due to lack of providing guidelines. This created an increased risk of infection among the crew.
During the second expedition cruise in the last week of July, the report said that people displaying symptoms or feeling unwell were treated according to general practices, but the suspicion of an outbreak was not followed up and COVID-19 testing was not carried out in time.
Wiersholm’s report also uncovered unclear communications from the ship’s doctors. Thee reasoning behind these issues was complex, but believed that in part, it created an expectation with management on the ship and onshore that the doctors followed up and implemented the necessary measures.
The report acknowledged that an announcement of the suspicions was delayed, saying, “by agreement with a local doctor pending test results from the infected person’s (past passenger) travel companion.”
The situation was complicated when the travel companion tested negative and by a “desire to deny that the infection could be linked to ’Roald Amundsen’, rather than assessing the possibility of infection on board the ship.”
Once Hurtigruten received the positive test results, it took time before the crisis management system was implemented. The report said that it was up to 12 hours before all passengers were notified. Furthermore, the crew was gathered for information meetings without social distancing precautions. “Crisis management was not carried out via the track required by the crisis management plan,” the report said.
The recommendations focused on organisational and cultural issues that were needed to enhance risk management and encouraged input from employees at all levels. A framework should be established for comprehensive risk management and a review of the safety management systems. Greater clarity of responsibilities should be defined and it recommended the hiring a permanent doctor.
“The investigation has revealed failures in routines that had serious consequences for employees and passengers. We very much regret this,” said Trygve Hegnar, Hurtigruten Group Chairman.
However, the board expressed its confidence in Skjeldam and his team’s ability to, “thoroughly and systematically improve risk management, ensure compliance with routines and procedures, and work with employees and unions to restore trust in Hurtigruten.”
Hurtigruten claimed that it had already begun to take steps, but at the same time, also announced that it was cancelling expedition cruising until 2021.
The 50-page report, in Norwegian, has been made public on the company’s website.