The MV Doña Paz Incident Last December 20, 1987, Proves Bad Systems DO KILL PEOPLE

December 20, 1987, would be a fateful date. Disasters happen any time of the year and that includes Christmas. Christmas tragedies are as real as tragedies in any time of the year. This would also include a critique against unscrupulous business practices. It's a trend where people go home for the holidays, right?Sadly, a lot of vehicular accidents happen worse on December because of disregarding safety rules than because it's December. Some Christmas season disasters could've been avoided if safety protocols weren't ignored. It's easy to get too excited for Christmas that people don't play it safe. Some people even prioritize Christmas over safety even during natural disasters.

It was in the late 1990s when I heard of Doña Paz. It was dubbed as the Titanic of Asia. It was also in the 1990s when the movie Titanic (which by the way, had fictionalized elements) such as the love story of Jack and Rose. It was that time I became a fan of Celine Dion's singing. It was that theme song "My Heart Will Go On" got popularized. I used to believe that Jack and Rose were real until Google. The Titanic had an estimate of 1,517 deaths. Some of the bodies were never recovered. 

However, the Doña Paz beat the Titanic as a disaster. The Safety4Sea website reveals this:

Despite not included in the ship manifest, an estimated total of 4,386 people perished in the disaster and only 26 were rescued, including 24 from Doña Paz and 2 crew members from Vector’s 13-man crew. Most survivors sustained burns from jumping into the flaming waters. None of the crew of Doña Paz survived. Until today, the death toll of 4,386 people remains the largest ever recorded in a single maritime incident in peace time.

It would be easy to blame the crew or the passengers. However, do we ever try to look at the fact that the ship itself was also to blame? As I was reading the Safety4Sea website, I looked at the probable causes. Take note that I'm just writing based on what I read. I'm not an engineer and blog to share the findings of other people with better expertise:

Probable causes

The fatal incident was result of a series of safety malpractices. In 1999, the Supreme Court of the Philippines ruled that it was the owners of Vector who were liable, as the ship was found unseaworthy and operating without a license, a lookout, or a qualified master.

However, the official investigation by Philippine Coast Guard also revealed that none of the Dona Paz crew members were at their posts when the collision occurred, while only one apprentice was monitoring the ship’s bridge at the time. Other officers were either drinking beer or watching TV in the recreation room, while the captain was watching a movie in his cabin. The crew found themselves unable to guide evacuation efforts onboard and this was compounded by the unavailability of life vests that were locked in deck lockers. No distress signal was sent out.

In addition, the magnitude of death toll was attributed to overloading, a common malpractice in the ferry sector. The official passenger manifest of Doña Paz recorded 1,493 passengers and 59 crew members, but amid the Christmas season, it is estimated that the ferry was carrying close to 4,000 people at that night, despite its capacity being for 1,518 passengers.

This would reveal one thing--the series of incidents is caused by faulty systems. Based on what I read, I can come up with this common sense analysis:

1. A poor system caused Vector, a ship that was unseaworthy and operating without a license, helped aggravate the matters.
2. There would be a lot of things for the shipping lines to answer for. How in the world was it that the Do­ña Paz crew members weren't in their posts during that time? Drinking beer, watching TV, watching a movie in the recreation room, watching a movie in the cabin? Sure, these people are liable but does it mean we can blame them alone but not the system? If there were stricter compliances, the chances of such an irresponsible crew wouldn't be that high!
3. There was a lack of equipment. In short, it was ill-prepared for such a disaster.
4. Even worse, the ship's capacity was only for 1,518 people in total, including the crew. A lax system allowed it to have 4,000 people. In short, the ship exceeded its capacity. Would the ship have been designed to hold more, having 4,000 people wouldn't be a problem!

What should be interesting is this detail from the extensive research by Safety4Sea:

The aftermath

It becomes apparent that the incident is an unpleasant mix of corruption practices -that allowed illegal purchase of extra tickets onboard amid Christmas season-, poor oversight by authorities -that allowed such corruption practices- inadequate safety culture onboard -that led to the collision- and lack of coordinated response that made SAR operations to start after 8 hours.

Despite being the deadliest shipping incident, the sinking of Doña Paz is only one of a long list of disasters in Philippines’ heavy maritime history. Notably, from 1972 to 1987, when the Doña Paz accident occurred, there were 80 collisions, 177 sinkings and 53 shipboard fires in the country’s waters that resulted in the deaths of more than 4,000 people. What is interesting is that specifically the owner company of Dona Paz was involved in a total of four deadly shipping accidents, resulting in death of about 5,000 people in 11 years:

• Dec 1987 – A total of 4,386 die after Dona Paz and an oil tanker collide off Mindoro Island.
• Oct 1988 – Dona Marilyn, sister ship of Dona Paz, sinks off Leyte province, killing around 300.
• Sept 1998 – Almost 200 die when the ferry ‘Princess of the Orient’, sister ship of Dona Paz and Dona Marilyn, sinks in stormy seas near Cavite and Batangas.
• June 2008– Princess of Stars sinks 3 km from Sibuyan Island, killing about 800 people. 
  

Earlier, in 1979, owned by the same company but named “Don Sulpicio”, the ship suffered a major fire that led it to be declared a constructive loss. However, the ship was refurbished and came back to service under the name “Doña Paz”. At the time of the accident, it was already 24 years old. Although the marine inquiry and the court ruling concluded that the Dona Paz owner was not to blame for the tragedy, overall evidence reveals some form of poor safety culture in the company’s history. In 2015, the CPC of the company was suspended. Now, it operates under different name and is limited in cargo services.

We look at this boat by Sulpicio Lines. Why was a ship that suffered from a major fire later refurbished? Wouldn't it be better to already get rid of the boat? If the boat is already too old, why not get rid of it? If we think about it, a 24 year old vessel is an old vessel. Right now, I wonder why the court ruling didn't blame the owner of Doña Paz? I can't be certain since I'm no legal expert either. Anyway, I would like to point out the overall evidence. The overall evidence pointed out to poor safety culture in the company's history. That would bethe bigger culprit--the bad system of the company and not just the ship itself! It's the poor safety culture, which is part of the system of the company!

It's easy to say, "It's common sense that it's not the system but the one running the system that's at fault." Please, a company should be based on systems-based leadership than people-based leadership. What will we do if the manager resigns? The late Jesse Robredo once worked with San Miguel's Magnolia division. What if they all relied too much on Jesse? Jesse became mayor in Naga City in Camarines Sur. If Magnolia relied too much on Jesse--it would've gone down without Jesse managing it! I wouldn't be able to enjoy the delicious ice cream while Jesse was mayor, if San Miguel relied on Jesse! It's easy to blame the negligent crew alone. However, what caused the negligent crew to get into their positions in the first place? Wouldn't it be the lousy system from one after the other, that caused the tragedy to blow up into epic proportions?

Based on the poor safety culture, a series of unfortunate events happened. The poor system led to the loss of Doña Marilyn, the Princess of the Orient, and the Princess of Stars? Sure, there was gap bvetween 1988 to 1998 to 2008. However, that doesn't excuse the poor safety systems. The poor safety culture of the workplace influenced the behavior. The poor safey culture in the Philippines influenced the behavior. All these influenced towards poor safety protocols which leads to disasters! While the authorities are to blame, why not look at the system that authorities have to follow? Despite all these, some people still insist that systems don't matter, just the people running the system!

What was needed was a structural change. It should be interesting that 1987 was also the time when the outdated constitition of the Philippines was written. Please, it's already 2024 meaning that the current constitution badly needs updates or even a total revision in the major areas! However, people still go by what I dub as the Monsodian Dialectic (read here). Blaming people alone will not help. What allowed people to rise up in the first place? For those complaining about Senator Robinhood C. Padilla, just ask why he got there in the first place. The presidential system is based on popularity-driven elections than party-based elections. Why complain about celebrities and athletes becoming lawmers when you support a system that's based on popularity? How do they intend to educate everyone to vote wisely? Social media trolling? Please, I've seen those attempts on Facebook and has it done a thing?

I don't think Doña Paz would've even sailed if there was a better system. A good safety culture would've already dumped the old vessel. Maybe, Doña Paz would've been built from scratch. Maybe, they would've been more careful with who they hire. At the same time, authorities would've probably been more watchful, which may reduce the illegal sales of tickets. The illegal sales of tickets was caused by poor oversight and corruption. A hurriedly written Constitution, further enforcing the lousy Filipino First Policy (and I wonder if its proponents can give me more papers beyond Alejandro Lichauco), etc. would create a domino effect. If there was more delegation of authority between Manila and Cebu (as well as the rest of the Philippines)--I believe that there would've been more easy monitoring against illegal ticket sales. Instead, it happened and the Doña Paz incident was part of the Domino Effect. One event can create a series of unfortunate events. One lousy system can create more lousy systems! 

What's so annoying is that some people believe system change is people change. Some people may think the system is, "Well system change is when you put Leni Robredo as president over Bongbong Marcos." However, Atty. Maria Leonor "Leni" Gerona-Robredo and President Ferdinand "Bongbong" R. Marcos Jr. are still under the same system. That means Bongbong and Leni, regardless of who was president, must follow the system. Please, we need to stop believing that the 1987 Consitution of the Philippines is absolute and should never be amended. If so, Article XVII wouldn't even exist! However, the problems such as economic restrictions framed into the constitution make it difficult to adjust for the modern times!

The Doña Paz incident already proves that bad systems have bad consequences. To say there's no bad systems need to look at several incidents around the world, not just the Philippines. Why do you think North Korea is poorer than South Korea? It's because one has a lousy economic system and the other has a good economic system. Why do you think Malaysia is doing better than the Philippines when most Filipinos are genetically identical to Malaysians? It's because of the system. Why do you think Venezuela is poor and the USA is rich? The late Hugo Chavez blamed former president George W. Bush instead of the country's lousy system. Why do you think Vietnam is now doing better than China? It's because Vietnam has a better system than China's curren system. 

This incident should be brought back to make people aware. It's not just to bring up the incident but not bring up the root cause. Doña Paz's tragedy was hit by a series of unfortunate events. A country with a mediocre constitution (which was hurriedly written), to the people following a lax system, which in turn makes businesses have the tendency to ignore safety protocols, and it leads to several tragedies. It's not just Doña Paz but also several tragedies before and after it. If there were better systems then I think this incident would've ever been not so severe or would've never happened at all. As always, think that a bad system always causes a series of unfortunate events!