Kristiansen Svein. Maritime Transportation: Safety Management and Risk Analysis

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following main topics:

. Emergency and life-saving regulations (i.e. SOLAS, the ISM Code and STCW)

. Emergency preparedness activities and functions

. Human behaviour in catastrophes

. Evacuation risk and the importance of emergency preparedness in evacuations

. Evacuation simulation

. Pollution emergency planning

1 4.2 E XA MPLES OF A CC IDE NTS

14. 2 .1 Amoco Cadiz

The VLCC (i.e. very large crude carrier) Amoco Cadiz was on a laden voyage when it lost

its rudder control 10 miles off the coast of Brittany (France) on 16 March 1978. The loss of

control happened at 09:46 and was due to failure of the steering engine (Hooke, 1989).

The weather was harsh and the vessel immediately started drifting towards the shore. The

Master of the Am oco Cadiz was not prepared for this very undesirable event, and over the

course of the next couple of hours he made a number of fatal decisions that in the end

contributed to the grounding off the village of Portsall almost 12 hours after the initial

failure. Subsequently the vessel lost its integrity and broke up, resulting in the entire

cargo of 223,000 tonnes of crude oil being spilt. Figure 14.1 illustrates the drif t route of

the Amoco Cadiz from when it lost control of its rudder until it grounded off Portsall.

Figure 14.2 shows the loss of the Amoco Cadiz.

After the failure of the steering engine, an unsuccessful attempt was made to repair the

engine. Given the harsh weather conditions, it was obvious that a salvage operation would

Figure 14.1. The d rift rout e of the Amoco Cadiz from when it lost control of its rudder until it grounded off

Portsall.

426 CH APTER14 EME RG ENCY PREPARE DNESS

be complicated. By pure chance, the radio traffic from the Amoco Cadiz was intercepted

by the ocean tug Pacific, which immediately started to steam towards the disabled vessel.

After some delay, for reasons described below, the tanker was taken under tow at 14:25,

but due to the hard weather the tow broke at 17:19. A second tow started at 20:35, but it

was not able to take control of the drifting vessel and the vessel went aground.

After the steering engine failure the captain took a number of poor and directly unwise

decisions that contributed to the loss of the vessel. These included the following:

. It took 1 hour and 45 minutes before a call for tug assistance was sent out.

. The main engine was stopped.

. It took 1 hour and 30 minutes to negotiate a towing contract. The Master of the Amoco

Cadiz wanted to avoid Lloyd’s Open Form, and the negotiations were complicated by

language problems on both sides.

. The initiation of the second tow was inadequately co-ordinated.

Through research, initiated as a result of the accident, it was found that the vessel

would have been easier to control had the propulsion and forward speed been maintained.

Having the superstructure at the aft, Amoco Cadiz could have sailed into the wind, which

was blowing towards land, and thereby kept the vessel offshore. It was also a tragedy that

valuable time was lost as the Master was reluctant to accept the Lloyd’s Open Form,

primarily for economic reasons.

Having a single propeller and a single rudder, Amoco Cadiz was obviously at risk

of the hazard of steering engine failure becoming reality. The tragic fact was that the

preparedness for the emergency situation of steering engine failure was inadequate, and

that such preparedness could have resulted in a much more desirable outcome.

Figure 14.2. Loss of the Amoco Cadiz.

(Source: http://response.restoration.noaa.gov/photos/ships/images/cadiz.jpeg)

14.2 EXAMPLES OF ACCIDENTS 427

14.2.2 CapitaineTasman

One of the key reasons why incidents sometimes lead to serious accidents is that the

seemingly non-serious initiating event is not handled with the necessary determination.

This happened in the engine room fire onboard the cargo ship Capitaine Tasman (Cowley,

1994). The key events of this accident are outlined in Figure 14.3. It was the motorman

who first detected smoke from the fuel oil heater. An attempt was made to extinguish the

fire with the use of a powder unit, but when this failed the chief engineer was called upon.

The chief sounded the general alarm and various measures were then taken to isolate the

heater electrically, but these mainly failed. 45 minutes after the smoke was first detected,

the fire was put out by a party of four firefighters in SCBA (i.e. self-contained breathing

apparatus) by means of powder and foam. However, the fire re-ignited and the fire-

fighting team had to return to fight the fire using water. The fire hose was left with

spraying water in order to prevent further re-ignition. It was then observed that the fire

had spread to the workshop above the heater, and only then was it decided to activate the

flooding system. Being without power and with empty SCBA bottl es, it was finally

decided to request tug assistance. Seven hours after the initial smoke detection a hose

party quenched the local hot spots.

The response to the fire was inadequate in a number of ways:

. The general alarm was not sounded immediately

. Oil supply to the heater was not shut off

. Failure to isolate the fuel oil heater electrically

Figure 14.3. Sequence of events in the engine room fire onboard Capi taineTasman.

428 CH APTER14 EME RG ENCY PREPARE DNESS

. Delayed start of fire pumps

. Persistent use of portable equipment

. Hot spots and secondary fires wer e not detected

It can be concluded that the crew was never in con trol of the situation during the

fire-fighting operation.

14 .2.3 HSC Sleipner

The HSC Sleipner (HSC ¼high-speed craft) stranded on a small rock/shoal on the west

coast of Norway on a dark autumn evening in 1999 (Anon., 2000). 45 minutes after the

impact the seriously damaged vessel floated/slid off the rock, disintegrated, and sunk to

about 150 metres depth. The evacuation of the 85 passengers and crew on board was

totally out of control, and 69 people had to jump into the water when the vessel sank. The

majority of these were picked up by nearby vessels, but a total of 16 persons perished. This

accident demonstrated that inadequate certification of life-saving applia nces and lack of

emergency training can result in fatal consequences when an unexpected accident occurs.

Although the accident was rooted in navigational failure, the dramatic nature of the

consequences was, in addition to poor emergency preparedness and improper life-saving

equipment, to a large degree a result of the heavy damage to the hull. In light of the

potential impact forces and the extent of damage in accidents involving high-speed craft,

the present design requirements for high-speed craft should be questioned.

The main events in the grounding/stranding of HSC Sleipner were as follows:

1. Stranding:

. Damage to the bottom on both hulls

. Water ingress, also in engine room

. Progressive list

. Starboard generator stopped

. Port generator started but stopped almost immediately

. Loss of internal communication

. Transitional emergency power did not function

2. Attempt to release starboard liferafts:

. Raft containers under the waterline

. Did not release due to lack of hydrostatic release units

. Manual release system did not function

. The release system was fairly complicated

. Lack of training in use of the system

3. Attempt to release port liferafts:

. Fore unit did not release upon activation. It eventually released but overturned

in the sea.

. Aft unit relea sed, but the container was filled with water

. The release line was tangled and did not function

14.2 EXAMPLES OF ACCIDENTS 429

The failure to attain a safe evacuation was also related to the following factors:

1. The lifejackets were stowed in enclosed recesses.

2. The liferaft release system was brand new and inadequately tested.

3. The organization of the evacu ation was chaotic due to shock and lack of training.

In the investigation that was initiated after the accident, critical remarks were made

regarding the lifejackets. It was found that the lifejackets were difficult to put on, did not

have a good fit, and had a tendency to slip off over the head. They also had limited

buoyancy and thermal protection. In the aftermath of the Sleipner acc ident there have

been discussions within the Norwegian maritime administration of whether the lifejackets

should have been approved, despite the fact that the approval process was formally in

order. HSC Sleipner was equipped with immersion suits for the crew, but the crew lacked

knowledge of their existence, as well as training in the use of these immersion suits, and

only a few succeeded in putting them on.

Given the fact that HSC Sleipner was certified to carry 380 passengers, it is not difficult

to envisage the potential for a major catastrophe under these circumstances. After

the accident the shipowner and operator of HSC Sleipner were heavily criticized for

inadequate safety management and lack of emerg ency preparedness. Without doubt,

proper execution of these activities would have reduced the con sequences of the accident.

14 . 3 EMERGENCY AND LIFE-SAVING REGULATIONS

14.3.1 SOLAS

A key section of the SOLAS (i.e. the Intern ational Convention for the Safety of Life at

Sea) regulation is Chapter III: Life-saving appliances and arrangements. This chapter is

organized into three parts (IMO, 2001a):

A. Gen eral

B. Ship requirements

C. Life- saving appliance requirements

The content of Chapter III is outlined in Table 14.1. The regulation has special

requirements for passenger ships on top of the general provisions for cargo ships. The

regulation focuses on two main aspects, namely design requir ements and guidelines

for operation.

As for IMO’s regulations in general, the main criticism of SOLAS has focused on the

following aspects:

. Too much concern about the technical details of life-saving appliances and systems.

. Too little focus on the overall performance of life-saving appliances, i.e. the ability to

save people.

. Unrealistic testing conditions – primarily in calm weather in protected waters.

430 CHAPTER14 EMERGEN CY PREPAR ED N ESS

These aspects have led to some ambivalence among seafarers. They know that the risk of

evacuation is high, but on the other hand they see no point in training with inadequate

systems under unrealistic conditions. In addition, the average passenger seems to have an

unrealistic perception of the effectives of evacuation and life-saving appliances and

systems. This is shown by the shock and anger found among the general public in the

aftermath of maritime catastrophes such as the loss of Herald of Free Enterprise,

Scandinavian Star and Estonia.

The increasing number of high-speed ferries and high-capacity cruise vessels has

brought to the surface the problem of inadequate approaches for the verification of

evacuation systems. There are obvious ethical problems related to realistic full-sc ale

testing of such systems, most importantly the significant risk of injury in such testing. In

this context the computer simulation approach to testing has aroused considerable

interest. The simulation approach is based on models of the vessel arrangement and the

flow of people towards mustering and lifeboat stations. The approach is very much

dependent on the ability to model and simulate both individuals and crowd behaviour

in emergency situations. As a response to this situation, IMO has introduced regulations

that address the use of simulation approaches in the assessment of life-saving effectiveness.

We will return to this later in the chapter.

Ta b l e 1 4 .1 . SOLAS Chapter III: Life-saving appliances and arrangements

Part Content

A. General Application of the regulation Evaluation, testing

Definitions Exemptions

Approval Production tests

B. Ship requirements Communications Launching stations

 Section I – All ships

 Section II – Passenger ships

Personal life-saving

appliances

Launching arrangements

Survival craft, rescue boats Line-throwing appliances

Stowage of craft Operating instructions

Rescue boat embarkation Abandon ship training

Manning of survival craft Operational readiness

Muster stations Maintenance

Muster lists Inspections

C. Life-saving appliance

requirements

Lifebuoys

Lifejackets

General emergency alarm

system

Immersion suits Training manual

Thermal protective aids

Requirements for liferafts

Instruction for onboard

maintenance

Requirements for lifeboats Muster list and emergency

Rescue boats Instructions

Flares, smoke signals

14.3 EM E RG EN CYAN D LI FE-SAVI N G REG ULATI ON S 431

14.3.2 ISM Code: Emergency Preparedness

The International Safety Management (ISM) Code focuses primarily on the imple-

mentation of systematic safety management but also has a chapter on emergency

preparedness (IMO, 1994). The ISM Code is now incorporated as Chapter IX in the

SOLAS Convention (IMO, 2001a). The requirements of the ISM Code were ad opted by

the IMO in 1993 through Resolution A.741(18). Guidelines on the implementation of ISM

are found in Resolution A.788(19) (IMO, 1995).

Chapter 8, ‘Emergency Preparedness’, in the ISM Code states the following:

. 8.1: The Company should establish procedures to identify, describe and respond to

potential emergency shipboard situations.

. 8.2: The Company should establish programmes for drills and exercises to prepare for

emergency actions.

. 8.3: The safety management system should provide for measures ensuring that the

Company’s organization can respond at any time to hazards, accidents and emergency

situations involv ing its ships.

It is clear that these requir ements go much furth er than the SOLAS regulations in the

sense that the company has to identify potential emergency situations and respond to

these, and not only equip its vessels in accordance with certain standardized (prescriptive)

requirements. These regulations also indicate that a shipping company or manager should

undertake contingency planning in terms of the foll owing aspects (ICS, 1994):

. Duties of personnel

. Procedures and checklists

. Lists of contacts, reporting methods

. Actions to be taken in different situations

. Emergency drills

The ISM Code introduces proactive safety management with regard to emergency

preparedness. The Code is examined in greater detail elsewhere in this book.

14.3.3 STCW Requirements

STCW is short for the International Convention on Standards of Training, Certification

and Watchkeeping for Seafarers. Chapter VI of the STCW Code specifies ‘standards

regarding emergency, occupational safety, medical care and survival functions’ for crew

members (IMO, 2002a). Key elements in securing minimum emergency preparedness are:

. Familiarization training:

– Communicate with other persons onboard on elementary safety matters

– Ensure understanding of safety information symbols, signs and alarm signals

– Know what to do if:

. a person falls overboard

432 CHAPTER 14 EMERGEN CY PREPA RED NESS

. fire or smoke is detected

. the fire or abandon ship alarm is sounded

– Identify muster and embarkation stations and emergency escape routes

– Locate and learn how to use lifejackets

– Learn how to raise the alarm

– Have basic knowledge of the use of portable fire extinguishers

– Learn to take immediate action upon encountering an accident or other medical

emergencies be fore seeking further medical assistance onboard

– Identify the location of fire- and watertight doors fitted in the particular ship

. Basic training for crew with designated safety or pollution prevention duties:

– Personal survival techniques

– Fire prevention and fire-fighting

– Element ary first aid

– Personal safety and social responsibilities

. Crew competence requirements:

– Competence to undertake defined tasks, duties and responsibilities

– Competence evaluation in accordance with accepted methods and criteria

– Examination or continuous assessment as part of an approved training programme

1 4.4 EMER GE N CY PREPARED NESS A CTIV ITI ES A N D F U NCTI ON S

14 .4 .1 Plannin g

The ISM Code requires that emergency preparedness should be based on an identi-

fication of hazards, estimation of risks, and the introduction of safety (or risk reduction)

measures. This requirement has obvious implications for how a company plans and

prepares for emergency situations. Key activities in the planning process include the

following:

. Risk assessment:

– Identify/locate hazards

– Outline accident scenarios

– Estim ate probabilities and consequences

. Establish resources:

– Ship arrangement

– Safety-related equipment an d systems

– Manning and safety functions

. Outline emergency plan objectives:

– Evacuation

– Safeguard people

– Mobilization of rescue operations

– Control and mitigation of incidents

14. 4 EMERG ENCY PREP AREDNESS ACTIVITIES AN D FUNCTIONS 433

– Salvage of vessel

– Rehabilitation of conditions onboard

. Maintain plan:

– Train

– Arrange drills/exercises

– Audit/review plan

Risk assessment may be undertaken using well-established risk analysis techniques

and accumulated experience. The description of the likely and relevant accident scenarios

should emphasize both the development of events and the role of equipment and human

resources. Figure 14.4 shows how the key elements of a fire accident scenario may be

outlined as a basis for the planning process.

The emergency plan should cover all the main accident scenarios, which may include

the following:

. Fire

. Explosion

. Collision

. Groun ding/stranding

. Engine breakdown

. Disabled vessel, loss of power and control

. Cargo-related accidents

. Person overboard

. Emergency assistance to other ships

. First aid

. Unlawful acts threatening safety and security

Figure 14.4. Ke y ele ments of a fi re accident scenario.

434 CHAPTER14 EMERGEN CY PREPAR ED N ESS

With regard to emergency preparedness plans, it is necessary to focus on realistic

scenarios that comprise many different event variations. The plans should be wide-ranging

in scope, because focus on all possibl e variations at a detailed level may result in too many

and complicated plans. Emergency preparedness plans must be based on a realistic time

frame, and should take into consider ation factors such as the likely speed of escalation,

how damage may propagate, and possible energy releases. The key elements in an

emergency plan are as follows:

1. Preface

2. Safety systems, life-saving equipment

3. Information systems, decision support systems

4. Organization of emergency teams, job descrip tions

5. Distress signals

6. Information to crew and passengers

7. For each accident scenario:

– Situation assessment

. Category 1: Minor accident

. Category 2: Alert situation

. Category 3: Distress situation

– Decision criteria

– Defence and con tainment measures

– External resources

8. Whom to contact depending on situation assessment

9. Evacuation plans:

– Muster plan, boat stations

– Evacuation routes

– Informati on systems, control

– Lifeboat /liferaft manning

10. Training:

– Familiarization, basic training

– Specialist training: fire-fighting, lifeboat coxswains, first aid

– Drills

11. Revision of plan

14 .4.2 Land Support

Experience has shown that the engagement of shipowner and manager is vital in the case

of a serious accident. They should serve as a support and co-ordinator for the crew

onboard and supply information on a co ntinuous basis to families, official agencies and

the press. The psychological effect of prompt and truthful information should not be

underestimated. In an otherwise difficult or even tragic situation, this may have a

considerable positive impact on the company’s goodwill. An example of how the

managing company sets up the organization ashore is given in Figure 14.5.

14. 4 EMERG ENCY PREP AREDNESS ACTIVITIES AN D FUNCTIONS 435