S1/2009M The impact of accident investigation on domestic passenger ship safety

Continuous similar cases have often appeared in the investigation of water traffic accidents and dangerous situations. Separate safety studies on these situations and their topic have been made in the Accident Investigation Board.

The basis of this safety study was safety study S2/2004M prepared by the Accident Investigation Board concerning the safety of domestic passenger vessel traffic. The purpose of the work was to update the previous safety study from above and, on the other hand, to clarify how recommendations in the abovementioned study have been obeyed. Procedures to advance safety in the domestic passenger ship traffic have also been presented in the work, and various safety recommendations have been given to designated areas. Topics concerning guilt and responsibility as well as indemnity liability were not processed, because they are not included in the area of responsibility of the Accident Investigation Board.

The cases concerning domestic passenger ship accidents and dangerous situations that have been investigated in the Accident Investigation Board after the safety study S2/2004M have been processed in the report: whether or not they include similarities on previous accidents and dangerous situations. Developing and updating the means to operate was found necessary in the previous safety study. It is researched in the work whether positive development has occurred in these areas. The main purpose of the safety study was to clarify the impact of the accident research on domestic passenger ship safety.

Because five years have passed since the previous safety study, the time interval was found long enough for the research that, using theory and interview research, surveys the safety situation on domestic passenger ship traffic nowadays and, at the same time, clarifies what kinds of changes are seen compared to the situation one year ago. In all the accidents researched in the previous safety study, the main cause was linked to human factors. It is also determined whether these factors are as important in the accidents that occurred after 2004. Based on the Accident Investigation Board discoveries, it seems that not enough attention has been paid to traffic supervision, surveillance and general security. The condition of the abovementioned circumstances nowadays has been noted and necessary recommendations have been given to designated areas in the work.

Effects of the previously given recommendations on safety are researched in the work, and at the same time safety study S2/2004M is updated. In addition, the connection between the research and previous researches is determined in the theory section, and conclusions and safety recommendations provided are researched as based on safety study S2/2004M, which is the basis of the thesis. The practical investigation is handled at the beginning of the empirical part of the report. The aim of the survey, methods used and the means and basis on which the questionnaires and interviews have been performed for the shipping companies and Navigation Administration are handled in more precise detail here. After this, results from the material used in the survey are analyzed.

After the introduction of the results the process continues to a more precise observation, consideration and conclusions. In this part of the survey, the conclusions on safety, education, guidance, initiation and the operation of public authorities are processed individually. More precise consideration and conclusions are found at the end of the survey, and they are used as the basis to present suggestions for development. These suggestions relate to investigation of the safety of passenger ship traffic, its effectiveness, given recommendations and practical actions in the domestic passenger ship traffic.

When observing the factors that have caused accidents and aberrations, it can be stated that they are highly similar to the ones on the previous safety study on domestic passenger ship traffic safety. It is still the case that not enough attention is being paid to planning and following the route. It was stated in the previous safety study that continually supplementing route planning of the regular paths should also be included in the risk investigation of the domestic passenger shipping companies. On the basis of the cases researched in this report, it can be said that no change to the situation has occurred in practice, despite the recommendations. In some domestic shipping companies, the danger fails to be recognized, and dangerous situations are not seen as risks. Negative attitudes concerning safety on these shipping companies also affect the views, behaviour and safety of individual workers.

On the basis of this safety study, the safety attitudes, crew training, guidance and orientation in some shipping companies of the domestic passenger ship traffic do not advance beneficial safety environment. Not enough attention has been paid on the traffic guidance, training, supervising and general safety. Generally more guidance, supervision and authority surveillance are needed in order to control the safety of this industry. On the basis of this report, most of the domestic passenger ship traffic shipping companies want to increase the cooperation between the shipping companies and the Marine Authority as well as Rescue Authorities. Increasing and developing cooperation with regard to this industry would be helpful in developing and continuing a beneficial safety environment.

In addition to education, strict instructions are needed: authorities that should provide concrete instructions and patterns on the right means to operate play the key role. Texts of law are often too ambiguous and indefinite, which the authorities or other specialists might not always recognize. In order for the safety of domestic passenger ship traffic to improve, various areas have a lot to improve with respect to their operations and cooperation. A safety culture does exist, but it is variable and lacks instructions that define a common minimum level of safety.

With the interview reports, the Accident Investigation Board clarified their own operations and conspicuousness of the safety study S2/2004M and thereby their impact on domestic passenger ship traffic safety. The results of the inquiries and interviews showed that the conspicuousness of the Accident Investigation Board is quite minor among the ship owners. Consistently, chiefs and inspectors of the Marine Investigation Supervision Units were well-aware of the operations of the Accident Investigation Board and its priorities. Of all the persons that were interviewed, however, 55% were not familiar with safety study S2/2004M. According to the interviews, only one respondent from these target groups was familiar with the safety recommendations provided in the previous safety study. On the basis of the facts that showed up during the investigation, it can be stated that the conspicuousness of the previous safety study and its impacts on domestic passenger ship traffic safety are quite minor.

According to the researchers, the discoveries that already in themselves increase coverage, as well as visits to the shipping companies and lectures at the educational facilities of the industry, all represent an excellent way to advance safety and achieve influence. When this safety study was in progress, the researchers from the Accident Investigation Board held a meeting for the stakeholders. During the meeting, there were discussions on domestic passenger ship traffic safety, and some introductory results of this report were presented. A meeting with similar content was held with the management group of the Finnish Transport Safety Agency’s Maritime Sector. While working on the safety study, the researcher also visited marine navigation education establishments and both gave lectures and arranged discussions on domestic passenger ship traffic safety.

S1/2009M Report (pdf, 3.78 Mt)

Published 3.5.2009