CHAPTER 22 RECOMMENDATIONS

The Commission notes that work has started on development of regulations in line with the three recommendations given in the Part-Report. This work includes IACS' new, stricter requirements on the strength of locking arrangements for shell doors. The requirements will apply retroactively to existing ships. New amendments to SOLAS require that damage to, or detachment of, a bow door may not cause damage to the upper extension of the collision bulkhead. IMO has also decided on full enforcement of the SOLAS 90 damage stability regulations. Several countries in Northern Europe have agreed on more stringent regional regulations on damage stability for ro-ro passenger ferries in regular traffic. These regulations address the effects of water trapped on a car deck. The work by IMO after the ESTONIA accident is reviewed in Chapter 19 of the present report. It is the opinion of the Commission that application of the new regulations will significantly improve the safety of ro-ro passenger vessels. However, based on the ESTONIA experience, the Commission finds reason to present the following further recommendations.

Ship design and construction

The installed bow visor locking devices were not thoroughly designed and manufactured, and were not inspected for approval by any external authority. The installation did not incorporate a sufficient safety margin with regard to the design load level used. Further, the consequence of mechanical interference between visor and ramp was not realised before this accident. For these reasons,

• formal safety assessments and strict quality assurance procedures must be applied in design, manufacturing, assembly and approval of components critical for the safety of passenger vessels. The design basis for elderly tonnage must be reviewed in the light of new knowledge and standards of safety. A clearer relationship and division of responsibility between the shipyard, ship owner, classification society and administration needs to be established in this context.

The visor lock indicator on the bridge was accepted by the national maritime administration according to the SOLAS amendments after the HERALD OF FREE ENTERPRISE accident. However, it did not show that the visor was detached. Therefore,

• alarm systems should be constructed so that the actual and complete status of entire functions is supervised, rather than only parts thereof. Alarms should be limited to critical functions and should always lead to defined operational actions.

Upgrading of design requirements and a series of visor incidents in the Baltic area had not led to strengthening of locking devices, nor to operative instructions. The extent of previous visor incidents was not generally known among operators at the time of the ESTONIA accident. Hence,

• procedures for collecting and analysing incident data must be improved and upgrading of existing vessels as regards the safety of human life must become regular. Ways of distributing this information efficiently and internationally must be established. The responsibility for following up the status of existing ships must be taken by the national authorities, supported by the classification societies.
• Operational guidelines and limits for manoeuvring in heavy weather should be issued to all passenger ferries. The safety limits should be based on shipbuilders' original design levels and on the level of upgrading of the vessel with respect to increased design requirements after building. Documentation of operational limits must be included in ship certificates, and,
• the crews of ro-ro passenger ferries should have clear instructions on maximising their vessels' chances of survival in cases of water ingress to the car deck. Possible corrective action should be simulated and practised.

A significant factor in the ESTONIA accident was the very quick increase in the list to an angle exceeding 30°, leading to the loss of manoeuvrability, to difficulties in getting out from inside the vessel and to the start of progressive flooding. Investigations have shown that relatively small changes in construction could have had a significant effect on the outcome of the evacuation. Therefore,

• all existing passenger vessels should be re-assessed with regard to evacuation and all reasonable measures taken to increase the time available and possibilities for evacuation.

Serious shortcomings in the effectiveness of the on-board rescue equipment became apparent during the ESTONIA accident and the rescue operation. The equipment fulfilled the requirements and is of standard type common on comparable vessels.

• The Commission recommends urgent action to develop new lifesaving concepts and equipment, especially for passenger vessels where large numbers of untrained people are to be rescued.
• Systems should be developed for enhancing the ability of passenger ferries to rescue people from the sea in heavy weather.
• All-weather systems should be developed for enhancing co-operation between ferries and helicopters in sea rescue.

No station conducted the distress traffic according to the procedures required by the radio regulations. In the normal work of deck officers and radio operators it is understandably difficult to maintain very firm routines for distress communications. However, good simulators for training in maritime radio systems and communications are available. Therefore,

• certain key persons, such as deck officers on large passenger vessels and rescue centre radio operators, should regularly update their practical knowledge of distress and safety traffic using a maritime radio simulator.