ACS Guidelines No.

15
Recommendations to improve safety of domestic ferries
and passenger ships

(Verdana , 14 point, spacing 1.15, bold )

2021
Association of Asian Classification Societies
www.asiancs.org
Recommendations to improve safety of domestic ferries and passenger ships
Rev.0

Recommendations to improve safety of domestic ferries and passenger ships

FOREWORD

Domestic Ferry and Passenger ship accidents result in fatalities, injuries of passengers and
damage/total loss of ships. Notably, the IMO is also considering this issue having included
an agenda item in the work programme of the Maritime Safety Committee and is scheduled
to deliver an output on this topic.

ACS constituted a project team to study this important issue. The project team collected data
of accidents on domestic ferries and passenger ships recorded in Asia and the Globe from
2008 – 2019. This team studied accident investigation reports published by the national
authorities and developed a set of recommendations to improve safety of ferries and
passenger ships. The team also recognized that lessons learned from accidents on passenger
ships in developed countries would also be beneficial to the Asian context, especially for the
developed nations in Asia.

The recommendations are developed in two parts. Part 1 contains the recommendations
specifically targeted at improving domestic ferry safety in Asia in countries with an adverse
safety record. Part 2 contains recommendations for improving passenger ship safety for
Asian countries with safety performance comparable to the global developed countries.

We look forward to your feedback and recommendations on any improvements to our

guidance/ questionnaire. This may be kindly provided to pso@asiancs.org or
technical.office@asiancs.org

DISCLAIMER
The ACS, its member, and their respective officers, employees or agents, individually and
collectively, assume no responsibility and shall not be liable to any person for any loss,
damage or expense caused by reliance on the information, advice and documents included in
these Guidelines.

ACS is an association of seven Classification Societies headquartered in Asia:

BKI, CCS, IRS, KR, NK, VR and SCM.
Recommendations to improve safety of domestic ferries and passenger ships
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Contents
PREAMBLE ............................................................................................................................. 2
PART 1 RECOMMENDATIONS FROM STUDY OF ACCIDENTS IN ASIAN FLEET
.................................................................................................................................................... 3
I. Establishment and enhancement of Maritime Safety Framework by National
Authorities.............................................................................................................................. 3
II. Improve Weather Forecasts and Reporting ................................................................. 5
III. Adequate Supervision by the Maritime Regulator ...................................................... 5
IV. Safety Management Systems of Operators ................................................................. 9
V. Ensure adequate training of Masters and Crew ......................................................... 12
VI. Improve the Search & Rescue (SAR) infrastructure ................................................. 13
VII. Life Saving Appliances ......................................................................................... 13
PART 2 RECOMMENDATIONS FROM STUDY OF ACCIDENTS IN REST OF
THE WORLD......................................................................................................................... 15
I. Safety Management Systems – General ....................................................................... 15
II. Maritime Regulations (For Large Cruise Ships) ....................................................... 17
III. Navigation Accidents (e.g. Collision, Grounding, Contact) ..................................... 17
IV. Fire Accidents ........................................................................................................... 21
V. Loss of Power & Propulsion Control ........................................................................ 27
VI. Damage to Ship & Equipment .................................................................................. 27
VII. Occupational Accidents & Injuries........................................................................ 28
VIII. Life Saving Appliances ......................................................................................... 30
IX. Voyage Data Recorders ............................................................................................. 31
APPENDIX: LIST OF ACCIDENTS .................................................................................. 32
Recommendations to improve safety of domestic ferries and passenger ships
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PREAMBLE

Recommendations are derived from a study of accidents on domestic ferries and

passenger ships and their investigation reports within the period 2008-2019
(Please refer Appendix for the list of all accidents studied). These investigation
reports were downloaded from IMO GISIS and National Authority websites.

The recommendations are not taken verbatim from the reports, since in the
actual reports, these pertained to specific scenarios on the ships. Rather, the
underlying aim of the recommendations is identified and included here.

It may be noted that the objective of the recommendations is not to provide

specific technical solutions or prescriptive requirements. The overarching
objective is to highlight major areas of concern (accident type, ship type,
location within the ship, stage of accident (prevention, mitigation, aftermath)
etc.) where National Authorities, Regulators, Operators and other Stakeholders
need to focus upon for improving domestic ferry safety. Detailed technical and
procedural requirements can be developed by the concerned national authorities
by carefully considering the various aspects focused within the
recommendations. Work on the issue of domestic ferry safety is also ongoing at
the International Maritime Organization (IMO) from MSC 102, the related
technical document will be developed by IMO in the near future. It is expected
that by considering these recommendations, onboard fatalities of passengers &
crew and total losses of ships/ferries would be reduced.

Unlicensed crafts/boats would also benefit from the recommendations, especially

the recommendations in Part 1, since these are derived from actual accidents. It
would be the prerogative of National Authorities to require all crafts/boats
transporting passengers to be licensed to improve safety.

Part 1 of the recommendations focuses on accidents in Asia, where these are

expected to have immediate impact on improvement of the present domestic
ferry safety. (Items marked in Blue font were identified for more than one
accident).

Part 2 of the recommendations collates recommendations from the accidents in

the Rest of the World. This will help enhance safety for those ships in Asia which
already have demonstrated an acceptable level of safety comparable to the
global scenario.

For both Parts 1 & 2, additional recommendations identified by ACS are marked
in Red font.
Recommendations to improve domestic ferry safety Rev.0

PART 1 RECOMMENDATIONS FROM STUDY OF ACCIDENTS IN ASIAN FLEET

I. Establishment and enhancement of Maritime Safety Framework by National Authorities
a) To set-up a disaster management cell to manage accidents and their aftermath.
b) Explore regional co-operation between several nations to explore common vessel safety standards for
vessels sailing in their common ocean areas.
c) Explore possible regional agreements on inspection of ships between regular surveys to ensure compliance
(for local international voyages between certain countries under special agreements).
d) To ensure adequate financial support to the Maritime Regulator to discharge its’ roles & duties
e) Require ships carrying passengers to maintain an accurate passenger manifest (including those in
buses/trucks transported on the ship).
f) Require ships carrying cargo & vehicles to maintain an accurate cargo manifest (including the cargoes
carried within vehicles)
g) Ensure adequate supervision of the passenger & cargo loading on the ships in accordance with the
declared manifests
h) Prohibit operation in rough weather for ships carrying passengers (those ships who are not certified to
operate in rough weather)
i) Prohibit fishing vessels & cargo ships from transporting passengers
j) Cultivate and nurture safety culture amongst the various stakeholders (viz. Terminal, Operators,
Passengers, Crew etc.)
i. Increase public awareness about safety in marine transport (which includes dos’ and donts’)
ii. Educate ship owners about the need for operating and maintaining ship in compliance with rules and
regulations
iii. Educate ship owners about using ship which has been designed and constructed in accordance with
established national rules & standards
iv. Educate ship owners about the importance of preparing accurate passenger and cargo manifests
including declaration of dangerous goods
v. Educate transporters & logistics providers in the country regarding the importance of declaring
dangerous goods carried in their trucks to the ship operator

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vi. Require operators to clearly display at common locations of passengers, the certified capacity of the
ferries in terms of number of passengers. Increase awareness amongst the ferry operators and
passengers regarding development of accurate passenger manifests.
vii. Implement system for anonymous reporting by passengers & crew to report violation of rules and
regulations by ship-owners & operators (e.g. ferry is carrying more passengers than the number on
the certificate). Increase awareness amongst passengers & crew about the presence of such system
and it use to lodge complaints/report irregularities.
viii. Popularize the public education for coping with the shipwreck, for example, consider incorporating
relevant content in the school physical education, especially for those countries constituted by many
islands where people often travel by means of water transportation.
ix. Cultivate and nurture the public the sense of solidarity and mutual assistance in dealing with sudden
disasters.
x. Conduct frequent drills of passengers considering various major marine accidents (capsize, collision,
stranding, fire, etc.) to enhance familiarization, psychological preparation and proper performance
of passengers to correctly deal with all possible kinds of unexpected marine accidents.
k) Provide adequate terminal/berth Facilities (this will be in co-operation with the operator)
i. Compatibility of the berth with the ro-ro passenger ship so that the bow ramp door is prevented
from gradual deterioration during the frequent embarkation/disembarkation process
ii. Providing weighing bridges to verify the cargo weights & vehicle weights
iii. Providing baggage scanning facilities to detect if dangerous goods are carried
iv. Ensuring the ship is permitted sufficient time to embark/disembark passengers and cargo.
v. Providing sufficient fire-fighting facilities at berth
l) Mandate passenger ships to regularly report position (at least once in every 30 minutes)
m) Ensure compliance with rules for granting sailing approval to passenger ships prior to departure
i. Check the declaration of goods, especially dangerous goods transported within trucks/vehicles
ii. No further embarkation of passengers or loading of goods should be permitted post submission of
passenger and cargo manifests
iii. Check of the ship’s final drafts before sailing

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n) Maintain safety and cleanliness of sailing routes (i.e. free of floating & undersea obstacles) (especially for
High Speed Craft (HSC))
o) Creation/update of a hazard map based on eyewitness information of sea creatures such as whales,
dolphins etc. Keep the operators informed of the sea areas where these sea creatures are frequently
spotted and advise to decelerate and maneuver carefully in these areas. This is very important for HSC
which have suffered accidents after coming in contact with these sea creatures
p) Periodically monitor the effectiveness of the Maritime Regulator in discharging its roles & duties
q) Standardize ship designs, operation and maintenance to the practicable extent
r) Consider establishing a policy to decommission passenger ships/ferries from service beyond a threshold
age [30][35] years
II. Improve Weather Forecasts and Reporting
a) Ensure to provide regular forecasts and updates to ships about the weather (preferably at least once every
hour)
b) Ensure availability of information (e.g. notify and update a website, app etc. for this purpose)
c) Ensure to communicate sudden changes in weather
d) Convey the weather information in simple language to master
e) Communicate the variability of weather forecast
f) Commission studies of meteorological information especially on extreme weather
III. Adequate Supervision by the Maritime Regulator
a) To ensure sufficient and competent technical and surveyor staff commensurate with the number of ships
under supervision
b) Develop and promulgate a Domestic Safety Management Code onboard all ships involved in carriage of
passengers
c) Ensure annual safety management system (SMS) audit
d) Ensure half yearly/annual surveys for all ships involved in carriage of passengers
e) Perform random checks from time to time to check condition of ship, in specific:
i. Check manning, competency and familiarization of crew
ii. Require each ship to maintain an approved stability booklet, safety and fire control plan
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iii. Require each ship to maintain an approved cargo securing manual (for ships carrying vehicles &
cargo additionally) and check its implementation
iv. Check items pertaining to ship’s watertight integrity & loadlines
1. Bow ramp doors
2. Watertight doors
3. Openings in the hull
4. Drainage system on decks (scuppers, ports etc.)
v. Check functionality of critical equipment (especially the Safety & Navigation Equipment)
vi. Check functionality of emergency generator
vii. Check records regarding performance of drills and emergency preparedness.
viii. Witness drills
f) Equip officers/surveyors with thickness gauging instruments to randomly check the plate thicknesses
g) Diligent checks during approval of plans and issuance of certificates only after the construction is
completed in accordance with approved plans (including satisfactory closure of all
recommendations/comments raised by the technical staff/surveyor)
h) Exercise sufficient oversight over its own technical staff, surveyors and recognized organizations (RO)
/bodies working on its behalf especially with regard to:
i. Ensuring existing uncertified ships brought for certification are thoroughly checked before issue of
certificates
ii. Ensuring that any modifications in plans/arrangements or repairs are reported and approved.
Ensure the assessment of the modifications is considered holistically (i.e. impact on ship structure,
stability, watertight integrity, fire safety, propulsion, lifesaving appliances etc.)
iii. Ensuring surveys to verify that the modifications are made in accordance with the approved plans
iv. Ensure historical records of previous modifications are available and considered in the approval
process
v. Ensuring survey reports are available and accessible (including previous reports) easily to all
surveyors
i) Mandate installation of Automatic Identification System (AIS) onboard.

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j) Develop and maintain rules for design & construction of Fiber Reinforced Plastic (FRP) boats 1 and
motorboats with outriggers used to transport passengers (and clearly mention the operational limits
considered by the rules)
k) Require an emergency source of power and periodically confirm its functionality
l) Ensure & implement rules & regulations for design for fire safety
i. Engine Room (E/R) requirements
1. Adequate ventilation
2. Grounding system for generators to protect against leakage currents
3. Require fire & smoke detections systems for totally enclosed E/R spaces of small FRP
crafts/boats
4. Insulation
5. Quick closing valves (QCV) (including remote operation capability)
6. Firefighting installations. In particular for small FRP craft/boats ensure firefighting for E/R
spaces using automatic CO2 release can be made possible without crew having to manually
enter the space and close all openings into the space
7. Protective cover to generator ventilation fans to reduce accumulation of impurities (dust,
water vapour etc.)
8. Appropriateness of materials used for electrical cables and in general to be suitable for
marine applications
9. Integrity and safety of the fuel system
10. Equipped with communication means with the bridge
11. For small crafts/boats with machinery spaces below passenger deck, ensure adequate
ventilation of the space
ii. Passenger Accommodation requirements
1. Use of appropriate materials of construction for marine use

1
Small Craft/Boats in this document imply those vessels which have typically L<24m and may have composite materials of construction (e.g. Steel,
FRP, Wood etc.) and mainly involved for carriage of passengers
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2. Require installation of sprinkler systems in passenger accommodation cabins

iii. Ro-Ro space requirements
1. Installation of smoke & fire detection systems
2. Adequate spacing between vehicles
3. Restrict the height of the loads within the truck to ensure that the sprinkler system is not
made less effective (i.e. sufficient clearance between the sprinkler and the highest point of
the cargo roof of the truck)
4. Safe carriage of dangerous goods (DG)
iv. Adequate provision and sizing of evacuation & escape routes
v. Require fire detection systems to be installed in the canteen/restaurant/galley areas
vi. Require safety systems for electrical installations in the canteen/restaurant/galley areas
vii. Rules & Regulations for machinery for ships with outboard motors
m) Require shock absorbing material in the cabins to avoid injuries to passengers in case of
collision/contact/grounding (for HSC)
n) Review and revise standards for strength of attachment of seats to the decks considering heeling
conditions of the ship (for HSC)
o) Require damage stability assessments to be performed for passenger ships and verify the correctness of
the outcome
p) Review the requirements for stability assessments considering the effect of wind in internal waterways
such as rivers, lakes etc.
q) Require evacuation analysis to be performed for new building passenger ships with more than 36
passengers.
r) Passenger quota and cabin space shall be clearly marked on passenger ships
i. It is strictly forbidden for passenger ships to sell tickets beyond the approved passenger capacity.
ii. It is forbidden to carry passengers in crew accommodation, ro-ro space, escaping routes and other
non-cabin spaces
s) For passenger ships, the ship's wind resistance capability shall be verified and specified in the ship’s
certificate. Before sailing or while in the waters to be navigated, if the wind force exceeds the ship’s wind
resistance level, the ship shall not sail or pass that waters
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IV. Safety Management Systems of Operators

a) General
i. Carry out risk assessment within the company and develop procedures for master & crew for
operation during rough weather
ii. Inform authorities of any crew change/missing crew prior to departure. Always replace with
competent crew
iii. Ensure closure of watertight doors before sailing and during the voyage
iv. Ensure intake valves of main fire pumps are always open after leaving port, so that fire-fighting
systems can be made functional quickly in case of fire
v. Permit smoking only in designated areas for passengers & crew
vi. Ensure no flammable cargo/items are stored near the smoking areas
vii. Make master and crew wear distinct uniforms so that they can be easily identified (for assistance)
during emergency
viii. CCTV installation & monitoring of E/R & the ro-ro spaces
ix. Ensure that evacuation routes are well highlighted and always clear of any obstacles
x. Keep trained Designated Person Ashore (DPA) to assist in management of emergency and dedicated
onboard crew member(s) to communicate
xi. Ensure hours of rest so as not to overfatigue crew
xii. Ensure awareness of crew not to utilize void tank as ballast tank
xiii. Regular check by the crew of the effectiveness of the deck's drains, scuppers etc. to ensure no
water accumulates
xiv. Carry out periodic internal audits for SMS on Ship
xv. Ensure materials for mooring equipment (ropes, rope ladders etc.) are not contaminated with
inflammable substances.
xvi. Ensure maintenance of the ship in accordance with the planned maintenance system (PMS)
1. Maintenance of emergency equipment so as to keep in state of readiness
2. Maintenance of the items such watertight doors, deck drains, ports, scuppers
3. Maintenance of machinery
xvii. Secure loose furniture before rough weather so that it does not block escape routes
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xviii. Ensure effective ventilation be provided for the ro-ro/vehicle space, and maintain the air exchange
rate for closed ro-ro and special category space as required by relevant technical rules.
xix. The operator and manager should proactively monitor the ship, improve the safety of navigation,
improve procedures for performing the berthing and operations of the ship in time, and to ensure
the ship be equipped with voyage data recorder (VDR).
xx. Obvious signs shall be provided to indicate fire-fighting and life-saving equipment and facilities,
emergency passage and relevant emergency measures in the public places of the ship, and also
provide appropriate safety instructions for the crew and passengers to read.
xxi. Patrol inspection shall be strengthened during navigation. If any potential safety hazard is found,
effective measures shall be taken in time to eliminate it; if it cannot be eliminated in time, it shall
be reported to the ship operator or manager. When necessary, it shall also report to the maritime
administration.
xxii. If the ship completes the inspection and confirms that it meets the relevant safety requirements in
accordance with the provisions (a)-(d), the master shall sign the list of safety self-check before
sailing.
xxiii. Patrol inspection system shall be formulated for navigation, berthing and operation; patrol
inspection scope, patrol inspection procedures, safety hazard reporting procedures, emergency
handling measures and post responsibilities of patrol inspectors shall be clearly defined.
xxiv. When ship encounters bad weather and severe sea conditions during navigation, crew shall operate
ship cautiously, strengthen patrol inspection, check and reinforce securing arrangements for cargo
and vehicles, prevent displacement or collision of cargo and vehicles, and report to the ship
operator and manager in time. When necessary, it shall also report to the maritime administration.
xxv. After ship sets sail, it shall be immediately explained to the drivers and passengers the location of
the safety instructions, the emergency passage and relevant emergency measures.
b) Cargo & Vehicles Stowage
i. Develop and implement effective cargo stowage onboard in accordance with the cargo securing
manual
ii. Ensure stowage of cargoes on lower decks to lower vertical centre of gravity (VCG) of the vessel

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iii. Ensure top-over lashing of heavy cargoes, vehicles and equipment (reinforced lashing may also be
considered) for rough weather
iv. Establish weight and volume limits of permitted luggage per passenger (at least for small
boats/vessels carrying solely passengers)
v. Prohibit passengers from staying in ro-ro spaces or within their vehicles in ro-ro spaces
vi. Prohibit overloaded trucks (both weight and volume)
vii. Prohibit trucks from keeping their engines switched on during the voyage and ensure to disconnect
their batteries
viii. If practicable, provide power supply points for truck especially those carrying refrigerated goods
ix. Ensure all fire detector systems are switched on before sailing (for the ro-ro spaces)
x. Implement correct stowage of vehicles by securing them
xi. Establish means to determine quantities of diesel and fuel in the vehicle tanks
xii. Develop scheme to regularly patrol ro-ro spaces and E/R spaces to identify any fires
xiii. Brief the bus/truck drivers vehicles to report any dangerous conditions to the ship’s crew
c) Navigation
i. Provide latest updated navigation charts to the ships
ii. Ensure passengers are seated with belts fastened throughout the voyage (for HSC)
iii. Ensure passenger luggage is well stowed & secured throughout the voyage (for HSC)
iv. Maintain proper & vigilant lookout including the time when ship navigates in channels, rivers etc.
1. Check position, course, speed, yaw at frequent intervals using all available navigation aids to
ensure vessel follows the planned route (for HSC)
2. Ensure navigation using the safe speed especially in restricted visibility (for HSC)
3. Review the major and important turning points in the route (for HSC)
v. Apprise passengers when entering an area where sea creatures are frequently reported to be
spotted. Instruct passengers to put on their seat belts and prohibit all movement. Suspend onboard
services till the time the ship is in the area (for HSC)
vi. Develop procedures to navigate with safe speed and maneuvering in areas where sea creatures are
frequently reported to be spotted (for HSC).

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vii. Ensure that persons in charge of look out and steering must not be disturbed by other crew
members for other trivial duties during their watch (for HSC)
viii. Reduce navigating speed in flooded waterways such as rivers & lakes to enable timely detection and
avoidance of sudden obstacles such as floating object/debris (for Fast Boats)
ix. To understand the limitations in the operation of ships with multiple water-jet propulsion systems
(sudden turning force due to unsynchronized reduction of power from one side) and ensure such
eventualities are communicated to the navigators
x. Establish procedures for emergency maneuvering when a sea creature is detected (for HSC)
xi. Ensure effective utilization of the active sonar and the underwater speaker (UWS) for detecting any
sea creatures in the vicinity and taking measures to avoid contact (for HSC)
d) E/R Procedures
i. Ensure cleanliness of the E/R. No oily rags lying around, no oil dripping around equipment left
uncleansed and no in-appropriate storage of flammable materials.
ii. Prohibit tightening of high pressure fuel pipes to stop leakage when the engine is running
iii. Ensure sounding pipes for fuel tanks are closed with caps
iv. Ensure hydraulic systems are regularly inspected for leakage of oil
V. Ensure adequate training of Masters and Crew
a) Adequate familiarization
i. Safety management system
ii. Safe operation procedures within the scope of responsibility
iii. Emergency response procedures and measures
b) Emergency preparedness
i. Brief passengers regarding the safety protocols, process of evacuation & muster and use of
lifejackets before voyage starts. This can be done by issuing safety brochures, pamphlets, videos,
public announcements etc.
ii. Emergency preparedness, crisis management drills (also include hotel/restaurant crews in conduct of
emergency preparedness training so that they can assist during the actual emergencies)
iii. Improve training of crew to respond to emergency operation under bad weather

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iv. Awareness of the firefighting systems & equipment onboard and their proper use
c) Cargo stowage & Securing
d) Enhance understanding of crew regarding the trim & stability of the vessel, operational limits of the
vessel to operate in a given environment condition
e) Safe navigation of the ship
v. Bridge resource management (BRM)
vi. Effective communication between ships
vii. Understand and operate navigational aids (e.g. Radar, Electronic Chart & Display Information System
(ECDIS) etc.) (especially for HSC)
f) Conduct emergency drills and training in accordance with the provisions of international treaties or
national regulations
VI. Improve the Search & Rescue (SAR) infrastructure
a) To ensure readiness of SAR to be deployed at short notice
b) To ensure that there is an adequate radio station network for ships to contact for SAR.
c) To ensure that these radio stations are manned 24x7 and are easily accessed by a single emergency
number disseminated to the shipping companies
d) To remind all masters about their duties to participate in SAR
e) Identify and maintain a list of assets
f) To explore if common air and marine assets for rescue can be shared by various departments
g) To explore a mutual association between nations sharing common ocean area through which their
domestic/international fleet navigates
h) To ensure adequate funds for SAR
i) Regularly update the registrations of Emergency Position Indicating Radio Beacon (EPIRBS)
j) Require passenger ships with EPIRBS to be fitted with Global Positioning System (GPS)
VII. Life Saving Appliances
a) Ensure sufficient number of children’s and infants’ lifejackets are carried onboard
b) Ensure liferaft capacity of atleast 125% of persons onboard (POB) (in case some liferafts do not inflate)
c) Ensure number of lifejackets are atleast 125% of POB
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d) Consider stowing a proportion of lifejackets in float-free lockers to be available after ship sinks for
passengers who were not able to locate and wear them.
e) Indicate location of storage of lifejackets clearly in the local language(s)
f) Stow lifejackets near the exits as practicable but not at the doorways (to avoid congestion)
g) Ensure that lifejackets are worn by passengers during the voyage at least for voyages of short duration
h) Ensure availability of sufficient flares, rockets, smoke signals etc. on board
i) Consider design of lifejackets such that these do not trap passengers when escaping from flooded
compartments
j) Require inflatable liferafts in lieu of rigid liferafts
k) Ensure installation of public address system onboard
l) For FRP boats consider appropriate stowage of life jackets keeping in view, the possibility of a fire
developing rapidly and subsequent difficulty for crew and passengers to access the same. If not
practicable, ensure life jackets are worn at all times during the voyage
m) For domestic ro-ro passenger ships navigating beyond 200 miles from shore, it is recommended to fulfil
the requirements for liferafts as provided in SOLAS III/26, Para. 2.4.

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PART 2 RECOMMENDATIONS FROM STUDY OF ACCIDENTS IN REST OF THE WORLD

I. Safety Management Systems – General
a) Synchronize all ship system times to a Master Clock
b) Develop accurate passenger & cargo manifests. This may also include nationalities of the passengers
for international voyages
c) Familiarization & Emergency preparedness
i. Roles and responsibilities of team leaders should be detailed within the emergency organization
manual.
ii. Develop Vessel system familiarisation-training package to ensure all team leaders understand
the limitations and capabilities of emergency systems.
iii. Consider the eventuality of key personnel being not available during emergencies while
developing emergency plans. Maintain personnel and technical resources for ensuring planning,
co-ordination and documentation of measures during complex damage scenarios.
iv. In case on board there is more than one person with same role (for example Chief Mate) for
which the SMS manual clearly establishes the tasks, the captain should specifically assign each
person the related tasks.
v. Keep ready blank checklists to complete muster and identify unaccounted passengers/crew
vi. Identify and mitigate possible emergency scenarios
vii. Brief passengers regarding the emergency situation and update them regularly
viii. Conduct drills considering flooding accidents to enhance familiarization of crew with their duties
ix. Display safety information regarding the various hazards at different locations where passengers
would be present regularly. Distribute safety brochures to passengers during their boarding
(Large Cruise Ships)
x. At the beginning of each voyage, apprise passengers to read the safety information
xi. Drills of passenger muster should be carried out at each port the ship calls, where passengers
board the ship, rather than only at the starting port (Large Cruise Ships)
xii. Inform passengers about emergency onboard in as many languages as possible. Train cruise
director to make clear announcements without causing panic (Large Cruise Ships)

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xiii. Crew to wear safety vests or uniforms which help passengers to identify them easily and seek
assistance
xiv. Provide Ultrahigh frequency (UHF) radios for use by the crew while conducting search of ship for
passengers
xv. Provide guidance to staff as to when to muster passengers. Ensure sufficient means to take
census of passengers after muster
d) Ensure pro-activeness of the ship superintendent to keep higher management informed about the
problems which pertain to safety critical systems (e.g. emergency generator)
e) Ensuring that the staff on board is actually familiar with the working language and that this language is
used on board
f) A detailed list of the cargo to be loaded to be provided in advance, considering the ship operational
features, including size, weight and any other technical requirements (including the notification of the
exact number of trucks that would require connection to the vessel’s electrical power etc.) so that the
loading plan can be prepared before the departure;
g) Plan to conserve food items (especially refrigerated) during extended power outage
h) Review and implement smoking policies
i) Ensure that unauthorized persons are not able to board the ship
j) Ensure supervision and audits of the manning agency who provides the crew including for
hotel/restaurant purpose (Large Cruise Ships)
k) Monitor the ship fleet in terms of their navigation routes (Large Cruise Ships)
i. The safety level of route plans, comparing the route planned by the master (Passage Voyage
Plan or Visual Passage Planner (VPP)) with the standard route;
ii. Actual position of each vessel compared with the route planned by the master (VPP) and the
standard route;
iii. Quickly and automatically identify unexpected changes of direction.

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II. Maritime Regulations (For Large Cruise Ships)

a) Discontinuity of compartments containing ship's essential systems (such as propulsion sets or main
generators sets) in order to preserve their functional integrity (reference should be made to regulation
II-2/21, SOLAS 74 as amended);
b) Specification of more detailed criteria for the distribution, along the length of the ship, of bilge pumps
and requirement for the availability of at least one pump having the capacity to drain huge quantities of
water (reference should be made to regulation II-1/35-1, SOLAS 74 as amended);
c) Relocation of the main switchboard rooms above the bulkhead deck (reference should be made to
regulation II-1/41, SOLAS 74 as amended);
d) Relocation of the UHF radio switchboard above the bulkhead deck, for all existent ships which are
provided with this equipment below this deck, and for the new ships, it should be located above the
bulkhead deck.
e) Increasing the emergency generator capacity to feed also the high capacity pump(s)
f) Provision of a second emergency diesel generator located in another main vertical zone in respect to
the first emergency generator and above the most continuous deck2 (Large Cruise Ship)
g) Verify that new emergency diesel generators are made according to aimed and specific building
techniques in order to guarantee an unfailing and long-lasting functioning (by performing periodic tests
by running them on load);2
h) Provision of an emergency light (both by Uninterrupted Power Supply (UPS) and emergency generator)
in all cabins in order to directly highlight the life jacket location. (Large Cruise Ship)
i) Consider need for extra embarkation ladders (In this accident, with the ship listed at an angle
exceeding 20°, it was demonstrated that traditional embarkation ladders were more useful as means of
escape off the ship)
III. Navigation Accidents (e.g. Collision, Grounding, Contact)
 Safety Management System
a) Ensure voyage planning and use of adequate navigational procedures considering the below factors:

2
Also Identified for ships which had fire accidents
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Recommendations to improve domestic ferry safety Rev.0

i. Navigating in narrow channels

ii. Include port entry and departure procedures and effect of different weather, available depth of
water, tides, currents and traffic condition in the voyage planning (Laydown the navigation speeds
for each stage as far as practicable)
iii. Awareness and familiarization with port entry requirements and protocols
iv. Use only SMS authorized equipment for navigation (as the primary means of navigation)
v. Use of all available navigational equipment (e.g. Radar, AIS, Automatic Radar Plotting Aids (ARPA),
ECDIS etc.) to obtain information to support decision making
vi. Conduct risk assessment prior to use of voyage plan to anticipate any dangerous scenarios
vii. Navigate with ‘safe speed’
viii. Ensure that the Bridge Navigational Watch and Alarm System (BNWAS) cannot be manipulated by
the crew (this happened before an accident when the watchkeeper disabled the BNWAS since it
was making too much noise)
ix. Be vigilant against complacency/overconfidence induced due to working on the same repetitive
voyages & approaches
x. Ensure priority is given to safety rather than pressure from passengers to go in more proximity to
coastline
xi. Facilitate effective information exchange between master & pilots, safe speed details provided on
‘Pilot Cards’
xii. Develop arrival procedures and checks when using propulsion/steering systems with complex
modes/controls to confirm their correct operation. Include critical and abort points in the
navigation plans using such systems. Provide alarms to indicate any incompatible/inconsistent
operations (e.g. proceeding below threshold speed when open sea navigation mode has been
selected). Provide maximum revolutions per minute (RPM) charts vs the ship speed (for HSC)
xiii. For ships with fin stabilizers, ensure that checks are made to see these are not deployed when a
vessel enters port
xiv. Develop procedures to determine if services of a harbour pilot should be requested to co-ordinate
vessel-tug communication.

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Recommendations to improve domestic ferry safety Rev.0

xv. For ships with complex systems such as azimuth propulsion, water-jet propulsion etc., ensure that
only competent and trained persons are in charge of operation. Ensure autopilots for such ships
are robust enough and do not provide abnormal control reactions.
xvi. Perform periodic navigational audits to ascertain compliance with SMS
xvii. Require master to submit the voyage plan to company before departure and maintain this record
until next document of compliance (DOC) audit
b) Provide training to crew (including persons who join the ship on a temporary basis during peak
seasons):
i. Provide training for BRM considering the below factors:
a. Improve communication
b. Situation awareness
c. Effective utilization of bridge equipment
d. Operation planning techniques
e. Clarity of roles & responsibilities
f. Simulate failure scenarios during drills
ii. Understanding and correct use of ECDIS
a. Knowledge of the various ECDIS function settings (including the ‘Look Ahead’ settings)
including the familiarization and awareness to select particular settings for safe navigation in
a given channel/area
b. Adjustment/Plotting of safety contours relevant to local conditions
c. Response to alarms
iii. Understanding and correct use of radar plotting
a. As a good practice, radars should be kept one at long and the other at intermediate range.
In determining the range scales it should be borne in mind that detection of targets,
particularly small targets, is generally better at short ranges.
iv. Training of watchkeepers
a. to ensure potential dangerous situations are identified at early stage
b. to ensure watchkeepers can determine passing distance as accurately as possible
c. to be familiar with their duties
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Recommendations to improve domestic ferry safety Rev.0

d. ensure newly appointed officers are given adequate training before participating in actual
watch
v. Steering & Maneuvering
a. Awareness regarding the emergency steering options in the event of malfunction/failure
(this recommendation stemmed from two different accidents on a ship with pod propulsion
system and controllable pitch propeller (CPP) system)
b. Ensure multiple maneuvering options are practiced so that the navigator can quickly adapt
in case of any malfunction/failure (this recommendation stemmed from an accident on a
ship fitted with azimuth propulsion system).
c. Familiarization & training of the operation of various ‘modes’, options and controls used by
propulsion and steering system consoles onboard. This is to enable quick and correct
troubleshooting in case of malfunction and respond accordingly.
d. Perform checks for verification whether controls of propulsion and steering systems are
working properly before entry into port waters (for propulsion/steering systems involving
complex controls/operation modes).
e. Ensure that operating manuals are up to date considering any modifications/updates to the
steering control systems along with technical reviews conducted to confirm the correctness
of the contents
f. Ensure bridge team also participates in drills addressing failures of the propulsion systems
(so as to ensure proper co-ordination/team work during actual accident)
g. As a good seaman ship practice, hard over helm order should be avoided with engines on
full ahead.
vi. All members of the bridge watch team to be competent in the safe operation of all bridge
equipment, particularly equipment required for emergency response procedures.
c) Develop Ergonomic & Human Centered Design of Bridge Equipment layout
i. To avoid distraction during duty
ii. Safeguard against inadvertent actions/operations (design and placement of buttons)
iii. Provide clear and unambiguous indications so as to assist the officer to make the correct decisions
iv. Avoid complex layouts/too many outputs & indications which may confuse the officer
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Recommendations to improve domestic ferry safety Rev.0

d) Ensure adequate hours of rest to the master and the crew (despite of their obligations to also play host
to passengers)
e) Ensure sufficient manning on the bridge, especially during the port arrival and navigating through high
traffic areas
 Port Supervision and Monitoring
f) Issue meeting bans in fairways for ships above a certain size as appropriate to the size of the fairway
g) Establish roles & responsibilities of the vessel traffic monitoring system (VTMS) to track vessel
movements and warn in case of impending collisions
h) Ensure berth location is safe enough for vessels to maneuver and does not endanger safety of
navigation (for HSC)
i) Study traffic movements and density in the Port waters and identify need for additional
berths/anchorage areas/review existing anchorages
j) Prescribe maximum navigational speed limits for various sections within rivers/channels after
assessment of the risk
k) Review communications between VTMS and Maritime Rescue Co-ordination Centre (MRCC)
l) Improve co-ordination between various municipal bodies to provide relief after accident at berth.
Configure and perform regular drills to address such events.
m) Publish and disseminate navigation charts including regular updates
n) Periodically ascertain adequacy of available channel depth for safe navigation considering silting
o) Explore possible shore based transportable passengers emergency evacuation arrangement for
disembarking passengers in emergency situations when ship is at/close to berth
p) Identify possible holding areas in case of temporary pier closures where boats can wait (for small craft
plying on rivers)
q) Perform periodic internal audits to ensure compliance of policies with the management system
IV. Fire Accidents
 Engine Room
 Prevention of Fire
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Recommendations to improve domestic ferry safety Rev.0

a) Identify hot surfaces which must be kept insulated

b) Perform periodic thermographic surveys to identify hotspots (Temperature > 220oC) (This will also help
to verify correct installation/functioning of insulation and shields)
c) Identify all areas in close proximity to hot surfaces
d) Identify all connections for systems with fuel/lube oil, hydraulic systems using oil fluids and others
within the proximal areas to the hot surfaces which upon failure would cause fuel oil to leak and
provide suitable shields.
i. Ensure such systems are installed with a high pressure alarm
ii. Ensure adequate means to dissipate the excess pressure which may develop in such systems
iii. Ensure periodic inspection and maintenance
e) Ensure fuel supply lines are well supported and do not vibrate
f) Identify safety critical equipment in the E/R
g) Ensure proper inspection & maintenance of the fuel system
i. Ensure procedures and documents provide adequate job specifications to crew to carry out
maintenance
ii. Ensure adherence to latest specifications and bulletins issued by the manufacturer while
developing installation & maintenance procedures
iii. Ensure proper maintenance especially of the components in the fuel supply system to avoid any
fuel leakage coming into contact with hot surface
iv. Ensure the documentation of the receipt of each spare along with the make and the date when
delivered.
v. Ensure machinery spaces are free from combustible materials or such materials are stored in
protected bins
vi. Ensure planning and execution of machinery space drills cover all areas of the machinery Space
which are susceptible to fire accidents (and not limit such drills to one area always)
vii. Deploy E/R ratings in the night (especially when maintenance tasks are scheduled)
viii. Regularly inspect fuel oil shield protection on board
ix. Ensure oilers cover all E/R areas during their work routes

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Recommendations to improve domestic ferry safety Rev.0

x. Ensure maintenance records are available after transfer of ownership (so that history of any prior
repairs or modifications carried out on system components is known)
xi. Periodic inspection regime of all fuel line securing/supporting arrangements
xii. Conduct risk assessments prior to starting onboard E/R work by Original Equipment Manufacturer
(OEM) technicians
h) Monitor the engine cylinder firing pressures in all engines to detect any failures which may lead to
explosions. Regularly inspect engine components (in the present case, this was a piston connecting rod)
to observe any evidence of damage
 Detection of Fire and Egress from Machinery Space
i) CCTV monitoring system with capacities to automatically detect flame and smoke
j) Ensure location of the emergency engine stop button at an accessible location considering possible
scenarios. Consider to provide multiple stops
k) Ensure valves for the fuel supply system are closed with the engine stop without any delay
l) Install systems to indicate the status of the fuel oil and gas oil closing valves
m) Ensure QCV of diesel flushing tanks has remote means of closure
n) Ensure sufficiency of emergency escape safety equipment provided for the number of crew envisaged
to be working in a given space
o) Use of high visibility fluorescent paint to mark location of safety equipment and egress routes
p) Ships’ crew working in machinery spaces to be provided with coveralls that have reflective material,
personal emergency man down alarms / lights, and personal escape masks.
 Firefighting
q) Ensure automatic release from local fire extinguishing systems
r) Ensure that ships with hi-fog firefighting systems are on auto mode
s) Ensure effective communication by providing appropriate equipment to fire-fighting teams
t) Ensure that E/R firefighting system operation is well understood by crew
u) Ensure suitable access routes to all the E/R areas so that during the fire-fighting, adequate time and
breathing apparatus (BA) capacity is sufficient (i.e. whether more time is spent in finding a route to the
E/R area by which time the BA set could be exhausted)
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Recommendations to improve domestic ferry safety Rev.0

v) Ensure inspection of diaphragms inside the fire hydrant at least once in 5 years to detect any damage.
Provide means to isolate fire mains passing through a space where CO2 has been released (in case the
fire hydrant diaphragm is damaged, this could lead to uncontrolled water release in the E/R)
w) Inspection of fire dampers and all penetrations to ensure their effectiveness in containing the fire
x) Consider separate CO2 system for garbage handling room (for large cruise ships)
y) Provide sufficient number of hand held radios for communication within the ship if main and emergency
power source are lost
z) Prefer providing lightweight BA sets to firefighters
aa) Consider increasing capacity for replenishing BA sets
bb) Ensure the design mechanism of the fire damper system of the emergency generator room to
prevent the inadvertent closing on the failure of the vessel’s compressed air system
 Fires in locations other than Engine Rooms
 Prevention of Fire
cc) Ensure batteries of cars are disconnected before voyage commences
dd) Ensure no combustible materials are stowed unprotected on open deck, especially mooring ropes and
lines which should be stowed in steel boxes
ee) Ensure fluorescent light fixtures (if installed) on the ro-ro spaces are inspected frequently and are
not kept close to sprinkler nozzles
 Detection of Fire
ff) CCTV monitoring system with capacities to automatically detect flame and smoke
gg) Improve the efficiency and effectiveness of patrols in the ro-ro decks, particularly before the ship
departure;
hh) Internal audits aimed at checking the compliance with the applicable regulations and procedures,
particularly with regard to stowage, lashing and connection of reefer sockets;
ii) To install fire detection systems in the ro-ro spaces also considering the impact of openings in the hull
 Firefighting
jj) Ensure Fire Control Plans are kept updated
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Recommendations to improve domestic ferry safety Rev.0

kk) Ensure markings for sprinkler systems on the ro-ro decks on the ship are in accordance with the fire
control plan without any ambiguity. Ensure such markings are visible clearly on the ship even in time of
reduced visibility during fires
ll) Manual valves fitted for firefighting purposes should be able to be remotely activated from a remote
and safe location when they become inaccessible by localized fires.
mm) Consider providing additional facility for refueling CO2 bottles especially for longer ships or store
additional bottles
nn) Install fire monitors on ro-ro open decks
oo) Periodically test valves of the drencher system to confirm their functionality
pp) Verify the operation of all wire/pulley systems for remote opening/closing of fire dampers.
qq) Periodically inspect and test sprinkler nozzles (MSC.1/Circ.1432)
rr) Ensure functionality of the fire-fighting systems by encouraging crew to report any malfunctions,
ensure periodic maintenance and repairs. Check this during internal audits
ss) The minimum distance among the vehicles lashed in the garage and for enabling the operational and
safe passage of the fire-fighting team on board shall be established;
tt) Close side openings of open cargo decks of ro-ro ships, to prevent/mitigate the devastating effects
produced by the uncontrolled inflow of external air;
uu) Provide passive protection of the areas where collective rescue means (including the marine
evacuation systems (MES) and evacuation stations as defined by SOLAS) are placed. Their placement
shall also be made considering any hull opening of ro-ro areas, so as to prevent direct contact with
open flames in case of fire;
vv) Review of fixed fire-fighting systems protecting ro-ro decks, the implementation of alternative
extinguishing/containment systems (Ex.: water barriers/water mist etc.) is recommended;
 Fires on small craft/boats
r) Provide adequate ventilation to prevent development of explosive atmosphere around batteries
s) Ensure secure rapid and proper access to enclosed bridge consoles for maintenance and regular
inspection and to enable efficient fire-extinguishing
t) Ensure that appropriate firefighting equipment is provided

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Recommendations to improve domestic ferry safety Rev.0

u) Ensure installation of a fire detector and a fire-extinguishing system for manual/automatic activation in
bridge consoles
v) Train the crew to ensure correct decision making as to when to call for technical assistance (rather than
trying to solve the problem onboard by themselves)
w) Provide ergonomic design of the engine and QCV buttons so as they do not lead to any confusion
x) Provide means to ensure ventilation to the engine rooms can be automatically initiated and closed (in
case of fire).
y) Provided training to crew on redundancy equipment and technical layout of the vessel in order to
ensure a better familiarization with the emergency equipment on board
z) Carry firefighter’s outfit with breathing apparatus (derived from accidents on FRP boat certified as HSC.
Though it is not a requirement for ships of category A to carry firefighter’s outfits with breathing
apparatuses. However, in this particular situation without having respiratory protective equipment, the
crew felt constrained/hindered in their efforts to move freely and safely around the ship to assess and
possibly extinguish the fire before it developed)
aa) Establish company procedure for supervision/approval of works going on at ship yards
bb) Do not store or use flammable material in the compartments containing heaters.
cc) Check that all the exhaust systems on the vessel are adequately lagged
dd) Inspect the exhaust pipes frequently for signs of deterioration and replace them if required.
ee) Ensure updated technical drawings are available for the electrical wiring systems onboard
 Power Supply to Emergency Systems
ww) Ensure continuity of electric power in emergency situation even when the emergency generator fails.
Consider having a second emergency generator spaced far away (this recommendation is from fire on
large cruise ship)
xx) Ensure that the installed emergency generator can supply power uninterruptedly for the designated
period (by checking design and testing the same)
yy) Run the emergency generator periodically under load to demonstrate proper operation
zz) Ensure redundancy and resilience in the electrical supply system

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Recommendations to improve domestic ferry safety Rev.0

aaa) Evaluate the redundancy of electric systems supplying the pumps for the fixed extinguishing system
of “Drencher” type so as to ensure the full operation of the system also in emergency conditions
bbb) Ensure electrical cables do not pass directly over the main engine, auxiliary engine and diesel
generator Sets. Otherwise consider providing additional insulation to such cables
ccc) Ensure only one starting air receiver to be kept open so as to conserve the compressed air during the
time of emergency
ddd) Improve the passive protection of cars and electric circuits running through the Ro-Ro space to
ensure uninterrupted function of emergency systems;
eee) Ensure safe and convenient means of access to fuel supply valves to start generators
V. Loss of Power & Propulsion Control
a) Ensure documentation pertaining to modifications and maintenance is obtained from previous owner
when the ship ownership changes
b) Ensure engine control room air supply is well filtered and free of any impurities. Ensure all penetrations
and glands are effective to prevent deposit of any impurities which may affect controls
c) Ensure ergonomic design of the electric switchboards so as to minimize human error
VI. Damage to Ship & Equipment
a) Ensure adoption of more pro-active approach to supply the weather information to the master.
Consider to engage a dedicated weather information update service provider (Large Cruise Ship)
b) Improve plans and procedures in the SMS when encountering rough weather
c) Develop procedures and policy to cover unprotected windows with portable covers in rough weather to
avoid breakage and subsequent injury to passengers (Large Cruise Ship)
d) Ship operators should review all certificates and documentation issued by the RO/Classification Society
and report back if there is any inaccurate or incomplete information
e) (Regulator) Review the provisions of the loadline regulation in relation to the windows (the accident
involved breakage of these windows upon impact by a wave in rough weather and subsequent injuries
to passengers. Other such accidents had also been reported in the past) with reference to use of
portable closing plates and review requirements for protection of windows and side scuttles of
passenger ships by dedicated storm covers.
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Recommendations to improve domestic ferry safety Rev.0

f) Set strength requirements for the windows of passenger ships. These may draw inspiration from the
strength requirements for the large square windows on the wheelhouse of offshore supply ships.
g) To ensure no passengers stay in the vehicles in ro-ro spaces when the ship is underway.
h) To ensure all vehicles have been effectively lashed so as to ensure adequacy during rough weather
i) To inspect vehicles prior to loading on the ship and reject vehicles with improper loading.
VII. Occupational Accidents & Injuries
a) Crew should be familiarized and trained regarding the operation of watertight doors
b) Watertight doors kept closed for safety reasons should not be made locally controllable
c) Review and explicitly define company’s required procedures for personnel transit through watertight
doors in the vessel operations manual.
d) Introduce a documented system within the SMS for the training and certification of personnel to
operate critical equipment and appliances such as watertight doors, the incorrect operation of which
could result in injury or fatality to personnel, or significant damage to the vessel.
e) Improve signage at watertight doors to:
i. clearly state the company’s required procedure for personnel transit through watertight doors
ii. warn of the potential dangers of entrapment if the correct transit procedures were not followed.
f) In the case of major conversions (e.g. lengthening), all watertight doors should operate identically,
irrespective of the original date of build, and should meet the regulations applicable to a ship of that
class whose keel was laid at the time of such conversion. In the case where one or more additional
watertight doors are fitted, without major modification to the hull, such watertight doors need only
meet the specification applicable at the original date of build.
g) Encourage implementation of a safety management system (small boats)
h) To ensure deck surfaces are not slippery (small boats)
i) Port Authorities should conduct surprise checks of crew members to verify if they are under influence of
alcohol (for small boats).
j) Ensure carriage of safety equipment for crew members of passenger ships in national navigation when
mooring or unloading (inflatable life jacket and, if necessary, safety belt) (for small boats)
k) Determine the operating limits for the safety of navigation of each type of ship within the Port waters

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l) Ensure minimum safe manning implemented (for small boat)

m) To include in the planned maintenance program the regular inspection of the ventilation fans in Ro-Ro
spaces (and others where applicable), in particular the coupling devices of the turbines on their shaft
and the nuts and bolts.
n) Crew to wear personal protective equipment in holds and spaces.
o) To describe precisely, in the technical documentation accompanying the equipment, the procedure to
be applied to disassemble and reassemble the equipment, indicating in particular the value of the
tightening torque to be applied to the coupling devices and the method of braking the fixing screws on
moving parts. Finally, warnings about the dangers presented by these devices should be included in the
technical documentation.
p) To equip the commercial appliances with personal protection devices, in particular because of the
danger presented by the turbine or the breakage of a part.
q) Ensure that crew members are thoroughly familiar with man overboard drills.
r) Ensure crew supervise visitors on the ship (for small boats/ferries)
s) Install barriers and signage in way of the shell doors (for embarking & disembarking) to prevent
unauthorised use of the doors (for small boats/ferries).
t) Ensure that any small modifications to shell doors are reported and approved (for small boats/ferries)
u) Ensure that shell door opens to the inside rather than to outside of a ship (for small boats/ferries)
v) Crew to have regular rounds/patrols (for small boats/ferries)
w) Improve passenger safety announcements at the beginning of the crossing and illustrate them with a
demonstration (collective and individual gear, safety procedures) (for small boats/ferries)
x) Ensure competent crew onboard (for small boats/ferries)
y) To check the environment with the operating limits before setting sail (for small boats/ferries)
z) Ensure reduced speed in rough weather so as to avoid discomfort and injuries to passengers (small
boats/ferries)
aa) Ensure seats are preferably not located in the places where large accelerations are expected.
bb) Means to help passengers secure themselves to the seats (e.g. seat belts, arm rests etc.) (small
boats/ferries)
cc) Remote control buttons for operating watertight doors should be secured.
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Recommendations to improve domestic ferry safety Rev.0

dd) Permanent indication of the current control mode, local or remote, should be set for the press-button
of remote control.
ee) The closure of watertight doors should be preceded by an audible alarm giving sufficient time in both
local and remote operation
VIII. Life Saving Appliances (LSA)
a) All safety devices (both electrical and mechanical limit switches) fitted to boat davit systems should
prevent over stress of falls and davit structure. Ensure that they are checked regularly and tested on
each occasion before a rescue boat is hoisted.
b) To replace all safety switches every two years or as per manufacturers’ instructions.
c) Exercise caution when doing hose washing in the vicinity of limit switches to protect them from coming
in contact with sea water. Care must be taken when cleaning and painting electrical equipment on deck.
d) Verify the effectiveness of watertight seals on electrical equipment fitted to boat davit systems on
weather decks
e) Davit safety devices should not be over relied upon. The davit winch must be stopped before it makes
contact with safety device cutting off electrical power to winch so as to be on safer side where safety of
life is involved.
f) To keep in view that to maintain and operate hoisting mechanisms of rescue boat safely requires in-
depth knowledge, specialized skill and relevant, clear and unambiguous operating instructions
g) Visual aids could be extremely beneficial to prompt when winch motors should be stopped
h) Check that the safe operation of all davit limit switches are included in onboard maintenance routines.
i) Carry out weekly, monthly inspections, routine maintenance periodic testing, examination and
replacement of safety devices, as defined by the manufacturer under the direct supervision of a senior
officer in accordance with the instructions provided by the manufacturer and seeking clarification from
manufacturers where ambiguity exists. Document properly the results of such inspections
j) To establish that risk assessments for the launching and recovery of rescue craft have been conducted
and recently reviewed. A responsible person on board to fully assess all identified risks and show how
these risks have been identified arising out of work activity and apply full proof controls.

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k) Compatibility of wire fall, winch and winch motor must be of concern and should be considered so as to
come out with better improved fail proof designs.
l) The fixed launching system may be provided with life lines or any other safe means so as to prevent
crew falling in water from heights leading to injuries / serious injuries / fatalities in case the boat falls
in water due to any reasons
m) Simplify the design of operating equipment with a view to increasing reliability, easing maintenance
and ensuring simplicity of operation with regard both to launching and recovery.
IX. Voyage Data Recorders (VDR)
a) Improve VDR resistance to fire and smoke so that data from it can be recovered
b) Record in the VDR the audio data originating from engine control room (ECR) and including, among the
registered data, the whole set of alarms recorded by the fire detection system
c) Implementing software for VDR which is of standardized and open source type and upgrade the
applications used for data playback;
d) Inclusion of the inclinometer measurements in the VDR.
e) Establish procedures for recovering VDR information in the event of an emergency.
f) Carry unscheduled/surprise audits using VDR downloads to verify its correct operation.
g) Make crew aware of the importance to preserve/safeguard the VDR data after accident
h) Place VDR capsules with hydrostatic release units so as to make it easier to retrieve VDR
i) Consider to increase the memory capacity, ease of use and the reliability of the VDR
j) Identify and eliminate any interference when testing the bridge microphones during the VDR annual
tests
k) Incorporating within the annual inspection schedule of the VDR and simplified-VDR, confirmation that
all incoming data is safely stored on the secondary data storage facility and is in a readable format

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Rev.0

APPENDIX: LIST OF ACCIDENTS

Certified
Date of Number
Sr. Ship Name (at time of Accident Relevance of
Build/Co GT of
no accident) Date Accident
nversion Passeng
ers

1 LAMMA IV 01-10-2012 1996 184 224 Asia

2 NORDLYS 15-09-2011 1994 11204 622 Rest of World
3 SEGESTA JET 15-01-2007 1999 493 500 Rest of World
4 SCOTTISH VIKING 05-08-2010 2009 26904 489 Rest of World
5 MARKO POLO 14-02-2014 1965 22080 800 Rest of World
6 SPIRIT OF TASMANIA ii 13-01-2016 1998 29338 2286 Rest of World
7 LE BOREAL 18-11-2015 2010 10944 194 Rest of World
8 SPLENDOUR OF THE SEAS 22-10-2015 1996 69472 2074 Rest of World
9 BAHAMAS CELEBRATION 31-10-2014 1981 35855 1878 Rest of World
10 ST HELEN 18-07-2014 1983 2983 772 Rest of World
11 BARFLEUR 16-07-2014 1992 20133 138 Rest of World
12 LC MGY 11-07-2014 1981 75 70 Asia
13 URD 04-03-2014 1981 13144 110 Rest of World
14 MSC MAGNIFICA 20-11-2013 2010 95128 3605 Rest of World
15 STENA ALEGRA 28-10-2013 1997 22152 252 Rest of World
16 GRANDEUR OF THE SEAS 27-05-2013 1996 73817 2400 Rest of World
17 VICTORIA SEAWAYS 23-04-2013 2009 25518 515 Rest of World
18 CARNIVAL TRIUMPH 10-02-2013 2000 101509 3540 Rest of World
19 MEDITERRANEE 02-07-2012 1989 30985 2772 Rest of World
20 COSTA ALLEGRA 27-02-2012 1969 28430 405 Rest of World
21 PRIDE OF CALAIS 22-10-2011 1987 26433 2290 Rest of World
22 MOON CLIPPER 05-10-2011 2001 98 138 Rest of World
MECKLENBURG-
19-11-2010 1996 37987 590 Rest of World
23 VORPOMMERN
24 PEARL OF SCANDINAVIA 17-11-2010 1989 40039 2000 Rest of World
25 LISCO GLORIA 08-10-2010 2002 20140 302 Rest of World
26 CARNIVAL ECSTASY 21-04-2010 1991 70612 2342 Rest of World
27 UEAN TE RAOI II 13-07-2009 2009 100 46 Asia
28 COTAI STRIP EXPO 01-07-2008 2007 700 411 Asia
29 EASTERN STAR 01-06-2015 1994 2200 534 Asia
30 BRYGGEN 05-04-2014 2000 50 60 Rest of World
31 SEA RESPONS 15-03-2012 1996 27 24 Rest of World
32 ALANDSFARJAN 23-10-2007 1972 6336 137 Rest of World
33 STENA DANICA 10-01-2008 1983 28727 171 Rest of World
34 MERCANDIA III 16-03-2008 1983 4296 300 Rest of World
35 QUEEN OF SCANDINAVIA 16-04-2009 1981 34093 2094 Rest of World
36 BARBAT 17-08-2011 2007 499 400 Rest of World

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Rev.0

37 MARKO POLO 24-10-2009 1973 10154 1500 Rest of World

38 TIN UJEVIC 22-10-2010 2001 4103 1000 Rest of World
39 GOTLANDIA 23-07-2009 2003 6554 780 Rest of World
40 KOBE V 12-04-2006 1976 126 215 Asia
41 OCEANIC 06-05-2008 1966 28891 847 Rest of World
42 BREAMAR 26-08-2009 1993 24344 987 Rest of World
43 SVALANDIA 04-06-2009 1936 65 48 Rest of World
44 NORMAN ATLANTIC 27-12-2014 2006 26904 852 Rest of World
45 PRINCESS ASHIKA 05-08-2009 1972 677 302 Asia
46 RABAUL QUEEN 02-02-2012 1983 259 550 Asia
47 PELLA 04-11-2011 1983 10675 1230 Asia
48 COSTA CONCORDIA 13-01-2012 2006 114147 3780 Rest of World
49 STAR PRIDE 22-12-2015 1988 9975 208 Rest of World
50 GAUDOS 30-01-2015 2001 4983 905 Rest of World
51 BOUDICCA 25-01-2015 1973 28551 960 Rest of World
52 ECC TOPAZ 14-02-2014 2011 11 12 Rest of World
53 FREEDOM OF THE SEAS 22-07-2015 2006 154407 4515 Rest of World
54 LE PALAIS 13-08-2011 2005 209 286 Rest of World
55 BRETAGNE 20-11-2009 1989 24534 2056 Rest of World
56 BRIJUNKA 22-09-2014 1996 30 80 Rest of World
57 GODFJORD 21-09-2015 1987 638 150 Rest of World
58 SKORPIOS 05-02-2015 1988 1523 160 Rest of World
59 M.V. SEWOL 16-04-2014 1994 6586 804 Asia
60 ST. TUDY 25-11-2015 1984 438 313 Rest of World
61 PEEJAY V 18-01-2016 2003 N.A 90 Asia
62 CARNIVAL PRIDE 17-09-2015 2000 85920 2680 Rest of World
63 HORIZON 07-06-2015 1971 7707 758 Rest of World
64 OGIA 05-01-2015 2003 172 309 Rest of World
65 PRIDE OF CANTERBURY 29-09-2014 2003 30635 2000 Rest of World
66 EUROPALINK 21-09-2014 2007 46119 730 Rest of World
67 MILLENNIUM DIAMOND 04-06-2014 2011 458 599 Rest of World
68 DIEPPE SEAWAYS 01-05-2014 2002 30551 1200 Rest of World
69 INSIGNIA 11-12-2014 1998 30277 777 Rest of World
70 L'AUSTRAL 09-01-2017 2010 10944 264 Rest of World
71 SIRENA SEAWAYS 22-06-2013 2003 22382 623 Rest of World
72 CARNIVAL DREAM 30-05-2012 2009 128251 4633 Rest of World
73 FINNARROW 16-02-2013 1996 25996 119 Rest of World
74 JIIMAAN 11-10-2012 1992 2807 400 Rest of World
75 BEAUMONT HAMEL 30-05-2012 1985 831 106 Rest of World
76 NILS HOGERSSON 03-05-2012 2001 36468 744 Rest of World
77 STENA FERONIA 07-03-2012 1997 21856 340 Rest of World
78 DEUTSCHLAND 15-01-2012 1998 22496 213 Rest of World
79 GRAND PEACE 26-11-2011 1990 24112 1066 Asia

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Rev.0

80 SUN CLIPPER 01-06-2011 2001 98 138 Rest of World

81 RIVER ROUGE 29-07-2010 1967 450 295 Rest of World
82 ARIAKE 13-11-2009 1995 7910 426 Asia
83 USHUAIA 04-12-2008 1970 2923 90 Rest of World
84 MONTE STELLO 02-05-2008 1979 11630 369 Rest of World
85 SCHLESWIG-HOLSTEIN 31-01-2008 1997 15187 1040 Rest of World
86 PRIDE OF CANTERBURY 31-01-2008 1991 30635 2000 Rest of World
87 PRIDE OF TELEMARK 11-09-2007 1980 28569 2036 Rest of World
88 PACIFIC STAR 10-07-2007 1982 35190 1411 Rest of World
89 LOGOS II 20-06-2007 1965 4804 600 Rest of World
90 LOGOS II 26-06-2007 1965 4804 600 Rest of World
91 MAHARLIKA II 13-09-2014 1984 1865 403 Asia
92 MERCRAFT 3 21-12-2017 2016 206 286 Asia
93 SEA DREAM 1 01-09-2016 1984 4333 113 Rest of World
94 BLACK WATCH 01-07-2016 1971 28613 804 Rest of World
95 LADY AIMEE 26-02-2016 2003 28 40 Asia
96 HAMBURG 11-05-2015 1997 15067 423 Rest of World
97 MB TAWASH 18-10-2015 1974 9 48 Asia
98 MV WONDERFUL STAR 15-08-2015 1978 1298 478 Asia
99 KIM NIRWANA 02-07-2015 2015 34 178 Asia
100 FRISIA V 16-06-2015 1984 1007 1338 Rest of World
101 MV STAR CRAFT 15-05-2015 2005 76 276 Asia
102 DOVER SEAWAY 09-11-2014 2006 35923 320 Rest of World
103 SORRENTO 28-04-2015 2003 25984 954 Rest of World
104 SEA GALE 20-05-2014 2013 244 24 Rest of World
105 SEALTHIEL 10-03-2015 2000 242 119 Asia
106 LE SOLEAL 20-09-2013 2013 10992 264 Rest of World
107 ZENITH 26-06-2013 1993 47413 2206 Rest of World
108 OSMAN GAZI 26-12-2011 2007 6133 1200 Asia
109 COASTAL INSPIRATION 20-12-2011 2008 21777 1604 Rest of World
110 QUEEN OF COQUITLAM 18-11-2011 2003 13646 1470 Rest of World
111 CLIPPER ADVENTURER 27-08-2010 1975 4376 122 Rest of World
112 VAN GOGH 23-02-2008 1975 15402 717 Rest of World
113 EXPLORER 23-11-2007 1969 2390 104 Rest of World
114 QUEST 27-06-2007 1991 1269 N.A. Rest of World
115 SINAR BANGUN 18-06-2018 2015 35 45 Asia
116 SEA PRINCE 29-11-2015 1976 101 142 Asia
117 KM Express Bahari 8C 22-08-2013 2009 250 347 Asia
118 BAHUGA JAYA 26-09-2012 1972 3972 1000 Asia
119 BEETLE 01-08-2016 1990 164 200 Asia
120 CATALYN B 24-12-2009 1987 80 126 Asia
121 COMMODORE CLIPPER 14-07-2014 1999 14000 500 Rest of World
122 OLDENBURG 03-08-2015 1958 295 359 Rest of World

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 Recommendations to improve domestic ferry safety
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123 SALUZI 21-07-2015 2003 1739 32 Rest of World

124 STENA NAUTICA 08-07-2014 1986 19504 900 Rest of World
125 ANUGRAH EXPRESS 01-01-2018 2010 6 48 Asia
126 MARINA NUSANTARA 26-09-2011 1970 5272 637 Asia
127 KAYONG UTARA 19-02-2018 2007 39 40 Asia
128 CAITLYN 21-02-2017 1986 2905 590 Asia
129 GILI CAT - ii 13-09-2016 2001 38 34 Asia
130 LAUT TEDUH-2 28-01-2011 1988 4216 535 Asia
131 MANDIRI NUSANTARA 30-05-2009 1989 8257 N.A. Asia
132 MUSHTIKA KENCANA 2 04-07-2011 1987 8181 690 Asia
133 ZAHRO EXPRESS 01-01-2017 2013 106 285 Asia
134 AWET MUDA 03-01-2018 2017 4 70 Asia
135 ARISTA 13-06-2018 2016 N.A N.A. Asia
136 BJL 1 14-01-2014 1980 2555 N.A. Asia
137 RAFELIA 2 04-03-2016 1994 1108 354 Asia
138 DHARMA KENCANA VIII 14-10-2016 1988 4734 450 Asia
139 DUMAI EXPRESS 22-11-2009 1990 147 265 Asia
140 FUNGKA PERMATA 17-09-2017 N.A 107 77 Asia
141 LESTARI MAJU 03-07-2018 2016 749 120 Asia
142 MARINA BARU 2B 19-12-2015 1998 125 226 Asia
143 MUNAWAR FERRY 03-01-2014 1992 522 N.A. Asia
144 TERRATAI PRIMA 11-01-2009 1990 747 N.A. Asia
145 WIHAN SEJAHTERA 16-11-2015 1986 9768 570 Asia
146 WINDU KARSA 27-08-2011 1980 1376 N.A. Asia
147 DHARMA KENCANA 18-05-2008 2006 2326 684 Asia
148 DHARMA KENCANA II 29-10-2017 1992 3580 580 Asia
149 LUCKY STAR 10-10-2015 1980 267 294 Asia
150 SEA KING STAR 25-10-2015 1980 267 250 Asia
151 LUCKY STAR 13-06-2014 1980 267 294 Asia
152 FIRST FERRY III 05-04-2013 2000 451 403 Asia
153 JUPITER 29-11-2013 1975 267 260 Asia
154 XIN HUI BA 03-04-2012 1975 267 260 Asia
155 LI LAU 08-05-2012 1979 267 243 Asia
156 URZELA 29-12-2012 1976 267 243 Asia
*N.A: Data not available

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