M2016-S1 Power Failures on Ships

In the beginning of year 2016 the Safety Investigation Authority decided to initiate an investigation into power failures on ships. The purpose of safety investigation is increasing public safety, preventing accidents and incidents as well as mitigating damages caused by accidents.

Power failures in narrow fairways and in areas with dense traffic can cause very serious sea- or environmental accidents. These risks are pronounced in the Finnish narrow and rocky fairways, both in sea areas and in inland waterways. This safety study strived to identify causes for the power failures on vessels. An evaluation concerning factors that decreased or increased safety was also conducted. These evaluations are presented in the incident reports included in this safety study, section 2.3.

Information about the power failure cases included in this safety study was received from the Finnish Transport Safety Agency, the Finnish Transport Agency, Finnpilot Pilotage Ltd. and the involved shipping companies. It was decided that 12 cases of power failures, or cases with similar consequences, would be investigated. The shipping companies were informed about the commencement of the investigations. The on site investigations were conducted by teams consisting of 2-3 experts. The scope of the investigations into individual cases was limited to the component-, system- and operational- levels. None of the investigated cases did result in a very serious sea accident or environmental accident. Reports were prepared on the results of the on site investigations. The reports are included in this safety study.

After a one-year monitoring period, the investigated incidents were analysed using the bowtie method of analysis. When scrutinising the findings in the analysis, it can be concluded that good quality of components, reliability of systems, sufficient skills of the crew and the circumstances are factors central for preventing power failures. The quality of the components, the reliability of the systems and the competence of the crew can be influenced and the impact of the circumstances can be anticipated.

The incident reports were sent to the concerned shipping companies for review. The draft report was sent for review to the Finnish Transport Safety Agency, the Finnish Transport Agency and to Finnpilot Pilotage Ltd. A summary of the reviews has been included in this report.

According to the ISM Code, shipping companies must, in the safety management system, identify the vessel's critical systems and equipment that, in case of a sudden failure or incorrect use, can result in a hazardous situation or accident. A power failure is a serious deviation. There is no aggregated or comparable information available on deviations in connection with power failures. The Safety Investigation Authority recommends, that

The Finnish Transport Safety Agency together with the shipping companies, develop procedures to obtain detailed information about power failures for analysing purposes.

The reform of the Finnish Maritime Code, when realised, creates favourable conditions for the implementation of this recommendation. In the draft of the new code, reporting of incidents is mandatory. It is important that the procedures for reporting to be developed, allow for concrete measures to be taken to address the identified problem. It is also important that the definitions needed in the reporting are clear and understood in the same way by the various parties. This recommendation, if implemented, would also contribute to identifying risks connected with the emerging transport system and to preparing for them.

The conditions and the cargos the vessels carry affect the graveness and extent of the consequences of the power failures. This is emphasised in the narrow fairways in the archipelago and in inland waterways where safety margins for navigation often are very small. A sea accident in these circumstances can cause a serious environmental accident. The reliability and sufficiency of the backup- and emergency systems are, for this reason, of utmost importance. The Safety Investigation Authority recommends, that

The Finnish Transport Safety Agency together with the Finnish Environment Institute, assess the adequacy of, and the need for, the development of the legislation concerning safe conduct of vessels in the archipelago and in inland waterway areas.

Procedures relying solely on the use of a shaft generator in the narrow fairways in the archipelago and in inland waterways increase the risk for accidents.

M2016-S1 Power Failures Safety Study pdf (pdf, 0.9 Mt)