When there is failure- who knows about it?

By Michael Grey, Lloyds’ List, 11 Feb 1998

?

Why should you read this: This article by Michael Gray is a passionate plea to our industry to share information and learn from each other. ?For students of incident investigation, this article underscores the recurring issues within the industry that demand a global solution.

Michael uses the Estonia tragedy to highlight the local and fragmented nature of information sharing that is limited by various geographies and different industries. He reminds us of our industry's fragmented disposition and systemic communication failures. While individual flags, a few companies, a few classification societies might know, the industry at large maybe unaware.

Another significant point the article makes, that aligns with the system view of safety is that accidents are avoided many a time by the prompt and effective action of the officers. When such events end effectively, then “what lessons that were drawn from it were probably confined to a very small number of people”

The article urges the industry to share and learn. While it may have been written in 1998, some of you may agree that we have not evolved much since.

This article gives students a passioned understanding of why a system of reporting and sharing information is important. This also underlines why our industry needs more trust not just among ship and shore but all interested stakeholders.

(I could not find a link to this article. There was a scanned copy that I came across, that too not as originally published but a reproduction elsewhere. I typed this entire thing out so I could share it with participants of an investigation course I was called to stand-in for a 90 minute lecture. All emphasis in the article below are mine)

ONE of the most harrowing documents I have read for many years is the official report into the loss of the Estonia' which was finally made public just before Christmas, more than three years after the event.

It contains much in it that will appal, from the terrifying incident itself to the inability of well-equipped ships on the spot to rescue people from the cold waters, and the nightmare which must have been experienced by the divers as they pushed their way into the collapsed wreckage of the ferry's internals.

I know there is much in the report that remains contentious, and the subject of further litigation, but one specific and recurring problem impressed itself upon me, reinforcing a long-held belief that something, which the industry itself has the power to fix, needs to be urgently done. I refer to the fact that by the time of this disaster, there had been a considerable number of incidents involving failure or part-failure of bow doors with ships at sea.

Those who drafted the report refer to only those which took place in the North Sea or Baltic, but it is surely reasonable to suppose that there have been others over the years, since administrations and classification societies judged that a drive through ship with a large bow opening was a safe option. The Estonia report admits that the list is by no means complete, as it contains only Finnish and Swedish vessels.

Some of these incidents, and they stretch back to the early 1970s, were very serious and potentially lethal, although it appears that prompt action by those in charge of the ships slowing or stopping, turning the vessels out of the weather and returning immediately to the safety of port prevented water getting onto the cardecks.

Additionally, the availability of a watertight door inside the visor or clamshell doors provided the necessary level of insulation and saved the day.

But the point is, and the question must be asked, just how widely knowledge about these accidents was promulgated by those who had knowledge of them? The Finnish and Swedish authorities would have been in possession of the full facts, and it is reasonable to suppose that those operating ships under these flags would have been made aware of the incidents.

A number of the major classification societies were also clearly informed about accidents which had taken place aboard ships they had responsibility for. Presumably the individual, owners, after an accident, made very sure that they closely inspected the fastenings and hinges of bow doors in other vessels of their fleets.

But who else learned about such accidents throughout the world, bearing in mind that drive-through ships are a more or less universal ferry type of today?

Were naval architects working on designs for big ferries ordered by Japanese operators made aware of the problems that had been experienced?

Were owners of ex-Baltic boats working in the Eastern Mediterranean or Far East ever told about the problems that were experienced by the operators of the Finlandia or Viking Saga, or the fright that the watchkeeper of the Wellamo received when he saw the bow visor lifting as he ran down from Helsinki to Stockholm in a storm one night in 1975?

There were drive through ships designed in North America and the United Kingdom, Italy and France - did any of their designers ever learn about the incident in which heavy seas tore off the clamshell doors of the Finnhansa in a storm off the Finnish coast in 1977?

Did the administrations which were busily approving plans for bigger and more sophisticated ferries with enormous passenger loads ever learn about these and other incidents?

Were the Japanese or Canadian or British or French government surveyors ever made aware of these operational problems? And indeed, was there any proper mechanism available for the transmission of accident information between one ferry owner and his competitor down the road, or owners of similar ships throughout the world?

Did the International Maritime Organisation ever become engaged in the receipt, study, or promulgation of information about such incidents?

The answer to all these questions, I'm afraid, is probably a resounding no, because the mechanisms for the transmission of such important operational information was not generally available.

Indeed, there is some evidence that the seriousness of such incidents, and the possible consequences for these ships if water had got onto their car decks was not properly contemplated. In the event, the officers aboard the ships reacted promptly and properly, the ships went back to port, were repaired to everyone's satisfaction and returned to service.

The incident had effectively ended, and what lessons that were drawn from it were probably confined to a very small number of people. Perhaps, in fact, the potential seriousness of the incidents were not fully comprehended, perhaps it was merely assumed that the secondary safety appliances would continue to be adequate, as they had been in these accidents.

This inability of the maritime industry to construct and maintain a system for the prompt and international promulgation of important safety information has worried a number of thoughtful people over the years, but there is still very little that is done about it.

The classification societies have probably gone rather farther than most, in establishing formal systems for alerting each other to elements prescribed by their rules which have been shown to give trouble, but there is very little else.

There is certainly nothing even approaching the systems in the aviation world which, if a bolt fails in the tailplane of a 737, alerts every operator of similar aircraft to this failure in a trice. The fatal bow door damage the Estonia, for whatever reason, is merely the worst possible example of this maritime industry system failure, which extends into every area of shipping. It is made infinitely worse by the fragmentation of the industry into so many different sectors, and the emergence of the [lag of convenience and corresponding weakening of the 'traditional' flags. There are some FOCs do their level best and provide an excellent maritime administration, but others don't bother.

'The International Maritime Organisation, some have suggested, could be an effective forum for an international system of incident or accident alerting. Indeed, there is an obligation for administrations which subscribe to IMO? conventions, to hold their accident inquiries and to inform the organisation of their discoveries, for the greater benefit of world shipping.

Most don't bother, and of those that do send IMO reports, these are collected, but nothing is done with them, for there is no budget to provide for such a system that would let relevant, I people know of the findings.

'There is a growing number of people who are suggesting that shipping is becoming over-regulated and that IMO ought to lay off for a few years. Accidents are declining in number and marine safety is improving. But this particular lesson from the Estonia, like the scandal of the bulk carrier sinkings before it, shows that there is one great gap in the system that needs to be addressed.

We fly different flags and are scattered around the world, with our different classification societies and clubs. But we need to know about accidents like those which prefaced the Estonia sinking. How otherwise will we ever find out? And above all, is this not a cause that should be canvassed?