Entry page » Investigation reports » Marine » Investigation reports by year » 2001 Investigations » B1/2001M Passenger-car ferry MS ISABELLA, grounding near Staholm in Åland archipelago on December 20, 2001

B1/2001M Passenger-car ferry MS ISABELLA, grounding near Staholm in Åland archipelago on December 20, 2001

The Finnish passenger-car ferry ms ISABELLA ran aground in Åland archipelago on December 20th 2001. She was sailing from Turku, Finland to Stockholm, capital of Sweden. Onboard were 663 passengers and 157 crew members. The accident occurred whilst one of ship’s mates was carrying out his piloting test as part of his examination for the line pilot certificate. The bridge watch crew consisted of officer of the watch, examinee and a line pilot, who acted as a lookout. Additionally there was a pilot inspector from the Finnish Maritime Administration supervising and accepting the piloting test.

ISABELLA’s bridge resource practices were not in balance with the latest technical developments and didn’t comply with the modern definition of an effective team work. In addition to that, piloting test routine broke the regulations and maritime safety practices. These habits are a part of maritime culture and the shortcomings in this culture created a clear safety risk at ISABELLA.

According to commonly accepted approach the responsibility of improving bridge resource management still remains on the master, instead of having been transferred to the maritime authorities and shipowners. This has lead to a situation where the master has no support for his decision making. The goals of regulations are not inherent in bridge work. Adequately high level of safety can only be achieved with common and criteria fulfilling bridge practices. This will be realizable only if the external organisations have the main responsibility of planning the bridge routines.

The piloting test practices and weather conditions increased the safety risk.

Usual work habits were biased due to the piloting test. The examinee was not allowed to use his printed route plan. Forbidden information also included the integrated navigation system’s electronic route plan. Piloting test arrangements indicate the historical culture of the authorities. The execution methods of the test are not in balance with the modern navigational technology of the ships.

The weather forecast indicated wind speeds of 17–21 m/s. This information led to an alternative route plan being considered before ship’s departure from Turku. According to this new plan the Långnäs harbour in Åland was not visited. However, the piloting test was still scheduled. During the voyage the wind force turned out to be exceptionally strong and made the piloting test very demanding but it was not cancelled.

In Stockground near Långnäs there were difficulties in controlling the turn, because nobody noticed autopilot’s exceptional rudder usage to the port. Additionally small steering commands during the turn reduced the ability of the autopilot to control the turn. These were due to special characteristics of the autopilot. These characteristics were not known by the bridge crew. Change to the manual steering at later a stage was not sufficient in preventing the grounding.

Several causes impaired the correct assessment of the vessel dynamics by the crew. They had no possibility to know all details of the autopilot, especially the adaptivity. This caused unawareness of autopilot’s performance. The rudder indicator was not actively observed and due to the piloting test the information contents of the radar display was reduced. All these factors raised the threshold to change to manual steering.

After the first grounding the ship had three more groundings before the situation was under control. Ship’s bottom plates as well as port rudder and port main propeller were damaged. Since the vessel had no instantaneous hazard of capsizing nor sinking, the passengers were evacuated to upper decks and the ship was not abandoned. The next morning she was towed to Långnäs harbour.

In ISABELLA’s case the internal rescue tasks were mainly executed well. However, the maritime authority’s instructions don’t adequately support the definition of ships rescue plan on concrete level. ISABELLA’s rescue plan was inadequate in the dealing with passenger crowd behaviour, when defining the distribution of crew resources. Additionally, some communication links of the rescue organisation were insufficient in some parts.

The commission of accident investigation addresses safety recommendations to the Finnish Maritime Administration (FMA) for changing the piloting test. Ship owners are recommended to enhance the training for integrated navigation systems and further develop standardised bridge routines. Furthermore the commission recommends that FMA requires and controls that the safety plans of vessels include optional scenarios of action according to different situations and requirements related to communication and command arrangements.

B1/2001M Report (pdf, 3.42 Mt)

B1/2001M Report (pdf, 1.38 Mt)

 
Published 18.2.2001