SAFETY REPORT Small Craft Passenger Transport in Greenland OCTOBER 2020 SAFETY REPORT on SMALL CRAFT PASSENGER TRANSPORT in GREENLAND Published By

SAFETY REPORT Small craft passenger transport in Greenland OCTOBER 2020 SAFETY REPORT ON SMALL CRAFT PASSENGER TRANSPORT IN GREENLAND published by

DMAIB Danish Maritime Accident Investigation Board Batterivej 9 DK-4220 Korsoer Denmark

The report is issued on 1 October 2020.

Photo: Passenger craft in Greenlandic waters Source: Private photo

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The investigations are carried out separately from the cri- minal investigation, without having used legal evidence procedures and with no other basic aim than learning about accidents with the purpose of gaining and promo- ting an understanding of safety. Consequently, any use of this report for other purposes may lead to erroneous or misleading interpretations.

2 Content

Board statement ��5 Introduction ��6

PART 1: PASSENGERS, CRAFT AND VENDORS ��7 Passengers ��8 Description of passengers on small passenger boats ��8 Passengers’ notion of safety ��10 Passenger craft and vendors ��11 Diversity in small craft ��11 Craft owner and crew’s notion of safety ��12 Types of craft – commercial or recreational ��12 Authorities’ notion of safety ��14 Craft used by professional vendors ��14 Manning the craft ��16 Language barriers ��17 Craft used by other vendors ��17 Safety implications ��20 Structural vulnerability of small craft ��20 Emergency equipment ��20 Attitudes towards lifesaving equipment ��22 Maintenance ��23 Operation of small craft ��23

PART 2: COASTAL NAVIGATION ��24 Navigation in Greenland ��25 Geography ��25 Climate ��29 Quality of sea charts ��30 Safety implications ��33

PART 3: SEARCH AND RESCUE ��35 SAR operations ��36 Reporting incidents ��36

3 PART 4: REGULATION OF SMALL PASSENGER CRAFTS ��37 Regulation ��38 Order on small commercial vessels carrying a max. of 12 passengers ��38 Provisions ��39 Safety implications ��41

PART 5: CONCLUSIONS ��42 Safety challenges ��43 Properties of the craft and equipment ��43 The operation of the craft ��44

ANNEX: GROUNDING OF JUVEL ��45 Investigation ��46 Background ��46 Sequence of events ��47 Navigation on JUVEL ��49 JUVEL’s regulatory history ��49 Analysis and conclusion ��50 The grounding ��50 The evacuation ��51

4 Board statement

The Danish Maritime Accident Investigation Board (DMAIB) has been notified of several serious accidents in Greenland involving small craft below 15 metres in length. Most of the accidents resulting in fatalities have not been investigated, because they were outside the scope of the regulatory framework of the investigation board, being legally considered to be leisure craft. Two accidents, which were within the DMAIB jurisdiction, because they were considered to be commercial craft transporting passengers, only resulted in damage to the craft, but had the potential to cause multiple fatalities.

The investigations showed that accidents involving small craft passenger transport cannot be explained without an understanding of the necessity of everyday seaborne travel and the highly specialised competencies necessary for navigating safely in the desolate and remote areas of Greenland. These competencies are largely based on traditions and skills derived from leisure boating. Therefore the investigation into small craft safety cannot be limited to commercial craft, but most also in part comprise leisure craft.

The intention of this report is to shed light on safety issues related to small craft passenger transport and is aimed at the Danish and Greenland authorities, navigational colleges and cruise ship operators who depend on small craft passenger transportation.

The scope of this safety report is thus twofold: Firstly, to provide a general overview of small craft passenger transport in Greenland and, secondly, to gain an understanding of the safety problems that the operators and the craft’s crews meet when they operate in the arctic waters of Greenland.

The investigation is based on data gathered from various parties directly and indirectly involved, e.g. the regulatory and judicial authorities, operators and crew, passengers, trade organisations and rescue services. There is little statistical information about marine accidents and incidents in Greenland, particularly related to small craft. The limited statistical information available has thus not been useful in shedding light on the subject.

The report is organised as follows:

• Part 1 outlines the passengers, the craft and the vendors and describes the safety implications of using small craft for passenger transportation. • Part 2 describes the challenges of coastal navigation and the safety implications for small passenger craft. • Part 3 briefly describes the organisational aspects of search and rescue in Greenland. • Part 4 describes how small passenger craft are regulated and how it affects the safe operation of passenger craft. • Part 5 presents conclusions from the safety implications described in the previous parts of the report. The conclusion can be read independently of the other parts of the report.

5 Introduction

The absence of land-based transport infrastructure in Greenland necessitates transportation by sea when travelling between the settlements and towns, which are predominantly located near Greenland’s coastline. Furthermore, many leisure and commercial activities involve transportation by sea such as fishing and hunting, recreational activities and guided tours to tourist attractions. In Greenland transportation by sea is a necessary and everyday activity which is highly interwoven with society and is not perceived as a high-risk activity that necessarily requires a formalised approach to safety, e.g. in terms of a formalised theoretical and practical training. Thereby, commercial and leisure activities at sea are inextricably linked.

Greenland’s 44,087 km coastline has a large variation in the geographic and meteorological conditions, which needs to be considered when navigating with small craft along the Green- land coastline, e.g. movement of ice, rapidly changing weather conditions and the location of underwater rocks. Knowledge about these conditions largely remains isolated to the local population who operate the small craft due to the remoteness of some populated areas.

In terms of safety, three different groups play key roles: The authorities responsible for regulating safety at sea, the operators/crew who manage the front line operational safety when navigating small passenger craft, and finally the passengers who make use of the services provided by the small craft operators. It is important to note that the notion of safety is not necessarily consistent across these different groups. To understand why accidents sometimes happen, and more importantly, why coastal navigation in Greenland is predominantly safe, it is necessary to also examine the various understandings of safety that exist, and how they affect the measures taken to ensure safety.

If the local perception of risk and safety is viewed on the basis of the same premises used for the assessment of risk associated with seaborne activities in e.g. Danish coastal waters, there will, for example, be a mismatch between the local crew members’ perception of safety and the authorities’ perception of safety. This mismatch can lead to unsuccessful attempts to manage safety by the authorities. Another implication of the geographical and societal conditions in Greenland is that accidents with small craft must be investigated with an understanding of the local context. Different analytical frameworks are thus required to explain accidents compared to those happening in e.g. Danish waters.

In this report the grounding of JUVEL (annex 1) and the foundering of INUK II serve as cases to exemplify some of the problems that seafarers experience when navigating in Greenland waters. The cases will also illustrate how difficult it can be to balance the mandatory requirements in the regulations and the formalised approach to safety with the necessity of provi- ding passenger transportation.

6 Part 1

Passengers, craft and vendors

7 Passengers

Description of passengers on small passenger boats

Passengers travelling on small passenger boats in Greenland include a variety of groups of people who have different needs for transportation. For the purpose of this report two main groups with subcategories have been defined: residents and non-residents.

The residents in Greenland are the largest group of passengers. In the absence of land- based infrastructure, transport by small craft or ships is often the only option when travelling between villages to family gatherings and sports events, etc. Most of the larger towns have airline and helicopter connections, but this mode of transportation is infrequent, expensive and has frequent delays and cancellations due to changing weather conditions. Transport with small craft is thus a convenient and cheaper mode of transport. Passengers who are residents also include passengers working for the local authorities, e.g. police and social services, travelling on official business. Travel arrangements by small craft are often made via informal networks or organised ridesharing. Residents travelling on small craft are characterised by having some understanding of the hazards of seaborne transportation and the necessary precautions to be taken. They do not expect the crew to provide for their safety in terms of safety equipment, etc. They are informed passengers.

CASE

On JUVEL (figure 1), which grounded on 24 August 2014, there were two crew members and a group of 12 passengers from the local community (9 children/ young persons and 3 adults). They were for the most part used to being at sea and kept calm during the evacuation which was considered to be a disruption of the voyage rather than an emergency situation.

Figure 1: JUVEL Source: Private photo

8 Tourists are the other main group of passengers and consist of two main categories: The first category consists of passengers travelling in groups whose transportation is arranged by travel agencies or local excursion providers on behalf of e.g. cruise ships. These tourists primarily travel on certified passenger craft carrying 7-25 passengers, specializing in excursion tours and the occasional transportation of passengers between villages. The second category of passengers is tourists travelling as individuals and making their own travel arrangements. They often arrange boat trips on their own initiative, without prior arrangements by travel agencies. The vendors are found via tourist offices, local ads, travel agencies or simply by asking locals to bring them on a tour. Neither category of tourists is familiar with the local conditions in Greenland, nor do they have prior knowledge about small craft transportation. These passengers not only pay for transportation and sightseeing, they also pay for the vendor to provide safety. Both categories of tourists are uninformed passengers (figure 3, next page).

CASE

On INUK II (figure 2), which foundered on 13 August 2016, the 23 passengers were embarked from a French cruise ship and were of Italian and French nationality. They had no experience being on a small passenger craft or being on a craft in an arctic climate. Up until minutes before evacuating the craft, they did not realise that they were in an emergency situation and relied on the crew to give them instructions. When the passengers stepped into the water on the aft deck, they were surprised to learn how cold the water was.

Figure 2: INUK II Source: Private photo

9 Informed passengers: Local residents

Uninformed passengers: Non-residents/Tourists

1. Tourists travelling in groups. Arrangements made by travel agents. 2. Individuals whose local travelling arrangements are made opportunistically.

Figure 3: Different groups of passengers Source: DMAIB

Passengers’ notion of safety

To the vast majority of the passengers who make use of the services provided by the small passenger craft, safety is something that is taken for granted when a ticket is bought or when other agreements are made about travelling on a craft. Uninformed passengers cannot be assumed to have any prerequisites for evaluating the safety of the craft. They need to rely solely on the immediate sense of professionalism observed and the presence of safety equipment, e.g. life raft, life buoys, etc.

Safety can be said to take the form of feeling safe, a prerequisite for being able to enjoy the primary reason for making use of the service, namely to reach a destination or to have an excursion experience. The experiences sought vary greatly. Greenland is branded as a place for exploration and explorers, and those who come to explore may seek out a more “authen- tic” experience. This results in pushing the boundaries of feeling safe. An example of this is when tourists engage craft with a local fisherman or hunter. In these cases safety is not a well-articulated or prioritised goal for the uninformed passengers.

The informed passengers, i.e. the local population, are uniquely qualified to make a judgement about the safety of the craft and its operation based on their previous experiences. That does not mean that they would automatically choose a professional vendor. Informed passengers judge safety on the basis of a view of safety based on the everyday activities they have been engaged in since childhood. This does not necessarily entail formalised safety precautions, e.g. written procedures, the use of life jackets, etc. Neither category of passengers can thus be expected to choose a craft which offers safety as defined by the authorities, i.e. they will not be concerned about the craft having permits, certifications, etc. They rather rely on knowledge about the experience of the person operating the craft.

10 Passenger craft and vendors

Diversity in small craft

There is great diversity in the types of small craft below 15 meters in length used for passenger transport in Greenland. Some craft are exclusively used for transportation of the various categories of passengers and some are also used for fishing, hunting and for recreational purposes, which can blur the distinction between the legal definition of passenger transportation and the recreational transportation of e.g. acquaintances, friends and family. This means that many of the available craft may potentially be used for passenger transportation, which makes it difficult to assess the actual number in use. For the purpose of this report, the vendors are divided between professionals who have procured the craft for the purpose of passenger transport and vendors who provide occasional seaborne transportation in their privately-owned craft.

Figure 4: POCA skiff with uninformed passengers Source: Private photo

Figure 5: Certified passenger craft with uninformed passengers Source: Private photo

11 Craft owner and crew’s notion of safety

For the craft owner and crew, the notions of safety are constructed by the necessity of travelling by sea and by financial gains. Safety is thus not an isolated goal and handling risk is integrated into the ongoing activities and concerns on board, alongside several others, e.g. getting to the destination on time.

Safety is created through a continuous assessment of the navigational circumstances that the passenger craft operates in. The owner and crew respond in order to mitigate perceived risks. This process of assessment and mitigation of risk is continuously ongoing when a craft is in operation, and it cannot be separated or extricated from other aspects of operating the craft, e.g. commercial interests. It is not a formalised set of safety measures (e.g. written procedures) or the application of specific legislative rules. For the owner and the crew handling safety often means a trade-off between a large number of conflicts, e.g. to apply high speed that ensures a timely arrival at the destination, while also increasing the risk of colliding with submerged ice floes. The conditions that the operators face and need to resolve vary to a large degree as a result of the geographic extent of Greenland and the structural properties of the craft. To this end, little guidance is found in rules and regulation. Regulation states which equipment is mandatory, but does not regulate the use of it.

Types of craft – commercial or recreational

Many of the smaller craft operating in Greenland waters are used for a number of different purposes depending on the situation and it is the use of the craft that determines whether it is a recreational or a commercial craft. The technical and educational requirements of The Dan- ish Maritime Authority (DMA) are stricter for commercial craft than for recreational craft. The reasoning for this is that for commercial craft there may to some extent be what is referred to as an ‘economical conflict of interest’ between the owner/operator/master and the passengers. The conflict is that, in many cases, the people responsible for the safety on board a craft (the owner/operator) are not the same people who rely on that safety (the passengers), and that the paying passengers have no influence on the safety level on board.

In the regulation, it is the use of a craft that determines whether it is a recreational or a commercial craft. In this context, the design, the appearance, the means of propulsion and the manning are not relevant; only the application of the vessel. A recreational craft is typically a craft that the owners use for leisure purposes such as excursions or yacht racing, and for hunting and fishing. The boat is, however, still a recreational craft, if the owners invite guests or hands aboard without receiving remuneration, lend the boat to other persons without receiving remuneration, or if they engage a crew. Fundamentally, only the owners have expenses in connection with the purchase, operation, maintenance and use of a recreational craft. The use will, however, not be considered commercial just because guests or hands contribute, to a limited extent, to food, fuel or harbour charges. Craft that navigate with paying passengers on board or are hired with a master, crew, guide or the like are considered commercial boats.

The two most important points from the above are 1) that the reason for distinguishing between commercial and recreational trade is mainly the conflict of interest that might exist between the passengers and the person responsible for the level of safety, and 2) that such a distinction can be difficult to make. For instance, the use of a boat will not be considered commercial, if passengers contribute to the boat’s fuel, but if they pay a fare it is. In a society where craft are the core of infrastructure, the distinction between a passenger and any other person can become blurred. For further elaboration on the legal distinction between types of craft, please read the section ‘Regulation of small passenger craft’.

12 Figure 6: Privately owned skiffs Source: DMAIB

13 Authorities’ notion of safety

The small craft passenger trade in Greenland is regulated by the Danish Maritime Authority. Safety is perceived to be achieved through the creation of rules and compliance with the same. This is manifested by the symbol of the “Permit for the Carriage of Passengers” that must be made readily available and displayed to the passengers on board a passenger craft. In this way the regulator communicates to both the operator and the passengers that the craft is structurally fit and equipped to serve the purpose of transporting passengers safely. At this level safety is associated with the goverment’s ability to uphold regulatory requirements by surveying and certifying the craft and crew. Operationalisation of safety plays a minor role, and the responsibility for safe operation is pushed down to the level of the owner of the craft and the crew. This may be observed in the rules with examples like “the shipowner … identifies the risks associated with the navigational activities”. With this wording a lot of factors are left to be resolved by the owner and crew.

CASE

The maximum capacity of passengers on INUK II was determined by the maritime authority on the basis of prescriptive legal requirements in terms of space, seats and the available lifesaving equipment. However, the regulation was abstract in relation to how the equipment was to be utilised, because there were no requirements for the content of the safety management manual or requirements for any actual testing of the lifesaving equipment. In order to bridge the gap between the prescriptive and the abstract requirements, the owner hired a consultant who had the necessary knowledge about how to create a safety management manual which could be approved by the maritime authority. However, the consultant had no knowledge about the operational realities of evacuating INUK II, and an actual test of the life-saving equipment was not conducted. The result was a procedure for evacuation which was unusable for the crew members on INUK II.

Regulation develops over time, and changes are frequently introduced based on knowledge of new risks that have been identified following accidents. Thus, the regulation that is seen to govern safety is of a predominantly reactive nature: It is developed after accidents and incidents.

Craft used by professional vendors

The craft used by the professional vendors, who specialise in transportation of passengers between villages or sightseeing tours, vary in type and size. They may be wooden cutters or glass-reinforced plastic (GRP) boats, such as POCA skiffs, carrying up to 12 passengers. According to the owners, GRP craft, e.g. Targa and Nord Star, are widely used, because they are cost effective to maintain, they are fast and highly manoeuvrable and can be structurally modified by the manufacturer to meet the arctic conditions. Safety considerations are also made in terms of the manoeuvrability and stability of the craft, which are necessary characteristics for the craft to possess when navigating at high speed in waters where ice and other obstacles can be met. Craft that do not have heated accommodation are primarily used for shorter excursions.

14 The overall considerations of the professional vendors when choosing a craft for passenger transport are cost effectiveness, speed and passenger comfort in terms of accommodation and available deck area for the passengers to view the scenery. Rigid inflatable boats (RIB) are used by the professional vendors and cruise ships on shorter excursion trips, but are not commonly used on trips lasting more than a few hours, because they offer no accommodation facilities for the passengers.

CASE

JUVEL and INUK II were older craft which could carry 27 and 22 respectively, because they were surveyed and approved according to older regulation. These types of craft are approved for carrying more than 12 passengers, which make the craft highly profitable, because they are permitted to carry a high number of passengers compared to their size.

Older wooden craft are used in trading areas were the distances to ports and sightseeing scenery are relatively short, because they are slower than other craft and typically have no lounge where the passengers can sit and watch the scenery while in transit to the sightseeing areas. These older craft have often previously served as fishing boats, patrol cutters or research craft.

The vendor’s choice of commercial craft is dependent on the above factors and the need to meet the regulatory requirements in order to be certified by the maritime authorities. Consid- ering the overall safety aspects of the craft’s design is seen as less pertinent.

From a safety perspective, the layout of the craft is vital for how effectively an emergency such as loss of buoyancy or a fire can be handled. The deck area available, for example, determines if there is enough space for the passengers to be assisted in donning the lifesaving equipment and later evacuated. Furthermore, an expedient and swift evacuation is only successful, if the craft is in a stable condition, e.g. without excessive list, which is difficult because small craft are highly susceptible to loss of stability when a flooding occurs. In case of fire the craft will quickly become engulfed in smoke which hinders an orderly evacuation from the deck area.

CASE

Having a small deck area became a safety problem on both JUVEL and INUK II, because there was no room for assembling all the passengers outside and aiding them in donning lifejackets or immersion suits. As the craft are small with few large compartments below the water line, they become sensitive to changes in stability and buoyancy, if a substantial water ingress occurs.

15 Manning the craft

The different types of passenger craft are typically manned by local residents. However, during the busy tourist season, between May and September, the high demand for excursion tours makes it difficult for the vendors to recruit certified local crew. It is thus common for crew members to be recruited from elsewhere in Greenland or from Denmark. Crew members from Denmark specifically have little or no knowledge about navigating in Greenland waters, which necessitates a period of training and familiarisation. This is provided by local residents or crew members that have experience navigating in the particular area that the craft is operating in.

CASE

On JUVEL and INUK II the masters were not local residents and had no prior knowledge about navigation in Greenland waters. Even though the masters held certificates as masters of cargo ships, it was necessary for them to receive training and guidance from locals, before they were able to navigate independently. Even though both were certified navigators and one had extensive experience in worldwide trade, they were both considered novices in terms of coastal navigation in Greenland.

In areas with a high influx of tourists in the peak season, e.g. during cruise ship arrivals in Ilulissat, some vendors struggle to meet the growing demand for excursion tours and transportation between villages. To optimise the capacity of the passenger craft, they have to be in use as often as possible, which necessitates the crew members to be at sea for prolonged periods of time. With the shortage of qualified crew members, the busy schedules often result in sleepiness and other fatigue symptoms among crew members. Given that most GRP boats travel at high speeds (25-30 knots), the lookout duty requires focus and concentration, which in turn adds to the navigator’s workload and thus fatigue.

The problem with recruiting certified masters has predominantly been with craft licensed to carry more than twelve passengers. The safe manning document on these craft state that the master is to hold a master home trade certificate (master home trade). This makes it necessary for the vendors to look elsewhere, even abroad, to find suitable candidates. These, however, have no knowledge about navigating in arctic waters. The vendor needs to balance the requirements set out in the safe manning document with hiring masters who have little or no knowledge and skill in navigating in the local area. For craft carrying twelve passengers or less, the certificate of competency is obtained by completing a four-week course in Green- land and having three months experience with a small passenger craft in the local area where it operates. Experience navigating in arctic areas in general is not a requirement. That is why some non-locals use the courses to obtain summer jobs as masters of small passenger craft without having any experience with passenger transport and/or navigation in arctic waters.

A dilemma thus exists between hiring a local person with experience and knowledge navigating in the local area, but with without the mandatory certificate, and hiring a person with the certificates, but no local knowledge. The result is that some craft are operated with crew members that do not hold the required certificates, which was the situation on INUK II. This situation poses a significant safety dilemma, which is not easily managed.

16 CASE

On JUVEL the master held a certificate as master mariner but did not initially have any experience navigating in arctic waters. Therefore, the deckhand acted as men- tor, so the master could gain the necessary skills to operate the craft safely. On INUK II the master was mentored by a former, uncertified master before being deemed qualified to operate the craft independently.

Language barriers

The uninformed passengers, i.e. tourists, are of all nationalities, resulting in a language barrier between crew and passengers, because many crew members and/or passengers are not proficient in English. With regard to the tourists from the cruise ships there is typically a guide or assistant from the ship who acts as a liaison between the crew members and the passengers.

On a small craft, time for evacuation is sparse. The language barrier can thus be a determining factor, if an emergency situation occurs where the passengers have to be instructed in donning immersion suits, life jackets, etc. The informed passengers will typically not have a language barrier, unless they are residents who do not speak Greenlandic and the crew does not speak Danish.

CASE

It was common for INUK II to carry passengers who did not speak or understand English, which the crew was proficient in. Therefore, there was a guide from the cruise ship on board on the day of the foundering. During the emergency many of the passengers were worried about the situation due to the lack of information provided, which was in part because of the language barrier.

Craft used by other vendors

It is a regulatory requirement that craft used for passenger trade are surveyed and approved by the Danish Maritime Authority (see section ‘Regulation of small passenger craft’). The majority of the professional vendors operate craft which are approved for carrying passengers, but DMAIB has been informed by various parties that the high demand for transportation has created a market for some professional vendors to provide transportation of uninformed passengers by craft not approved by the maritime authority. Transportation by non-approved craft is mostly provided by locals who provide the occasional tour for individual tourists look- ing for a short fishing trip or excursion. It is, however, uncertain how many craft are involved in these activities and how many passengers are being transported by non-approved craft.

The cruise ships are another type of vendor, who also provide excursion tours to see icebergs, wildlife or on short trips ashore using small, rigid inflatable boats. The types of craft used by the locals for hunting, fishing or transportation between villages are basically the same as the ones the professional vendors use. However, the skiffs, e.g. POCA, used for hunting and fishing trips and general transportation of family and friends, are not spacious or comfortable enough to carry large groups of people. Therefore, it is typically individuals whose local travelling arrangements are made opportunistically that travel with local skiffs.

17 Figure 7: Privately owned skiff Source: Private photo

Figure 8: Certified passenger craft with informed passengers Source: Private photo

18 The local population and occasionally officials (police responding to emergencies, medical staff, etc.) are also transported by local vendors who operate craft not approved by the maritime authority. Among these vendors there is a pragmatic approach to the concept of being a passenger, which is not grounded in the legislative understanding of a passenger. This pragmatic approach can be the result of practises where informed passengers are transported as a friendly gesture or for a small fee, blurring the regulatory distinction between what constitutes a passenger and a person who is not a passenger. Sports teams, authorities and family members are therefore transported due to the fundamental necessity of transportation between villages where there is no other viable infrastructure. These informed passengers weigh the benefits and drawbacks of each travel arrangement and make decisions about the choice of craft.

At times, the uninformed passengers also use local vendors, as exemplified by an accident which occurred with a Nord Star 26 GRP craft that foundered on 26 August 2014 near Appat. On board were four tourists and one crew member. All five persons perished. The boat was bringing the four tourists from the village Saqqaq to Ilulissat, a distance of approximately 50 nautical miles. The motivation for choosing a private craft was that the regular boat service did not have a convenient schedule. The craft and the crew member were never found, but the bodies of the tourists were found drifted ashore, not wearing lifesaving equipment. There are conflicting reports about the payment for the transportation. The tourists did most likely pay for the transportation and were thus in a regulatory context passengers, but they knew the owner of the boat, and the fee might well have been paid as a courtesy.

The crew on craft not approved for passenger transport have varying backgrounds in terms of formal navigational training and schooling. Because many of the craft are mainly used for hunting and fishing, the crew members are highly knowledgeable about navigating in the local area and in arctic areas in general. The craft are not, however, equipped with sufficient lifesaving equipment for passengers, since the craft are not mainly used for the transportation of passengers. Uninformed passengers are not aware of this and do not take it into account when hiring a local non-approved craft for an excursion tour.

Figure 9: Commercial passenger craft (INUK II) with uninformed passengers Source: Private photo

19 Safety implications

Structural vulnerability of small craft

As the passenger craft are relatively small, they are vulnerable to various kinds of accident scenarios. If an incremental or massive flooding occurs, the stability is quickly diminished, so the crew has little time to act before it is too late to initiate an orderly evacuation. Further- more, if the craft is carrying e.g. 12 passengers with luggage, the weight of the passengers accounts for a high percentage of the total weight of the craft. This makes the craft unstable, when the passengers start moving to one side, e.g. when evacuating the craft due to flooding.

Small craft are particularly sensitive to water ingress, because they are typically not designed with water tight bulkheads that enhance the survivability of the craft. Furthermore, the crew are typically not familiarised with the stability characteristics of the craft and the consequences of even small leakages. These problems have been evident in various small fishing boat accidents in Denmark which DMAIB has investigated. From those investigations it has been evident that easy accessibility of the lifesaving equipment is vital for the survivability of the people on board due to how few minutes are available before the craft capsizes or loses buoyancy.

CASE

The investigation into the accident on 14 August showed that INUK II’s designed ability to deliver a successful evacuation could be questioned, because of the sparse time available to evacuate the boat, which was closely connected to the size of the craft and the number of passengers that the boat was certified to carry. Furthermore, INUK II became increasingly unstable and listed excessively to both sides. In order to compensate for the rolling motion, the guide on INUK II stood on top of the wheelhouse trying to use his body weight to keep the boat upright.

Emergency equipment

There is great variety in how the various small craft are equipped with emergency equipment ranging from none at all to being fully equipped according to the regulation for small passenger craft (see section Regulation of Small Passenger Craft). The type and amount of emergency equipment depends on the size of the craft and the trading area. On approved passenger craft the equipment typically consists of lifejackets, anti-exposure suits, EPIRBs and life rafts. Some craft are so small that it is not possible to carry a life raft, and they are therefore exempted by the authorities from carrying one – but are then only allowed to trade in restricted areas close to shore.

Depending on the size of the craft, regulation requires passenger craft to carry life rafts, thermal protective equipment and lifejackets, but the regulation does not specify how or where to store the equipment which affects the time it takes to don the equipment and deploy the life raft. In other words, the regulations do not state how the equipment is intended to be used. It is thus the owner of the craft who must design a concept for the handling of emergency situations with the use of the mandatory equipment.

20 DMAIB has noticed a lack of consistency in how the owners and crew members assume the equipment is to be used in an emergency situation. There seems to be no coherent strategy for the practical use of the individual types of equipment. The safety instructions developed for the various craft are highly generic and do not offer instructions for varying circumstances. For instance, there is uncertainty about the purpose of the anti-exposure suit. It is unclear, whether the suit is meant to provide redundancy to the life raft, i.e. if the life raft is unavailable, the passengers and crew can don anti-exposure suits and be evacuated directly into the sea. Alternatively, the anti-exposure suit could be intended to keep the passengers warm once they are in the life raft. This would mean that other thermal protective clothing could be used instead of the anti-exposure suit. Additionally, it is questionable whether there is sufficient time to assist the passengers in donning the equipment and carrying out an evacuation, before the craft is submerged or capsized.

One factor that delays the process is the limited space available for assisting the passengers – a problem that was evident on INUK II and JUVEL. Passengers are not familiarised with the use of immersion suits and must be assisted in donning the suits and lifejackets, prolonging the evacuation process. Typically, the craft are not equipped with immersion suits for children, and the survivability of children is thus diminished, if the passengers are to be evacuated into the sea.

When entering the water in arctic areas, it is a matter of seconds before the bodily functions are diminished, rendering it difficult to board a life raft from the sea or to swim ashore. Most types of lifejackets are designed to be used as passive floating devices, and the person wearing the lifejacket is not intended to be mobile while wearing it, which makes it difficult to swim, enter life rafts, etc. Wearing such a floating device in arctic waters does therefore not significantly increase the survivability unless thermal protective clothing is worn, e.g. immersions suits. If a passenger has donned an immersion suit and lifejacket, it becomes difficult to get the passengers on board a life raft, because it requires knowledge and skills that most passengers do not possess. It is therefore not a viable strategy to have the passengers enter the life rafts from the sea. The only viable way of evacuating a craft is thus from the craft directly into a life raft or donning an immersion suit and jump into the sea, before the craft founders.

CASE

From the INUK II report: The crew’s perception of how long it would take to evacuate the boat was one notable area where there was a discrepancy between the general principles of the lifesaving equipment and the practical implementation of the equipment.

The investigation into the layout of INUK II and its lifesaving equipment confir- med the doubts the crew members had about the effectiveness of the lifesaving equipment and the emergency procedures in an evacuation scenario – specifically that time would be an issue in an evacuation scenario. Before the accident, at the table top exercises, it was recognised by the master that a successful evacuation would be completely dependent on the time available, and it was concluded that the passengers would most likely not have time to put on the immersion suits and lifejackets prior to boarding the life rafts.

21 Figure 10: Commercial passenger craft (JUVEL) with informed passengers Source: Private photo

Attitudes towards lifesaving equipment

The low number of emergencies that involve a successful evacuation from small passenger craft means that there is little available data on how usable the emergency equipment is. However, interviews conducted with a variety of operators also suggest that there is wide- spread pessimism regarding the practical utility of the equipment in emergency situations.

DMAIB has found that this pessimism can be related to the absence of practical drills where the equipment is tested. The implication is that an emergency evacuation is usually often the first time the safety instruction and the safety equipment are tested. Taking also the various notions of safety outlined above into consideration, this further reduces the chances of a successful evacuation.

22 Maintenance

The passenger craft not certified by the authorities are not surveyed. This means that little verified information is available about their emergency equipment. As the craft are only occasionally used for passenger transportation and are often too small to carry a life raft, they are not equipped in the same manner as certified craft and do not have elaborate safety instructions describing the evacuation process. For these craft, the safety of the crew and passengers is dependent on the mechanical and structural reliability of the craft. Continuous maintenance and the quality of repairs are thus vital for the reliability and safety of the craft.

CASE

From the INUK II report: “The investigation of the foundering of INUK II established that during the repairs of INUK II’s rudder stock or the fuel system, a hose connecting the aft deck drain to the discharge pipe was removed. After the repairs were completed, the drain hose was not mounted again. The investigation did not bring clarification as to why the hose was not mounted. Presumably the mechanic, for unknown reasons, forgot to mount the hose again after having removed it to get access to components in the cramped steering gear compartment.

The local workshops that carried out the repairs were not able to test the systems on the boat, neither while it was on shore nor in the water, because it was not customary for the workshops to carry out sea trials as they were not specialised in boat repairs.”

Operation of small craft

As described above, a number of aspects need to be considered when assessing the navigation with small craft in the arctic waters of Greenland. Whether the passengers are informed or uninformed, whether the craft is approved for the transportation of passengers and equipped with the required safety equipment and adequate instruction for its operation. The structural vulnerability of the small craft, maintenance levels and language barriers must all be taken into account.

As mentioned earlier, a dilemma also exists between hiring a local person with experience and knowledge about navigating in the local area, but not holding the mandatory certificate, and hiring a person with a certificate, but with no local knowledge. This dilemma highlights how safe navigation in Greenland rests on the crew’s specialised knowledge and expertise. The following section will therefore describe and analyse some of the challenges that crews on small passenger craft meet in the coastal waters of Greenland.

23 Part 2

Coastal navigation

24 24 Navigation in Greenland

Navigating in Greenland coastal waters is substantially different from navigating in non-arctic coastal waters. The strategies and practises that small craft use are the result of years of adaptation to the specific geographic and climatic conditions along Greenland’s 44,087 km coastline. In addition, the quality of sea charts also affects the navigational practices. In the following, it will be elaborated how these conditions influence the way small passenger craft operate in Greenland coastal waters.

Geography

Travel is not limited to transportation between villages and cities. The trading pattern of small passenger craft comprises the entire coastline as a potential destination for passengers to villages, tourists on sightseeing excursions and other types of passengers such as students being transported to camp sites.

Due to the large distances between cities, villages and other destinations, the craft often navigate in desolate areas where assistance cannot be rendered quickly, if an emergency arises. Therefore, the crew on small passenger craft will typically notify others about where they are heading, and when they are scheduled to arrive at their final destination. However, when an accident occurs, emergency assistance may be delayed for mainly three reasons. Firstly, among operators there is an understanding that the presence of ice or a sudden change in weather conditions might cause considerable delay in the expected arrival time, so a craft will not immediately be reported missing. Secondly, the crew might not have the opportunity to transmit a distress signal before the craft founders, making it difficult for the search and rescue services to define a manageable search area. Thirdly, the crews on small passenger craft do not necessarily use the regular VHF distress channels to make emergency calls, but working channels, and a distress message might therefore be delayed in reaching the emergency services.

Figure 11: The entire coastline is a harbour Source: Private photo

25 Figure 12: The entire coastline is a harbour Source: Private photo

CASE

For the crew on JUVEL it was customary to call the coastal radio station Aasiaat Radio upon departure on longer voyages to inform them about the plan of the voyage. In the event that JUVEL went missing, the coastal radio station could inform the authorities.

CASE

The Nord Star 26 GRP craft, which foundered on 26 August 2014 near Appat, transmitted a distress message which was received by Aasiaat Radio, but the crew member did not provide a sufficiently accurate position for the search and rescue efforts to be effective.

26 Due to the large distances between destinations, the craft also tend to keep a high speed (25-30 knots) for a timely arrival at the destination. Choosing the craft’s speed depends on a variety of factors, e.g. distance travelled, the presence of ice, shoals, local knowledge, changing weather conditions, etc. Sometimes high speed is necessary, because the crew has safety concerns, e.g. getting to the destination before dark (depending on the season) or arriving at the destination before the weather or the presence of ice makes navigation hazardous. At times the speed is kept low, because the presence of ice or the sea conditions do not allow for high speed. So the crew has to balance various goals simultaneously when choosing the speed. The crew’s ability to balance these goals is key to ensuring safe navigation – an ability obtained by experience and the passing on of knowledge between relatives, friends and colleagues.

With that experience and knowledge, the crew is able to make critical decisions about safety, e.g.:

• Determining when it is safer to navigate close to shore in a poorly surveyed area instead of in the middle of the fjord where there might be scattered ice and or a higher wave height.

• How to manoeuvre the craft at high speed in areas with scattered ice while observing which route to choose to get safely through the area.

• How the presence of uncharted obstacles, e.g. shoals, affects the choice of route, also taking into account the tidal conditions.

• How the topography provides information about the presence of underwater rocks, etc.

• How to predict the local wind force, sea state and reduced visibility from e.g. changes in temperature.

• Which VHF channels to use when calling for assistance, because the local craft are typically not listening on VHF distress channels.

• Deciding when it is an advantage to navigate outside the protected waters of fjords where there might be unknown underwater rocks, which in turn means navigating in open sea with adverse weather conditions.

Figure 13: Small passenger craft navigating in an area with scattered ice Source: DMAIB

27 Figure 14: Small passenger craft at high speed close to the shore line Source: DMAIB

Figure 15: Commercial passenger craft navigating in area with icebergs Source: Private photo

28 Climate

In Greenland the climate is arctic, and the coastal waters contain varying degrees and types of ice all year round. The ice poses a considerable obstacle and hazard to navigation for small craft. For example, deviation from a planned route may be necessary in order to avoid drifting ice, ice may pack around a craft and trap it, and ice may be overlooked with fatal consequences when navigating at high speed. Along the Greenland coastline, it varies greatly how the ice affects navigation. Some areas are more prone to large ice formations. It also depends on seasonal changes which cause large ice formations to break into smaller parts, opening the opportunity for small craft to navigate through. However, if the weather changes, the ice may pack, trapping smaller craft in the large ice formations. Emergency calls to events where small craft are caught in packing ice are common.

Navigating in ice or close to large ice formations requires specialised knowledge about which ice is problematic or unproblematic to navigate in or near by. That specialised knowledge is mainly obtained by years of experience operating small craft in local areas. This is not taught in navigational schools in any detail usable for practical purposes. DMAIB has interviewed crew members from small passenger craft and has learned that crew members have difficulty explaining in detail what that knowledge and experience consists of. This means that the knowledge is to a large extent tacit and implicit and difficult to explain. Many variables must be taken into account, e.g. the position of shoals, how the local weather conditions affect navigation, that some large ice formations can be dangerous to approach and that some are safe, etc. This knowledge is applied daily when planning routes and/or when deciding the safe distance to various types of iceberg.

Figure 16: Certified passenger craft with uninformed individual passengers Source: Private photo

29 CASE

The navigation of INUK II was primarily based on the crew’s shared knowledge about the local area, which had been passed on from other crew members, who had more experience navigating the area. This knowledge consisted, inter alia, of what type of ice it was safe to manoeuvre in, and which icebergs could be approached safely. When navigating in the local area, the voyage was not planned in detail, because the presence of ice made improvisation necessary.

It can be hazardous for crew members who do not possess that tacit and implicit knowledge to navigate in areas where the presence of ice makes it necessary to deviate from routes or tracks that are known to be safe. Considering that the entire coastline is a potential destination, some voyages can be characterised as explorations with an unknown risk.

The Danish Meteorological Institute (DMI) provides information about weather and ice conditions through a number of communication channels, including a service telephone. However, for various reasons it is not necessarily common for all small craft operators to consistently make use of weather observations and forecasts. There can be several reasons for that. The local population has an extensive knowledge about the local weather conditions, making it superfluous to systematically use weather reports to plan far ahead. Furthermore, the weather conditions can be highly changeable and can worsen quickly, because the local topography influences the weather conditions. There is no fixed stop rule for when weather conditions are so adverse that it becomes hazardous to travel by sea. It is more a matter of when the weather is good enough for reaching the specific destination. As with determining the safe speed of the craft, the weather is also a matter of negotiating the necessity of travel with the presence of ice and the weather forecast.

Quality of sea charts

Most sea charts covering Greenland waters are based on data derived from imprecise, limited and older surveys. This makes the charts highly unreliable with respect to actual positioning. The positions that can be obtained from satellite navigation aids, such as GPS, are of greater precision relative to the paper charts and will therefore not reflect the craft´s position as plotted in a chart. This makes the use of satellite navigation aids unsafe in Greenland waters1. urthermore, systematic hydrographic surveying of Greenland waters is generally sparse along the coast and in many places the seabed is un-surveyed, and exact water depths are unknown. Many of the available paper charts are based on different datum than the WGS 84 datum, which may require a changeover on the satellite navigation aid equipment. However, an effort is in progress to develop new charts that meet contemporary stand- ards. These will include ENC charts for e.g. ECDIS systems and various chart plotter systems

CASE

The crew on INUK II primarily used the chart plotter for showing the tourists the progress of the tour and pointing out specific locations. It was not used for navigation, because no reliable charts were available for the area. When the tour boat was on whale watching tours, the echo sounder was turned off, because it could disturb the whales and drive them away.

1 Source: Danish Geodata Agency

30 Figure 17: Ice formation close to shore Source: Private photo

31 Figure 18: Navigational equipment on small passenger craft Source: DMAIB usually used on small craft. Official ENC charts are typically not in use in standard chart plotting equipment in small craft.

Despite the good positioning obtainable by satellite navigation aids, relative to the quality of the paper charts, some limitations constrain the performance of for example GPS positioning equipment. Both satellite based and ground-based augmentation systems such as EGNOS, WAAS and DGPS are either ineffective in the arctic area due to satellite-receiver geometry, or beacons are unavailable due to infrastructural challenges in Greenland. This makes improved position quality through these systems unavailable. Magnetic and gyro compasses are equally known to potentially become unusable or unreliable far north. Floating navigation marks are generally not used in the Greenland waters because of the ice conditions and the great water depths.

In the light of the above it has been recommended by the maritime authorities to rely primarily on radar and other terrestrial navigation methods and use satellite navigation as a secondary means which can be verified against terrestrial or radar data.

The practical implication of having unreliable sea charts is typically not seen as problematic for the day to day operation of small passenger craft, because the crew members have developed other methods for navigating safely. Some of these methods have proven to be effective but can also become hazardous. E.g. some crew members use chart plotter tracks from other craft to navigate in areas that they are not familiar with. However, following such tracks can be inexpedient, if the changing tides are not taken into account, and it is not taken into consideration that some craft have larger draughts than others. Furthermore, it is hazardous to deviate from the track, even when drifting ice is met on the intended and known track, because the craft then moves into waters where there is little knowledge about e.g. shoals.

32 CASE

On JUVEL the chart plotter was used with a track supplied from another craft. It proved to be effective, but only to the extent that the track was followed precisely. Once JUVEL deviated slightly from the track, it went aground on an underwater rock.

The chart plotter track may or may not be compared with charts or radar parallel index lines which may also be useful as a position reference. However, navigating by the use of radar can be problematic for many small craft, because the radar equipment on small craft does not offer the same overview and functionality as radars on larger ships. The screens on the radars are often small, and they are often mounted in such a way that it becomes trouble- some to continuously operate the equipment especially when the equipment is e.g. mounted from the ceiling of the wheelhouse. When travelling at high speeds, the crew must choose between operating the radar and chart plotter and keeping a visual lookout for obstacles in the water. That choice can result in important information not being recognised. From interviews with crew members from both approved and non-approved small passenger craft, it becomes apparent that safe navigation is dependent on the interaction between professional navigational practices and having local knowledge and expertise about travelling in an artic climate with unreliable charts.

Safety implications

It is difficult to generalise about how the challenges outlined above are handled. The majority of the official guidance offered on navigation in Greenland waters is mainly aimed at larger ships, and the advice offered is not necessarily practicable or suitable for small passenger crafts. Furthermore, the formal navigational training and certification, e.g. in navigation colleges, will not suffice. The formal navigation strategies taught may be inappropriate or ineffective for handling the challenges of navigating in an arctic climate and with unreliable charts. In other words: Having the mandatory certificate will not be enough for navigating safely in Greenland coastal areas, fjords, etc.

However, the crew on small craft possesses considerable knowledge and expertise about navigating in arctic conditions with changing weather conditions and unreliable charts. This knowledge and expertise is largely empirical and handed over and shared in the community or with colleagues in the trade, as few or no official records about the local navigational hazards are available. Due to the large geographical variations in Greenland, the knowledge about particular circumstances in a particular location may not be transferable to another location, e.g. knowledge about shoals, tidal conditions, underwater rocks etc. And, as previously described, the knowledge and expertise is tacit and implicit and thus difficult to describe in detail.

The necessity of possessing this knowledge and expertise becomes apparent when the crew members are met with the varying conditions which can make it difficult to make detailed voyage plans for longer or even shorter voyages. It may become necessary to deviate from the planned route, which means that navigation in coastal waters will be encumbered by a significant degree of “exploring” in uncharted waters.

33 The safety implication for small passenger craft is that having a certified crew does not in itself ensure that the challenges of navigating in Greenland waters are adequately met. On the other hand, the transportation of uninformed passengers requires a skill set, e.g. about the use of navigational equipment and the use of lifesaving equipment in a professional capacity, which is not obtained unless the crew has been professionally schooled and trained.

When there is an increasing demand for passenger transportation, e.g. during the busy summer season, it becomes difficult for vendors to recruit crew members who meet the criteria of having both the informal and formal knowledge and expertise. For approved passenger craft, regulation requires crew members to be certified.

CASE

INUK II and other craft operated by the owner of INUK II were normally manned with two crew members and occasionally a guide. The crew members were mostly local residents, but some were also hired from Denmark. This was because it was difficult to find available seafarers with the mandatory certification for operating the boats in the local area during the peak. Familiarisation and training was achieved by crew members being supernumerary on one of the boats and by oral handovers. The master on INUK II had been hired from Denmark and had operated the boat for a summer season the year before.

It is a regulatory requirement that the crew shall have knowledge about the craft and the trading area of the craft (see section Regulation of Small Passenger Craft). The difficulty is to specify what that local knowledge is. For vendors of approved passenger craft, it becomes a matter of balancing the requirements of hiring crew members with the right certification and also having local knowledge and expertise about navigating in Greenland. To solve that problem, some crew members are hired on the basis of having a particular certificate and will receive on-the-job training to be familiarised with the craft and the precautions necessary to navigate in the local area. The vendors who offer transportation with craft not approved for passenger transportation will typically have ample competencies for navigating in the local area. They do not necessarily, however, have any competencies related to the professional use of lifesaving equipment and do not recognize the necessity of having such equipment and training. Non-approved craft are thus typically not equipped with adequate lifesaving equipment.

34 Part 3

Search and rescue

35 35 SAR operations

SAR operations in Greenlandic waters are formally the responsibility of the Ministry of Defence and the Ministry of Justice (The Danish Police). At operational level, SAR operations are carried out by the Joint Arctic Command and the Danish police. Approximately 80-100 marine SAR operations are carried out annually by the Joint Arctic Command and the police. The operations include ships in distress and the transportation of sick/injured persons. A significant part of the operations are carried out in the summer and concern craft less than 30 feet in length. The distress calls are predominantly sent from small craft used for hunting and fishing in the local areas and small craft where families are travelling between villages. The emergencies are typically related to problems with the craft’s propulsion, which fails due to a lack of maintenance, etc. The majority of the distress calls are from the south-western parts of Greenland during early summer – April and May – during the migration of large ice masses where small craft become trapped in the ice.

The police authority in Greenland is responsible for SAR operations within the base line (i.e. the lines along the coast, from which a states maritime zones and territorial waters are measured). This would ordinarily be in populated areas where regular police work is carried out and where everyday traffic occurs. At their disposal are helicopters from Air Greenland, police vessels and smaller private vessels hired for a specific task. Dependent on the scale and complexity of the accident, the Joint Arctic Command can upon request assist the police or take over the SAR operation. Outside the large populated areas, the residents are not flu- ent in neither Danish nor English, making it difficult for the Joint Arctic Command personnel to communicate with the craft in distress. That is why it is expedient for local police to be in charge of the search and rescue efforts. In local communities the police use local craft and ships to aid in search and rescue efforts, because the locals have in-depth knowledge about the area, they are already present in the area and can respond quickly to an emergency.

Reporting incidents

DMAIB has not received specific information about distress situations involving small passenger craft operated by professional vendors since February 2019. However, the low number of reported emergencies does not mean that no incidents have occurred. During DMAIB’s visits to Greenland, it was reported that approved and non-approved chartered small passenger craft request assistance every year. In DMAIB’s experience there are many types of incidents that crew members and vendors do not consider to be hazardous until an emergency is imminent. These events, e.g. clogged filters, small water ingresses, loss of power, etc., are dealt with by calling other craft in the vicinity for assistance. Because passenger craft often operate in desolate waters with little or no maritime traffic, even minor accidental events requiring assistance can be hazardous, because it is difficult to receive swift assistance. Small passenger craft operating in desolate areas must therefore rely on being self-sustaina- ble to a higher degree than seaborne transportation in areas with denser marine traffic. This self-sustainability is dependent on mechanically reliable craft and having suitable emergency equipment. However, numerous other challenges exist for maintaining this self-sustainability, as elaborated in the section ‘Coastal Navigation in Greenland´.

CASE

INUK II sent a message that was transmitted by VHF to another passenger craft positioned nearby. The passengers and crew were evacuated to this passenger craft and to RIBs launched from a cruise ship which was located a few hundred meters away. Neither the police authority nor the Artic Command were directly involved in the rescue operation.

36 Part 4

Regulation of small passenger crafts

37 Regulation

Order on small commercial vessels carrying a max. of 12 passengers

With regards to safety, the main legal basis for commercial transportation of passengers in small craft is DMA’s “Order on small vessels carrying a maximum of 12 passengers”2. In this context, “small vessels” constitute craft that have a length below 15 metres and scantlings (length x breadth) below 100. It should be noted that INUK II and JUVEL were issued trading permits before this regulation came into force. The below regulation is thus not applicable for those craft.

The above mentioned order on small vessels is divided into two parts: one dealing with vessels whose scantlings are below 20 and one above 20. Further, the regulatory requirements depend on whether the propulsion power is above or below 100 kW. The order contains requirements with regards to construction, survey, certification, equipment, etc. with reference to requirements set out in DMA’s Notice F3. A schematic overview of the regulatory requirements is provided in figure 19 below.

Craft carrying up to 12 passengers Length below 15 m and scantlings below 100

Scantlings below 20 Scantlings above 20 Order on small vessels carrying a • Order on small vessels carrying a max. max. of 12 passengers of 12 passengers. • DMA Notice F.

Below 100 kW Above 100 kW propulsion propulsion

DMA can survey Survey by DMA No mandatory certificate Certificate required: Permit for carriage of passengers

Figure 19: Schematic overview of the regulatory requirements Source: DMAIB

2 DMA Order no. 956 of 26 September 2012 on small vessels carrying a maximum of 12 passengers

3 Notice from DMA F no. 1008 of 18 September 2014 - Construction and equipment, etc. of small commercial vessels

38 Provisions

The general provisions in DMA’s ”Order on small vessels carrying a maximum of 12 passengers” state that:

“The purpose of this regulation is to enhance the safety of commercial passenger voyages by small vessels carrying passengers by determining the framework within which the companies and persons carrying out the voyages shall independently establish appropriate safety measures and determine a high safety level for passenger voyages.”

“The shipowner shall ensure: 1. that the vessel is used in accordance with good seamanship and that human lives at sea are secured in a fully satisfactory way; 2. that the vessel is manned, constructed, equipped and maintained so that it is suitable for its purpose.”

The reasoning behind these provisions is that the responsibility for the safe construction and operation of the ships should lie with the owner and operator of the ship, and not with the authorities. This approach combines two factors. First that it is assumed that the operator best knows his own operational reality. And secondly, that it would not be feasible for the authorities to effectively lay down the stipulations for each individual enterprise. Instead, the authorities set minimum structural and functional requirements. Guidelines have also been made available, intended to help the operators develop their safety systems. The safety instructions are thus not subject to approval by DMA or other authorities, but can be subject to evaluation by DMA. The safety system comprises the development of “written safety instructions for the safe use of the vessel”.

The set of safety instructions required in the order for small passenger craft comprises 12 mandatory points, with an extra list of specific requirements for navigation in Greenland, see information boxes below.

Safety instruction

The shipowner shall develop safety instructions for safe navigation by the vessel(s) that the shipowner uses for the navigational activities. The purpose hereof is that the shipowner:

1. identifies himself as the one who has the 8. ensures that it is possible to save everyone overall responsibility for the navigational in case of an accident, activities, 9. ensures the calling of assistance in case of 2. establishes the navigational activities con- an accident, cerned, 10. ensures that information about the number 3. identifies the risks associated with the na- of persons on board is known and kept vigational activities, ashore and is easily accessible in case of a 4. takes technical and operational measures rescue operation, that effectively counter the risks, 11. ensures that safety instructions are always 5. ensures that the vessel(s) is suitable and given to new persons on board before initi- fitted with the necessary equipment, ating the voyage, 6. ensures that the crew is sufficient and 12. ensures the collection of experience with competent, a view to improving safety on an ongoing basis. 7. describes the operational measures to be observed by the crew and the passengers,

39 Special instructions regarding navigation in Greenland

For vessels navigating in Greenland, the guidelines state that special consideration shall be given to the following risk factors:

1. Reduced geographical coverage by using 7. Vessels with their trade areas in Greenland means of communication such as mobile waters shall be fitted with a float-free 406 MHz telephones, EPIRB (emergency position indicating radio 2. VHF/MF and other means of communica- beacon), a VHF radio system as well as a MF- tion and emergency signalling. DSC radio system. 3. Reduced possibility of assistance reaching 8. Vessels with their trade areas in Greenland the place of the accident. waters shall be fitted with tents and sleeping bags as well as an insulated approved immer- 4. Quickly changing weather conditions. sion suit complying with the requirements of 5. Special risk of hypothermia as a conse- chapter II, regulation 2.4 of the LSA Code for quence of low water and air temperatures. everyone on board. 6. Special risks associated with voyages in icy waters.

The legislative requirements are goal based, describing what goals the instructions should fulfill, e.g. “ensuring that it is possible to save everyone in case of an accident”. This leaves it up to the shipowner and crew to implement the necessary means to achieve that goal. Whether or not the shipowner is in compliance with the regulation only becomes evident, when the result of an accident is known. If a passenger or a crew member does not survive an emergency, then the safety instruction was not in compliance with the regulation.

This kind of safety instructions do have the advantage that they can be tailored to fit any passenger craft depending on type of craft, trading area, etc. This means that they can become a meaningful tool for the crew on the craft. On the other hand, there can be a discrepancy between how the shipowner, the crew and the authorities view safety and thereby what constitutes a good safety instruction. The premise of the regulation is that risks are discernible and can be described in such detail that risks can be effectively countered. However, the ongoing professional assessment of risk in a given situation depends on a subjective judgement based on a persons’ particular skill set. In DMAIB’s experience there is a tendency for shipowners to create safety instructions in accordance with the authorities’ expectations and less in accordance with the crew’s expertise. This may result in a gap between the content in the safety instruction, and how the navigation and emergency response are actually carried out on board.

The order on small passenger craft requires that the person creating the instructions possesses the relevant knowledge and skill in navigating the particular craft and trading area. However, it stands out that the persons most skilled at navigating in Greenland waters are not necessarily skilled at producing safety instructions. This would require a different skill set, e.g. understanding regulatory requirements and writing text that is easily understood by others. When the crew members do not have sufficient knowledge and skill navigating small craft and about the regulation, they employ a marine consultant to create the safety instructions. By hiring a consultant, the operators ensure that the safety instructions are made to the satisfaction of the regulatory requirements. That is why safety instructions may appear to have the same overall structure and content. The problem being that the safety instructions are to some degree viewed by craft owners as a matter of compliance and responsibilisation, and not a matter of creating safety.

40 Safety implications

DMAIB has observed that the safety instructions tend to be either too detailed or too general and therefore not useful for practical implementation on small crafts. The main problem is not the legislation per se, but how the instructions are produced, i.e. the quality of the doc- uments.

There is no evidence to suggest that the regulated transport of uninformed passengers will change the traditional way that informed passengers are being transported. So a master or crew member from a regulated passenger craft may transport family, friends and tourists in a private craft without following the legislative requirements related to e.g. safety equipment. Having safety instructions will not necessarily be meaningful for a person who is an expert navigating in Greenland waters. Furthermore, the safety equipment is expensive for an individual to purchase, and if the usefulness of the equipment in an emergency situation is doubted, there will be a tradeoff between the contingency measures and the financial burden they would bring to the owner of the craft.

41 Part 5

Conclusions

42 42 Safety challenges

Safety at sea is often represented solely as a statistical concept where the numerical trend is determinant of whether the level of safety is good or bad, and a low number of accidents is normally perceived to indicate a satisfactory safety level. Such a representation does not necessarily reflect the issues outlined in this report and thus holds few cues for understanding the mechanisms that underlie the statistics and cause the trends. Subsequently, improve- ment of safety depends on an understanding of the challenges the operators of small passenger crafts face, and how they manage safety on a daily basis.

A great diversity was found in the types of small craft below 15 meters in length used for passenger transport. Some craft are exclusively used for transportation of passengers and some are also used for fishing, hunting and for recreational purposes, which can blur the distinction between the legal definition of passenger transportation and the recreational transportation of e.g. acquaintances, friends and family. This means that many of the available craft may potentially be used for passenger transportation, which makes it difficult to assess the actual number in use.

The safety challenges for small passenger craft operating in Greenland waters have been found to be twofold: 1) the properties of craft and equipment and 2) the operation of the craft and equipment. These two issues will be treated separately.

Properties of the craft and equipment

Small passenger craft safety primarily depends on the craft’s structural and mechanical reliability, because they operate in remote desolate areas where other ships are few and far between, if an accident occurs. The types of craft that are typically used in Greenland have been used for many years and can be characterised as highly reliable, both structurally and mechanically. However, the reliability depends on expert planned maintenance and repairs, which faces craft owners with the challenge of obtaining access to expert knowledge to pre- vent e.g. engine failures, malfunction of radios and radar, etc. Access to qualified technical personnel was found to pose a risk to passenger craft’ reliability.

The size and design of the craft makes them vulnerable towards a number of accident events such as flooding, which causes immediate loss of stability, and fire, which quickly engulfs the craft in smoke. DMAIB has found that once an accident occurs, it is uncertain how effective the emergency equipment (e.g. immersion suits, life rafts, life jackets) will be, because the crew is rarely trained in the practical use of the on-board safety equipment in context of an emergency, i.e. how the specific equipment items are to be utilised and combined in a particular accident scenario.

The implication is that in an emergency situation it will be the first time the safety instruction and the safety equipment is in use because the crew has never tried to e.g. inflate liferafts, have the passengers don immersion suits and disembark the passengers from a craft which is about to lose stability. In the absence of practical testing and training, it is uncertain how effective the evacuation strategies on small craft are. Once an accident happens, it will be a matter of the crew experimenting to achieve the most effective method of evacuation. In this context the safety instructions do not provide assistance, because they typically do not offer specific information about e.g. how to dress the passengers in immersion suits on a small deck area. DMAIB has found that the absence of actual testing of the equipment has resulted in pessimism among crew members in relation to the usefulness of the emergency equipment. Among non-professional providers of passenger transport, this pessimism, along with the financial burden, translate into not having various types of safety equipment on board.

DMAIB has observed that the safety instructions tend to be either too detailed or too general and therefore not useful for practical implementation on small crafts. To counter this problem, it is necessary for the craft owners and crew to obtain improved competence in creating safety instructions in line with the regulation, but with an emphasis on representing the operational reality.

43 This would, however, require a shift from creating procedures for compliance purposes towards creating procedural tools for a particular craft and a particular crew. The safety instructions do not in themselves guarantee a positive outcome of an emergency scenario. The safety instructions must therefore be supplemented by continuous training and testing of the strategies because they are seldom self-explanatory and the understanding of them depends on the particular crew. This training and testing has generally been found to be absent.

Therefore, it is essential to establish set programs for creating, practicing and testing evacuation strategies for the specific type of craft. These must include drills or exercises on the craft in question, utilising the safety equipment actually available on the craft within a realistic time frame. This would help uncover problem areas and contribute to the crew’s understanding of the practical challenges involved in emergencies on small passenger craft. This would also serve to bridge the existing gap between the formal safety requirements and the practical realities of emergencies on small passenger craft in arctic waters.

The operation of the craft

Navigation in Greenland coastal waters is about negotiating and prioritising various factors (see individual sections of this report), and experience with these conditions is the main con- tributor to safety. Crew members on small passenger craft in Greenland generally possess considerable knowledge and expertise about these factors, which is largely empirical, handed over, and shared in the community or with colleagues in the trade, as few or no official records about the local navigational hazards are available. This means that the navigational expertise is largely tacit and implicit. However, due to the large geographical variations in Greenland, the knowledge about particular circumstances in a particular location may not be transferable to another location, e.g. knowledge about shoals, tidal conditions, underwater rocks etc.

Regulation requires that crew members are knowledgeable about the local area in which the craft is navigating. In practice, the regulatory requirement is sought to be met by giving the crew an introduction to the craft and the area of operation. However, in reality this introduction does not cover the actual need for sufficient knowledge and expertise about navigation in Greenland coastal waters. It has become evident that it is difficult to establish the nature of the tacit knowledge and expertise about coastal navigation. It is therefore difficult to convey this knowledge to new crew members, even if they have the mandatory certification. Thereby, craft owners face the challenge of getting local qualified personnel who are knowledgeable about the local navigational dangers while also holding the mandatory certification. Due to the high demand of excursion tours, especially in summer months, this may not always be possible. This leaves the craft owners with a choice between hiring crew members who have the required certification or hiring crew members with local knowledge.

Additionally, transportation in small passenger craft is largely perceived as a routine, everyday activity – not a high-risk one. Consequently, the premise itself – the regulation and safety instruction as a tool for creating safety – is not one universally recognised among the groups involved: craft owners, vendors, crew members and the various categories of passengers.

Goalbased regulation thus contributes to a bureaucratisation of navigational practises, creating procedures that are difficult to follow in a dynamic reality of quickly changing circumstances, where individual knowledge, expertise and adaptability is essential to the creation of safety. The on board procedures has thus been found to have little value in the safe operation of passenger crafts. Therefore, training, certification and local knowledge should go hand in hand, recognizing the changing conditions present when navigating the arctic waters around Greenland. This tacit knowledge and expertise should therefore be part of a formalised training regime specialising in navigation in Greenland coastal waters, e.g. by navigational colleges and vendors, to try to solve the problem with the regulatory requirements not addressing the inherent problem with varying navigational competences among vendors and crew in navigating the coastal waters in Greenland.

44 Annex

Grounding of JUVEL

45 Investigation

Background

JUVEL (figure 20) was owned and operated by a private foundation working with child and youth welfare. Apart from the welfare activities, the craft was also used for regular chartered passenger trade, e.g. with tourist groups sightseeing in southwest Greenland. The crew members were from the Faroe Islands and worked periodically on the craft on a voluntary basis. The craft was certified by the Danish Maritime Authority to carry 27 passengers and two crew members. On the day of the accident, JUVEL was manned with one master mariner (STCW II/2) and one additional person with no formal marine training, but who had knowledge and experience with the craft and the trading area.

JUVEL did not have a high maximum speed as other passenger craft operating in the area and was therefore mainly used for sightseeing and passenger transport of larger groups, if other faster craft were not available. Therefore, it was usually not used for regular local passenger transport between villages. In the summer of 2014, JUVEL was hired by the municipal authority to bring a group of 12 passengers (9 children/young persons and 3 adults) from Qaqortoq to a camp at “Knaekket”, approximately 9 hours sailing from Qaqortoq, for hunting reindeer. The group stayed at the camp for one week after which JUVEL was to pick them up and return to Qaqortoq. It was during the return voyage to Qaqortoq that the craft went aground.

Figure 20: JUVEL Source: Private photo

Name of ship: JUVEL Type of vessel: Passenger ship Nationality/flag: Greenland Port of registry: Qaqortoq Call sign: XP 5364 DOC company: Qaamasoq, Den selvejende institution. Year built: 1977 Shipyard/yard number: Jupiter Ship Yard, Bogoe, Denmark/330 Overall length: 11.90 m Breadth overall: 3.60 m Draught max.: 2.08 m Gross tonnage: 11.6 Engine rating: 397 kW Service speed: 14 knots Hull material: GRP

46 Sequence of events

JUVEL departed from Knaekket in daylight on 24 August 2014 at 0750, heading for Qaqor- toq with 12 passengers, luggage, 12 reindeer and 2 muskoxen that were lashed onto the forward deck. The voyage was expected to take 7-8 hours (figure 21). As usual, the voyage was planned to be made mostly in sheltered waters in fiords and between smaller islands with a short stop in Arsuk to bunker diesel. The crew considered the weather to be good with a gentle breeze, smooth sea and good visibility. There was no significant presence of ice hindering the passage.

After 4-5 hours, at approximately 1230, and about one hour before arrival in Qaqortoq, the craft navigated through a channel of approximately 100 metres across called Nordlysets Loeb. It was the fourth time the master navigated in this area, and he knew that there were two underwater rocks on each side of the channel (figure 22).

Departure: Knaekket

90 nm

Destination: Qaqortoq

Figure 21: Approximate route From Knaekket to Qaqortoq Source: © Made Smart Group BV 2016, C-Map data © Jeppessen AS 2016

Underwater rocks

47 The intention was to navigate by following the previous track in the opposite direction, but the craft came a few meters too far to starboard and ran aground on a submerged rock at full speed, approximately 12-14 knots. Immediately after the grounding, the crew transmitted an emergency message by VHF to the coastal radio station Aasiaat Radio. It was established that none of the passengers were injured, and the children were told to don life jackets.

The structural condition of the craft was examined, and it was soon established that there was no flooding of any compartment, but the diesel oil tank was apparently damaged, because traces of diesel oil could be seen on the surface of the sea. It was apparent that the craft was aground with no possibility of getting afloat without assistance or until the tide had risen (figure 23).

Figure 23: JUVEL grounded Source: Private photo

The police in Qaqortoq was notified by Aasiaat Radio, and three boats were dispatched to aid JUVEL. A leisure craft, PASCAL, was nearby and reached JUVEL approximately 45 minutes after the grounding. As JUVEL was stable with no significant water ingress, it was decided to wait with the evacuation of the passengers, until the ocean patrol cutter TULUGAQ would arrive after approximately two hours at 1410. Once the patrol cutter TULUGAQ arrived, the passengers were transferred from JUVEL to TULUGAQ by a fast rescue boat from TULUGAQ.

During the afternoon, as the tide rose, sea water started to leak into the engine compartment from a crack in the hull. It could be discharged by the craft’s bilge pump, but as a precau- tionary measure a bilge pump was brought from TULUGAQ to the craft. The diesel oil tank had been damaged, and the tank was taking in sea water.

After the tide had risen at approximately 1600, JUVEL was towed afloat by a rigid inflatable boat that had arrived from Qaqortoq. It was apparent that JUVEL could not continue the voyage, because the diesel oil had been contaminated with sea water. A towing line was therefore set up between TULUGAQ and JUVEL, and TULUGAQ started towing JUVEL to Qaqortoq, where they arrived safely at approximately 2100 in the evening.

48 Navigation on JUVEL

JUVEL was equipped with two radars, three GPS, one echo sounder and three electronic chart plotters. However, navigating by the use of GPS and chart was not accurate enough, because there was no reliable paper or vectorised charts of the area due to the lack of accurate surveys. Therefore, the crew on JUVEL navigated by using knowledge about the local conditions obtained by sharing experiences from various people in the area who had for dec- ades been sailing in the waters of southwest Greenland. Navigating in the confined waters was necessary, because the trading permit for the craft did not permit the craft to trade with passengers in open sea – only within the coastal areas.

The crew members on JUVEL had in the previous years received general advice and tracks from other ships’ chart plotting systems. Even though the charts were not accurate, the GPS track could be used in conjunction with the radar. At times it was confusing, because it was not uncommon that the tracks on the chart plotter showed the craft sailing over land. Therefore, the main navigational strategy for positioning the craft was by visual observations of land and by the use of radar. On the day of the accident, the crew used the only available charts of the channel, chart 1116 (scale 1:80.000) and 1132 (scale 1:40.000). The notes on the charts indicated that it was not usable for precision navigation, as it was stated: “sound- ing tracks in the inshore routes is of a reconnaissance nature only”. Furthermore, it was stated that the age and origin of the data in the chart made satellite derived positioning more accurate than the charts.

The speed of the craft was adjusted to the varying circumstances, e.g. the presence of ice, but the speed was mainly kept on the maximum of 12-14 knots. The speed was important in order to keep the time of the voyage within acceptable limits with regard to rest and comfort for the passengers and crew. For the crew on JUVEL it was customary to call the coastal radio station Aasiaat Radio upon departure on longer voyages to inform them about the plan of the voyage. In the event JUVEL went missing, the coastal radio station could inform the authorities.

JUVEL’s regulatory history

JUVEL was built as a recreational craft in 1977 and was registered as a commercial craft in Greenland in 1984. In 1986 it was surveyed and approved as a passenger craft operating out of Qaqortoq on the basis of the principal order from 1965. From 1994 it was additionally surveyed according to guidelines regulating passenger ships in national trade and a gross tonnage below 20. From 2002, the craft was to adhere to the ISM Code4 and was subject to a periodical verification process where the safety management system was to be audited. A new regulatory basis for these smaller passenger ships (GT below 20) was introduced by the Danish Maritime Authority in 1999, covering construction and equipment on passenger ships in national trade5.

Since its approval as a commercial craft in 1986, JUVEL’s trading permit had undergone a development with various restrictions. At the time of the accident the trading permit was restricted to 27 passengers with 2 crew members with a trading area within the outer rocks and four hours from the nearest port between Arsuk and Prins Christian Sound (figur 24).

4 Order no. 2 of 11 January 1996 – ISM code

5 Notice from the Danish Maritime Authority D of 1 May 1999

49 Arsuk

Prins Christians Sound

Figure 24: Approximate route From Knaekket to Qaqortoq Source: © Made Smart Group BV 2020, C-Map data © Jeppessen AS 2020

Analysis and conclusion

The grounding

The crew had to rely on knowledge shared verbally with local seafarers about the local conditions, e.g. presence of sunken rocks and ice, because the charts were not of a quality to be used for accurate navigation. Among small commercial craft operators this was a normal and necessary method for navigating safely. In the channel, Nordlysets Loeb, the crew on JUVEL therefore relied mainly on following the previous track which had in the past proven to be safe, but this provided only a small margin for failure, because the route was only verified to be safe in that particular track. Any deviation could be considered unsafe, which left the crew little margin between safe waters and the risk of grounding.

The craft travelled at its maximum speed of approximately 12 knots, which was necessary for reaching port in due time. However, determining the appropriate speed also depends on the navigational dangers, e.g. wave height, presence of ice, underwater shoals, etc. The choice of speed will thus be a matter of weighing the benefits and drawbacks of any given speed. Determining the appropriate speed is a matter of judgement on the part of the person operating the craft. When JUVEL was passing through Nordlysets Loeb, the speed of 12 knots did not offer enough time for aligning the craft correctly on the safe track.

50 The evacuation

The grounding of JUVEL did not result in any fatalities or serious injuries for mainly two reasons: Firstly, because the water ingress did not influence the stability of the craft, which ena- bled the passengers and crew to stay on board after the grounding. This was instrumental for the successful evacuation of the passengers to the fast rescue boat. Secondly, the damage to the hull primarily affected the fuel oil tank, and the bilge water pump capacity was sufficient for emptying the other compartments. The buoyancy and stability were thereby kept intact.

An early and orderly evacuation of a small craft like JUVEL is dependent on the time available to don survival equipment and receiving instructions on how to abandon the craft safely. In situations where there is large water ingress, the craft will rapidly lose stability and buoyancy. Additionally, in a severely damaged condition, the weight of the passengers assembling on one side of the craft could make it list excessively, hindering the orderly evacuation of the passengers