November 10, 2000
The Commission's principal conclusions include that, on the whole, MS Sleipner was designed and built in accordance with the applicable rules in regard to strength, workmanship, structural construction, layout, watertight divisions, stability and buoyancy both in the intact and in the damaged condition (defined in the HSC Code).
The main and auxiliary engines were in compliance with the rules, so was the navigation and communications equipment. However, some faults and defects are mentioned, in particular thetransitional emergency source of electrical power and the liferaft arrangements.
The transitional emergency source of electrical power, that is to say the accumulator batteries that are to supply power in the period before the emergency generator starts up and if the emergency generators should
According to the HSC Code these were to be installed above the waterline in the final condition of damage. On MS Sleipner the transitional emergency source of power was located down in the port pontoon, partly below the final waterline after damage. This location was not in accordance with the specifications (the drawings). This location contributed towards causing power failure at an early juncture.
The Commission says neither the Norwegian Maritime Directorate, the Directorate for Product and Electrical Safety, nor Det norske Veritas discovered this defect during their inspections.
There was a serious defect in the liferaft arrangement the raft containers were not equipped with type-approved hydrostatic release units. These would have ensured that the containers were released from the craft
Type-approved hydrostatic release units were on the original drawings,but were removed from the drawings at some point. The Maritime Directorate approved the drawings without hydrostatic release units. The absence of these units was not discovered at subsequent inspections and their absence was a contributory cause of the two liferafts on the starboard side not being released,. The port side liferaft containers were
As far as can be judged the other port liferaft container filled with water and therefore did not have the buoyancy needed for inflation. Therefore this liferaft container went down with the craft.
The Commission is critical of the design of the evacuation system and liferaft arrangement, . In the worst case up to 313 passengers would have to be evacuated through the lobby, which is enclosed on all sides. This represents a risk of crowding and panic in an emergency situation. In the opinion of the Commission, further difficulties could easily arise when evacuating a craft in adverse weather, especially because operating the liferaft arrangement was extremely difficult,
There is a risk that it would be impossible to carry out the complicated liferaft launching process even with quite small waves.
Investigations have shown that the sister ship MS Draupner was directionally stable and the navigators had no difficulty in maintaining the set course in wind and wave conditions corresponding to those on the night of the disaster. The Commission presumes that this was the same in the case of MS Sleipner.
The navigators possessed the formal qualifications required for operating high-speed craft, but, in the opinion of the Commission, had not received adequate training in use of the navigational aids on MS Sleipner, nor had they received adequate training in use of the complicated evacuation system.