NATIONAL AUDIT OFFICE

REPORTBYTHE COMPTROLLERAND AUDITOR GENERAL

Departmentof Transport:Ship Safety

ORDEREDBY THE HOUSEOF COMMONS TO BE PRINTED 18 JANUARY1992

LONDON: HMSO 188 f7.10 NET DEPARTMENTOF TRANSPORT:SHlP SAFETY

This report has been prepared under Section 6 of the National Audit Act, 1983 for presentation to the House of Commons in accordance with Section 9 of the Act.

John Bourn National Audit Office Comptroller and Auditor General 15 January 1992

The Comptroller and Auditor General is the head of the National Audit Office employing some 900 staff. He, and the NAO, are totally independent of Government. He certifies the accounts of all Government departments and a wide rangeof otherpublic sector bodies: and he hasstatutory authority to report to Parliament on the economy, efficiency and effectiveness with which departments and other bodies use their resources. DEPARTMENTOF TRANSPORT:SUP SAFETY

Contents

Pages Summary and conclusions 1

Part 1: Introduction and background 5

Part 2: Extent and causes of accidents 7

Part 3: Accident investigation and response 11

Part 4: Accident prevention 18

Appendices

1. The major international conventions and codes relating to ship safety 28

2. Accident investigation reports examined by the National Audit Office 29

3. Types of survey, frequency and coverage 30

4. Defects identified during 28 concentrated inspections 31

5. Recommendations of the investigation into the accident between the passenger launch Marchioness and MV Bowbelle 32 DEPARTMENTOF TRANSPORT:SHIP SAFETY

Summary and conclusions

1 Responsibility for ensuring that vessels are fit to go to sea, are properly manned and are operated in a safe manner rests with ship owners and masters. The Department of Transport are responsible for promoting marine safety and the safety of seamen, for preparing new legislation and implementing the Merchant Shipping Acts, and for making and implementing regulations prescribing standards which they have negotiated and agreed internationally. In doing so they play a major role in the activities of the International Maritime Organisation. In 1990-91 the Department spent some El3.9 million on surveys and other work to maintain or improve safety and pollution prevention standards on United Kingdom ships and on foreign ships using United Kingdom ports and received some f4.0 million in survey fees.

2 This National Audit Office report examines the extent and causes of marine accidents; accident investigation and response; and the measures taken by the Department to prevent or reduce the risk of accidents and to improve ship safety. The main findings and conclusions are: On the extent and causes of accidents (a) The Department’s published accident statistics show that losses of United Kingdom registered merchant vessels over 100 gross tons fell by 75 per cent between 1978 and 1989; and the accident rate fell from 190 to 130 per 1000 vessels. Over the period 1979 to 1989 the United Kingdom lost a significantly smaller percentage of its shipping fleet, of all types of vessels, than most of the world’s largest fleets: and losses were about average for North Sea states (paragraphs 2.1 to 2.3). (b) Working on merchant ships is more dangerous than most occupations. Deaths and injuries are almost three times higher than the average for all industries. Passenger fatalities, however, are few and far between; but when a serious accident or loss of a vessel does occur the loss of life can be high, as in the cases of the HERALD OF FREE ENTERPRISE in 1987 and the MARCHIONESS in 1989 (paragraphs 2.4 to 2.6). (c) Operational failure and human error are the main cause of the majority of accidents to ships; few accidents result directly from faulty equipment. There has nevertheless been a concentration internationally on the design of ships and their equipment rather than the operation of a ship as a whole. But the Department have addressed the safe operation of ships through their requirements on qualification and training of officers and crew. And the balance between the ship, its equipment and operational management is being reviewed by the shipping industry and the Department (paragraphs 2.7 to 2.13 and 4.25). (d) The introduction of a new computerised information system in 1992 will provide the opportunity to integrate current systems for recording and analysing accident data. Standard forms and checklists could then assist in identifying the main causes and risks of accidents and support and enhance the Department’s accident prevention activities (paragraphs 2.14 to 2.16).

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(e) There are a number of areas of concern in relation to the safety of fishing vessels. These particularly involve smaller vessels below 12 metres, where there has been an increase in the number of relatively minor accidents since 1978 (paragraphs 2.2, 2.10 and 2.11). On accident investigation and response (f) Decisions to investigate accidents depend on the degree of public concern, the actual or potential risk of loss of life or serious injury, the damage to vessels or the environment, and the potential for learning useful lessons from recurring themes. Between July 1989 and June 1990 the Marine Accident Investigation Branch directly investigated 162 out of 2,313 reported accidents and made more general inquiries into a further 360 (paragraph 3.3). (g) Investigations into main areas of risk have resulted in revised guidance to the shipping industry; changes to the frequency and scope of Departmental inspections; commissioning further research; and proposing new legislation and initiatives to revise international conventions (paragraphs 3.8 to 3.16). (h) The Department have given particular attention to the safety of passenger vessels, including steps to improve design to enhance damage stability standards of roll-on/roll-off ferries. They have introduced new procedures for passenger control and they are working in the International Maritime Organisation for better evacuation systems. They also expect by 1992 to have new regulations in force governing the design and operation of small passenger vessels (paragraphs 3.17 to 3.23 and Appendix 5). (i) In a number of areas, however, progress within the United Kingdom and internationally towards the development, acceptance and implementation of revised and improved safety standards has taken a considerable time, sometimes several years. Improvements recognised as needed in survivability standards and life-saving appliances are to be phased in over extended periods. The aim is to achieve international agreement to universal standards, and the Department try to avoid imposing differing standards for United Kingdom and foreign registered vessels (paragraphs 3.18 to 3.21, 3.24 to 3.28, 3.32 to 3.33). On accident prevention (i) Adequate manning by qualified and competent crew, linked with control over working hours, is a key element in ship safety. The Department have a long standing responsibility for ensuring the proper qualifications and certification of crews. On crew competence, they set and monitor training and qualification standards and enforce safe manning through inspections and a voluntary certification scheme; and they expect to finalise new regulations and a code of practice on working hours by late summer 1992 (paragraphs 4.3 to 4.7). (k) The Merchant Shipping Acts and the surveys and inspections which result from them are the Department’s main instruments for discharging their responsibilities for ship safety, using their own surveyors and those of five classification societies and other bodies for certain survey work. Surveys are carried out on new ships and at specified intervals thereafter (paragraphs 4.8 to 4.13).

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(1) On inspections, the Department have exceeded targets set for Port State Control inspections of foreign registered vessels entering United Kingdom ports (paragraph 4.30). For United Kingdom registered vessels the Department have set targets for river passenger vessels and roll- on/roll-off ferries. The Department consider that setting overall targets for the number of inspections of United Kingdom registered vessels to be carried out would not be appropriate since any target would be dependent upon the number of ships visiting United Kingdom ports. The Department rely on the district chief surveyors, to determine the level and focus of work to be carried out within the resources available, using their professional judgement and guidelines provided by the Surveyor General’s Organisation headquarters (paragraphs 4.16 to 4.17). (m) The Department have achieved their intended level for inspections of United Kingdom registered roll-on/roll-off passenger ferries and river passenger vessels; for foreign registered ferries they have met their minimum operational target (paragraphs 4.19 and 4.32). They have not set targets for inspections of fishing vessels, pending the results of a pilot study in 1991, or for cargo vessels (paragraphs 4.18 and 4.20 to 4.21). The nature and depth of inspections may vary, and the National Audit Office consider that the Department should define their inspection targets not only by number but also in terms of the type of inspection to be carried out. This would enable performance to be measured more clearly against the targets set (paragraph 4.19). (n) The Department took an important initiative in 1988 in developing concentrated inspections which do more to target operational factors. These have revealed defects which would not have been identified during general inspections. So far only a relatively small part of the available resources have been diverted to concentrated inspections, but the Department plan to devote more resources to this work on a regular basis and to set inspection targets (paragraphs 4.28 to 4.29). (0) Although the Department have carried out some basic analysis they have not carried out any regular or in depth analysis of the results of their inspections to identify the level or pattern of serious defects, common causes, incidence across different kinds or ages of ships, or according to ownership. National Audit Office analysis along these lines suggested that regular exercises of this kind would provide valuable information in planning and carrying out inspections, and in taking effective follow up action. The Department have accepted this and are planning an expanded computerised recording system for early 1992 so that such analysis could be carried out (paragraphs 4.22 to 4.27; 4.38 to 4.39). (p) Action is taken to remedy serious defects disclosed on inspections, and the Department are increasingly delaying or detaining ships until faults are rectified. They have powers to prosecute owners and masters and do so when necessary; but generally they find it more effective to secure remedial action by enforcement orders, delay or detention (paragraphs 4.40 to 4.41).

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(q) In recognition of owners’ responsibilities for ship safety, the Department have encouraged the introduction of “safety audit” procedures by all shipping companies. But this measure has a good way to go to realise its potential benefits; and the National Audit Office concluded that more active participation by the Department in the wider development of safety audits could also assist them in making better use of their own resources (paragraphs 4.42 to 4.45).

3 Throughout the examination the National Audit Office noted that the Department’s approach and action on ship safety was strongly dependent upon the experience and judgement of the Department’s surveyors in determining the level and extent of inspections, in the selection of ships and areas to be examined, and in reporting and dealing with defects. This approach has a number of strengths, but without in any way detracting from the value and flexibility of the work carried out, the National Audit Office concluded that further action was needed to complement and strengthen the present arrangements. Developing better information and analysis of the results, patterns and trends of survey and inspection activities, under central oversight, would sharpen targeting of main areas of risk and improve forward planning and use of resources. The Department have recognised the scope for strengthening their current arrangements and are taking action to improve the planning and use of surveyor resources.

4 Given the weight that rests on individual surveyors in discharging the Department’s responsibilities for ship safety, the National Audit Office recommend that the Department should consider the costs and benefits of introducting a “peer review” or other quality assurance arrangements to underpin the professional delivery of the key tasks concerned, and to provide appropriate assurances on consistency of approach, standards and reporting.

5 As and when more reliance is placed on the safety systems of ship owners the National Audit Office also see scope for greater partnership between the Department and ship owners on safety developments and implementation, without blurring lines of responsibility or compromising professional and operational independence. For example, the Department could identify with owners those inspections which are duplicated and agree a common programme. The Department have however recognised an inherent conflict in such an arrangement and must err on the side of maintaining their independence.

6 Finally, it has to be recognised that on many aspects of ship safety the Department are not able to act independently, or would be ill-advised to do so, because of the need to operate within international conventions and to work closely with the International Maritime Organisation and other maritime nations. As noted in the Report, however, international liaison may also involve substantial delay in agreeing amendments to current regulations and procedures and in implementing changes in practice.

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Part 1: Introduction and background

1.1 Responsibility for ensuring that vessels are fit international voyages which has to make a to go to sea, are properly manned, and are single, exceptional voyage. operated in a safe manner rests with ship owners, operators, and masters. The 1.5 In accordance with the international Department of Transport are responsible conventions, vessels visiting United Kingdom more generally for promoting marine safety ports flying the flags of countries which have and the safety of seamen; they implement the not ratified them must nevertheless comply Merchant Shipping Acts which, in the case of with the standards of those conventions. The foreign-going ships, apply the standards of main convention relating to safety at sea is the relevant international conventions: and the International Convention for Safety of they make and implement regulations Life at Sea 1874 (Appendix 1). prescribing standards consistent with those accepted internationally. They also support 1.6 In 1990-91 the Department spent some f13.9 research into a variety of topics related to million on activities aimed at discharging marine safety, and use their experience and their ship safety and pollution prevention expertise to give advice and guidance to the responsibilities and received some f4.0 shipping industry. million in examination and survey fees. The National Audit Office examination 1.2 To meet their objective of maintaining or concentrated on whether, within the improving safety standards on United reswrces made available and other Kingdom ships and on foreign ships using constraints, these activities are effective in United Kingdom ports, the Department carry achieving the Department’s ship safety out regular surveys for the issue and renewal objectives. In doing so the examination of safety certificates; inspect United Kingdom considered the planning, targeting and ships and foreign ships in United Kingdom efficient use of inspection and survey ports; and investigate accidents to United rescurces and the strength of the supporting Kingdom ships wherever they may be and to management systems, where greater foreign ships in United Kingdom territorial information and analysis is a key element in waters. evaluating the costs and benefits of action being taken and proposed. 1.3 The United Kingdom as a member state of the International Maritime Organisation 1.7 Against this background the National Audit supports international efforts to improve Office examined: safety standards and is responsible for . the extent and causes of accidents (Part 2 enforcing international conventions and agreements. Since the Organisation was of Report); established in 1958 the United Kingdom has . accident investigation and response [Part played a major role in its activities, including 31: work leading to the present agreements on ship safety. . accident prevention [Part 4). Certain aspects of the ship survey and 1.4 The major international conventions are inspection arrangements dealt with in this concerned with ship design and equipment. report were also covered in the National The conventions are implemented in the Audit Office report on Oil and Chemical United Kingdom by the Merchant Shipping Pollution at Sea published in February 1991 Acts and related statutory instruments. These [HC 225, 1990-91). do not necessarily ccwer all United Kingdom registered vessels, for example a regulation 1.8 The National Audit Office examination did may apply only to new ships or those above a not extend to such matters as the provision certain tonnage. Exemptions may also be of coastal navigation facilities, the activities granted under the legislation, for example to of the coastguard, and the marine search and any ship not normally engaged on

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rescue services-although these all have an involved analysis of the results of over 1,700 important role to play in ship safety. ship inspections; review of the Department’s investigation and follow-up to 28 accidents 1.9 As part of the examination, views were which occurred between 1965 and 1989, and sought from a number of interested bodies, 3 recent major accidents: and two ships were including the International Maritime visited during a survey and inspection. Ship Organisation, ship owners, professional safety arrangements in Norway and Holland bodies and classification societies. The work were also reviewed.

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Part 2: Extent and causes of accidents

2.1 Although travel by sea is in scme respects rate increased from 16 to 71 per 1,000 vessels. one of the safer means of transport, the The increase in accidents is largely waters around Western Europe are amongst attributable to an increase in the reporting of the busiest and most hazardous in the world, damage to machinery and to an increase in with some 31 ships being lost in 1989 the numbers of smaller vessels (under 12 according to Lloyds casualty returns. metres]. Since 1986 there has been an Nevertheless, the Department’s published increase in search and rescue activities accident statistics show that the number of associated with fishing vessels (Figure I] and United Kingdom registered merchant vessels this has been partly due to better involved in accidents decreased between communication systems which have enabled 1978 and 1989. Losses of merchant vessels fishermen to call for assistance when in over 100 gross tons fell by 75 per cent trouble. between 1978 and 1989; and if the figures are revised to include accidents as well as 2.3 Over the period 1979 to 1989 the United vessels lost, the accident rate dropped from Kingdom lost a significantly smaller 190 to 130 per 1,000 vessels. percentage of its shipping fleet than a number of the world’s largest fleets, 2.2 Losses of fishing vessels also fell by 49 per particularly Cyprus, Greece and Panama. cent over this period, although the accident

Figure 1: Search and rescue operations by type of vessel (1978-89)

Numberof incidents

160 Merchantvessels

60 I ’

’ ’ 1978 ’ 1979 ’ 1980 ’ 1981 ’ 1982 ’ 1983 ’ 1984 ’ 1985 ’ 1986 ’ 1937 ’ 1938 ’ 1989 ’

Source: TransportStatistics in GreatBritain (1978- 1989). Figure 1 shows the increasingactivity for search and rescue operationsrelated to fishing vessels. DEPARTMENTOF TRANSPORT:SHIP SAFETY

Table 1: Number oi ships of all Woes lover 100 Table 2: Tonnage of ships of all types (over gross tons) lost 1979-89 -. . 100 gross tons) lost 1979-89 country Averagenumber of vesselslost country Averagetonnage of vessels lost as a percentageof the fleet as a percentageof the average World’s Largest Fleets fleet size Cyprus 1.59 World’s Largest Fleets Panama 1.06 Cyprus 1.64 GEW2 1.06 G*l?ece 0.90 Panama 0.60 Liberia 0.46 USA 0.18 United Kingdom’ 0.08 Japan 0.06 WorldAverage USSR 0.04 World Average 0.35 North Sea Slates Denmark North Sea States Norway Netherlands 0.13 W.Germany Norway 0.09 UnitedKingdom’ France 0.09 FrXlCe United Kingdom’ 0.08 Netherlands W. Germany 0.07 Sweden Sweden 0.06 North Sea States Average 0.27 Denmark 0.04 Source:Lloyds Shipping List. North See States Average 0.08 Note: * excludes vessels registeredin /s/e of Man and Channel Source:Lloyds Shipping List. Hands. Note: * excludes vessels registeredi” isle of Man and Channel Islands. Table 1 shows the UnitedKingdom has lost proportionallyfewer vessels than most of the world’s largest fleets and about Table 2 shows the percentageof fleet tonnage lost by the averagefor Nolth Sea states. United Kingdom is less than the averagefor the world’s largest fleets and equal to the averagefor North Sea states.

Losses were about average for North Sea loss of a vessel does occur the loss of life can states (Table I]. In terms of average tonnage be high. Some 88 per cent of passenger of ships lost the United Kingdom is well fatalities between 1979 and 1989 were as a below the world average and equal to the result of the HERALD OF FREE average for North Sea states (Table 2). ENTERPRISE (1987) and MARCHIONESS (1989) accidents (Table 3). 2.4 Between 1979 and 1989, 309 merchant seamen, 243 fishermen and 234 passengers 2.5 On a wider front, the available figures on died as a result of accidents on United passenger fatality rates by mode of transport Kingdom registered ships (Table 3). The show that the fatality rate per passenger pattern of passenger fatalities shows that kilometre for travelling by water was more accidents involving loss of life are few and than ten times greater than that for travel by far between; but when a serious accident or air: but the fatality rates per passenger trip

Table 3: Deaths at sea on United Kingdom vessels (1979-89) Year Merchant Fishermen Passengers TOId SealIE”

1979 47 38 i ii 19801981 6738 ;: 1 64 1982 44 14 60 1983 15 25 42 1984 14 0

Total 309 243 234 786 Source:Denalfment of Transoort. Note: * 155 passengers(151 confirmeddeaths, 4 probable deaths) and 38 crew lost as a result of the loss of the Herald of Free Enterprise. t 50 passengers, 1 crew lost as a result of the loss of the Marchioness. Table 3 shows that althoughthere are no discernibletrends, passengerdeaths were rare and infrequent,except for two major accidents.

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Table 4: Passenger fatality rates by mode of Table 5: Selected occupational accident rates transport 1979-88 (1989-90) Mode of Fatalities Fatalities Fatalities Occupation’ Accident rate per TMlSPOrt per 100 per 100 per 100 1,000 employees million million million Coal extraction 61.3 PFlW”QH PBSLZ”QH passenger Merchantseamen’ 22.8 kilometres trips hours Construction 19.7 Car’ 0.4 5.2 12.4 Forestry 18.8 Bus’ 0.06 0.4 1.4 Manufacturing 12.9 Air 0.04 70.0 20.0 Sea i?shing’J 4.9 water 0.8 34.0 16.0 All Industries 6.1 Rail 0.1 2.6 6.0 Source:Health and Safety CommissionAnnual Source: Transpwi Statistics GreatBritain 1979-89 (TableA I). Repm- 1989-90: and Marine Accident InvestigationBranch Notes: Review for 1989. 1. 1966raes. Notes: 2. 1984f0 1988rates. 1. Industries quoted are examples. not a comprehensivelist. Table 4 shows fatality rates far passengerstravelling by water 2. The figure is for 1989 only. are higher than for those travelling by car. bus or rail. 3. Thesefigures may be understateddue to under-reporting (paragraph26). Table 5 shows accident rates for merchantseamen are almost and per passenger hour are greater for air three times higher than the averagefor all industries. than for water. On all measures, however, fatality rates for travel by water are higher operational failure: than for travel by car, bus or rail [Table 4). where procedures and operational practices The comparative safety record of water and have not been followed or are inadequate (for rail travel are influenced by the HERALD OF example, failure to keep a proper look-out, or FREE ENTERPRISE accident in 1987 and the to check that the cargo is properly stowed); Clapham rail accident in 1988. human factors: 2.6 Working on merchant ships is nearly three for example, poor seamanship, inadequate times more dangerous than the average for training, unfitness for duty, fatigue, all industries, with 90 per cent of accidents inexperience and panic; occurring while the crew member was on bad weather and other unforeseen or duty. The figure of 22.8 killed or injured per unknown factors: 1,000 merchant seamen in 1989 compared to for example, 24 fishing vessels were reported an average of 8.1 per 1,000 employees for all missing between 1978 and 1989 with a loss of other industries [Table 5). (Although the 63 lives. Causes are unknown btit have been figures show that 4.9 fishermen per 1,000 attributed to bad weather, capsizes while were killed or injured at work, the fishing or possibly contact with submarines. Department consider the true figure for injuries to be higher due to under-reporting 2.9 These various causes of accidents may inter- of accidents). act, and the human element is almost always present. Research commissioned by the Department in 1985 found human error to be Causes of accidents the main cause of accidents to fishing vessels in 50 to 60 per cent of cases. Departmental 2.7 Accidents are caused by a range of factors, accident statistics for 1988 indicate that separately or in conjunction; but their operational failure or human errca occurrence and seriousness in terms of injury contributed to or was the main cause of 84 or loss of life depend on ship and equipment per cent of accidents to vessels; and technical design and layout, on the training and failure or poor design was a factor in only 17 response of the crew, the safety systems and per cent of accidents. Other countries have equipment on board, the behaviour of similar statistics: for example, the Norwegian individuals, proximity of rescue services and Maritime Directorate have concluded that quality of communications. only 10 per cent of accidents directly result from technical faults. Research commissioned 2.8 The causes of accidents can be grouped into by the Department in 1982 concluded in 1988 four main areas: that human error was present in wer 90 per technical failure: cent of collisions or groundings and in over malfunctioning of equipment or defects in 75 per cent of contacts, fires and explosions. ship design or construction:

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2.10 More recent research commissioned by the determining the adequacy of bridge design United Kingdom, France and the European and that they needed to give further Community into the safety and safe operation attention to bridge design and look out of small fishing vessels in 1989 concluded arrangements. They stressed, however, that that: design needs to take account of the vessel’s intended function which may require little account had been taken of the reasonable and practical solutions. Quite human factor in trying to understand the apart from questions of design, it remained causes of acidents; the responsibility of the master to keep a accidents to United Kingdom and French proper look-out. vessels and crew had not been well documented or reported; numbers of reported accidents to fishing Information systems vessels and crew had remained constant since 1975 but the number of small 2.14 To assist in learning necessary lessons as an fishing vessel accidents was making up an aid to accident prevention the Department: increasingly high proportion of the total; gather information from their vessel design and operation could only be investigations into accidents: made safer by taking into account the obtain relevant information from ship human factor and through better crew owners and masters who are obliged to training and certification. report all accidents involving crew, passengers and vessels: 2.11 To address these factors the Department intend to sponsor the remaining phases of commission research into causes of this research project. The aim is to develop accidents. by 1993-94 a code of practice on operational features to supplement existing guidance on 2.15 The Department have separate systems for safe working practices to prevent accidents recording accidents to vessels and accidents on fishing vessels. to people, with information recorded in narrative form in the Department’s files. This 2.12 The interaction between design and does not lend itself to ready analysis, and the operational factors also emerged from the National Audit Office concluded that there Department’s investigation into the would be significant benefits in recording key MARCHIONESS accident. The inspectors features on standard forms or checklists noted that the Department ought not to have which would enable the Department to allowed the designs of the MARCHIONESS identify patterns and trends in the causes of and the BOWBELLE; and they pointed out accidents. Analysis of this information could that there had been a pre-occupation over be used by the Department to target many years by the Department and the investigations and inspections on the main maritime community with details of areas which cause accidents and to identify equipment at the expense of a ship’s areaswhich needfurther research,guidance operation as a whole. In simple terms, safety or regulations. had concentrated on things rather than people. The Inspectors believed, however, 2.16 The Department are planning to introduce a that the pre-eminent importance of good ship new computerised information system in management in the broader sense was now 1992 which will include the key features of being recognised by the Department and such a checklist and this will provide an within the shipping industry as a whole: and opportunity to integrate the separate systems if this were so, then in the future such for recording and analysing data on accidents matters as the design of ships and their to vessels and to people. It will be important equipment would be looked at in total and, to ensure that the system provides improved first, with an eye to the people who would information and analysis in order to identify have to operate them. the main causes and risks of accidents, to target their specific accident investigations 2.13 In response, the Department accepted that (see Part 3), and to support and enhance their operational requirements were crucial in accident prevention activities (see Part 4).

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Part 3: Accident investigation and response

3.1 The Marine Accident Investigation Branch 3.5 When determining the appropriate response (the Branch) was set up as a separate and follow up to investigation reports the organisation in July 1989; the work had Department take into account: previously been undertaken by the Surveyor the extent to which recommendations General’s Organisation. The purpose of the reflect the evidence in a single report or a re-organisation was to separate the number of reports; responsibility for investigating accidents from the responsibility for the regulation of ship the feasibility of implementing the safety. The Chief Inspector reports directly to recommendations; the Secretary of State. The arrangements for the extent to which regulations or the investigation of marine accidents are now procedures should or can be enforced by similar to those for air accidents. Similar inspection and survey; arrangements for marine accident investigations operate in Norway and the burden new legislation and guidance Holland. places on the shipping industry, owners and masters; 3.2 The Branch are responsible for: the need for international acceptance of determining the circumstances and causes new safety rules and conventions. of marine accidents and making recommendations with the aim of improving the safety of life at sea and Results of accident investigation avoiding accidents in the future; 3.6 The National Audit Office reviewed 28 preparing accident statistics. investigation reports from 1985 to 1989 and the follow up action taken (Appendix 2). The 3.3 The main purpose of the Branch’s investigations covered several different types investigations is to determine the cause of of accidents and vessels and included all accidents in order to prevent their happening vessels lost and all formal inquiries. They again. Although the findings may result in were chosen to represent the varying types of action against masters or owners, the action the Department have taken in allocation of blame is not an objective of the response to accidents and because of the investigation. Inspectors decide which extent of the damage caused, and the accidents to investigate based on the degree potential for lessons to be learned. of public concern, the actual or potential risk of loss of life, serious injury or damage to 3.7 The examination also reviewed the vessels or the environment and the potential Department’s response to three major for learning useful lessons from recurring accidents involving substantial loss of life themes. Between July 1989 and June 1990 the during the 1980s: Branch directly investigated 162 out of 2,313 reported accidents and made nmre general . EUROPEAN GATEWAY/SPEEDLINK inquiries into a further 360. VANGUARD (1982) . HERALD OF FREE ENTERPRISE (1987) 3.4 Accident investigation reports identify the causes of accidents, the types of vessels . MARCHIONESS/BOWBELLE (1989) involved and the persons at risk. They Investigation and follow up of these three include information on the underlying cause cases has in practice taken up a considerable of accidents, covering such matters as the amount of the available resrxurces of the circumstances and events leading up to the SurveJior General’s Organisation and also, accidents, condition of the vessels involved since 1989, the Marine Accident Investigation and actions by crew. Branch.

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3.8 Recommendations resulting from these and Table 6: Accident reports reviewed by National other investigations have resulted in the Audit Office where poor watchkeeping was Department: identified as a contributory cause of the . revising guidance to the shipping accident industry; Vessel oate Nature 1 GOLDENSTRAND! Jan. ‘86 Collision . changing the frequency and scope of THIERRYPASCAL inspections: (fishing vessels) . commissioning further research; 2 RATHOOWN/OUICKTHORN Jan. ‘86 Collision (tanker/cargo) . proposing new legislation and initiatives 3 BRIDGENESS Jun. ‘86 Grounding to revise international conventions. (tanker barge) The National Audit Office review 4 WAVECREST/ARDENCY Dec. ‘86 Collision concentrated upon the action taken on (fishing vessels) findings on use of radar; watchkeeping: fire 5 SHEERWATERIII/KINGFISHER Jan. ‘a7 Collision prevention and control: and safety of (hydrofoil/cabin cruiser) passenger vessels. 6 MAID OF THE HARBOUR JUT. ‘aa Collision (pleasurelaunch) Use of radar 7 GOLDENSTRAND Jan. ‘89 Grounding (fishing vessel)

3.9 The ABERTHAW FISHER/DUTCH MASTER B FAITHFULII Apr. ‘89 Grounding collision (1985) and the grounding of the (fishing vessel) fishing vessel FOXGLOVE (1986), highlighted 9 MARCHIONESS/BOWBELLE Aug. ‘89 Collision problems with the use of radar. As a result, (small passengervessel/ the Department issued guidance in May 1988 S”CllO”oreoger, to train masters of fishing vessels in the use Source:DeDartment of Transoort of radar. Fire prevention and control Watchkeeping 3.12 Fire was identified as the main cause of 17 3.10 Nine of the accident reports reviewed by the per cent of losses and serious accidents National Audit Office identified poor involving United Kingdom registered vessels watchkeeping as a contributory cause of the from 1979 to 1989, and in four of the accident accident (Table 6). In most cases, it resulted investigation reports reviewed by the in a collision between two vessels. In one National Audit Office (Table 7). The sources case-a relatively minor collision between and causes of fires on ships can be numerous the cargo ship QUICKTHORN and the tanker given the risks arising from a variety of RATHDOWN on the Thames in January flammable materials, fuels and sources of 1986-the report identified the main causes ignition that are concentratedin a relatively as inadequate manning on the bridge, poor confined area on board a vessel. In three of watchkeeping, difficulties with visibility due the accident reports, the fire was caused by to shore lights, and excessive speed. The fuel line fractures and leakages, and in the Department issued guidance on fourth the fire arose from an electrical fault; watchkeeping in December 1986, and bridge and in all four cases the fires originated in visibility in January 1987. the engine room.

3.11 Watchkeeping was also identified as a 3.13 The Department have over the years issued significant factor in the investigation into the extensive guidance on fire prevention, MARCHIONESS/BOWBELLE accident. The including guidance in 1986 on the prevention inspectors made 27 recommendations as a of oil fires in machinery rooms. Following result of their investigation: the main five fires on ferries between March and July recommendations relevant to this Report are 1988 the Department decided to x-issue their at Appendix 5. The Department accepted all 1986 guidance. There have been five the recommendations. but seven of the subsequent engine room fires on United recommendations had not been fully Kingdom passenger vessels. Research implemented by August 1991 (Appendix 5). commissioned by one ferry owner (Sealink

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Table 7: Accident reports examined by the National Audit Office where fire was identified as the main cause VWSel me CalBe 1 DUNEDIN Oct. ‘86 Brief fire in engine room caused by fracture in fuel pipe (cargo/container) 2 MARALR Aug. ‘a7 Extensive damageto vessel by fire probably caused by leakagefrom fuel line in engine room @we) 3 EUROPEANTRADER day ‘aa Engineroom fire caused by fuel spraying from break in pipe. Extensive damageto electrical (roll-on/roll-off passenger/ wiring cargo ferry) 4 GULDBORG Aug.‘aa Total loss of vessel by fire in engine room, thought to have started becauseof failure in (fishingvessel) electrical system Source:Department of Transponaccident reports

Stem Line) interviewed by the National the Department’s surveys and inspections Audit Office confirmed that most fires in will include specific checks that they have machinery spaces result from fuel or oil been properly implemented. spraying onto hot surfaces. The company has since undertaken specific fire audits of its WSdS. Safety of passenger vessels

3.14 Recognising that fire is a major area of risk, 3.17 The EUROPEAN GATEWAY sank off the Department commissioned 10 research Harwich in 1982 with the loss of 6 lives after projects between 1983 and 1989 into fire being struck amidships by a cargo roll- prevention, control and extinction at a cost of on/roll-off ferry. The rapid capsize of the some f200,OOO[at 1990 prices). This work vessel was due to the inability to close the represented five per cent of all ship safety hand operated watertight doors in time. The research projects and two per cent of total Department secured international agreement ship safety research expenditure in the in 1989 to the provision of power operation of period. In June 1991 the Department issued watertight doors and improved operating further guidance on prevention of oil fires in procedures. In 1987 the HERALD OF FREE machinery spaces of ships incorporating the ENTERPRISE capsized after sailing with the 1986 guidance, supported by recent cases. inner and outer bow doors open. The Department are satisfied that subsequent 3.15 A review published by the Department in amendments, instigated by the United 1991 into the human element in shipping Kingdom, to the Convention for Safety of Life casualties, identified greater use of non- at Sea 1974 (Appendix 1) should prevent a flammable materials on board ships and repetition of the events leading up to the better alarm systems as areas worthy of HERALD OF FREE ENTERPRISE disaster. further research. Restrictions on the use of The main changes were: flammable materials and the provision of alarm systems are already requirements of l the provision of indicators and the international convention, but the surveillance systems on the navigation provision is to be reviewed by the bridge of all roll-on/roll-off ferries to International Maritime Organisation in Spring ensure loading doors are closed and that 1992 in the light of the findings of the no leakage exists:

investigation into the SCANDINAVIAN STAR l closure and locking of all cargo loading (Bahamas registered) fire in 1990 where some doors and weathertight ramps before a 160 lives were lost. ship proceeds on any voyage.

3.16 The International Maritime Organisation are 3.18 The Department have also taken steps to preparing new rules to be approved in 1992 improve passenger vessel design so that they which will reduce the use of flammable are better able to survive a collision or materials on board ship: improve the means grounding. Between 1982 and 1987 the of escape; increase the efficiency of fire Department spent EO.3 million on research doors; strengthen the fire zoning into the damage survivability of roll-on/roll- arrangements and require the installation of off passenger ferries. An additional fl fire detection, fire alarm systems and million of research was initiated by the automatic sprinklers on all ships. When these Secretary of State in response to new convention requirements are introduced recommendations of the Court of Inquiry into

13 DEPARTMENT OF TRANSPORT: SHIP SAFETY

Table 8: Damage stability standards for roll-on/roll-off ferries in August 1991 United KingdomRegistered Vessels ForeignRegistered Vessels Built before April 1990 Built after April 1990 Built before April 1990 Built after April 1990 United Kingdomstandards The InternationalMaritime InternationalMaritime InternationalMaritime introducedunimrasy in 1980 Organisation1990 SOLAS Organisation1965 standardsor Organisation1990 SOLAS standards any higher standardsrequired by standardsor any higher country of registration standardsrequired by country of registration Source:Department of Transport Table B shows foreign registeredvessels built before 1990 operating in and out of United Kingdomports may be built to lower standardsof stability than United Kingdomregistered vessels and vessels built before April 1990 are unlikely to meet the 1990 Internationalstandards.

the HERALD OF FREE ENTERPRISE Maritime Organisation 1965 standards incident. The aim was to enhance the (Table 8). survivability and damage stability of similar vessels. 3.21 The Department pressed for an appropriate amendment to the international requirements 3.19 In 1980 the Department introduced revised because they believed that it was important United Kingdom damage stability standards that all ferries, of whatever age, operating for all ships built after that date. As a result from United Kingdom ports should meet the of the recommendations of the court of International Maritime Organisation 1990 inquiry into the HERALD OF FREE standards. The International Maritime ENTERPRISE the Department in 1988 also Organisation in May 1991 agreed that their required all existing United Kingdom roll- 1990 stability standards should be applied to on/roll-off passenger ferries built before 1980 all existing ferries. and provisionally agreed to comply with the 1980 standards. The 1980 that the implementation would be phased standards were higher than the minimum over the five years from October 1994. required by international conventions. By March 1990 the Department had evaluated all 3.22 Following the MARCHIONESS accident the 70 United Kingdom ferries built before 1980; Department took action to ensure greater and they found that 17 of the vessels enforcement of safety standards on small surveyed did not comply with the 1980 passenger vessels by increasing the level of standards. By December 1990 12 of the 17 inspections of the 900 passenger vessels using ferries had been upgraded to comply with the the Thames and other river estuaries and 1980 standards but the remaining 5 had left introduced passenger counting systems the United Kingdom flag before modification. (paragraphs 4.34 to 4.39). In May 1991, in line Although the United Kingdom’s 1980 with recommendation 20 of the inspectors’ standards are higher than the international report (Appendix 5) the Department sent standards for ships of a similar age, they are proposals for enhancing safety standards to still not as high as the standards which the shipping industry for comment by August research by the Department. published in 1991. The proposals covered new regulations 1990,indicated were necessary. for life savingappliances, including the provision of liferafts for 110 per cent of 3.20 The International Maritime Organisation persons on board and lifejackets for every never adopted the United Kingdom’s 1980 person, and new survivability standards for standards but decided instead on even higher small passenger vessels covering their standards for new passenger vessels built stability and construction, particularly after April 1990. These standards were watertight sub-division and escape designed to provide greater protection against arrangements. On both of these proposals the capsize in the event of an accident. However, Department have indicated that the new no amendments were made to the stability regulations should apply at once to all new requirements for existing ships, and foreign ships, but that the new requirements would ships visiting the United Kingdom could be phased in for existing ships over the five therefore continue to operate to less year period up to 1996. demanding standards. They are not subject to the Department’s 1980 standards and are instead governed by the International

14 DEPARTMENT OF TRANSPORT: SHIPSAFETY

Passenger evacuation and control orderly abandonment involving firstly the assembly of the passengers at the muster 3.23 Passenger evacuation and control stations where the lifejackets would be arrangements present particular hazards in issued, and secondly that the public the event of an accident and were a nxxns would provide protection from the particular feature of the investigation into the elements to the passengers while they abandonment of the EUROPEAN GATEWAY were waiting to abandon ship; following collision with the SPEEDLINK . if the hull was breached, the ship would VANGUARD in 1982 (Table 9). The main remain afloat in a nearly upright hazards included lack of adequate escape condition for at least 30 minutes and that routes, the difficulty in evacuating high-sided the life-saving equipment located in both vessels, unfamiliarity with the vessel, and sides of the ship could be deployed. It dealing with the consequences of severe was assumed that it would be possible to listing and capsize. The Department have use all, or nearly all, of the lifeboats and taken action on each of the recommendations life-rafts. in the accident investigation report; for example, life saving equipment is now tested 3.25 The Court of Inquiry concluded that these to ensure that it continues to operate fundamental assumptions were not valid for satisfactorily when a ship is listing at 20 roll-on/roll-off ferries when the vessel’s degrees as opposed to 15 degrees. watertight integrity is lost, because such vessels are then unlikely to remain upright 3.24 The Court of Inquiry into the loss of the for 30 minutes. HERALD OF FREE ENTERPRISE noted that the emergency procedures for dealing with 3.26 Passenger vessels built since 1986 and abandonment of a passenger ship operating operating between the United Kingdom and on short sea crossings were based on three Europe are required to carry enough lifeboats fundamental assumptions: and life-rafts for a full complement of passengers and crew, plus an extra 25 per l all the lifeboats and life-rafts could be cent. The Court of Inquiry into the HERALD launched within a period of 30 minutes OF FREE ENTERPRISE concluded that the and that there would be sufficient time to carrying of lifeboats on vessels never far from complete the abandonment: land should be reviewed by the International . there would be sufficient number of Maritime Organisation, and recommended trained persons on board for mustering the Department should take the lead in and assisting passengers and that there initiating these discussions. The Department would be sufficient number of crew for in March 1990 sent a paper to the launching and thereafter operating all the International Maritime Organisation on a life-saving craft. This made the further reduction in the number of lifeboats, and assumption that there would be an increased life-raft capacity but no agreement

Table 9: European Gateway/Speedlink Vanguard accident 1982 -Investigation report findings on passenger control and evacuation Findings (i) The collision betweenthe vessels and subsequentlisting and capsize of the EuropeanGateway made it impassible either to board or launch the lifeboats on the EuropeanGateway. Embarkation in the port liferaff was difficult becausethe ladder was too short to reach the raft as the list to starboard developed. (ii) The public addresssystem failed as did communicationbetween officers using portable VHF sets (iii) There was confusionas to where the lifejacketswere stored; passengerswere mistakenly told to get them from their cabins and some attempted to don children’s lifejacketsbecause they were not clearly marked. (iv) Panic was not a factor in this case. Howeverthe report noted: “mast of the passengerswere long distance lorry drivers- men of independentspirit and resource.If the ferry had a full complement of holiday makers, it is idle to pretend that any crew. howeverwell trained would be able to prevent panic leading to heavy loss of life.” RecommendedAction The report made a number of recommendationsincluding: (1) Considerationshould be given to catering for the possibility that a vessel may have to be abandonedwhen listing to mole than 15 degrees. (2) Oistributionand use of portable VHF sets should form part of the drill practised at musters. (3) Passengervessels should carry at least two pottable loudhailersfar communicationwith passengersin emergencies. (4) There should be uniformity of practice in the stowage of life jackets in vessels of the same class. (5) Both childrens‘ life jackets and their stowage should be clearly marked “FOR CHILOREN”.

15 DEPARTMENTOF TRANSPORT:SHIP SAFETY

was reached on changes to the relevant announcement. Some 80 per cent of the international convention requirements for passengers who were shown a muster station lifeboats. In May 1991 the Department sign, “identified the sign correctly or got the obtained International Maritime Organisation general idea”. In an earlier survey of 135 agreement to a limit on the height above passengers travelling in June 1990, however, water at which survival craft can be stowed, 41 per cent had failed to identify the sign. although this will only apply to new The Department have told the National Audit passenger ship designs. Office that they will continue to insist on the publicising of safety symbols through safety 3.27 Since July 1986 international standards announcements to increase still further require all new passenger vessels to have passenger understanding. “dry-shod” evacuation facilities, for example ** lifeboats, davit-launched life-rafts or marine 3.31 In response to the HERALD OF FREE escape systems, so that passengers can board ENTERPRISE findings the Department have the survival craft directly from the ship since March 1988 required all ferries without entering the water. The Department operating out of United Kingdom ports to have emphasised that the United Kingdom have passenger boarding card systems to was at the forefront in developing these ensure an accurate count of the total number standards, having encouraged owners to of passengers on board, and that the number install marine escape systems and davit- does not exceed that on the Passenger Ship launched life-rafts for many years before the Certificate. These regulations apply to all international regulations were implemented, United Kingdom registered passenger ships and all foreign passenger ships on voyages 3.28 Marine escape systems, which are similar to from United Kingdom ports. aircraft slides and allow faster evacuation of passengers, are now available on about 12 per 3.32 The difficulty of evacuating passengers is cent of passenger ships operating out of likely to increase substantially with higher United Kingdom ports. Following suggestions passenger density. The available information from various countries, including the United however suggests that the systems operating Kingdom, the International Maritime on vessels of different ages, built to different Organisation in May 1991 agreed to start regulations, vary in scope and effectiveness. reviewing the requirements relating to The Department are currently involved in marine escape systems in 1992. In the testing evacuation systems in practice and meantime the Department will test the reviewing systems in operation. The reliability and operation of such systems and Department expect to complete this work in present their results to the International 1993 and will issue guidance cm best practice Maritime Organisation. and will decide whether changes in regulations and international conventions are 3.29 Passenger control in an accident involves required. ensuring individuals, properly clad, are evacuated without panic from cabins and 3.33 The whole area of securing satisfactory public spacesto appointedassembly areas proceduresfor passengerevacuation and away from the hazard to await evacuation or control, and seeking to ensure that they work the end of the emergency. Effective effectively in practice, are complicated and passenger mustering and control difficult matters. They also involve arrangements depend upon experienced responsibilities going beyond those of the crew, and adequate communication and Department, both within the United Kingdom safety systems which take account of difficult and internationally. It can therefore take a operating circumstances and panic reactions. long time to develop and implement revised Crew must therefore be trained and tested in regulations and improved safety procedures. evacuation procedures by regular drills, Even individual aspects of development can exercises and inspections, and basic take a long time to resolve; for example, instruction given to passengers. research within the United Kingdom into developing a better lifejacket has been in 3.30 The Consumers Association in a report progress for more than 6 years. Following an published in February 1991 based on a accident (PRINCE IVANHOE] in 1981, the survey of 637 passengers travelling on ferries Department commissioned research in 1984 in November 1990, found one in four did not into developing a life jacket that could be put choose to listen to, or did not hear, the safety on within one minute without assistance.

16 DEPARTMENTOF TRANSPORT:SHIP SAFETY

This required a radical change in approach so don’ lifejackets to be provided as standard as to meet international convention equipment on all new and existing passenger requirements, and because of the difficult vessels. The International Maritime specification development was slow. Organisation have accepted the new Following the HERALD OF FREE regulations in principle and expect to agree ENTERPRISE inquiry further research on them in April 1992 for implementation by finding a suitable lifejacket to meet the about October 1993 in accordance with the required specifications was set in hand in timetable for the various consultation stages 1989. The Department have proposed new imposed by the international convention. regulations which would require ‘simple to

17 DEPARTMENTOF TRANSPORT:SHIP SAFETY

Part 4: Accident prevention

4.1 Important responsibilities for ship safety Manning levels within the Department rest with the Surveyor General’s Organisation. Their 4.4 Owners are responsible for ensuring that overall objective is to ensure the safety of their vessels are adequately manned. The United Kingdom registered vessels and those Department are responsible for ensuring that on board, but without imposing unnecessary the statutory provisions on manning are burdens on the industry greater than the complied with; these relate to the number minimum required by international and qualifications of the master, deck, convention. Their main tasks are: engineer and radio officers, doctor and cook. . to ensure the proper qualification and The Department may detain any ship which certification of crews; they think to be unsafe because of undermanning. Between 1985 and 1989, 57 . to carry out surveys and inspections of out of 308 ships detained by the United Kingdom registered ships; Department’s surveyors were for . to survey and inspect foreign registered undermanning. vessels using United Kingdom ports to ensure they comply with international 4.5 At the request of owners, the Department and national requirements. will issue safe manning certificates for any United Kingdom registered vessel, stating the 4.2 To carry out their work the Department minimum number and rank of personnel employed some 190 marine surveyors at required for safe operation. This scheme February 1991, based in a headquarters office incorporates the principles of safe manning and six marine districts around the United set out by the International Maritime Kingdom. In addition they monitor the work Organisation. The certificate enables the of the classification societies to whom much ship’s master to demonstrate to a foreign of the required surveys are delegated (see inspector that his vessel is manned as paragraph 4.10 below). required by the United Kingdom. The recommended minimum manning level takes into account the geographical area of Crew qualification operation and an assessment of the workload under both routine and emergency conditions including watchkeeping, mooring, closure of The Department are responsible for ensuring 4.3 watertight openings, radio watch, mustering, the proper qualification and certification of evacuation of passengers, and operation and crews, which are essential to the safe maintenanceof fire and life saving operation of a ship. They set training and appliances. competency standards for crews and in 1988 introduced a scheme for revalidating 4.6 The present scheme is voluntary and only certificates of competency for deck and 410 United Kingdom registered ships of over engineering officers. Although the setting and 100 gross tons out of a total of 1.832 eligible marking of written examinations was vessels over 100 gross tons had a certificate delegated to a national education council in in 1991. The Department consider this is 1968, the Department are still responsible for because a large number of the eligible vessels approving these papers. The Department may be United Kingdom registered coastal continue to conduct the oral examinations for vessels whose owners do not perceive the all certificates of competency issued to need to be assessedfor such certificates since officers. The nationality of the master, mate they are not subject to inspections in foreign and chief engineer on United Kingdom ports, although they are liable to inspection registered ships is restricted to citizens of the by United Kingdom surveyors. From 1992, Commonwealth and the Irish Republic. however, international regulations will Proposals to relax these requirements are require all vessels over 500 gross registered under consultation with the industry. tons to have a safe manning certificate. At

18 DEPARTMENT OF TRANSPORT: SHIP SAFETY

present 339 out of 767 vessels over 500 gross comply with the appropriate regulations and tons on the United Kingdom register have have the necessary certificates. The surveys certificates. and inspections carried out vary by type of vessel (Table 10). 4.7 The safe manning certificates do not include specific guidance on working hours. The Surveys Department consider that, since this is a 4.9 Surveys of new ships are carried out during matter which falls to another international and at the end of construction as a basis for convention, it would be inappropriate to issuing the initial ship certificate, with cover it in a safe manning certificate agreed further surveys at specified intervals to cover internationally. A report commissioned by continued compliance and renewal. The the Department nevertheless concluded, in frequency and coverage of the main types of 1990, that new regulations on working hours survey are set out in Appendix 3. would be justified and would enable the United Kingdom to comply fully with the 4.10 The Department’s surveyors carried out 6,700 International Labour Organisation of the surveys of United Kingdom ships in Convention on merchant shipping standards. 1990 representing scnne 30 per cent of the Following public consultation the total survey workload of the United Kingdom Department expect to finalise new fleet. The remaining 70 per cent was regulations and a code of practice on working delegated by the Department to five hours by late Summer 1992. classification societies. These are private organisations that survey and classify ships primarily for insurance purposes. The Surveys and inspections Department are satisfied that the five classification societies are competent to carry 4.8 Surveys are the basis for the issue, renewal out the work delegated to them to the or review of certificates for ships, their required standard. But following machinery and equipment. Inspections are recommendations of an efficiency scrutiny of carried out periodically to ensure that ships the Marine Survey Service in 1987, and of a Transport Committee report on the Decline

Table 10: Main types of vessel covered by survey and inspection by the Department of Transport Type of Vessel Coveredby: Survey GeneralInspection Concentrated port state Control Inspections Inspections United Kingdom registered: cargo Vessels Variety of Yes Only chemical Not applicable surveys set Old tankers and in Appendix 3 vessels carrying packaged dangerousgoods Fishing Vessels One s”rvey Yes NO Not applicable wer 12 metres every 4 years Fishing Vessels Not applicable Yes a pilot NO Not applicable under 12 metres inspection programme from 1990 Roll-on/Roll-an Annual wrvey Yes Yes Not applicable PassengerVessels River Passenger Annual S”WY Specificinspection NO Not applicable VeSSelS in 1989 along same guidelinesas general inspection Foreign registered: cargo Vessels Carriedout by Not applicable Only chemical Yes Flag State tankers and vessels carrying packaged dangerousgoods Roll-on/Roll-off Carriedout by Not applicable Yes Yes PassengerVessels nagF.-- arareO.~.~ Source:Department of Transporr

19 DEPARTMENT OF TRANSPORT: SHIP SAFETY

of the United Kingdom-registered Merchant number of surveyors, with a further review Fleet in 1988 (HC 303), the Department began to be carried out later in 1991. The periodic audits of societies in June 1991 and Organisation have estimated the resulting intend to inspect some ships surveyed by annual savings at sane f 240,000 - societies to check their work. This follows a equivalent to scnne 3 per cent of their similar pattern to Norway, whose Maritime running costs. The inspection also found a Directorate have delegated much of their number of defects in the management surveys of safety equipment to classification information systems which hindered the societies and began auditing their work in Organisation in allocating resources and 1987. monitoring accurately its progress towards stated productivity targets. 4.11 The statutory requirements on fishing vessels required the Department from 1975 to carry out an initial survey of fishing vessels of over 1.14 The Department undertook some 2,700 12 metres on entry to the United Kingdom inspections in 1989 under four main register and a renewal survey at four yearly headings: intervals thereafter, and to undertake periodic further inspections at about two general inspections (540 a year) years after the last survey. There is no examining United Kingdom registered requirement to survey fishing vessels under ships for compliance with statutory 12 metres in length. To meet these regulations; requirements the Department employed 13 concentrated inspections (16 a year) fishing vessel surveyors as at I February which are unscheduled general 1991. inspections at selected ports examining United Kingdom and foreign registered 4.12 The National Audit Office noted that, despite vessels and concentrating on procedures the statutory requirement, no periodic as they are operating in practice: inspections had in fact been carried out port state control inspections (1,800 a because the Department concentrated on year) examining foreign ships visiting completing the initial round of surveys. United Kingdom ports for compliance Amendments to the regulations in 1978 and with international conventions; general exemptions issued in 1981 and 1983 provided exemptions for the first round of river passenger vessel inspections (351 periodic inspections but not for subsequent recorded in 1989) following up action rounds. In 1985 a Departmental working taken as a result of the MARCHIONESS group recommended that the requirement for disaster. periodic inspections should continue to be deferred pending a review. The review, in 4.15 Each year the Department also carry out consultation with the fishing industry sOme 1,900 miscellaneous inspections on representatives, took place in Autumn 1991 specific or individual areas of risk selected by and a further exemption was issued in the surveyors or brought to their attention. September19%. Theseinclude suchmatters as the safe stowage of explosives, passenger boarding 4.13 The resources of the marine offices of the card procedures and scane 400 radio Surveyor General’s Organisation were most inspections delegated to British Telecom. All recently reviewed in March 1991 by a inspections give a measure of the safety departmental staff inspection. The inspection standard of the vessel concerned although noted that, although the Organisation was the scope of each inspection is left largely to operating against the background of a the professional judgement of the surveyor, continuing decline in the size of the United working to guidelines issued by the Surveyor Kingdom merchant shipping fleet, the survey General’s Organisation’s headquarters. work was organised and conducted effectively in support of what the inspection team concluded was an excellent United General inspections Kingdom marine safety record. Nevertheless, the inspection team noted that the time spent 4.16 When a general inspection is completed the on miscellaneous work was well in excess of surveyor is required to issue a standard letter the estimates and agreed with the of compliance to masters of the ships Organisation a 4 per cent reduction in the inspected and copy the letter to the Surveyor

20 DEPARTMENT OF TRANSPORT: SHIP SAFETY

General’s Organisation’s headquarters. The example, to emphasise the importance of letter provides a single system of coding inspections of vessels other than cargo ships, defects identified by inspections of United such as passenger ferries (see below] and Kingdom and foreign passenger and cargo river craft (see paragraphs 4.34 to 4.39). ships. Also the Department require surveyors to record on the letter of compliance any 4.19 Passenger ferries include conventional roll- major areas not inspected. on/roll-off ferries and those which carry only lorries and their drivers. The Department 4.17 The Department have not set an overall have an operational target of carrying out target for the number of general inspections inspections of each United Kingdom to be carried out in total on United Kingdom registered roll-on/roll-off passenger ferry registered ships because they consider any ideally at least twice but certainly Once a target would depend on the number of such year although the Forward Plan of the ships visiting United Kingdom ports. (They Surveyor General’s Organisation specifies a consider it is nmre feasible to set targets for target of two inspections a year. In 1989 the the percentage of inspections, under the Port Department carried out 475 ferry inspections. State Control arrangements, to be carried out Of these 48 were general inspections where a on foreign vessels because their visits to letter of compliance was issued; and these United Kingdom ports are nmre predictable, covered only 32 out of 52 United Kingdom paragraphs 4.30 to 4.33 below). They rely roll-on/roll-off ferries [over 100 tons) with instead on the district chief surveyors using only 16 ferries being inspected twice. The their professional judgement and guidelines remaining 427 inspections involved specific issued by headquarters to determine the checks of such individual aspects as level and focus of work within the resources passenger counting procedures or newly available. The National Audit Office installed equipment. The extent of these examination of the general inspections specific inspections varied according to the carried out in 1989, analysed by type of surveyor’s judgement. time available for the vessel, showed that 57 per cent of tankers, 80 inspection and the need to check the per cent of cargo vessels, 36 per cent of implementation of any new regulations. The passenger vessels had been inspected and a National Audit Office recognise the letter of compliance issued (Table 11). difficulties involved but consider that the Department should define their targets not 4.18 The efficiency scrutiny carried out in 1987 only in terms of numbers of inspections but (paragraph 4.10) recommended that the also in terms of the type of inspection, so that Department should aim to carry out an performance can be more clearly measured annual general inspection on each United against the targets set. (Inspections of non Kingdom cargo vessel above 500 gross tons United Kingdom registered ferries are trading in and out of United Kingdom ports. covered in paragraph 4.32 below]. The Department did not accept this recommendation because they preferred to 4.20 Special considerations also apply to the level rely on the professional judgement of their of inspections carried out on fishing vessels. surveyors to target vessels which they In 1989 the Department carried out sane 127 consider pose the greatest risk, and to vary general inspections on fishing vessels cwer 12 priorities according to changing metres but they did not issue letters of circumstances. This would enable them, for

Table 11: General inspections by type of vessel in 1989 Numberof Number of Number in Fleet2 Number Inspectedas a Type of Vessel Inspections’ (1989) Ships Inspected1(1989) (over 100 tons) Percentageof the Fleet Tanker 69 122 57 Cargo 3:: 253 316 Passenger 61 44 122 ii FishingVessel 517 Other 99 99 659 12 Details not recorded 3 3 - - Total 537 468 1,936 w Source: I Letters of complianceissued in 1989. *Merchant Ships RegistrationStatistics 1989. Notes: ‘The Departmentdo not issue letters of compliancefor fishing vessel inspections. fExcluding fishing vessels. DEPARTMENTOF TRANSPORT:SHIP SAFETY

compliance and so the results of this work working space; were not separately identified. They are, life saving and fire fighting appliances: however, proposing in 1992 to study ways of accident prevention and safety in general; reporting and analysing deficiencies identified by general inspections of fishing alarm signals; vessels over 12 metres. cargo, load lines, mooring arrangements; machinery; 4.21 Until 1990 there was no regular programme navigation and radio; of general inspections of United Kingdom registered fishing vessels under 12 metres in pollution. length, which accounted for some 6,762 out The Department carry out a basic computer of the 10,736 registered vessels in December analysis of the location of inspections, the 1990. Achieving an acceptable level of safety deficiencies found and the action taken in on such vessels is difficult not only because each case. of their large number but also because they have diverse designs, varied commercial 4.23 The Department do not, however, carry out operations and often one-man ownership. any further analysis of the results of their Vessels have been subject to miscellaneous general inspections to identify the level or inspections. but the Department have not pattern of serious defects, common causes, recorded the number and results in a form incidence across different kinds or age of which would enable them to be analysed ships, or according to ownership. The centrally. In July 1990 the Department Department have undertaken a study, for introduced a pilot inspection scheme for completion in early 1992, to examine how these vessels in recognition of their poor they should analyse the results of their safety record. Late in 1991 they assessedthe inspections. The Department also propose to results of the first round of inspections as a develop appropriate indicators identifying preliminary to setting targets for the number serious defects by those giving rise to to be undertaken each year. detentions, improvement notices and prohibition notices. The National Audit Analysis of defects Office therefore reviewed the letters of compliance of the 537 general inspections 4.22 On completion of a general inspection the carried out in 1989 (Table 12). Nearly 1,500 surveyor issues a letter of compliance setting defects were reported by the regional out the defects found and the remedial action surveyors. As a result of the defects found 22 taken or required. If the surveyor cannot detentions, 66 improvement notices and 7 complete the inspection, then he should note prohibition notices were issued to United the letter of compliance to indicate the major Kingdom ships in 1989. areas not inspected. The Department schedule the defects found and the action 4.24 Defects were then grouped into the areas taken under the following headings: already identified as the main causes of accidents and of risks of injury or fatalities: e ship certificates; . crew; l ship’s condition: defects affecting the structure or essential equipment of the l food and catering; l accommodation;

Table 12: Types of ship covered by general inspections in 1989 and the defects found Type Of Number of Inspections Numberof Defects Defectsper Inspection “CWLS

Detail not recorded by inspection report 3 9 3.0 TO!& 537 1,489 2.8 Source: GeneralInspections, Letters of Complianceissued by Departmentof Transport(1989) Note: I Letters of compliancenot issued for fishing vessels and there is no central analysis of the results of fishing vessel general insPecbons (paragraphs4.20 and 4.21)

22 DEPARTMENTOF TRANSPORT:SHIP SAFETY

Figure 2: United Kingdom general inspections Department consider that operational factors for 1989 -defects reported by type are already addressed by their certification and manning requirements, design Accident response requirements and inspection of operational 46% practices by their surveyors and the recent introduction of concentrated inspections. In addition the Department has supported a change in emphasis towards operational requirements in the international field. Nevertheless in the National Audit Office’s view there may still be scope, within the Department’s resources for better targeting of inspections on operational factors, many aspects of which can only be properly tested during actual operation at sea.

4.26 The National Audit Office examination also 33% noted that the average number of defects Source:General Inspection returns for 1989 (Departmentof varied according to the vessel’s owner. The Transpoti) majority of wmers had vessels with an Figure2 shows the relatively small number of operational average of less than three defects. However defects identified. 29 out of 184 Owners had vessels with an average of nmre than six defects. Analysis ship, for example propulsion, indicating whether smne owners have better accommodation and cargo storage; standards of safety than others, and why, would again provide useful information in l accident response systems: defects in equipment which may be needed in an targeting inspection work. emergency, for example lifeboats, fire fighting equipment and lifejackets; 4.27 The National Audit Office analysis also showed that, not surprisingly the average l manning and operational: defects related number of defects varied according to the to the way the ship is operated, for vessel’s age, with ships over 30 years old example the qualification and training displaying nmre defects than newer ships and experience of the crew, operational [Table 13). When selecting ships for drills, etc; inspection surveyors take account of the l other: defects which either cannot be vessel’s age: and the National Audit Office classified, or refer to pollution control analysis showed that 5 per cent of general rather than safety. inspections, for which letters of compliance were issued, were carried out on ships built 4.25 Some 46 per cent of reported defects were before 1960 and that the average age of ships related to the ship’s accident response inspected was 16.8 years. But the available systems, with 33 per cent attributable to the information did not make it possible to assess ship’s condition (Figure 2). Only 17 per cent the extent to which older ships had been of defects related to manning and operational targeted, because no figures were available factors notwithstanding the general on the number and average age of United acceptance that human and operational Kingdom registered ships built before 1960 factors contribute to sane 80 per cent of and operating in United Kingdom waters. accidents (paragraphs 2.7 to 2.13). The

Table 13: Age and average defect rate of United Kingdom ships covered by 1989 general inspections for which letters of compliance were issued Year of Number of inspections PercentageOf Total number Average number build of ships in age range inspections of defects of defects Before 1960 148 5.5 1960-1974 2:; 4: 714 2.9 1975-1989 257 48 617 2.4 Detail not recorded 4 1 IO 2.5 by inspection repott Source:General Inspectfons. Letters of Compliance(1989) Departmentof Transport

23 DEPARTMENT OF TRANSPORT: SHlP SAFETY

Concentrated inspections inspections, but they have confirmed that they plan to devote more resources to this 4.28 General inspections are essentially “static” in work on a regular basis and to set inspection that they concentrate on such matters as targets. levels and fitness of equipment, and whether there are valid certificates and laid down 4.29 The National Audit Office analysed the procedures rather than how well things results of 28 concentrated inspections carried operate in practice on board ships at sea. out in the period 1989-1991 and covering 14 This is potentially an important gap. given United Kingdom vessels and seven foreign the acknowledged significance of human and vessels (seven vessels were inspected twice]. operational factors in the causes of accidents. In general, the inspectors concluded that In recognition of the need to support their standards of operation and maintenance were general inspections by further examinations satisfactory; but the inspections nevertheless in such areas, the Department in 1988 took identified a number of defects, related to ship the lead internationally by introducing operation and passenger control (Figure 3). concentrated inspections alongside their These defects could in practice have had a general inspections. They target these serious impact on the survivability of concentrated inspections on roll-on/roll-off passengers in the event of an accident, and passenger ferries. chemical carriers and the Department are confident that in each packaged dangerous goods vessels. On each case the defect was brought to the attention inspection the surveyors examined of the master and rectified. The National approximately four to five vessels whilst in Audit Office’s analysis confirmed the operation. The Department have so far Department’s view that a number of defects diverted a relatively small proportion of the would be more likely to be picked up by available resources to concentrated concentrated inspection than other types of inspection. (Figure 3 and Appendix 4).

Figure 3: Detects identified by 28 concentrated inspections categorised by type

BoardingArrangements

Safety Announcements

Car Deck

Bridge Procedures

Fire Prevention

Lifejackets

Muster List

Passenger/CrewEvacuation

LifeboaWLiferafts

1 2 3 4 5 6 7 8 9 10 11 12 13 14 Numberof defectsfound Key: defectsthat can only be found by concentratedinspection (details of defectsat Appendix4)

defectsmore likely to be found by concentratedthan other inspections(details of defectsat Appendix4)

defectsthat could be found by generalor pelt state control inspection (detailsof defectsat Appendix 4)

Source:National Audit Officeanalysis of concentratedinspection resolts between 1989and 1991 Figure3 shows the range of defects identifiedduring concentratedinspection. many of which could not be identifiedan other inspections.

24 DEPARTMENT OF TRANSPORT: SHIP SAFETY

Port State Control inspections ferries using United Kingdom ports were inspected at least twice. The Department 4.30 As part of the Memorandum of concluded that where vessels were not Understanding on Port State Control signed inspected twice the explanation lay in the by 14 countries, the United Kingdom is fact that their surveyors were being used on required to inspect a minimum of 25 per cent higher priority work. of all foreign vessels entering United Kingdom ports. The Department, however, On completion of each Port State Control have set themselves a higher target of 30 per inspection the surveyor issues a Report of cent; and in 1990 they inspected 34.4 per cent Inspection. The National Audit Office of visiting foreign vessels, mostly cwer 500 analysis of the information available on the tons. results of these inspections showed that defects were recorded on 60 per cent (900) of 4.31 The Memorandum of Understanding does not foreign registered vessels inspected in United allow countries to target their inspections on Kingdom ports in 1989, as compared with particular flag states. The National Audit defects noted on 66 per cent of United Office analysed a sample of 800 (44 per cent) Kingdom vessels examined under the of Port State Control inspections carried out Department’s programme of general in 1989 and found that scnne 50 per cent of inspections. Although these figures suggest the sample involved eight flag states; and prima facie that there are mcne defects on there was no clear relationship between the United Kingdom vessels than foreign vessels, coverage achieved and the frequency of the Department pointed out that: defects found (Table 14). The frequency of the Departmental surveyors’ local inspections broadly reflected the trade knowledge of the standard of the United carried by flag states; but only some two per Kingdom fleet enabled them to target cent of inspections were carried out on ships inspections on those vessels at most risk built before 1960, even though these older and the inspections were therefore likely vessels had a higher number of defects. to disclose mrxe defects; under the Port State Control agreement 4.32 The Department have also set themselves a target of inspecting, by a Port State Control the scope of an inspection of a foreign inspection, every non United Kingdom ship is subject to constraints which do not roll-on/roll-off ferry ideally at least twice a apply to general inspections of a United year but certainly once a year. Although in Kingdom ship (paragraph 4.31); 1989 they undertook a total of 57 inspections only 30 per cent of United Kingdom of such vessels, (with no record of the results registered vessels inspected abroad under of one of the inspections) only 11 out of the the Memorandum of Understanding, by 44 non United Kingdom roll-on/roll-off foreign inspectors, had defects.

Table 14: Flag states covered by Port State Control inspections (1989) PercentageOf Number of inspections United Kingdom as percentageof Port trade carried by Rag Average number country State Control inspections’ state VeSSelP of defects’ West Germany 12.3 10 0.9 Norway 8.7 6 1.6 Panama 6.3 4 3.4 Cyprus 6.1 3.2 Netherlands 5.9 1.2 Bahamas 4.8 i 1.6 GW% 4.4 2 2.7 Eire 4.2 2.6 Other 47.3 42 2.3 100

Source: ’ Analvsis of 800 out of 1.800 Potl State Controlinsoections in 1989. 2 Depkment of TransporiStatistics in Great Britain j979 to 1989. Note: * Includedin “other” countries. Table 14 shows that some 50 per cent of the sample of Pelt State Control inspectionsconcentrated on eight flag states with no clear relationship betweenthe coverageachieved and the incidenceof defects found. The incidenceof inspectionsbroadly reflectedthe trade carried by the flag states. DEPARTMENT OF TRANSPORT: SHIP SAFETY

River passenger vessel inspections 4.37 None of the defects identified were considered sufficiently serious for the 4.34 There are some 900 river passenger vessels surveyor to withdraw the right to carry under 100 tons operating in United passengers and the Department are confident Kingdom waters. Following the that the surveyor took immediate steps to MARCHIONESS disaster, the Department ensure that the defects were rectified so as to instigated a special exercise in September allow vessels to continue in service. In 1989 to inspect all 142 Thames river accordance with the recommendations in the passenger vessels in fourteen days, and 25 report on the MARCHIONESS the particular per cent of the remaining vessels (a total of issue of shortcomings in wheelhouse 190 inspections) before the end of 1989. The visibility was dealt with and regulations are inspections carried out were based on the in preparation (paragraphs 3.11, 3.22 and procedures for general inspections, but with Appendix 5). special attention being given to: 4.38 The National Audit Office also reviewed the . safety equipment; inspection reports completed by surveyors and categorised the defects recorded and l escapes and markings: found that 58 per cent of the defects l visibility from the wheel house; identified related to the accident response . procedures to count passenger numbers; system (Figure 4). Though the reports may not have contained an analysis of the l arrangements to inform passengers of the accident or safety implications of the defects action to be taken in an emergency. noted the Department consider the reports enable surveyors to assessthe degree of risk 4.35 The Department met their target; 351 and confirmed that the surveyor concerned inspections were carried out, including all with the inspection would have taken action 142 Thames vessels, and 541 defects were to eliminate any significant risks before identified. The surveyors concluded that the allowing the vessel to continue in service. overall condition of vessels on the Thames was satisfactory and most owners had some 4.39 National Audit Office analysis showed that form of passenger counting system. The sole the average number of defects per vessel exception was the Woolwich ferry, owned by varied according to the owner: and although the Department of Transport, but a passenger the majority of owners had vessels with less counting system was subsequently than three defects there were three owners introduced in August 1990. with vessels with more than six defects and

4.36 Defects noted on these inspections included: a lack of clearly marked or illuminated Figure 4: River passenger vessel inspections, escapes on a large number of vessels; defects reported by type Accident response thirty vessels on the Thames (21 per cent] 58% with restrictedvisibility, of which nine required the operator to leave the wheel in order to look astern; inconsistencies between the surveyors in each district on how they were interpreting whether a public announcement system was needed. and if visibility was satisfactory. (This was resolved as the inspection programme progressed).

17% Operationalerror 12% Source:National Audit Officeanalysis of 335 out of 351 inspectims carriedout by the Departmentin 1989. Figure4 shows most defects identified by inspectionsrelated to accident n?sponsesystems.

26 DEPARTMENT OF TRANSPORT: SHIP SAFETY

30 owners with vessels with between three this requirement was made mandatory on all and six defects. As noted in paragraph 4.26, United Kingdom passenger ferries from information of this kind would assist in December 1988. targeting inspections at higher risk owners. 4.43 A subsequent report by the Departmental committee overseeing research into roll- Action on defects on/roll-off ferry safety in March 1990 concluded that it would be prudent to place 4.40 If a surveyor identifies a defect during an more emphasis on the human element in inspection which he considers puts the safety operational procedures and recommended of the ship or its crew at risk he can delay that “safety audit” procedures should be the ship or formally detain it until the faults adopted by all shipping companies. Safety are rectified. The number of such ship audits include checks on the arrangements detentions is rising; the number of merchant for fire and boat drills and inspections of ships detained in United Kingdom ports as a safety equipment. result of United Kingdom general and Port State Control inspections increased from 33 4.44 So far, two passenger ferry companies are in 1985 to 103 in 1990. Foreign registered known to have introduced safety audit vessels are more frequently detained, with procedures. The Department do not at only 19 per cent of detentions in 1990 being present take account of such audits in United Kingdom registered vessels. The main selecting ships for inspection because the use reason for these detentions were defective of such audits is still unproven, and they do life saving appliances or fire fighting not necessarily cover the same ground or equipment, lack of ship’s certificates, and have the same degree of independence as undermanning. inspections by Departmental surveyors. The Department have not attended any company’s 4.41 The Department also have powers to safety audits. prosecute the owners and masters of vessels for serious offences identified during 4.45 In the National Audit Office’s view the wider inspections. Prosecutions are pursued where development of safety audits in partnership necessary, but the Department generally find with owners is a matter which it could well it more effective to secure early remedial be beneficial for the Department to pursue. action by enforcement orders, delay or Their surveyors’ experience and expertise detention. would be invaluable in helping to extend and improve the extent and coverage of companies’ safety audit arrangements, Safety audits including crew understanding of operational procedures, resources devoted to safety, and systems for passenger control. Evaluation of 4.42 In July 1986 the Department published company safety audit arrangements and guidance on ‘Good Ship Management’ and results, perhaps supported by peer reviews updated it in August 1990 to take account of and quality assurance procedures, could then international guidance on management for usefully be taken into account by the the safe operation of ships. The guidance Department in selecting ships for their own recommended that every company operating general or concentrated inspections, allowing ships should designate a person ashore with better use of the Department’s own responsibility for monitoring the technical resources. The Department however have and safety aspects of the operation of ships considered there may be inherent conflict in and providing land-based backup. Following such an arrangement and must err on the the HERALD OF FREE ENTERPRISE disaster side of maintaining their independence.

27 DEPARTMENT OF TRANSPORT: SHIP SAFETY

Appendix 1 The major international conventions and codes relating to ship safety

Title Purpose lntematianal Conventionfor the Safetv of Life at Sea. 1974 as Main internationalinstrument relating to maritime safety The Conventionspecifies the amendedby its Protocol of 1978 safety celtificateswhich ships on internationalvoyages are requiredto hold and the ?.urwyswhich have to be undertakenbefore they can be issued. It regulatesship safety by laying down:

l constructionrequirements for stability. machineryand electrical installations: l requirementsfor fire protection.detection and extinction; l the life saving appliancesto be kept on board: l radiotelegraphyand radiotelephonyrequirements: . safety navigationrequirements; . specificationsfor the safe carriage of grain and dangerousgoods: l basic requirementsfor the safety of nuclearships. Conventionof the InternationalRegulations for Preventing The Collision Regulationsaim to reducethe possibility of collisions at sea by laying down Collisions at Sea, 1972. steering and sailing rules (including look-outs, speed and traffic separationschemes): lights and shapes to be used under different circumstances;and sound and light signals. InternationalConvention for Safe Containers.1972 as The Conventionlays down requirementsfor handling.stacking and transporting of amended. Containerson ships by specifying their testing, inspection.design and approval and ma,ntenance. InternationalConvention Load Line 1966. as amendedin 1971. The Conventionrequires countries to supply ship owners and masters with a certificate 1975. 1979 and 1983. detailing the load line and freeboardspecifications. This prescribesthe maximum level to which a ship can be loaded or ballasted without creating structural stresses. and the distance betweenthis and the deck level to ensure stabifi[y. The Conventionexcludes fishing vessels. InternationalConvention on Standardsof Training Cettification The Conventionprescribes minimum standardsfor seafarersin the areas of examinations and Watchkeepingfor Seafarers.1978. Cerdficationand qualifying service, navigational,engineering and radio watchkeeping:and medicalfitness. It lays down special requirementsfor tankers and for proficiencyin survival craft. The Conventiondoes not deal with manning levels. InternationalMaritime DangerousGoods Code. 1990. The Codeprovides guidanceon the classification.terminology, identification,packing. marking. labelling. documentationand emergencyprocedures relating to dangerousgoods transportedby sea. It contains special provisions for freight containers.pottable tanks and roadtankvehicles, storage and segregation.fire preventionand fire fighting. and the carriage of dangerousgoods in roll-on/roll-off ships. InternationalLabour Office ConventionNo. 147 (Merchant This Conventionlays down safety standards.including standardsof competency,hours of Shipping (minimum standards)). work and manning.in order to ensurethe safety of life an board ship.

28 DEPARTMENT OF TRANSPORT: SHIP SAFETY

Appendix 2 Accident investigation reports examined by the National Audit Office-

Date of Accident Name of Vessel Type of Vessel Nature of Accident December1982 EuropeanGateway/Speedlink Vanguard PassengerRoll-on/Roll-off. Roll-on/ Collision Roll-off Rail Cargo January 1985 GoldenStrandilhierry Pascal FishingVessels Collision/Total loss April 1985 JohannaV cargo Grounding/Totalloss May 1985 DutchmasterlAberthawFisher Tanker, Roll-on/Roll-off Cargo Collision June 1985 Norland PassengerRoll-an/Roll-on. cargo Near Collision October 1985 Boston Stirling Fishing Grounding/Fire January 1986 RathdownfQuickthorn Tanker/Cargo Collision April 1986 Foxglove Fishing Grounding June 1986 Bridgeness Tanker barge Grounding/Totalloss August 1986 Arco Tees Dredger Explosion October 1986 Dunedin Cargo/Container Fire in engine room December1986 Wavecrest/Ardency Fishing Collision January 1987 SheerwaterIll/Kingfisher Hydrofoil/CabinCruiser Collision March 1987 Herald of Free Enterprise PassengerRoll-on/Roll-off Capsize/Total loss March 1987 SpanishJohn Cargo Loading Craft Severe Listing August 1987 Maral R cargo Extensive damagecaused by fire October 1987 St Christopher PassengerRoll-on/Roll-Off Heavy weather damage October 1987 Girl Maureen Fishing Foundering December1987 Christian Tanker Stranding January 1988 Grit/Bow Prince Cargo/Sanddredger Collision May 1988 EuropeanTrader Roll-on/Roll-off PassengerCargo Engineroom fire/damage to electrics June 1988 Maid of the Harbour Passenger Collision August 1988 Guldborg Fishing Total loss caused by fire in engine room November1988 Sam0 cargo Collision December1988 OeepdaleH Tanker Capsize/Foundering January 1989 GoldenStrand Fishing Grounding January 1989 Kerry Kathleen Fishing Grounding/Flooding January 1989 Touchstone TUO Collision April 1989 Faithful II Fi&ing Grounding August 1989 Bowbelle/Marchianess Dredger/Passenger Collision/Total loss &,,“,,a l!m!s Far, rrrmailla Roll-““,R”ll-off Plaaenner Grnll”di””

29 DEPARTMENT OF TRANSPORT: SHIP SAFETY

Appendix 3 Types of survey, frequency and coverage

Survey work includes the examination of plans for new ships, of work in progress during construction and regular surveys of ships in service. In service surveys include checks that hull, machinery and radio and safety equipment are satisfactory. The Department’s own surveyors continue to survey all passenger vessels except for 50 per cent of the work on the hull and machinery on passenger vessels engaged on long international voyages. They also survey the safety equipment on cargo vessels unless they operate abroad, in which case for four years out of five an individual classification society may be appointed to conduct the survey. They survey the safety provisions of fishing vessels every four years.

Initial A thoroughand complete examinationof a ship or vessel’s structure,equipment, fittings and arrangementsand materials,as covered by the relevant Certificate.to ensurethat the Cerbficatecan be issued for the Brst time. Annual A general examinationof a ship and its equipment,as covered by the relevant Certificate,to confirm that the ship and its equipmentremain satisfactoryfor the service for which the ship is intended (not applicable to fishing vessels). Intermediate An examinationof a ship and its equipmentat least once during the life of the Certificateto ensure compliance with the applicable requirementsof the Regulations(applies only to Cargo Ship Safety Constructionand EquipmentCertificates). Periodic An examination.at intervals not exceedingWe years, to ensurethat the ship’s structure. equipment,finings. arrangementsand materials comply with the requirementsof the Regulations(applies only to the Cargo Ship Safety ConstructionCertificate). RelleWal A thorough and complete examination.at least every five years (four years in the case of fishing vessels) of a ship or vessel’s structw equipment,fittings. arrangements,and materialsto ensurethat the Certificatecan be renewed(not applicableto Cargo Ship Safety Equipment,Radio or PassengerCertificates).

Certilicates issued Cargo Ships PassengerShips FishingVessels Cargo Ship Safety Passengerand Safety United Kingdom Construction Certificate(Class I Fishing Vessel Certificate and II Ships) Certificate Cargo Ship Safety PassengersCerbficate Equipment (all other United Certificate KingdomPassenger Ships) Load Line Load Line Cerrificate Certificate CargoShip Safety Radiotelegraphy/ Radiotelephony

30 DEPARTMENT OF TRANSPORT: SHIP SAFETY

Appendix 4 Defects identified during 28 concentrated inspections

Frequencyof Defect United Kinodomvessels 1141 Foreionvessels 171 Total BoardingArrangements: . surveyor able to walk onto vessel and up to wheel - 1 1 house without being challenged; . boarding cards not checkedby crew on boarding 2 - 2 ship. Safety Announcements: . public announcementspeakers either inaudibleor 6 3 9 inoperative,and emergencyannouncements not made until after the ship had left the breakwater; . some passengersnot aware of what the announcements - 2 2 said and what they should do during an emergency. Car Deck: passengerson car deck during sea crossing; 2 accessto car deck not preventedduring crossing; 1 vehicles inadequatelylashed; master unawareof dangerouscargoes on board until 1 durino sea crossino: list ai dangerous&goes not drawn up until vessel 1 - 1 underway. Bridge Procedures: . no-one an bridge referredto TQ sets showing bow 1 - 1 doors on crossing. Fire Prevention: . fire doors unable to shut or wedged open: 1 . fire doors unmarked; - . engine room not clean. or equipment likely to 1 causefire not properly maintained: . key in break glass far fire hose missing. 1 - 1 Lifejackets: . insufficientadult lifejackets at muster station: 4 4 . insufficientchilds lifejacketsat muster station. 4 7 5 Muster List: . some members of the crew were not confidentof - 1 1 their ability to marshal or control passengers: . muster list did not identify whether specified 2 - 2 crew could operate the lifeboat; . two crew allocatedto lifeboat duty did not 1 - 1 hold appropriatecertificate; . chief cook allocatedto be second officer in 1 - 1 charge of a lifeboat, and to help launchthe lifeboats.

PassengerCrew Evacuation: l IMO safety signs not used: 4 - 1 41 . emergencysigns not clear and emergency equipmentnot marked; . exit door tied shut with string; - 1 1 . emergencyexit blocked by ladder: - 1 1 . controls to operatethe escape shutes were - 1 locked and the keys not readily available. Lifeboats/Liferafts: level of proficiencyof crew in lowering lifeboat - 1 1 inadequate; membersof lifeboat crew failed to steer boat 1 - 1 clear of ship during drill; instructionson operating/loweringlifeboat 1 1 2 missing or illegible; vessels name an lifeboat illegible. 2 - 2 Total 45 19 64 Source:National Audit Officeanalysis of concentratedinspection results behvm 1989 and 1991. Appendix 4 shows ranges of defects identifiedduring concentratedinspection; many of which could not be identifiedon other inspections.

31 DEPARTMENT OF TRANSPORT: SHIP SAFETY

Appendix 5 Recommendations of the investigation into the accident between the passenger launch Marchioness and MV Bowbelle

1 In June 1990, the Chief Inspector of Marine Accidents published his 27 recommendations on the above tragedy although for legal reasrms he did not publish the full Report until August 1991.

2 By the end of December 1991 action had been completed on 20 of the recommendations. Five of the outstanding seven recommendations will be the subject of legislation, which requires public consultation before regulations are made; another (number 4) has almost been implemented but full implementation requires action in the International Maritime Organisation; and the seventh (number 191,the erection of a Thames bridges signalling system, is expected to be operational early in 1992 but has been delayed due to local planning difficulties.

3 Eleven of the 27 recommendations are particularly relevant to this report and the Department’s responsibilities: Recommendation 1 On Watchkeeping In all vessels of more than 40 metres in length with wheelhouse aft navigating in the River Thames above the Thames barrier, a look-out should be stationed forward at all times. He should be instructed to report all sightings and should have communication with the wheelhouse, preferably by telephone or, if no telephone is fitted, by UHF/RT. [The Department and Port of London Authority).

Action completed Recommendation incorporated into Port of London Authority General Directions and came into force on 18 September 1989.

Recommendation 4 On Vessel Design 4 The existing guide-lines on navigational bridge visibility for sea-going ships should be enforced if necessary by Regulations (a) while in the long term the aim should be to develop requirements which apply internationally: (b) action in respect of United Kingdom ships should not await international agreement: provided that the requirements are set out clearly so that they can be taken into account at the design stage, they should not penalise domestic owners. (The Department).

Action Although the International Maritime Organisation have proposed that the present guidelines should be upgraded the United Kingdom have been asking for an amendment to the Safety of Life at Sea Convention to ensure that adequate standards of visibility are achieved. Most United Kingdom ships comply with International Maritime Organisation guidelines and the Department have requested owners of all vessels with wheelhouse visibility which do not meet International Maritime Organisation Guidelines to submit proposals for rectifying the problem.

32 DEPARTMENT OF TRANSPORT: SHIP SAFETY

Recommendation 5 Regulations should be introduced requiring minimum standards of visibility from the steering position of passenger launches. (The Department).

Action The Department have examined all passenger launches operating on tidal waters throughout the United Kingdom to determine how their wheelhouse visibility compares to the Department’s standards. Compliance was high but the Department are requiring wmers of remaining vessels to take steps to comply with the standards. All vessels operating on the Thames now comply. Ministers have decided to introduce legislation to give statutory effect to these standards. The Department intend to issue a consultation document on this in January 1992 and complete the review by Summer 1992.

Recommendation 20 A full review should be carried out of the requirements for Class V vessels relating to stability and construction. Particular attention should be paid to ensuring adequate escape arrangements. (The Department).

Action Following a thorough review, the Department is proposing a radical change in requirements. Their proposals will improve the safety of all types of small passenger ships operating on the rivers, lakes and around the United Kingdom coast. The proposals were contained in a Consultative Document circulated in May 1991, a revised version of which was issued in November 1991.

Recommendation 6 On the relevance of The Report submitted by the consultant “The MARCHIONESS Inquiry-Relevant human factors in the Human Factors” will be submitted to Marine Directorate of the Department of cause of the accident Transport, and its recommendations should be examined; a submission to the International Maritime Organisation should be considered when the examination is complete. (The Department).

Action completed The consultant’s report draws attention to human factors which may have had a bearing on the night of the casualty. It makes a number of recommendations on navigation lights including flashing lights and coded flashes, together with observations on the length of periods of duty. Greater conspicuity has been dealt with by illuminating an area of the stern of passenger launches which is painted “day glow” orange. Hours of work are dealt with under recommendation 17.

Recommendation 12 On qualification of crew In addition to their minimum operational crew, passenger launches should be required to carry persons trained in emergency procedures, the number required to be linked to the number of passengers actually carried at the given time. These additional persons could be bar or catering staff. (The Department).

Action completed Local agreement has been reached on minimum manning levels for day-time and night-time vessels on the Thames. These requirements are set out in the Passenger Certificate issued by the Department on completion of the annual survey and operating trials. In addition training courses in safety and emergency procedures will be required for all crew, including those designated as bar/catering staff. The Consultative Document on proposals for a new Boatman’s Licence requires the

33 DEPARTMENT OF TRANSPORT: SHIP SAFETY

number of crew to be shown on the Passenger Safety Certificate for both day and night working.

Recommendation 13 All launches on the tidal Thames when carrying passengers should be commanded by a man who is, at least, fully qualified as a Waterman. (The Department and Port of London Authority).

Action completed The current statutory requirements provide for regulation of the competency of persons navigating passenger boats and lighters on the Thames. Licences are required by all persons who navigate a boat used for carrying passengers for reward. The Port of London Authority have introduced improvements before licences can be renewed. These include for new entrants from July 1990 a medical fitness certificate and from December 1991 for existing Watermen and Lightermen, demonstration of up-to-date experience.

Recommendation 1.5 For small passenger vessels elsewhere, the Boatman’s Licence should be given statutory status and made the minimum requirement for the Skipper, and its syllabus should be revised. (The Department).

Action The Department accepts, in principle. the recommendation for a statutory licence and are reviewing the licensing arrangements and requirements. The Department circulated a Consultative Document in September 1991 to industry to consider the statutory status of the Boatman’s Licence and intend to complete the review in Spring 1992.

Recommendation 17 The development by the Department of Regulations to cover permissible hours of work should be pursued and should cover persons operating river craft as well as sea-farers. Pending the development of requirements, passenger launch operators should ensure that crews do not undertake two successive cruises on the same night. (The Department, Port of London Authority and Launch Operators Association).

Action The Departmentcommissioned a study into “Hours of Work, Fatigue and SafetyAt Sea” before the MARCHIONESS. A formal Consultation Document was circulated in September 1991. Following the study, preliminary draft regulations and a code of practice were circulated to representative organisations for informal consultation. The Department fully endorse the desirability of limiting the hours worked by river craft operators and have proposed that they be limited to those currently in force for Public Service Vehicle drivers.

Recommendation 24 On life-saving appliances A further review of life-saving appliance requirements for Class V vessels should be made before the draft regulations are submitted for consultation. [The Department].

Draft Regulations were developed for circulation to industry in August 1989. However, as a result of the MARCHIONESS the Department decided to delay publication pending further recommendations from Marine Accident Investigation Branch. These recommendations were taken into account in a Consultative Document issued in May 1991. The proposals will improve the safety of all types of

34 DEPARTMENT OF TRANSPORT: SHIP SAFETY

small passenger ships operating on the rivers, lakes and around the United Kingdom coast. After taking account of the many comments received revised draft Regulations were circulated to the industry for further discussion and comment in November 1991.

Recommendation 26 On operational practice The Department of Transport should make every effort within their power to ensure that compatibility with good operational practice is the first consideration in the design of ships and the provision of their equipment; and should use their influence to foster this approach throughout the maritime community, both in the United Kingdom and at the International Maritime Organisation (The Department).

Action completed The Department are taking account of this recommendation at all appropriate opportunities and will continue to monitor matters to ensure that continuing attention is given to its provisions.

35