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Crisis Management and Human Behaviour Training

INTRODUCTION

1. Introduction
When the 1978 STCW Convention entered into force in 1984 it was expected that its requirements
would ensure the competence of masters, officers and ratings of all seagoing ships and their safe
operation through efficient watchkeeping. As with all IMO conventions it reflected the highest
practicable standards which could be globally agreed at the time of its adoption.

Despite its broad global acceptance, it was realized in the late 1980s that the Convention was not
achieving its purpose. Instead, the Convention was gradually losing credibility as its acceptance widened.
The main cause for this appeared to be the general lack of precision in its standards, the interpretation
of which was left ‘to the satisfaction of the Administration’. This resulted in widely varying
interpretation of standards and many Parties failed to effectively administer and enforce Convention
requirements. STCW certificates could no longer be relied upon as evidence of competence.

It was decided in 1993 to give high priority to a comprehensive review. The main aims of the revision
were:
.1 to transfer all detailed technical requirements to an associated code;
.2 to clarify the skills and competence required and to take account of modern training methods;
.3 to require Administrations to maintain direct control over and endorse the qualifications of those
Masters, officers and radio personnel they authorise to serve on their ships;
.4 to make parties to the Convention accountable to each other, through IMO, for their proper
implementation of the Convention and the quality of their training and certification activities; and
.5 to have the amendments enter into force for all Parties to the Convention with the least possible
delay.

The trainees must be made aware of the human-related causes of shipping disasters.
The inclusion of Chapter V of the Code is mainly as a direct result of the tragedies suffered by the
‘Herald of Free Enterprise’, Scandinavian Star’, and ‘Estonia’. Summaries of these are included in
Appendix 1.

Outside assistance is rarely immediate and often not available. It must be stressed to trainees that they
must always consider their actions and continually operate a safe working system.

ROLL-ON ROLL OFF SHIPS


The roll-on/roll-off ship is one of the most successful types operating today. Its flexibility, ability to
integrate with other transport systems and speed of operation have made it extremely popular on many
shipping routes. The roll-on/roll-off ship is defined in the November 1995 amendments to Chapter II-1 of
the International Convention for the Safety of Life at Sea (SOLAS), 1974 as being "a passenger ship with
ro-ro cargo spaces or special category spaces..." One of the ro-ro ship's most important roles is as a
passenger/car ferry, particularly on shortsea routes. But despite its commercial success, the ro-ro
concept has always had its critics. There have been disturbing accidents involving different types of ro-ro
ship, the worst being the sudden and catastrophic capsizing of the passenger/car ferry Herald of Free
Enterprise in March 1987 and the even more tragic loss of the Estonia in September 1994.
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The development of ro-ros The modern roll-on/roll-off ship can trace its origins back more than one
hundred years to the early days of the steam train. Ships were specially designed to take trains across
rivers which were too wide for bridges: the ships were equipped with rails, and the trains simply rolled
straight on to the ship, which sailed across the river to another rail berth where the train would roll off
again. An example is the Firth of Forth ferry in Scotland which began operations in 1851. It was not until
the Second World War, however, that the idea of applying the ro-ro principle of road transport became
practicable - and was used in constructing the tank landing craft used at DDay and in other battles. The
principle was applied to merchant ships in the late 1940s and early 1950s. It proved to be extremely
popular, especially on short-sea ferry routes, encouraged by technical developments on land as well as
sea, notably the increase in road transport. For the shipper, the ro-ro ship offered a number of
advantages over traditional ships, notably speed. As the name of the system implies, cars and lorries can
drive straight on to a ro-ro ship at one port and off at the port on the other side of the sea within a few
minutes of the ship docking.

Today the world ro-ro fleet can be subdivided into a number of different types. They include ships
designed to carry freight vehicles only; to carry a combination of containers and freight vehicles and to
transport cars without passengers. There are various other types and freight-only roro ships form about
two thirds of the world ro-ro fleet at present.

However, the best known ro-ro ships are ferries designed to transport commercial vehicles and private
cars, together with large numbers of passengers, usually on short voyages.

The problem areas:

Although ro-ros have proved commercially very successful, some concern has been expressed about ro-
ro ships from the safety point of view virtually ever since the first ro-ro ships were introduced. The
whole design concept is different from that of traditional ships because of the introduction of a number
of elements which make ro-ro ships unique.

1. The lack of internal bulkheads On conventional ships, the hull is divided into a number of separate
holds by means of transverse bulkheads, many of which may be watertight. In the event of the hull
being holed, the bulkheads will limit or delay the inrush of water, resulting in the ship sinking slowly
enough for the evacuation of those on board or even preventing the ship from sinking at all. With ro-ro
ships the installation of unpierced transverse bulkheads is a major obstacle, at least on the upper
"through" decks: the whole idea of the ro-ro ship depends upon being able to drive cargo on to the ship
at one end and off again at the other. The installation of fixed transverse bulkheads would prevent this.
Although ro-ros are all fitted with the watertight collision subdivision, and engine-room bulkheads
below the freeboard deck prescribed by SOLAS, the huge vehicle decks make it possible for water to
enter very rapidly and fire can also spread very quickly for the same reason.

2. Cargo access doors The cargo access doors at the stern and bow of the ship represent a potential
weak spot, as do the side doors with which some ro-ro ships are equipped. Over the years such doors
can become damaged or twisted, especially when the door also serves as a ramp.

3. Stability The movement of cargo on the vehicle deck can affect the intact stability of the ship, causing
it to list. The sudden inrush of water following damage to the hull or failure of watertight doors can be
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even more serious (and rapid). The fact that ro-ro ships generally have a very large superstructure
compared with other types means that they can be more affected by wind and bad weather.

4. Low freeboards Cargo access doors fitted on cargo-only ro-ros are often very close to the waterline.
This means that a defective trim or a sudden list, caused, for example, by the movement of cargo, can
bring the access threshold below the waterline, resulting in a sudden inrush of water (if the door is
open) which will in turn result in the list increasing and a possible capsizing of the ship.

5. Cargo stowage and securing A list can cause cargo to break loose if it is not correctly stowed and
secured. The problem is made worse because the crew of the ship cannot normally see how the cargo is
stowed inside or on the trailer in which it is transported. A heavy load which breaks loose can cause
other units to follow suit. The result can be an increased list, the spillage of dangerous substances and,
in extreme cases, damage to the hull and ship's structure.

6. Life-saving appliances The high sides of many modern ro-ros, including passenger ships, pose
problems regarding lifesaving appliances: the higher a lifeboat, for example, is stowed the more difficult
it can be to launch, especially if the ship is listing badly.

7. The crew The factors referred to above indicate that ro-ros are highly sophisticated ships which
require very careful handling. This makes them exceptionally vulnerable to human error.
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2. Loading and embarkation procedures


Loading and discharging cargo units can be dangerous if the proper procedures are not followed. Some
pre-planning may have been undertaken before arrival however the ship’s officers must not proceed
until they are sure that the ship is ready to load or discharge safely. Because the operation can be
undertaken quite quickly, car deck personnel must be highly visible, and totally familiar with CRISIS
MANAGEMENT AND HUMAN BEHAVIOUR TRAINING, INCLUDING PASSENGER SAFETY, in the area.
Drivers may be tired, stressed and unfamiliar with their surroundings, so personal safety and the safety
of others is essential. Noise levels are high which often inhibits effective communications.

2.1 Procedures for loading and discharging vehicles, rail cars and other transport units, including related
communications

Car decks are dangerous working areas for crew members and drivers and passengers as they leave their
vehicles. The risks to each can be controlled: to crew, by ensuring that only authorized crew are present
and that they wear high visibility working gear. Decks must be kept clear of chains and other securing
devices.

Drivers and their passengers should be marshalled clear of moving traffic and the speed of traffic flow
controlled. Crew should be alert to petrol spillage from over-filled tanks that can lead to liquid and
vapour spillage. Absorbents should be ready to tackle such events.

This work involves significant judgement in planning, technical and leadership functions related to the
loading/unloading, and embarkation/disembarkation of passengers on a roll-on roll-off vessel. And this
work may be carried out by day or night in both normal situations and under any possible operational
conditions.

This kind of cargo may involve loading/unloading road vehicles, including cars trucks, buses, etc., rail
cars and other forms of transport units; Containers on transport units, general cargo and dangerous
goods.

Measures to control the trim and stability of the vessel may include :
 Adjusting weight distribution of load,
 pumping ballast water to compensate for load distribution,
 pumping of flooded compartments,
 implementing damage control measures to maximise watertight integrity of hull where it has been
damaged.

Cargo handling hazards may include :


 faulty cargo handling equipment
 damaged cargo
 cargo handling operations in poor weather or sea conditions
 incorrectly stowed dangerous cargo
 incorrectly stowed cargo
 poor ventilation on vehicle decks
 incorrectly lashed or secured cargo/vehicles, rail cars or other transport units
 incorrect procedures for opening, closing and securing the hull openings of the vessel
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 using equipment beyond safe working limits


 non-compliance with safe working procedures

Documentation and records may include :


 ISM Code safety management system plans, procedures, checklists and instructions
 operational orders
 established vehicle loading/discharging procedures
 established passenger embarkation/disembarkation procedures
 passenger lists
 sections of the AMSA Marine Orders and the IMO STCW Convention and Code related to roll-on roll-
off vessels
 'Trim and Stability Booklet'
 material data safety sheets
 IMDG Code
 vessel manufacturer's instructions and recommended procedures
 OH&S procedures relevant to roll-on roll-off vessels
 instructions of relevant maritime authorities concerning the operation of roll-on roll-off vessels
 relevant Australian and international standards

Applicable legislation , regulations and codes may include :


 sections of the maritime regulations related to roll-on roll-off vessels, including the International
Ship and Port Facility Security (ISPS) Code
 relevant sections of AMSA Marine Orders
 IMDG Code
 Code of Practice for Cargo Stowage and Securing
 MARPOL Convention
 SOLAS Convention
 notices and instructions of relevant maritime authorities concerning the operation of roll-on roll-off
vessels
 relevant OH&S and pollution control legislation

Plan the loading, and stability of the vessel:


 Stability and stress information for a roll-on roll-off vessel is obtained and interpreted
 Stability and trim for various conditions of loading are calculated using stability calculators or
computer programs provided
 Load factors are calculated for decks in accordance with established procedures
 The impact of ballast and fuel transfers on stability, trim and stress are calculated in accordance
with established procedures
 Weight distribution is organised to maintain the vessel within acceptable stability limits for
anticipated operation situations likely to be experienced during the voyage
 Calculations are made to determine the draught and centre of gravity of the vessel after adding,
removing or shifting weight
 Trim, draughts and list of the vessel are controlled as required to ensure they are suitable to
progress all anticipated vessel operations
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 Plans for the loading/unloading, embarkation/disembarkation, and ballast and fuel management are
prepared in accordance with established procedures, vessel's ISM Code safety management system,
and regulatory requirements
 Checklists for use in the loading and embarkation of a roll-on roll-off vessel are obtained or
developed
 Operational plans and procedures for the loading/unloading, embarkation/disembarkation, and
ballast and fuel management are documented and made available to relevant staff in accordance
with tanker procedures and regulatory requirements

Manage the loading / unloading and embarkation / disembarkation procedures:


 Ramps are lowered and hoisted in accordance with established procedures
 Vehicles, rail cars and other cargo transport units are loaded and discharged in accordance with
established procedures and loading plan
 Retractable vehicle decks are set up and stowed in accordance with established procedures
 Special safeguards, procedures and requirements regarding the carriage of dangerous goods on
board roll-on roll-off vessels are applied in accordance with regulations
 Passengers are embarked and disembarked in accordance with established procedures and
embarkation plan
 Appropriate special attention is provided during embarkation and disembarkation procedures for
disabled persons and persons needing assistance

Open, close and secure hull openings on a roll-on roll-off passenger vessel:
 Established procedures are properly applied for the opening, closing and securing of bow, stern and
side doors and ramps and the operation of associated systems
 Appropriate checks are made to confirm the watertight integrity of the vessel prior to departure
 Problems with the operation of bow, stern and side doors and ramps and associated systems are
promptly reported in accordance with established procedures
 Surveys on the proper sealing of hull openings on the vessel are conducted in accordance with
established procedures and regulatory requirements

Complete cargo handling and passenger embarkation / disembarkation documentation:


 Correct reports are completed relating to cargo and vehicle loading/unloading and passenger
embarkation/disembarkation operations and incidents in accordance with established procedures
and regulatory requirements
 All documentation is completed in accordance with requirements and regulations

2.2 Procedures for safely lowering and hoisting ramps, setting up and stowing vehicle decks

Operating ramps and retractable vehicle decks must be strictly controlled. The operator(s) must be
competent and proved this having completed training. On occasions the operator’s view may be
restricted and so before the operation, he should liaise closely with another crew member who can then
give verbal instructions, or clear hand signals, to lower and hoist. The ship will have operating
procedures on board which must always be followed or checked if in doubt. Control boxes must always
be locked and power isolated to prevent inadvertent use and use by unauthorized persons.
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Ensure that:
- the established procedures are properly applied for the opening, closing and securing of bow, stern
and side doors and ramps and the operation of associated systems
- Appropriate checks are made to confirm the watertight integrity of the vessel prior to departure
- Problems with the operation of bow, stern and side doors and ramps and associated systems are
promptly reported in accordance with established procedures
- Surveys on the proper sealing of hull openings on the vessel are conducted in accordance with
established procedures and regulatory requirements

2.3 Procedures for safely embarking and disembarking passengers, with special attention to the
disabled, and persons needing assistance

The safety of passengers whilst embarking and disembarking is essential. Access must be well lit, secure,
unrestricted and easy to use, especially for those with disabilities. Cars should be allocated spaces near
to lifts for disabled passengers, so that the least inconvenience is suffered. Full details on these
procedures can be found in the Annex.

A passenger can expect assistance in ports, including embarkation and disembarkation. If a passenger
requires assistance with personal care, however, (such as feeding, breathing, using medication or using
the toilet) the passenger may wish to travel with a companion who can assist.
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3. Carriage of dangerous goods


3.1 Special safeguards, procedures and requirements regarding the carriage of dangerous goods on
board ro-ro passenger ships

Passenger Ro-ro ships will be restricted in the amount and type of dangerous goods that can be carried
as cargo, however overfilled petrol tanks or vehicles whose contents may present their own dangerous
risk need to be monitored. The segregation tables in the International Maritime Dangerous Goods Code,
(section 15), must be referred to. Dangerous goods which are well separated, stowed and secured,
cannot react with one another. Dangers arise, however, especially with vapours being given off, or liquid
spillages caused by heavy weather or poor loading and stowage. Ventilation fans must always be
efficient and operational, and all doors to accommodation or engine room spaces must be firmly closed.
When dangerous vapours are being exhausted, the master must always consider the effects of wind in
relation to accommodation and engine room air intakes.

Once loading is complete no access should be made by passengers or unauthorised crew members,
unless accompanied by an authorised crew member. Notices stating this regulation should be
conspicuously displayed.

Regular patrols and closed circuit television monitoring will help to ensure that early detection of any
hazard is promptly noted.

In passenger ships and in ro-ro cargo ships carrying ro-ro goods, the master shall, with a view to proper
stowage of dangerous goods, if any, prior to boarding of vehicles, check the nature of goods in all ro-ro
units, lorries, trailers, railway wagons etc. This check of the nature of goods may be carried out on the
basis of the documentation/declaration pertaining to the ro-ro unit and the marking of the unit or on
the basis of a declaration issued by the lorry driver, railway personnel or terminal personnel to the
effect that the unit does not contain dangerous goods. The above check may, however, be omitted if a
proper system has been established for the sorting and control of goods before boarding. With regard to
tank lorries, railway tank wagons or tank containers that contain dangerous goods or have not been
cleaned since they last contained dangerous goods, in addition to the declaration, a declaration shall be
presented on boarding issued by the lorry driver, the railway personnel or the terminal personnel,
stating that the wagon or container was tight immediately prior to boarding. If the wagon or container is
provided with durable marking referring to its dangerous goods content, even though it has been
cleaned or has not most recently contained dangerous goods, a corresponding declaration hereof shall
be issued.
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4. Securing cargoes
.1 Provisions of the Code of Safe Practice for cargo stowage and securing
.2 Use of cargo securing equipment and materials

Guidance may be utilised from IMO Assembly resolutions A.533(13) and A.581(14), appendix 3 and 4 to
the CSS Code.

Among the difficulties which cargo stowage presents to the ro-ro operators are the following:
1. Stowage of cargo on deck: since the cargo is driven on and off the ship and, once on board, stowed
tightly together, it is often difficult to position the lashings and other arrangements for securing the
cargo in the best possible locations.

2. The variety of vehicles and cargo carried: ro-ro ships have to be able to carry many different types of
wheeled cargo from small cars to 45-ton trailers and, in special cases, loads of several hundred tons. It is
almost impossible to devise a lashing system which is ideal for all of these cases.

3. The design of trailers and containers: trailers which are carried on ro-ro ships are not normally
designed primarily for this use. The fact that they occasionally have to be carried by sea is often of
secondary importance to the land operator who is not always aware of the forces which act upon the
ship and its cargo.
Since trailers and lorries are designed primarily for road usage they very often lack adequate securing
points, which makes it difficult to secure trailers to the ship. An additional complication is the trailer's
suspension system, which may cause the lashings to become disengaged if proper precautions are not
taken.

4. Securing the cargo within the unit: containers and other units carried on ro-ro trailers are frequently
sealed when they leave the place where they are loaded and they are not opened again until they arrive
at their final destination. This is done for reasons of security and also to satisfy customs regulations. But
it means that the crew of the ship and the port staff responsible for loading it are unable to examine the
cargo to make sure that it is properly secured. They are dependent on the skill and diligence of people
who very often have no knowledge of the forces which may be encountered on board a ship in rough
seas.

5. The lack of transverse bulkheads on board ro-ro ships means that a relatively minor incident - such as
a trailer toppling over as a result of a defective lashing - can rapidly escalate into something more
serious. Nearby units can be dislodged with the result that a series of units eventually fall like dominoes.
Such shifts of cargo can cause severe stability problems for the ship.

6. It is difficult to arrange the best loading conditions since cargo units arrive at the port of embarkation
in a random order and it is equally difficult for the crew to obtain detailed information about the
vehicles, the cargo, weights, etc. in advance.

7. Stability and rolling periods: road trailers tend to have a very high point of gravity when they are
loaded: the cargo may be stable on the trailer, but the trailer and cargo together are not necessarily very
stable on the deck of the ship (or even on the road, as the number of overturned articulated lorries and
trailers testifies).
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Ro-ro ships themselves have a low centre of gravity. This results in a rolling period (i.e. the time taken
for the ship to roll from the furthest point on one side to the furthest point on the other) of as little as
seven seconds. This is very short, and the movement of the ship and its cargo is therefore very rapid.
This can put a severe strain on lashings.

Cargo transport units are normally stowed fore and aft because transverse motions are usually greater
than longitudinal ones. A variety of securing equipment and securing points will be available.

Stowage must conform with the ship’s cargo securing manual and IMO Code of Safe Practice for Cargo
Stowage and Securing (R4). Securing arrangements vary from deck to deck and from ship to ship. Those
responsible must be familiar with arrangements on their ship. Further information can be found in the
Annex.

Some important sources of danger which can affect the safety of roll on/roll off ships and of persons on
them include:
1. Cargo badly stowed or inadequately secured inside or on cargo units.
2. Free surface effects in tank vehicles, tank containers or other bulk units which are slack.
3. Poorly maintained ramps, lifts and stern doors.
4. Poorly maintained or inadequately illuminated decks.
5. Wet decks.
6. Failure to apply brakes correctly
7. Insufficient or incorrectly applied lashings or the use of lashing equipment of the wrong type or of
inadequate strength with respect to mass and centre of gravity of the cargo unit and the weather
conditions likely to be encountered during the voyage.
8. Free play in the suspension of vehicles.
9. Failure to comply with the stowage, segregation and marking requirements for vehicles carrying
dangerous goods.

Some recommendations:
1. Tractor unit and trailer brake systems should be applied; ideally deck crew should verbally check with
drivers that this has been done.
2. Vehicles should be put in gear; again, ideally, deck crew should verbally check with drivers that they
have done this.
3. All freight units are to be stowed and secured in line with the requirements of the Cargo Securing
Manual and CSS Code. If changes are made to the stowage and securing arrangement onboard, the
revised cargo securing manual is to be submitted to the Flag State for review and authorisation.
4. Haulage contractors should be encouraged to fit ferry securing rings to both their tractor units and
trailers, in line with the requirements of the ISO standards.
5. The number, type, positioning and spacing of lashing securing points on vehicle decks should comply
with the guidelines contained within CSS Code or the ISO standards.
6. The MSL of lashings should comply with the requirements of the Cargo Securing Manual. An
inspection regime should also be implemented as part of the vessel’s planned maintenance system with
prescribed discard criteria along with a maximum working life for lashing equipment.
7. Ideally, prior to sailing, vehicle stowage and securing arrangements should be checked by a Deck
Officer to ensure that both are in compliance with the requirements of the Cargo Securing Manual.
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Some operators, realising that this may be impractical on intensive sailing schedules, require at least one
random inspection per day.

Evaluation of forces acting on cargo units.


A cargo unit stowed on board will be subjected to the same movements the vessel experiences at sea.
The most important, for securing purposes, are:
1. Rolling.
2. Pitching.
3. Heaving.
4. Wind Force.

The Cargo Securing Manual specifies arrangements and cargo securing devices provided on board the
ship for the correct application to and the securing of cargo units, containers, vehicles and other
entities, based on transverse, longitudinal and vertical forces which may arise during adverse weather
and sea conditions.

It is imperative to the safety of the ship and the protection of the cargo and personnel that the securing
of the cargo is carried out properly and that only appropriate securing points or fittings should be used
for cargo securing.

The cargo securing devices mentioned in this manual should be applied so as to be suitable and adapted
to the quantity, type of packaging, and physical properties of the cargo to be carried. When new or
alternative types of cargo securing devices are introduced, the Cargo Securing Manual should be revised
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accordingly. Alternative cargo securing devices introduced should not have less strength than the
equipment which it replaces.

There should be a sufficient quantity of reserve cargo securing devices on board the ship.
Information on the strength and instructions for the use and maintenance of each specific type of cargo
securing device, where applicable, is provided in this manual. The cargo securing devices should be
maintained in a satisfactory condition. Items worn or damaged to such an extent that their quality is
impaired should be replaced.
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5. Stability, trim and stress calculations

Ship specific considerations


.1 The use of stability and stress information
.2 Stability and trim for different conditions of loading
.3 Load factors for decks
.4 Impact of ballast and fuel transfers on trim, stability and stress

Personnel who are responsible for this area will have had prior knowledge of the subject, however,
conditions will be ship specific. The ship’s stability booklet, and computer, will be provided to enable a
rapid calculation of the ship’s present and future condition.

The ship’s plans show the axle loading for each deck which can easily be calculated from the number of
axles and the gross weight of the cargo unit. This is an easy calculation, however if there is any doubt
advice should be sought from the classification society.

-The stability and stress data required to be supplied to ship under the current Load line Regulations,
stating for each how such information might be used.

The load line regulations require the master of the ship is to be provided with information relating to the
stability of the ship. This usually takes the form of Stability Information Booklet which contains all that is
needed to safely manage the vessel’s stability.

The required information is as outlined as below:-

-General Particulars
This includes the ship’s name, official number, and port of registry, tonnage, dimensions,
displacement, deadweight and draught to the Summer Load line. Useful as a reference in
supplying information to various official organizations such as Port Authorities, canal
authorities etc

-General arrangement Plan


This usually consists of a profile and plan views of the ship showing the location of all compartments,
tanks, store rooms and accommodation. Used to locate and identify individual compartments.

-Capacities and Centre of Gravity of cargo, fuel, water, stores etc:


This will show the capacity and the longitudinal and vertical centre of gravity of every compartment
available for the carriage of cargo, fuel, stores, fresh water and water ballast.
This information is required for
a) transverse stability calculations (to calculate ship’s KG) and
b) Longitudinal Stability calculations (to calculate ship’s LCG).
Also used to calculate the space available for items of deadweight such as fuel, water, cargo etc.

-Estimated weight and disposition of passengers and crew:


Of particular relevance to the passenger ships. For use in transverse and longitudinal stability.
-Estimated weight and disposition of deck cargo including 15% allowance for timber deck cargo)
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For use in transverse stability calculations involving calculation of the ship’s KG and GM. Used effectively
so as to ensure vessel complies with the load line regulations throughout the voyage.

-Deadweight scale
A diagram showing the load line mark and load line corresponding to the various freeboards, together
with a scale showing displacement, TPC and deadweight for a range of draughts between Light and Load
condition.
Particularly useful when loading cargo (eg., comparing draught to estimate cargo loaded)

-Hydrostatic particulars (Displacement, TPC, MCTC, LCB, LCF, KM)


A diagram or table showing the hydrostatic particulars of the ship such as Displacement, TPC, MCTC,
LCB, LCF, KM etc.
Particularly useful for a variety of stability calculations including transverse stability and longitudinal
stability (eg., worksheets for the calculation of GM, trim and draughts forward and aft)

-Free Surface Information (including an example)


Usually in the form of Free Surface Moments (FSM) for each tank in which liquids can be carried. The
FSM given will be for a stated relative density of liquid (often 1.00) which will need to be adjusted if the
liquid is of another density.
Used in transverse stability calculations in order to find the ship’s fluid KG and fluid GM.
There should also be a worked example.

-KN tables / Cross curves (including an example


This will take the form of a diagram or table showing the righting levers for an assumed KG (the KN is
the GZ of the vessel assuming the KG is zero). There should also be a worked example showing how a GZ
curve can be obtained using the tables / cross curves.
KN tables are used to obtain the value of GZ (as GZ = KN=-KGsinθ)
Cross curves are used to find the GZ of the vessel for any angle of heel.

-Pre-worked Ship conditions (Light ships, Ballast Arr/Dep, Service loaded Arr/Dep, homogenous
loaded Arr/Dep, Dry docking etc)
To include for each condition:
a) a profile diagram indicating disposition of weights.
b) Statement of light weight plus disposition of weight on board.
c) Metacentric height (GM)
d) Curve of statical stability (GZ curve)
e) Warning of unsafe condition.

Very useful in cargo planning since it is easier to use a ship condition similar to the proposed load
condition. Also useful where the ship’s tables are presented in a form unfamiliar to the ship’s officer
who can now follow the method of calculation normally used on that vessel.
Dry dock: Enables officer to plan the stability condition for entering dry dock.
Loaded: Provides officer an example to establish stability condition of the vessel when loaded with
relation to draught, trim, displacement, stress (SF & BM) and also compliance with the loadline criteria.
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Ballast: Provides officer an example to establish stability condition of the vessel when in ballast
condition with relation to draught, trim, displacement, stress (SF & BM) and also compliance with the
loadline criteria.
Homogeneous loaded: Provides an example on cargo distribution for a given cargo to achieve a required
stability criteria so as to enable the officer to plan for loading of various cargoes.

-Special Procedures (Cautionary Notes)


Sometimes known as Cautionary notes. These may take the form of procedures to maintain stability
such as the partial or complete filling of spaces designated for cargo, fuel, fresh water etc. Examples of
this are:
a) Sequence of ballasting during the voyage to maintain adequate stability, particularly to
compensate for fuel/water consumption
b) Ballasting to compensate for strong winds when carrying containers or other deck cargo.
c) Measures to compensate icing in Arctic waters
d) Any special features regarding the stowage behaviour of a particular cargo.

-Inclining experiment report:


This will take the form of a report on the details of the inclining test showing the calculation and other
Light Ship information.
Useful in assessing the accuracy of the Lightship KG given in the stability booklet (which may change
over time)

-Information as to Longitudinal Stresses for vessels over 150m in length


This applies to vessels over 150 mtrs in length and contains information on the determination of the
longitudinal stresses such as Shear Force, bending moment and torsion. This will usually be in the form
of comparison with maximum stress levels for the Seagoing condition and the Harbour condition.
In this way the ship’s officer can assess the magnitude of the stresses before, during and after any
loading, discharging or ballasting operations whether in harbour or in a seaway.

STABILITY PROBLEMS ASSOCIATED WITH A CONVENTIONAL RO-RO FERRY.

The stability of vehicle ferries poses particular problems due to the following:

Free Surface Effect:


(a) Because the vehicle deck usually extends over the length and breadth of the vessel
without restriction, this type of vessel is especially vulnerable to the effects of free
surface
(b) Such vessel may rapidly lose all stability and capsize if the vehicle deck becomes
flooded.
(c) Causes of such flooding include
 Damage to bow or stern door at sea
 Bow or stern door left open at sea
 Bow or stern door open and unattended during loading / discharging
operations.
 Loss of watertight integrity due to collision with another vessel or rocks.
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 Loss of water tight integrity due to shift of a vehicle in heavy seas.


 Use of water curtains (coupled with inadequate drainage)

Inadequate Stability Information due to:


1) Speed of turnaround in port.
2) Lack of detailed information about cargo units and disposition

Other factors:
1) High KG of cargo units on vehicle deck
2) Vulnerability of Ro-Ro units to shifting in bad weather.
3) High windage area of Ro-Ro vessels.

What precautionary measures must be adopted to improve stability of Ro-Ro ferries

1) Automatic draught gauges at the stem and stern with remote readout should ensure that flooding
of the vehicle deck in port is avoided.
2) A loading computer must be available to the ship’s officer in port for rapid calculation of stability
before the vessel sails.
3) Indicator lights must be provided on the bridge to show when shell/loading doors are open /
closed.
4) Heavy Ro-Ro cargo units must be weighed ashore and the information provided to ship’s officers.
Such units must be secured by chains to the deck before departure.
5) Increased drainage requirements for vehicle decks.
6) Stockholm agreement provides enhanced stability requirement for Ro-Ro passenger ferries with 50
cms of water on vehicle deck.
7) Provision of some form of sub-division on the vehicle deck.

Subdivision and damage stability

The feature which distinguishes the ro-ro ship from other types is the open vehicle deck (or decks) which
run the full length of the ship with a door at either end. It is crucial to the whole ro-ro concept - and one
of its most controversial features, since it has led to considerable concern about the safety of ro-ro ships
is their stability in both the intact and damaged condition. Under the International Convention on Load
Lines, 1966, ships are divided into two basic types: type A ships include tankers, which are assigned
lower freeboards than type B ships. Type A ships are better protected from the sea because they have
more internal subdivision and fewer surface areas for openings. Dry cargo ships, including ro-ro ships,
are type B with larger freeboards and are subject to less stringent requirements for subdivision and
damage stability. As far as SOLAS is concerned, subdivision and damage stability requirements for
passenger ships are contained in part B of chapter II of the 1960 version and chapter II-1 of the 1974
version. In both, the standard of subdivision varies according to the length of ships and the number of
passengers on board. Passenger ships are defined as ships which carry more than 12 passengers. This is
important as far as ro-ros are concerned because it means that passenger ferries, including car ferries,
are classed as passenger ships. The most important result of this is to make it mandatory for passenger
car ferries to be constructed in such a way that the deck on which the vehicles are parked is above the
waterline. The area beneath this deck must be subdivided by vertical watertight bulkheads.
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6. Opening, closing and securing hull openings


6.1 Procedures established for the ship
6.2 Sealing surveys

Competent, nominated operators will follow the ship’s procedure for maintaining hull integrity and
positive reports made to the bridge once this is complete. Inspection of hull opening seals and the
condition of all moving parts must be frequently monitored in addition to the planned maintenance
programme.

Those responsible must be familiar with the specific arrangements on their ship for opening, closing
and securing bow, stern and side doors and ramps. They must be able to correctly operate the
associated systems and conduct surveys to ensure that proper sealing is achieved.

The following closing appliances shall be securely closed before a ship proceeds on any voyage and shall
be kept so closed until the ship has been secured at a berth or anchorage-
(a) watertight doors below the ship's margin line fitted in bulkheads which are required to be watertight
and which separate cargo spaces;
(b) sidescuttles which can be opened and which are situated below such margin line;
(c) deadlights of any sidescuttles which are situated below such margin line and which-
(i) are not accessible while the ship is at sea; or
(ii) are situated in spaces appropriated for use at times for the carriage of cargo and at other
times for use by passengers, while the spaces are used for the carriage of cargo; and
(d) gangway and cargo loading doors below such margin line.

A closing appliance shall not be regarded as being securely closed unless it is locked.

These requirements are applicable to the survey of bow, inner, side shell and stern doors of Ro-Ro
passenger (Ro-Pax) and Ro-Ro cargo ships, to the extent appropriate to the arrangement and equipment
of each ship.

Securing device Securing device - a device used to keep the door closed by preventing it from rotating
about its hinges. 2.6 Supporting device Supporting device - a device used to transmit external or internal
loads from the door to a securing device and from the securing device to the ship’s structure, or a device
other than a securing device, such as a hinge, stopper or other fixed device, that transmits loads from
the door to the ship’s structure. 2.7 Locking device Locking device - a device that locks a securing device
in the closed position.
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7. Ro-ro deck atmosphere


There is no specific requirement for carrying equipment to monitor the atmosphere on vehicle decks
however it is necessary for those responsible to effectively operate such equipment. Air changes will
be effected by the vehicle deck fans and enhanced, when safe to do so by opening the other bow or
stern door. It is apparent that drivers prefer to start their vehicles a long time before it is possible to
proceed. This must be stopped until disembarkation is required, especially when considering the
noxious gases that could pocket or accumulate.
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CRISIS MANAGEMENT AND HUMAN BEHAVIOUR TRAINING

8. Ship design, layout, emergency plans, procedures and drills

Ship familiarisation is so essential before any emergency plans can be formulated or considered. (see
‘Scandinavian Star’ condensed case history, (T2)).

The location of BA teams or search parties must be fully appreciated so that ships plans can be marked
and updated on the bridge. The bridge may also be in a position to warn of any possible dangers e.g.
ship stores or cargo.

International and national regulations are further supported by Company and ship specific procedures.
Certain personnel will be required to hold a thorough overview of these. Emergency plans and checklists
will need to be devised for all possible eventualities fire, pollution, bomb threats etc. and specific
training should focus on these areas. Obtaining a full muster should be straight forward, but crew and
passengers will often delay for many reason: retrieving possessions from cabins, looking for relatives or
because the situation appears normal in their location they do not respond. Enormous amounts of
energy and time can be wasted looking for people who are safe as against those that require assistance.

What is Crisis Management

Crisis Management: The overall coordination of the ship’s response to a crisis, in an effective, timely
manner, with the goal of avoiding or minimizing damage to the ship’s operations, injuries to reputation,
or ability to operate.

Various events can happen aboard which result in individuals or the entire crew being subject to
extreme stress which can lead to various reactions. This might involve an accident aboard, or bad news
from home, an attack by pirates or a workmate in crisis.

Emergency management and business continuity planning (collectively referred to as contingency


planning) are vital programs for any organization that wants to survive and prosper. In the absence of
proper planning, a crisis or disaster could devastate an organization, its people and its assets.
Contingency planning will improve the odds of an organization’s survival.

A challenge for organizations is lack of knowledge about how to effectively implement a contingency
planning system and incorporate it into the entity’s strategic plans. “Strategic planning is the process of
formulating and implementing decisions about an organization’s future direction. This process is vital to
every organization’s survival because it is the process by which the organization adapts to its ever-
changing environment, and the process is applicable to all management levels and all types of
organizations”.

Contingency planning should be part of an organization’s quality cycle as well. Contingency planning is a
systematic process. A well-developed contingency planning system might consist of policies,
procedures, checklists, guidelines, plans, and other documents and resources. Components of
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contingency planning such as first response, a command structure, crisis management and work
resumption are typically addressed.

The ship's contribution to mitigate the damage from a shipboard crisis – ‘crisis management’ - is crucial
to the successful minimization of damages due to the crisis.

Progressively, shipping companies are beginning to look out for improved quality to sustain their
operations. They look towards the masters and his crew to safeguard their ships and the cargoes the
ships carry. To prevent a crisis from becoming a catastrophe, the master and his crew need to learn and
re-learn crisis management and be familiarized with the many problems likely to be encountered during
and after an accident. Shipping companies also know that the time during a crisis is not the time for
learning. They know very well that major maritime accidents are so rare today that almost no officer
currently sailing on board ships would have had the opportunity and therefore the experience in dealing
with maritime accidents. Therefore, when accidents happen, damages are usually tremendous.

Apparently, it seems one of the best means to achieve this learning objective is to undergo regular
shipboard training. But time is of essence in operating a ship safely and efficiently. The master and his
crew just do not seem to have time for shipboard training. Moreover, shipboard training comes with
risks to the ship and her crew - imagine the ship having to go through a situation of "simulated crisis" to
learn from it.

Generally a Crisis Management Plan (CMP) is prepared to help in this. The CMP identifies the potential
risks to onboard operations and the events which will cause the CMP to be activated. This plan ensures
that appropriate individuals are kept apprised of developments related to the emergency situation in a
timely and efficient manner and identifies the authority and procedures by which these persons may
respond to these situations. The plan is intended to complement the normal operations of the vessel
and to prevail only during emergency/crisis situations.

The emergency situations which place the ship at risk are those which have the potential to shut down
ship operations for unspecified lengths of time. In general, a crisis can be defined as a situation which
can:
▪ Escalate in intensity;
▪ Fall under close sponsor, government or media scrutiny;
▪ Interfere with normal operations; and
▪ Jeopardize the company’s public image.

Emergency/Crisis Situations

1. Fire, explosion, serious accident onboard ship or natural disaster resulting in:
a. Evacuations and casualties (including deaths or injuries)
b. Loss of vessel
c. Serious damage to structure or equipment resulting in:
(1) Major mechanical failure
(2) Loss of navigability
(3) Inability to house or feed participants
(4) Inability to operate equipment necessary to ensure safe operations
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(5) Inability to communicate, or


(6) Environmental pollution.

2. Deliberate criminal or terrorist acts, resulting in:


a. Casualties (including deaths or injuries);
b. Hijacking or impoundment of the vessel in a foreign port;
c. Kidnapping or arrests of employees in foreign countries.

EMERGENCY PRIORITIES

1. Human Safety.

2. Maintenance and preservation of property to prevent further deterioration of the situation.

3. Environmental protection.

CONTINGENCY PLANNING

SOLAS Ch. IX and Ch. III, Reg. 24-4 and MARPOL 73/78 Annex I, Reg. 26 present regulations regarding
emergency contingency on board. The ISM Code, Item 1.2.2.2 and Item 8 stipulate requirements to all
shipping companies to ensure such emergency contingency plans on board and ashore.

An emergency can occur at any time and in any situation. Effective action is only possible if pre-planned
and practical procedures have been developed and are frequently exercised. The Contingency Plan
provides guidelines and instructions that assist in making an efficient response to emergency situations
onboard ships.

If the vessel encounters a dangerous situation that may develop into an emergency, it is extremely
important that the whole crew know exactly what they should do to save their lives and minimize
damage.

It is worth stating that an abnormal condition need not necessarily be cargo related, it might be in the
engine room, or involve deck machinery such as a mooring winch failure for instance. Any condition that
could compromise the vessel’s ability to carry out a smooth, incident free operation may be considered
abnormal.

The crew must be drilled to take certain actions more or less automatically. However, nobody must act
without considering the superfluous consequences.

These plans should be used actively during emergency drills. The objective of an emergency plan is to
make the best use of the resources available. This will be the shipboard personnel whilst the ship is at
sea but may include resources from shore when the ship is in harbour or passing through coastal waters.

The plans should be directed at achieving the following aims:


 rescue and treatment of casualties
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 safeguarding others
 minimising damage to property and the environment
 bringing the incident under control.

The plans should include advice on the following:


1. fire
2. collision
3. grounding
4. cargo spillage/leak
5. personnel casualty

Most of these plans will be practiced during emergency drills and exercises. Make sure you know what
to do and how to use the safety equipment if in doubt ask an officer.

In any emergency situation, you MUST CONTINUE using the DPA or alternate contact number you have
already used when advising of the emergency.

Procedures for Safely Embarking & Disembarking

The training also emphasizes various difficulties in managing and evacuating different categories of
passengers. Besides dealing with reactions from parents who are separated from their children and
children who are separated from their parents, the course deals with managing special passenger
categories such as various kinds of disabled persons, elderly people, drunk people, so-called ”VIPs”
(people who demand special respect and treatment or who challenge the crew members’ authority),
passengers unable to understand the languages spoken onboard and travellers in groups with guides.
Fellow crew members’ possible reactions and their impact on passengers are also dealt with.
On the basis of understanding and skilful assessing, crew members learn various strategies for reducing
the effect of unwanted or irrational behaviour and to cope with and control it. Findings and examples
from real emergency situations and accidents are used in the training.

Ship design, layout, emergency plans, procedures and drills


Ship familiarisation is so essential before any emergency plans can be formulated or considered. (see
‘Scandinavian Star’ condensed case history, (T2)).

The candidates have to be aware of the general design and layout of the ship:
- study the ship’s plans including:
- the deck reference system
- numbering on the doors and stairways
- emergency exists and alternative means of escape
- reference system for the assembly stations
- location and use of all life-saving equipment
- any specific or unusual features relating to the ship

The location of BA teams or search parties must be fully appreciated so that ships plans can be marked
and updated on the bridge. The bridge may also be in a position to warn of any possible dangers e.g.
ship stores or cargo.
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Safety Regulations

The seafarers must be able to extract and apply information from safety legislation codes and egulations
including:
- company fleet regulations
- ship specific procedures including any limitations of equipment, stability etc
- cargo securing manual
- ISM Code
- IMDG Code
- Codes of Safety Working Practice
- national regulations

International and national regulations are further supported by Company and ship specific procedures.
Certain personnel will be required to hold a thorough overview of these.

Emergency Plans

The emergencies may include:


- structural failure
- machinery failure
- collision
- grounding/stranding
- fire
- bomb threats
- pollution

Emergency plans and checklists will need to be devised for all possible eventualities: fire, pollution,
bomb threats etc. and specific training should focus on these areas. Checklists are required to ensure
that the correct procedures are followed, i.e. decision support system for Masters of passenger ships
- emergency power supplies
- ballasting, de-ballasting
- emergency repair equipment
- communications for assistance
- breathing apparatus procedures
- containment of smoke or extraction activated
- search procedures for suspicious packages
- location of pollution prevention equipment and procedures for notifying port or nearest coastal
authorities

Shipboard emergency drills


The candidates must recognize the need to pre-plan drills for shipboard emergencies:
- national and international requirements for shipboard emergency procedures
- crew members assigned and familiar with emergency duties before voyage begins
- muster of passengers where required
- safety brief
- familiarity with all life saving equipment
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- scenarios set for drills with specific objectives to achieve


- a conditioned response, to pre-set emergencies, where everyone is familiar with their duties will often
lead to a rapid, successful conclusion

The need for all personnel to be aware of and adhere to pre-planned emergency procedures
It is required that all personnel should be aware of and adhere to preplanned emergency procedures as
carefully as possible in the event of an emergency situation. They should:
- immediately go to emergency stations so that missing persons can be identified
- frequent drills will lead to the correct procedures being followed
- be prepared to take charge if the leader is missing

Obtaining a full muster should be straight forward, but crew and passengers will often delay for many
reason: retrieving possessions from cabins, looking for relatives or because the situation appears normal
in their location they do not respond. Enormous amounts of energy and time can be wasted looking for
people who are safe as against those that require assistance.
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9. OPTIMISATION OF RESOURCES

Responses to many shipboard emergencies have been lacking because of poorly trained crews who have
been unable to react effectively. Legislation requires training however, motivation must come from the
senior ranks.

Drills can operate in two forms:

Reaction to the alarm


The crew will respond to the unknown emergency and a realistic exercise will ensue. Problems and
mistakes will always occur but these can be discussed and rectified at the de-brief. An independent
crew observer, who has devised the drill, can take charge of the de-brief.

A pre-planned drill
The emergency is discussed and equipment prepared. The drill can then proceed at whatever pace is
required. This allows for mistakes to be rectified and although slower, the learning process and
outcomes for some crews, initially, may be beneficial. As always this must be followed by a full debrief.
Maintenance of emergency equipment is essential and continuous. Even if some of it is not used at a
drill, it must be inspected. Equipment used during the drill must be made ready for immediate use, e.g.
BA cylinders recharged.

Emergency resources available


The resources available in an emergency may be limited. Therefore,
- equipment should be well separated and have safe access should an emergency occur
- immediately move any emergency equipment from a potentially unsafe area eg. medical equipment,
spare BA. Sets and cylinders
- age and fitness may limit certain personnel to less arduous, yet essential positions
- immediately plan ahead to obtain assistance and back up resources from ashore or other ships
- carefully rotate personnel who have strenuous tasks, allowing time for adequate rest periods and
refreshments
- advise Company who can activate their emergency response plan and send further details on stability,
structural strength and assist in co-ordination of any other assistance that is required

The amount of emergency equipment available has increased but the personnel required to use this
equipment has generally remained the same. Allocation of task roles is often dependant on
rank/position which for senior positions would generally remain the same, however exercises will reveal
those ideally suited for particular jobs.

Make full use of personnel and equipment available


We must make full use of personnel and equipment immediately available and if necessary to improvise
so that:
- ensure that all equipment is serviced, fully operational and ready for use including protective clothing,
fire, chemical, oil spill, breathing apparatus cylinders are full, back up equipment, hoses, B.A cylinders,
foam, oil dispersant, first aid equipment resuscitators and any other equipment required
- emergency party leaders are in place to take charge
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- ensure that personnel are suitable for their emergency positions, e.g. adequately trained, sufficient
experience, physical and mental ability etc.
- be aware that often the rank of personnel automatically dictates a particular position on the muster list
which may be inappropriate for them
- appoint personnel best suited to the position

Organise realistic drills to maintain a state of readiness


The officers, especially the senior officers must demonstrate how to organise realistic drills to maintain a
state of readiness, taking into account lessons learn from previous accidents involving ships carrying
passengers. Further they should carry out de-briefing after drills.

Each exercise should be planned by a different officer, who may co-ordinate and debrief the exercise.
Some points that this officer can follow:
- advice is sought from more senior personnel if required
- do not plan unannounced drills, always give forewarning
- prefix public address announcement, when available with ‘this is a drill’ or ‘for exercise purposes’
- remove key personnel to allow ‘second in charge’ to take over
- place observers in strategic positions to observe the drill
- ensure that all equipment is re-stowed and ready for use
- de-brief all of the crew using the observers to comment on the actions taken in their particular area
- encourage the crew to discuss how the incident developed and what actions were taken
- summarise the good and bad points and note which areas require further training
- it may be appropriate, on some ships, for an officer to talk with the crew separately after the initial de-
brief with senior personnel
- compile a port folio of exercises that are ship specific but can still be varied
- exercises may be undertaken having discussed the plan which can then proceed after all equipment
has been prepared
- incorrect procedures can be repeated until the basics have been achieved
- discuss incidents and lessons learnt from other passenger ship incidents
- use company incident reports if available

Responses to many shipboard emergencies have been lacking because of poorly trained crews who have
been unable to react effectively.

Legislation requires training, motivation must come from the senior ranks.

Drills can operate in two forms:

Reaction to the alarm


The crew will respond to the unknown emergency and a realistic exercise will ensue. Problems and
mistakes will always occur but these can be discussed and rectified at the de-brief. An independent
crew observer, who has devised the drill, can take charge of the de-brief.

A pre-planned drill
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The emergency is discussed and equipment prepared. The drill can then proceed at whatever pace is
required. This allows for mistakes to be rectified and although slower, the learning process and
outcomes for some crews, initially, may be beneficial. As always this must be followed by a full debrief.

Maintenance of emergency equipment is essential and continuous. Even if some of it is not used at a
drill, it must be inspected. Equipment used during the drill must be made ready for immediate use, e.g.
BA cylinders recharged.
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10. CONTROL RESPONSE TO EMERGENCIES

Emergencies require good leaders which is not restricted to the master on the bridge, but to all support
group leaders, e.g. on-scene commander, engine room control, back-up parties, first aid, zone
commanders etc. All are essential. Information can be very sparse in the early stages however the
mobilisation of all personnel and resources must be started under a calm, decisive leader. When the
picture begins to form, as more information is received, tasks can be allotted and forward planning can
begin. Leadership style must be firm, decisive and perhaps autocratic and some degree of consultation
may be appropriate, but this is not the time to form committees! Extracts from video V1 may be used to
illustrate points.

Personnel will respond to well motivated leaders as they will to motivated instructors. Energy and
enthusiasm generally tends to spread throughout the group, however any emergency will heighten
stress levels. The heart beats faster, the breathing rate is rapid and sweating increases. This must be
identified as soon as possible so that work loads can be lessened, tasks re-allocated and extra support
requested. Unless the leadership can be firm and directional the teamwork and general response will
start to disintegrate.

How to lead and direct others in emergencies


The senior officers must demonstrate how to lead and direct others in emergency situations, by
- setting an example during emergency situations
- taking immediate control
- remaining calm
- being decisive
- being dependable and thus gaining the respect of other members of the group

Focus decision making


Focus the decision making, given the need to act quickly in an emergency. This can best be achieved by
- listening to information gathered by personnel already at the scene
- assessing the situation
- allocating tasks
- planing ahead for extra equipment and personnel
- adjusting plan as required
- leadership style is required, autocratic, dictatorial, directive
- being aware that consultation may not be appropriate in a crisis

Motivation of passengers and other personnel


It is important that the officers motivate, encourage and reassure passengers and other personnel. This
can be done by:
- stimulating interest
- giving support to the team
- being enthusiastic
- energy shown will spread to others
- always passing on the basic, truthful developments
- conveying to others that a concerted effective response is being undertaken
- always being positive
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Stress
We need to recognize the development of symptoms of excessive personal stress and those of other
members of the ship’s emergency team. When under stress, the brain detects a change in the
environment which it interprets as highly threatening. This leads to flight/fight reaction: run away or
deal with the problem. The heart beats faster and breathing rate increases. People will sweat more than
normal.

The effects of stress


Stress generated by emergency situations can affect the performance of individuals and their ability to
act on instructions and follow procedures. Their attention could be focused on one area and the overall
plan may not be considered. There may be a lack of concentration and over reliance on trial and error
rather than established procedures. Constructive suggestions may be ignored. Stress also reduces ability
to solve complex problems due to a narrowing of attention. It may lead to consideration of fewer
alternative solutions.
The strain of responsibility leads to :
- over delegating
- being impossible to contact
- general loss of control
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11. HUMAN BEHAVIOUR AND RESPONSES

People never believe that emergencies are going to happen to them. How many passengers show
complete disinterest during the safety brief on an aircraft or continue to talk on a ship during the safety
announcements? When escape is delayed exits can become blocked and visibility may be decreased;
this is when genuine fear and panic can arise. Panic is not as common as is reported because this
involves escape without concern for others. In fact, people are desperately attempting to escape from a
danger but can often be seen assisting one another.

Concern is always likely when family groups become split up. Members force their way against the
escape flow causing more delays. Although this is completely understandable every effort must be made
by announcements, coupled with the efforts of the stairway guides and assembly station personnel to
direct passengers to safety and reassure them that every effort will be made to reunite groups.

Thorough searches of the accommodation must be made for people who may not have heard the alarm
or failed for some reason to respond. Plans can be marked off to show areas that have been searched so
that time and personnel are not wasted by double searches.

If a ship does begin to list passengers will tend to move to the high side however if the list increases it
may become more difficult, or impossible to launch life saving appliances on the high side.

Effective marshalling and control of passengers in the assembly stations is essential.

Passenger response

Regarding a crowd’s reaction patterns in a crisis or in emotional turmoil, unpredictable behaviour must
be regarded as regular. There is a need to have a flexible approach as well as intelligent and effective
improvisations by the crew. To accomplish this, we need to understand the basis for how people react.
Such knowledge facilitates for all crew members to read, recognize and understand various types of
behaviour and to address the underlying emotional origin, instead of only vainly fighting the behavioural
consequences. On the basis of understanding and skilful assessing, crew members learn various
strategies for reducing the effect of unwanted or irrational behaviour and to cope with and control it.

The officers need to be aware about the timing and use of alarm signals. Most accidents have taught us
that alarm signals, together with distress calls, often are transmitted too late. Hesitations in using alarm
signals are understandable because of their consequences onboard, their impact on passengers, the
stress they cause and the difficulties in reversing the arising situation. This discussion is aimed at
understanding the psychological dynamics behind the reasons for delay in order to be able to cope with
undue hesitations in a rational way.

Experience shows, for example, that alarm signals seldom cause panic among passengers. On the other
hand, alarm signals are mostly not immediately understood. They give no guidance to the passengers
and must therefore be followed by vocal instructions and information.
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The normal reaction among passengers when an alarm signal sounds is a sudden interruption in
whatever activities the they are involved in. Most people will turn their faces and start looking at the
device which produces the alarm signal. After some moments of silence most of them will start
discussing the signal and questioning each other in order to investigate possible interpretations, rule out
misunderstandings and to reach a joint conclusion regarding its significance. This rather slow reaction
pattern is formed by a mix of surprise and disbelief together with a reluctance to be intruded upon by
something stressful and potentially dangerous in whatever pleasurable activities they are involved.

The alarm signal as such gives no guidance to the passengers about what they are supposed to do. Past
experience shows that most passengers don’t look at instruction posters and if they do, they are not
able to remember what the posters said. Experience seems also to show that the International General
Emergency Alarm signal is too complicated. Seven short (or more) and one long signal are not
spontaneously regarded by most people as a distress alarm. Moreover, the signal is long and may be
misinterpreted if someone only hears parts of it.

Passengers may believe that five or six short signals followed by a long signal denote something else
than a General Emergency Alarm. Furthermore the signal does not form a rhythmical pattern or a
melody like other familiar signals such as the fire-brigade’s or the ambulance’s. Furthermore it is not
continuous as most other signals but instead repeated.

Besides this, the General Emergency Alarm signal is not easy to distinguish for people who are unable to
count, such as small children.

Using only alarm signals, leaves passengers alarmed and usually confused. They are left on their own to
evaluate the situation and to find out what is expected of them. Therefore alarm signals by themselves
may create a disorganized situation if people evaluate the situation differently and follow one another in
a variety of actions. The officers are therefore informed that alarm signals immediately must be
complemented by vocal messages giving instructions and more information.

A vocal message can give passengers directives and information and assure that all perception of the
situation and options for actions are in line with the current situation and what is wanted by the
Command Team. The importance of directives, instructions and information through the public address
system directed to the passengers is heavily stressed in the Crowd Management Course because this is
the most effective means to handle masses of passengers.

Passengers must have instructions for rational action. Otherwise they are left to themselves to find out
what to do in an unfamiliar environment and this may result in a variety of irrational behaviour. People
also tend to forcefully react in line with their own perceptions of a distressful situation and therefore the
crew must take charge of the passengers’ understanding. The means for this is to give adequate
information. Information alone is, however, seldom sufficient onboard vessels because merely
understanding a situation will not always lead passengers to rational actions if they are unfamiliar with
the onboard environment.

When sounding alarms, the best way is therefore to immediately use the public address system to
complement the alarm signal. In this case the message should be reversed, with instructions first,
followed by information, i.e. actions primary, understanding secondary.
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It takes some time before people accept the fact that there is an emergency situation.
- attention is not paid to announcements, written instructions and familiarisation with the area
- passengers believe that disasters will never happen to them
- disbelief of even the most obvious signs of danger
- passengers are afraid of being seen as foolish by drawing attention to themselves when reacting to a
non apparent danger
- continual false alarms result in no response
- passengers are reluctant to issue warnings for fear of starting a panic
- passengers will try to find some way of confirming that the warning is correct rather than making an
escape

Some people may panic and not behave with a normal level of rationality, that their ability to
comprehend may be impaired and they may not be as responsive to instructions as in non-emergency
situations
- panic involves not only anxiety but genuine fear
- the fear is not irrational but well founded
- there is a perception that action must take place immediately and people move as quickly as possible
to an escape route
- it also involves escape without concern for others
- panic may also occur when people make decisions on false Information
- as the mind is focussed only on escape, often in unfamiliar surroundings, direction by personnel or
information broadcast are ignored

Passengers and other personnel may start looking for relatives, friends and/or their belongings as a first
reaction when something goes wrong
- instinctive reaction to look for members of the group especially those who are vulnerable, e.g.
children, elderly, disabled
- passengers are normally content that children will be safe on a ship as trained staff are always
available
- family groups will have different interests, play areas, gaming machines, bars, cinemas etc.
- a group could easily be spread throughout the ship
- passengers on passenger ships will have dedicated assembly stations so groups will re-unite
- passengers on ro-ro passenger ships will be directed to the nearest assembly station, re-allocation of
passengers to other assembly stations will be undertaken by the crew should one area become
overcrowded
- muster personnel must reassure family groups that every effort to locate other members is being
made
- announcements on the public address system, telephone or radio communication between those in
charge of the assembly areas must be made
- personnel may also be sent to other assembly stations to locate missing members and escort them to
the family group
- once passengers have assembled they must not be allowed to leave
- continually reassure them that the ship’s organisation is designed to resolve this problem
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Passengers may seek safety in their cabins or in other places on board where they think they can escape
danger
- all cabins, public spaces and other areas must be searched to ensure that the evacuation to assembly
stations is complete
- follow the ship’s emergency procedures to ensure that all areas have been searched either by direct
messages to a control point, or marking plans and/or doors, so that no time is wasted in duplicate
searches

Passengers will tend to move to the upper side of the ship


- effective marshalling of passengers to their lifeboat/raft station
- appreciate that passengers may go to the high side where, because of the ship’s list, some life-saving
appliances may be outside of their launching limits
- appreciate the possible problem of panic resulting from
separating families
- family members will be concerned for the safety of their group
- group leaders may go to areas that are dangerous to search
- orders from muster personnel may be ignored
- orders must be calm, clear, informative and reassuring
- assign a specific crew member to calm those concerned and explain the ship’s procedures
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12. ESTABLISH AND MAINTAIN EFFECTIVE COMMUNICATIONS

There is often a reduced ability to understand complicated messages in stressful situations, so they must
be kept simple and as concise as possible. The voice pitch can rise and also speed up leading to more
confusion.
Passengers will always be requesting more information but that said they do need to be informed, and if
possible, in their native language. This may cause problems for the crew who are assisting, however
basic phrases can easily be learnt to identify decks, or directions and signs can be pointed out.

Prominence is essential when controlling crowds both in an elevated position and wearing highly visible
clothing. Always maintain this position and allocate crew members to do specific tasks as required.

Concern is raised when passengers do not know what is going on. They do not need to know detail but
they must not be told lies. If breathing apparatus teams are seen proceeding through passenger spaces,
passengers will know that things are not normal! Announcements, therefore, need to be calm
informative and the degree of response required should be upgraded if the emergency begins to
deteriorate.

The importance of effective communications


The officers must be able to demonstrate the delivery of clear and concise instructions and reports:
- speak slowly and clearly
- do not attempt to give too much information
- only tell passengers what you know
- do not invent information or pass on rumours that they may be spreading

You may encourage exchange of information with, and feedback from, passengers and other personnel
- be attentive to their needs and delegate other personnel to give extra assistance if required
- answer their questions
- if the request is relevant and important advise them that you will obtain the information
- bear in mind that passengers will continually ask what is happening, so keep them occupied

We must be able to communicate in the language or languages appropriate to the principal nationalities
of passengers and other personnel carried on the particular route
- identify crew members who can communicate in more than one language
- place them in strategic positions e.g. assembly areas
- train personnel to use basic phrases e.g. identifying decks, directions to take, and simple reassuring
information regarding the emergency
- select other passengers who may be able to translate

We may possibly need to communicate by some other means such as demonstration, by hand signals,
calling attention to the location of instructions, assembly stations, life saving devices or evacuation
routes when oral communication is impracticable
- be prominent, stand on a platform, chair or table
- indicate the illuminated emergency signs and other instructions using extended arm signals possibly
holding a baton or a torch
- use a life jacket to demonstrate slowly the donning procedures
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Selects the language in which emergency announcements may be broadcast during an emergency or
drill to convey critical guidance to passengers and to facilitate crew members in assisting passengers
- identify personnel who can make bi-lingual or multi-lingual announcements locally or on the public
address system
- standardise expected announcements that could be used during an emergency on written cards on the
bridge
- ensure announcements made in different languages are identical or very similar to the main language
spoken aboard
- ensure that announcements that are made are fully understood by the crew especially those who are
assisting passengers
- ask crew members during drills to explain the announcement and detail the action taken after it has
been made
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13. PRACTICAL EXERCISES


Suggestions for practical exercises are shown in Appendix 2. To be of value these should be as realistic
as possible. The ship plans utilised should be those of the vessel to which the training applies.

The Formal Investigation into the Capsize of the Ro-Ro Passenger Vessel ‘Herald of Free Enterprise’
6th March 1987
Report No. 8074, Formal Investigation. HMSO Publications Centre, P O Box 276, London SW8 5DT, UK

Approximately 459 passengers had embarked for the voyage from Zeebrugge to Dover. The ship
proceeded to sea with the bow doors open. In a light easterly breeze and very little sea or swell the
‘HERALD’ passed the outer mole at 1824 and capsized 4 minutes later resulting in 188 fatalities.

When loading and unloading at high water springs in Zeebrugge, it was necessary to trim the ship by the
head, however the bow doors could be closed at the berth. These duties were different to those on the
Dover-Calais run. No thought was given to this, and the Chief Officer felt under pressure to go
immediately to harbour stations once loading was complete.

Three crews and five sets of officers were employed in manning the ‘Herald’, accordingly the officers did
not always have the same crew. This made it not merely desirable, but essential that there should be
uniformities in the duties of each set of officers and of the members of each crew.

It was stated that when entering or leaving Zeebrugge, trimmed by the head, care was taken to restrict
the speed to a level which would avoid water coming over the bow spade. On departure speed was built
up to between 14 and 18 knots. Experiments showed that the bow wave would be about 2 metres up
the bow doors. The rate of inflow of water was considerable and as the bow spade dug deeper the ship
lurched to port due to free surface instability, and soon sank on her beam in the shallow water outside
the channel.

The questions arise, as a consequence of the casualty; why was the absence of the assistant bosun from
his harbour station, not noticed? Why was there not a foolproof system which would ensure that the
vital task of closing the bow doors was performed irrespective of the potential failure of any one
individual, especially as this had happened before.

The sense of urgency to sail from Zeebrugge as soon as possible in order to maintain schedules, was
exemplified by a memorandum from the Zeebrugge operations manager. He indicated that pressure
should be put on the Chief Officer if he was not moving fast enough, concluding:
‘let’s put the record straight, sailing late from Zeebrugge isn’t on. It’s 15 minutes early for us’!
Although it did not apply to this voyage, concern had been raised by other Masters on the Dover-Calais
route, that ships had been carrying more passengers than allowed by the Passenger Safety Certificate. In
fact one memorandum indicated varying excess passenger numbers of between 40 and 250.

The ‘HERALD’ had proceeded to sea before with bow or stern doors open. One Master advised the office
in October 1983 that indicator lights on the bridge could be fitted to show that the hull integrity was
complete. This sensible proposal was met by derision from some superintendents.
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It is a legal requirement that the Master should know the drafts of his ship, and that these be entered
into the official logbook before putting to sea. It was particularly important for the Master of the
‘HERALD’ to know the draft of his ship, because of the restrictions on the numbers of passengers that
could be carried, and of equal importance the trim on departing Zeebrugge. No attempts had been
made to read the drafts, fictitious figures were always entered into the log book which always showed
that ‘HERALD’ sailed on an even keel!

A Brief Synopsis of the Recommended Immediate Actions


1. Failsafe indicator lights should be fitted on the bridge, to all superstructure doors, such as passenger
access, bunkering, storing and cargo loading doors.
2. The condition of the indicator lights should be logged before departure.
3. Closed circuit TV surveillance of the car deck should be fitted to monitor doors and cargo.
4. Freight vehicles should always be secured.
5. All doors and ramps should be secured at the berth, however, if this is not possible doors should be
secured once the ship has cleared the berth.
6. It is desirable that each berth should carry an approved certificate specifically listing the ships which
can operate from it, and can shut their bow and stern doors without moving from the berth.
7. Mechanical, pneumatic, electrical or hydrostatic draft gauges or indicators must be fitted. Desirably
they should show the forward, aft and midships draft at location of loading positions and on the bridge.
8. Draft gauges should be interfaced with the loadicator at a suitable central position with, if possible,
work stations at the two loading stations and on the bridge.
9. Operators should be encouraged to provide weigh bridges.
10. As a matter of urgency, sufficient self contained, watertight, maintained emergency lighting should
be fitted.
11. Escape windows which are reliable, uncomplicated and able to be opened from either side.
12. Means of escape are often fore, aft and at the top of the vessel which could be very high. An audit of
the escape routes should therefore be undertaken.
13. Parties agreed that:
2. lockers to be fitted on the upper deck containing axes, torches, ladders, ropes, lifting devices and
harnesses, including some for small children.
(b) glass partitions designed with intermittent gaps.
(c) permanent footholds are fitted to assist movement at extreme angles of keel.
14. Various recommendations are now covered by the ‘Code on Intact Stability’, see R6. It can be seen
that many of the recommendations have now been adopted internationally.
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The Scandinavian Star disaster of 7th April 1990

Norwegian Official Reports 1991. (ISBN 82-583-0236-1).


On 30th March 1990 the ‘Scandinavian Star’ ‘was put into service on voyages from Frederikshavn
(Denmark) to Oslo (Norway). Of the 99 crew all were new to the ship except for 9. On Friday 6th April the
ship left Oslo with 383 passengers and between 0145 and 0200 hours on the following morning a fire
started in a pile of bedclothes on deck 4. After the fire was extinguished a new fire started on deck 3
which rapidly spread to deck 4, 5 and further upwards. 158 people died, mostly from smoke inhalation,
probably by 0245 hours.

Manning
The crew possessed the necessary qualifications but as for safety functions, the Committee stated that
the navigating officers should have had a better training in safety routines. One had no training in fire
fighting and others had received training many years before. As a whole the crew had little or no
knowledge of English.

Preparation for service


Many of the crew were not familiar with the emergency plan or their functions in it. The original
emergency plan was difficult to apply to the new operation of the ship and the relevant officers did not
devote the necessary care and attention to the changes required. The evacuation group had too few
members to be able to function efficiently, and there were several areas where the resources of the
crew had not been properly deployed. The crew should have familiarised themselves with the use of
equipment by means of drills and other methods. The training of the fire patrol was to a very large
extent defective. No fire or abandon ship drills were held within 24 hours of the ship leaving
Frederikshavn on 1st April, which was a clear infringement of SOLAS regulations. The ship was clearly
subjected to severe commercial pressures.

The first fire was discovered and extinguished quickly but although the officer of the watch and Captain
suspected arson, no search was made of the accommodation. The second fire, however, spread rapidly
to the decks above leaving many passengers trapped in their cabins. Many people aboard did not hear
the fire alarm. Some bells were fairly quiet and were sounded relatively few times over short periods.
During this fire some of the crew, mostly on their own initiative, played significant roles in sounding the
alarm and evacuating passengers however through lack of organisation, they never responded as a unit.
No real attempts were made to put out the fire because the fire party was never assembled or
established.

The Captain ordered the lifeboats to be prepared but the evacuation was undertaken by crew who
lacked experience in working together and in handling the ship’s equipment. The most serious
consequence, due to the lack of organisation, remained with the ship’s command who had no idea of
how many people had left the ship in lifeboats, nor did they seem to be aware that they ought to have
known this.

The Captain had a duty to remain longer on board the ship, especially as he had the opportunity to do so
without exposing himself or any other crew members to unacceptable risks.
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Recommendations
1. Sprinkler system and smoke detectors should be fitted to all accommodation spaces on passenger
ships.
2. Safety training should be undertaken by all personnel aboard passenger ships, the standard of which
to be dictated by their responsibilities. The benefits of 5 yearly refresher training should be evaluated.
3. The Port State Control in Scandinavian countries was inadequate and must be improved. It should
incorporate:
(a) inspection with or without prior notification.
(b) satisfactory performance of fire and boat drills.
(c) sufficient command of a common language for the crew to be able to communicate with each other
and with the passengers.
4. Fire patrols making rounds every half an hour.
5. An alarm should continue to function until it is manually turned off or is temporarily interrupted by
messages on the public address system.
6. An alarm system with a strength in every cabin of at least 75 decibels and at least 10 decibels above
the background noise.
7. All decks and stairways on a passenger ship should have the same design and layout.
8. The escape route from cabin door to exit to a sheltered escape stairway or open deck should not
involve more than one change of direction.
9. There should be escape routes on both sides of the ship so that passengers do not have to cross over.
10. The number of stairs to be climbed should be limited.
11. Stairways and corridors should have an increasing width in the main direction of the escape route.
12. Stairways should be continuous, interrupted only by landings.
13. There should be a continuous bannister.
14. Dead end corridors should not be allowed.
15. The number of stairs to be climbed should be limited.
16. Ventilators should keep stairwells free of smoke.
17. Provision should be made to keep exits, assembly stations and lifeboat areas free of smoke.
18. Requirements should be laid down for the fitting of ventilation systems to extract smoke.
19. Audible signals distinct from the alarm bells should be installed by exit doors.
20. A uniform system of signs is used.
21. Smoke masks are supplied in cabins.
22. Evacuation analysis is carried out on all passenger ships.
23. Alarmed smoke detectors should be able to close fire doors.
24. Indicators should show whether fire doors are open or closed.
25. More breathing apparatus sets with integral communications and a compressor should be supplied.
26. More stringent requirements should be applied to the use of non combustible materials.

It can be seen that many of these requirements have now been incorporated into SOLAS.
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The Final Report on the Capsizing of the Ro-Ro Passenger Vessel M.


V. Estonia 28th September 1994
Ref: Final Report on the Capsizing on 28th September 1994, in the Baltic Sea, of the Ro-Ro passenger
vessel ‘M.V. Estonia’, 1997. Edits Ltd. Helsinki. (ISBN 951-53-1611-1).
The ‘Viking Sally’ was built in 1979 for the rapidly expanding ferry traffic between Finland and Sweden.
However after several name changes the ship transferred to the Talinn - Stockholm route and was
renamed Estonia.
Surveys and maintenance.
Survey of the bow visor and ramp for class was part of the continuous hull survey scheme. Just before
transfer to the Estonian flag, attention had been paid to the strength of the ramp and visor locking
devices, however no work was undertaken.
Operations on board
The work schedule for the crew of approximately 150 was two weeks service aboard followed by two
weeks leave. The working language was Estonian but English was compulsory for all persons in positions
involving work contact with passengers.
Circumstances of the voyage
Prior to departure at 1900 hours on 27th September 1994, a Port State Control exercise was undertaken
in Talinn, under the supervision of Swedish inspectors. (No deficiencies would have warranted
detention.) It was noted that the bow visor rubber seals were worn, torn and required replacement.
Watertight hatch covers on the car deck were open and at least one indicated that it was never closed.
The ship sank in the northern Baltic Sea during the early hours of 28th September 1994. Of the 989
people aboard 137 survived. The wind was south westerly force 8 with a wave height of 4 metres on the
port bow. The locking devices and the hinges of the bow visor failed under one or two wave impacts
shortly after 0100, allowing water to enter the car deck, and led to the eventual capsize.
Two reports of unusual sounds from the bow area were given to the officers of the watch, and attempts
were made to find the reasons. Speed was not reduced from 14 knots until a list developed.
The time available for evacuation was very short, between 10 and 20 minutes, and was not organised.
Evacuation was hampered by the rapid increase of the list, narrow passageways, transverse staircases,
objects coming loose and by crowding. The life saving equipment, in many cases, did not function as
intended and lifeboats could not be lowered.
Reports from the survivors vary considerably on the behaviour and conduct of crew and passengers.
It is difficult to comprehend the feelings of people suddenly awakened and possibly trapped in
unfamiliar surroundings. Statements included:
‘Many were in panic, shouting and screaming.......... they ran back and forth searching for
staircases and colliding with one another’
‘Some of them were standing still, apparently in shock’
‘Häire, häire, laeval on häire’ meaning ‘Alarm, alarm there is alarm on the ship’, in Estonian, which could
not be understood by the Swedes.
‘There were many panic stricken crew members in the corridor’
‘On the deck there were plenty of lifejackets and by the open doors a crew member was trying to lead
people out. People formed a human chain, helping each other out to the port side of the deck’
One witness said that the chain was mostly made up of crew members.
Some were not able to distinguish what messages they heard, and others stated that they could not
possibly hear the alarms due to the screaming.
‘Under the bridge was a small crowd who were quite calm’
‘There were 20 people as well as drunken youngsters’
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Some passengers said that there was panic, others said not.
‘On deck a crew member talked calmly to the others and together with other crew members tried
unsuccessfully to release a lifeboat’
Another witness reported seeing a man standing composed and assured trying to calm those who were
frightened.
The boatswain was seen doing a heroic job helping many passengers and releasing rafts.
A few of those who survived behaved in an irrational way, but most did not. A number of people reacted
incredulously to the very early signs. They slowly realised that the sounds they heard were abnormal, or
rather they failed to persuade themselves that the situation was still normal. When they became clear
about the situation they acted promptly and with a clear goal to get out to the deck and were the first to
evacuate.

The main points


1. The bow visor locking devices failed due to wave induced impact loads.
Was the ship going too fast in the prevailing conditions?
2. The bow visor locking devices should have been several times stronger to have a reasonable level of
safety for the regular passage between Talinn and Stockholm. The wave height probability on this route,
was significantly higher than the ship’s previous 12 years trading on much shorter and more sheltered
routes, see chart.
3. Bow visor incidents had occurred on her near sister ship ‘DIANA II’, but this did not lead to systematic
inspection and requirements for reinforcement of visor attachments on existing vessels.
4. Information on bow visor incidents was not generally sent to the shipping industry, thus Masters had
little knowledge of the potential dangers.
5. The initial action by the officers on the bridge indicates that they did not realise that the bow was fully
open when the list started to develop.
6. The bridge officers did not reduce speed after receiving two reports of metallic sounds and
investigation of the bow area. A rapid decrease of speed at this time would have significantly increased
the chances of survival: was this commercial pressure to maintain the schedule or lack of basic
seamanship?
7. The visor could not be seen from the conning position which the Commission considered a significant
contributing factor to capsize.
8. The bridge crew apparently did not look at the TV monitor which would have shown them water was
entering the car deck, nor did they ask those in the control room from where the ingress was observed,
or get information from them.
9. The lifeboat alarm was not given until about five minutes after the list developed, nor was any
information given to passengers over the public address system. By the time the alarm was given, the
list made escaping from inside the vessel very difficult. This, together with problems using lifesaving
equipment, contributed to the tragic outcome.
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