Investigation of pilot boat accident at Suomenlahti, which led to the deaths of two people on 8 December 2017, is complete – the safety of pilot boats and the pilotage sector must be improved
A high-speed pilot boat L-242 of the Kewatec Pilot 1500 type,capsized and sank in the Gulf of Finland to the south of Emäsalo, when on its way to transfer a pilot. Two pilot boat operators, who did not have the possibility to exit the cabin, died in the accident.
Insufficient account had been taken of the risk of losing stability and capsizing in strong waves. It is generally assumed that pilot boats are self-righting and safe in all circumstances, for which reason the capsize was unexpected. At the time of the capsize, the direction of the waves and their greater height and steepness created fatal and unexpected conditions for the pilot boat. The rescue operations were impeded by darkness and the weather.
The Safety Investigation Authority issues five safety recommendations for the prevention of similar accidents and improving the safety of pilot boats and the pilotage sector.
The Safety Investigation Authority recommends that the Finnish Transport Safety Agency draw up rules applying to commercial craft, which take account of special requirements related to the various purposes of such craft and the conditions in which they are used. There are no clear official requirements related to commercial craft, which has led to the interpretation and application of a wide range of rules. There is a risk that insufficient account is taken of the special requirements applying to commercial craft intended for various purposes and conditions when manufacturing and ensuring the safe use of boats.
To the pilotage company Finnpilot Pilotage Oy, the Safety Investigation Authority recommends that it describe the pilot transfer process in its enterprise resource management system and develop and implement the deviation reporting system in such a manner that it includes a more comprehensive picture of the hazards and safety deviations that occur during pilot transfer.
Pilotage transfer processes are not included in the guidelines of Finnpilot Pilotage Oy. In addition, little deviation reporting is carried out by pilot boat operators in comparison to reporting by pilots. The few deviations reported in the case of pilot boats concern the boats’ technology. Boat operators’ practices are largely based on experience and silent knowledge, rather than documentation and systematic risk assessment. Pilot boat operators must also be included in the risk assessment process.
Secondly, the Safety Investigation Authority recommends to Finnpilot Pilotage Oy that it develop the induction and competencies of pilot boat operators in such a manner that the seaworthiness and safe handling of various kinds of boats is guaranteed in the conditions in which pilot boats are used. The induction of pilot boat operators is inconsistent and is not necessarily sufficient with respect to the demanding nature of the work and to ensure its safety. The task-based induction of pilot boat operators had not been systematically documented, and did not cover the safety risks associated with the handling, steering and stability of a boat in sufficient detail.
The Safety Investigation Authority recommends to the Finnish Border Guard that it also prepare for non-standard emergencies and develop procedures for obtaining the background information required in rescue operations. The Maritime Rescue Sub-Centre was not prepared for this kind of accident and sea rescue mission. A sufficiently accurate situational picture could not be formed for the sea rescue mission, nor could the related procedures be formed in support of decision-making and management when the unexpected accident occurred. No advance plan had been formulated for rescuing people from a fully capsized boat. When the rescue operation began regarding the pilot boat, insufficient information was available on the cabin structures and lifting chains. The Finnpilot Pilotage Oy staff who participated in the rescue operation should have had more precise information on the boat's technical features.
In addition, the Safety Investigation Authority recommends that, together with the Ministry of Social Affairs and Health, the Finnish Border Guard clarify the procedures for alerting psychosocial support services during sea accidents, in such a manner that the chain of assistance takes account of the national role and tasks of municipal emergency social services and the Vantaa social and crisis emergency services.
During the investigation, a technical analysis was performed of the pilot boat, which is presented as an attachment to the investigation report. In addition, a capsizing test was performed on another, corresponding pilot boat and the operational condition of the rescue equipment was checked. Captain and MSc. Tech. Tapani Salmenhaara acted as the head of the investigation team and M.A. Ilona Hatakka, Ph.D Tech. Jerzy Matusiak, Captain Teemu Leppälä, Naval Architect Niklas Rönnberg, Lieutenant Commander (ret.) Matti Salokorpi and Safety Investigator Heikki Harri served as members. Risto Haimila, Chief Marine Safety Investigator of the Safety Investigation Authority, served as the Investigator-in-Charge.
Veli-Pekka Nurmi, Executive Director, tel. +358 295 150 701
Risto Haimila, Chief Marine Safety Investigator, tel. +358 295 150 730