M2017-04, capsizing and sinking of pilot boat 242 (FIN) in the Gulf of Finland, to the south of Emäsalo, on 8 December 2017

On the afternoon of Friday 8 December 2017, the MT Sten Nordic left Kilpilahti in Porvoo under piloting, following a 15.3 metre-deep channel towards Antwerp in Belgium. The MT Sten Nordic passed by the pilot station at Emäsalo at 16.08 hours, at which point pilot boat L-242 followed the vessel from behind, where it was protected from the strong waves and wind. The pilot boat L-242 was a high-speed pilot boat of the Kewatec Pilot 1500 type.

The MT Sten Nordic began providing shelter for the transfer of the pilot, by turning to the port side (left), upon which the pilot boat began moving from behind the vessel towards its port side. As the MT Sten Nordic turned, the pilot boat L-242, which was behind the vessel, was exposed to rough waves coming from the side, as well as recurring steep and high waves due to the sea conditions combined with the effect of the moving vessel’s hull. In the strong waves, the pilot boat keeled over losing much of its stability, rocked back and forth a few times and capsized onto its left side around 20–30 metres from the MT Sten Nordic at 16.56 hours. Around 10 minutes later, the pilot boat L-242 turned upside-down and began to gradually fill with water.

The MT Sten Nordic reported the incident, to the Helsinki VTS, which relayed the information to the Helsinki Maritime Rescue Sub-Centre (MRSC Helsinki). The commander of the sea rescue operation began a surface search, and gave the commander of the diving operation the task of planning the rescue of people from the capsized pilot boat. The first rescue units arrived at the scene of the accident at 17.38 hours, but no sightings could be made of the crew or life raft. The crew members of the pilot boat could not be found during the surface search and the capsized pilot boat could not be stabilised or righted in the harsh conditions, but eventually detached from its suspension and sank. The operators of the pilot boat were found dead in the cab, in their survival suits, during an inspection dive to the wreck at 00.13 hours on 9 December.

The maritime search and rescue authorities were not sufficiently prepared for a sudden accident of this kind. GMDDS distress communications were not activated as the radio communications regulations require. The activation of distress communications as required by the radio communications regulations would have secured information exchange between the pilot boats and stations involved, and the units directing and participating, in the rescue operation.

The risk of the pilot boat capsizing had not been identified. In the investigation, it emerged that in Finland no clear official standards exist with regard to commercial craft, which has led to the interpretation and adaptation of a wide range of rules. This creates the risk that insufficient account is taken of special standards applying to various intended uses of commercial craft, and the conditions in which they will be used, during the vessels’ design, manufacture and when ensuring their safe use. The pilot boat L-242 must be capable of operating in rough waves according to design category B, which means a wave height of 4 metres and a wind speed of 21 m/s. During the investigation, it was observed that the L-242 can temporarily lose up to 70% of its stability in strong waves, during which a sudden, strong external force can capsize the boat. Such an external force can occur due to a rudder movement or a powerful gust of wind. No account has been taken of these factors in the design, manufacture or use of the boat. On the basis of the investigation, there is also reason to believe that the crew of the pilot boat L-242 had no grounds for believing that the boat would capsize. The pilot boats were regarded as safe in all conditions and were assumed to be self-righting, due to which the capsizing of pilot boat L-242 was unexpected.

The stability characteristics of a pilot boat are not considered in the pilot company’s operating manual, the manual for the pilot boat L-242, or the safety manual for pilot boats. The users were not sufficiently aware of the boat’s stability characteristics in strong waves. The induction of pilot boat operators is variable and is not necessarily sufficient in terms of the challenging nature of the work or ensuring safety. Risk identification and safe practices are largely based on silent knowledge rather than documentation and systematic risk assessment. Finland has no monitoring system for the safety management of piloting or piloting service operations, and there are no statutory auditing obligations for the operations or operating manuals of piloting companies.

Municipal social emergency response centres did not receive information from the maritime search and rescue authorities. During the investigation, it was revealed that the emergency response centres and maritime search and rescue authorities have a range of practices for the alerting of psycho-social support services. It was also observed that the relatives of the deceased were informed of the accident in various ways, for which reason some were not given direct guidance on obtaining crisis support. Alerting the municipal social emergency response services would have ensured the linkage of psycho-social support to news of the deaths.

As a result of the investigation, the Safety Investigation Authority, Finland recommends that

• the Finnish Transport Safety Agency draw up rules for commercial craft that take account of the various purposes for which commercial craft are used and the special requirements related to the operating conditions

• in its ERP system, Finnpilot Pilotage Oy describe the pilot transfer process and develop and implement its deviation reporting system in a manner that provides a more comprehensive picture of the hazards and the observed safety deviations that occur during pilot transfer.

• Finnpilot Pilotage Oy develop the induction processes and competencies of its pilot boat operators in such a manner, that the seaworthiness and safe handling of different types of boat can be guaranteed in all conditions in which pilot boats are used

• as the leading maritime search and rescue authority, the Finnish Border Guard prepare more comprehensively for unusual, as well as more common, emergencies and develop practices for obtaining the background information needed for rescue operations

• together with the Ministry of Social Affairs and Health, the Finnish Border Guard clarify the practices to be followed for the alerting of psycho-social support services during maritime accidents and that the chain of assistance take account of national social emergency services, and the national role and tasks of the Vantaa social and crisis emergency support services.

M2017-04 Report (in Finnish) (pdf, 3.96 Mt)

Analysis of capsizing of pilot boat (in Finnish).pdf (pdf, 0.93 Mt)

Bulletin (pdf, 0.49 Mt)