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November 10, 2000
Sleipner ... continued
The Commission has not found any grounds for formal criticism of the Sleipner's owners, HSD, in regard to the design and equipment of the craft. The company also endeavoured to develop a safety management
system in accordance with modern safety management principles. However the company’s control of actual compliance with safety management requirements failed in several respects. This particularly applies in regard to implementing formal requirements to training and drills for the crews, ensuring compliance with these requirements, and establishing and ensuring compliance with speed limits and procedures for communication and cooperation on the bridge.
The Commission considers that more active supervision and control of safety management from the management and directors of the company,would have helped to establish a more adequate safety culture.
In its capacity as developer, supplier and fitter of parts of the evacuation system, it would be natural that Selantic Industrier AS had ensured that installation of the liferafts and release units satisfied the applicable
rules.
Austal Ships Pty. Ltd. built the craft in accordance with approved plans and the requirements of the HSC code, except for the transitional emergency source of electrical power not being located in accordance with code requirements. The Commission considers that the shipyard should have ensured that the transitional emergency source of power was installed in accordance with the rules and the approved drawings
.
The Maritime Directorate approved drawings of a liferaft arrangement with release units that were not in accordance with the rules, as the rafts lacked approved hydrostatic release units. Based on an overall appraisal the Commission considers that the evacuation arrangements should not have been approved.
A provisional operating permit with an operational limitation of a significant wave height of 1 meter, should not have been granted. Instead the Maritime Directorate should have waited, and not issued the permit until the adverse weather trial of the evacuation system had been carried out.
The Commission expresses some skepticism about the Maritime Directorate’s understanding of its own capacity and considers that this may have led to a weakness in dealing the matter of approva.
The incorrect location of the transitional emergency source of electrical power was not discovered in Det norske Veritas’ inspections.
Based on observations of MS Sleipner’s sister ship MS Draupner, it seems that DnV may have overlooked minor openings in the longitudinals between the wet deck and the main deck openings. resulting in these longitudinals not being watertight.
The extensive damage to the wreck of MS Sleipner made it impossible to determine whether MS Sleipner had similar deficiencies. Other than this the Commission is unable to see that DnV’s role in the building process gives any cause for special comment.
The inspection of the electrical installations by the Directorate for Product and Electrical Safety’s did not lead to a complaint regarding the incorrect location of the transitional emergency source of power. Other than this the Commission is unable to see that the Directorate’s role in the approval process gives any cause for special comment.
Principal recommendations
The Commission makes a number of recommendations designed to contribute towards preventing similar casualties.
Several of the proposals will necessitate amendments in international rules. EU law imposes clear restrictions on the Maritime Directorate’s possibilities for issuing special national requirements. This must be borne in mind when reading some of the recommendations, as they are given in the form of requests addressed to the Maritime Directorate.
The principal recommendations are:
- The scope of the regulations for high-speed craft should be extended
- More stringent requirements should be introduced for survival after damage – raking damage in the full length of the craft
Emergency power elements should be located higher up above the waterline
- Introduction of requirements for immersion suits for passengers should be considered
- .
Test procedures for life-saving appliances should be further developed
- Requirements for self-righting liferafts should be introduced
- Dryshod evacuation of a craft in damaged condition should absolutely be possible, including in adverse weather,
- Functional requirements should be drawn up for radar and other navigational aids, especially adapted for high-speed craft,
- Active work should be done to arrange conditions for use of modern navigational aids and integrated bridge designs
- .
Electronic navigational systems (ECDIS) should be introduced on high-speed craft as soon as the charts permit this. For the time being, the Commission recommends that high-speed craft obtain good electronic charts (ECS) and follow the routes at slow speed to correct any errors in the charts by means of dGPS.
- Requirements for training of crews on high-speed craft should be more stringent. Simulators should be used in the training. Courses should attach particular importance to bridge procedures
- Companies owning high-speed craft should review their safety management systems to ascertain whether there are adequate barriers against undesirable incidents. Formalized bridge procedures should be stressed and periodical checks should be introduced to ensure that procedures are followed.
- Supervision by the authorities should be stricter, particularly in regard to technical inspections of craft, control of crew qualifications and compliance with operational restrictions.
- Coastal infrastructure should be strengthened. It is particularly important to complete the work of issuing electronic charts in the near future. Work on special marking of channels for high-speed craft should also be speeded up
- Rules should be introduced requiring 15 minutes turn-out time for rescue helicopters.
Central elements in preventing casualties will be:
- Requirements for modern navigational instruments
- Good training in use of navigational instruments, including simulator training, and
- Good bridge procedures, especially between navigators
- If grounding or other casualties do occur, the craft should be better able to retain its buoyancy
- If survival capability is not sufficient, the craft should have a life-saving system that permits dryshod evacuation, including in the case of events such as encountered by MS Sleipner.
- The crew should be given training that enables them to master evacuations and other critical situations.
- If the life-saving system fails and persons end up in the sea, those on board should have personal life-saving equipment providing sufficient buoyancy and thermal protection.
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