The results of the independent investigation into Hurtigruten and the events contributing to the COVID-19 outbreak at the end of July have been released.
While confirming many of the details outlined in the previous audit by the Norwegian Maritime Authority, the report provides 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 MS 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 lawyer at the Wiersholm firm in Oslo that 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 a news conference held yesterday in Oslo is part of Hurtigruten’s commitment to provide transparency.
During the second expedition cruise in July aboard the Roald Amundsen a suspected outbreak of COVID-19 appeared with several crew members starting to feel ill and one passenger from the prior 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. Passengers were permitted to disembark and start 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 MS 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 apologize for these failings.”
The Wiersholm report looks at four elements starting with the preparation for the return to service, the enlistment of crew for the cruise ship, steps before the outbreak, and how the outbreak was handled.
As with the Norwegian Maritime Authority report, this investigation also calls 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 nonetheless concludes, “Hurtigruten’s risk management process was not sufficient.”
The report highlights 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 they cite is a lack of training for the crew and a lack of a systematic approach to monitoring and reviewing the COVID-19 risk. Crew recruitment is also highlighted saying that Hurtigruten failed to implement sufficient risk-reduction measures including testing for the foreign crew members.
Again pointing to the lack of training, they say once onboard quarantine protocols were not observed, practiced 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 says 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.
The Wiersholm report points to unclear communications from the ship’s doctors.
They say the reasoning behind these issues is complex, but believe it in part created an expectation with management on the ship and onshore that the doctors followed up and implemented the necessary measures.
The report acknowledges 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 aboard the ship.”
Once Hurtigruten received the positive test results it took time before the crisis management system was implemented.
The report says that it was up to 12 hours before all passengers were notified. Further, the crew was gathered for informational meetings without social distancing precautions.
“Crisis management was not carried out via the track required by the crisis management plan,” says the report. The recommendations focus on organizational and cultural issues needed to enhance risk management and encourage input from employees at all levels.
They believe a framework should be established for comprehensive risk management and a review of the safety management systems. They call for greater clarity of responsibilities and recommend 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, chairman of Hurtigruten Group AS.
The board however 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 said that it has already begun to take steps, but at the same time also announced that it was canceling expedition cruising till 2021.
The 50-page report, in Norwegian, was made public on the company’s website.