What We Should Learn from Ferry Disasters

After a serious ferry disaster with significant loss of life, it is human nature to seek to punish those “who are responsible.”  Is this the right thing to do?  Should we hang the culprits from the nearest lamppost and move on? The IMO says not.

The IMO Casualty Investigation Code calls for an investigation to be safety focused, to provide safety recommendations so as to prevent future recurrences – not to apportion blame or liability. IMO Guidelines also call for seafarers to be treated fairly during an investigation.  An investigation under the Code does not preclude separate civil or criminal legal action; however, safety and responsibility are often different issues.

The Worldwide Ferry Safety Association believes, based on data it is continuing to research, that casualty investigation may be an important factor in breaking the cycle of repetitive incidents. Investigation to determine cause, rather than culprits, is the key to understanding why these incidents took place and to help prevent them from recurring in the future, says Association member and naval architect John Dalziel.

The Kim Nirvana-B Capsize

The recent Kim Nirvana-B capsize with loss of life in the Philippines would be a good case for an investigation following the principles of the IMO Casualty Investigation Code, says Dalziel, as would some other recent incidents. “I believe significant technical and operational issues may be revealed, ones which may not have been fully understood.”

Around 60 people died after the capsize of the Kim Nirvana-B early in July. The vessel had just left port in Ormoc City and was a mere 200m (650 feet) from shore when it overturned in calm seas. The vessel was a canoe-style craft with outriggers, and it was powered by a small engine. The vessel rolled while attempting to turn.

Capsizing and swamping are the most likely of all marine incidents to result in fatality. A significant loss of stability can occur with loading (a change in the vertical center of gravity), when freeboard is minimal, when there is water on deck or when there is down-flooding of water to lower decks.

“Multi-hull vessels have some very specific stability characteristics which are often not fully appreciated,” says Dalziel.

A technical investigation done in accordance with the principles of the IMO Code would highlight the causes of the accident, be they technical (such as a lack of stability), operator error (such as navigation) or systemic (such as insufficient revenues to operate a safe service, general non-compliance with regulatory requirements, etc.). 

Using an investigative process aimed solely at identifying cause, rather than responsibility, it may be able to identify facts and issues and make recommendations, all of which may be excluded in a legal case. Publishing these reports puts pressure on all parties to be thorough and objective, hopefully limits bureaucratic interference, and can educate the public as to what are safe operations, says Dalziel.

In its recently published “Manila Statement” on domestic passenger vessel safety, the IMO and the other participating agencies have endorsed the importance of thorough and prompt investigations to identify the causal factors for marine incidents.

The Worldwide Ferry Safety Association recently presented statistics at the World Maritime Rescue Congress, held in Germany and hosted by the International Maritime Rescue Organization. Over 17,000 deaths occurred in ferry accidents between 2000 and 2014, and 97 percent took place in developing countries. Many of these countries have not investigated the cases in accordance with the principles of the IMO Casualty Investigation Code (or at least have not published the results). In comparison, in countries which have tended to conduct thorough accident investigations focusing on cause, relatively few fatalities took place, and repetitive accidents from the same cause were infrequent.

The Uean Te Raoi II and Lady D Capsizes

In arguing that better investigations can help mitigate the situation, Dalziel cites a New Zealand Transport Accident Investigation Commission report into the capsizing in the South Pacific Island nation of Kiribati of the outrigger ferry Uean Te Raoi II:

The vessel Uean Te Raoi II was loosely based on the proven KIR-5A design, but with some significant variations. Most dimensions were increased by about 25 percent, which resulted in a vessel of almost twice the volume of the original design. The layout of the vessel was changed, resulting in a cabin structure that caused more wind resistance, and with the passengers being carried relatively higher in the vessel. These factors contributed to a decrease in the vessel’s safety, with regard to its resistance to capsize.

An earlier decision not to allow weight to be carried on the cross beams addressed a structural issue, but prevented the traditional method of stability improvement used on this type of vessel. The resulting vessel did not provide an acceptable level of safety in anything beyond sheltered waters operation. It was at significant risk of capsize with loads of over 30 persons, combined with wind conditions of over 30 knots, or in beam sea conditions of over about 1.5m.

And another case, this time in the U.S., the capsizing of the pontoon boat type ferry Lady D:

On March 6, 2004, the small passenger vessel Lady D, a pontoon water taxi with two crewmembers and 23 passengers on board, was enroute from Fort McHenry to Fells Point, Maryland when it encountered a rapidly developing storm with high winds. The pontoon vessel began to roll in the waves and eventually continued over onto its starboard side and capsized.

As a result of the accident, five passengers died; four passengers suffered serious injuries; and 12 people sustained minor injuries.

?The National Transportation Safety Board determined that the probable cause of the capsizing was its lack of intact stability, which was insufficient to withstand the strong winds and waves that the boat encountered. The lack of intact stability was caused by overloading, which resulted from a combination of the following:

 * The Lady D was erroneously granted sister status by the U.S. Coast Guard to a pontoon vessel with different design characteristics;

 * The Coast Guard certificated the Lady D to carry too many people as a result of an inappropriate stability test on the vessel to which it was granted sister status; and

 * The Coast Guard’s regulatory stability test standards on which the Lady D’s passenger allowance was based use an out-of-date average passenger weight.

Problems with Multihull Vessels

Both of the foregoing incident reports highlight stability characteristics that may cause apparently stable multi-hull vessels to quickly capsize (the technical description with diagrams on pages 80 – 91 of the Lady D report is particularly instructive, says Dalziel).

As pointed out in both reports, multihull vessels are particularly prone to changes such as loading, angle of heel and wave angle. Although initially very stable, which may give a misleading sense of security, they can capsize very quickly. Apparently this is what happened to the Kim Nirvana-B.

A full incident report, on the technical level of the New Zealand and American reports, would highlight why this vessel sank. Were the operational aspects of this type of vessel fully understood? Is this type of vessel suitable for this type of ferry voyage? Was there wrong-doing in this case which would justify legal proceedings? Dalziel says that perhaps the answer will be that with some better understanding of the stability characteristics of these multi-hull craft they are able to operate safely and economically to the benefit of the local people.

Sufficient stability is one of a vessel’s most important safety characteristics, he says. “It is important the operating personnel understand stability and its limitations, and it must be remembered that compliance with any stability standard does not guarantee freedom from risk of capsizing or sinking.

“Should the Philippines produce and publish, in Filipino and in English (for international distribution), a report similar to New Zealand and American reports above?  I believe this would be a step forward in breaking the continuing cycle of tragic losses,” says Dalziel.

The U.S. NTSB Lady D capsizing report is available here. 

The NZ TAIC report - Uean Te Raoi II - Kiribati - stability report – is available here (page 49 of report onwards).