This presentation looks at issues around domestic ferry safety in the developing world.

2. Domestic Ferry Safety
- in the developing World
John Dalziel, M.Sc., P.Eng., MRINA
Roberta Weisbrod, Ph.D.
Worldwide Ferry Safety Association
World Maritime Rescue Congress
Bremerhaven, Germany
June 2015

3. Domestic Ferry Safety
is Far Behind International Ferry Safety
 The record of ferry safety creates the perception that
maritime transport as a whole is unsafe and negligent
about human life.
 Ferry transport in the developed world has a good
record.
 But in parts of the developing world there are frequent
accidents with large numbers of fatalities.

4. Ferry Industry Background
 WHAT IS A FERRY – A vessel used to transport
passengers / goods / vehicles across a body of water on
a regular, frequent basis.
 HOW BIG - Roughly as many passengers as the
commercial airline industry (over 2 billion per year).
 FERRY USAGE – In the ‘West’ ferry usage is often
discretionary – pleasure and/or an alternative to other
modes. In the developing world it is often the only
practicable means of necessary transport.

5. Domestic Ferries in the Developing World
A Wide Variety of Vessels – A Wide Variety of Tragic Incidents

6. Domestic Ferries in the Developing World
A Wide Variety of Vessels – A Wide Variety of Tragic Incidents

7. Ship deemed to be Unsafe
(Source - Rabaul Queen Commission of Inquiry Report)
A ship shall be deemed to be unsafe where the Authority is of the
opinion that, by reason of–
(a) the defective condition of the hull, machinery or equipment; or
(b) undermanning; or
(c) improper loading; or
(d) any other matter,
the ship is unfit to go to sea without danger to life having regard to
the voyage which is proposed.
our

8. Ferry Industry Regulation
 Large international ferries – subject to IMO
Conventions, enforced by robust inspection regimes
and Port State inspections– good safety record.
 Domestic ferries – National (Flag State) regulatory
regime – regulations may be lacking, enforcement may
be weak and subject to political interference – in many
developing countries domestic ferries have a poor
safety record.

9. IMO – Manila Statement on
Enhancement of the Safety of Ships Carrying
Passengers on Non-International Voyages (1)
 Conference held 24 April 2015, Manila, the Philippines
 Focus - urgent need to enhance the safety of domestic ferries.
 “The public expects safety standards on domestic passenger
ferries to be as strong as those on international vessels,”
 “Casualties and incidents involving domestic ferries can be avoided
if adequate laws, regulations and rules are developed and
effectively implemented and enforced,”
 Strongly recommends the use of the ‘Guidelines on the safe
operation of coastal and inter-island passenger ships not engaged
in international voyages’.

10. IMO – Manila Statement on
Enhancement of the Safety of Ships Carrying
Passengers on Non-International Voyages (2)
Guidelines on the safe operation of coastal and inter-island passenger
ships not engaged in international voyages - addresses:
 Purchase of second hand ships
 Conversion or modification of ships prior to entering service
 Existing domestic passenger carrying vessels
 Change in the ship’s operating limits
 Passenger counting
 Voyage planning
 Regulatory enforcement

11. Domestic Ferry Safety in the Developing World
Some Issues for Consideration
1. WFSA research data into ferry incidents
2. Incident Reporting
3. Safety Culture
4. Economics of ferry operations
5. Safe affordable ferries
6. Some questions for workshop attendees

12. Worldwide Ferry Safety Association Data (1)
Domestic Ferry Incidents in the Developing World
Statistics & Causes
WFSA compiled statistics – over the period 2000 - 2014
 17,000 lives lost (conservative estimate).
 Looked for trends which would indicate common
causes for these incidents.
 Further details in the following presentation:
‘Statistics, Analysis, and Trends of Major Ferry
Accidents Worldwide, 2000 – 2014.’

13. Worldwide Ferry Safety Association Data (2)
Domestic Ferry Incidents in the Developing World
Search & Rescue
WFSA compiled statistics – over the period 2000 – 2014
 Identified some of the recurring SAR related issues.
 This information was shared with the IMRF for analysis
 Further details in the following presentation: ‘FERRY
ACCIDENTS, the Challenge of Rescue’.

14. Incident Reporting (1)
Why?
 To establish & retain in the public domain the ‘facts’.
 Was it ‘an Act of God’?
 Was it the result of some sort of human failing? If so,
was it an individual failure, or were there systemic
factors?
 E.g., Widespread malfeasance,
or perhaps
 Insufficient funds to provide the required services

15.  Objectives:
 How to prevent future recurrences
 Public knowledge of what is a safe operation
 Organizational knowledge of what is a safe operation
 Political Will to demand Safety Standards be Maintained
 Not to apportion blame or determine liability
 Focus on why (technical explanation) in addition to what
happened
 ‘The final report shall be made available to the public’ -
encourages objective reporting, public understanding of
the facts, pressure to perform on all parties
Incident Reporting (2)
IMO Casualty Investigation Code
‘Objective of preventing marine casualties.. in the future’

16. Dona Paz – Philippines
4,386 Lives Lost – 24 Survivors
In memory of Corazon Canezal (age 11) and her father, a school teacher
- died Dec 20, 1987
“If the world had taken
more notice, the
subsequent inquiry
might have had more
impact.”
(source – Fairplay 20 Dec 2007)

17. Safety Culture (1)
Regulatory Capture
A world-wide phenomenon
 “The accident -- blamed by many on regulatory
failings, official incompetence and the ship's illegal
redesign -- deeply traumatised the nation and sparked
soul-searching about lax safety standards in Asia's
fourth-largest economy”
 "We have marched all this way because the
government and the president did not keep their
promise to get to the bottom of this tragedy,"
(South Korea parents march – April 2015)

18. Safety Culture (2)
The Safety Inspector’s Predicament
A world-wide dilemma
 “An aged vessel not maintained to
industry standards”
 “Meets the letter of the Regulations
…(but) the configuration is inherently
unsafe.”
 “Recommended…ISM be revisited”
 “further implication from your part will be
considered insubordination …”
 “to be absolutely clear on behalf of
management …the issues are considered
closed…not to be raised again”

19. Safety Culture (3)
The Seafarer’s dilemma
 It is the Master’s
decision whether to
sail.
 It is the owner’s
decision who is the
Master.
(Charles S Price, Great Storm of 1913)

20. Safety Culture (4)
Top down – or Bottom Up
 It is easy to point the finger at management & assume
that a culture of cutting corners started at the top, & was
motivated by money.
 The same (lack of safety) culture can also originate at the
bottom, driven by the desire to get the job done (and
perhaps a macho attitude).
 The task of management is to know this & make sure the
job is done safely.
(from Trevor Kletz, Trevor’s Corner 17)

21. Safety Culture (5)
‘Mere compliance with the Rules’
“Specifically, inspections should not be limited
only to compliance with the rules. We believe
there is an intent behind those rules, and that
intent is to keep crew members and passengers
safe, by recognizing and addressing unsafe
practices and conditions not necessarily
proscribed by regulations.”
(Chairman of Canadian Transportation Safety
Board, comments on True North II investigation)

22. Safety Culture (6)
Willful Blindness? – Regulatory Failure?
Who was responsible?
Lac Megantic, Quebec,
Canada - rail disaster - July
2013 – 47 deaths

23. Safety Culture (7)
Safety Inspectors Protect the Public.
Who Protects the Safety Inspectors?
 “…concern relates to the ongoing condition of specific vessels …
these vessels could place many … lives at risk…”
 “We trust that we all agree that it would be regrettable if any
unfortunate … action were to put (the Union) in the position of
having to vigorously defend those individuals who have put the public
safety first and foremost.”
(Letter - Union to government officials)

24. Safety Culture (8)
Regulatory Enforcement
“In competitive markets whatever is possible becomes
necessary”
(Treasure Islands …, Nicholas Shaxson, p 130)

25. Safety Culture (9)
Who is to Blame?
 “Once again, a captain has been made the scapegoat as a result of
political pressure and media misrepresentation,”
 “Pinning the blame on an individual in this way helps to obscure the
underlying causes of the accident, including regulatory failure,
overloading and design changes,’ he pointed out. ‘It is the law-makers
that determine the actions of owners and set the levels of safety. It
should not be masters that suffer for their failure.”
(Nautilus International Union, on sentencing of Sewol Master, 28 April 2015)

26. Economics of ferry services
Funding a Safe Ferry Service
 Sustainable safe ferry operations require a balance between
revenues & expenses.
 COSTS - The initial & ongoing costs of the ferry is part of the
issue.
 REVENUES - Underfunding is one of the factors often leading to
unsafe ferry services. If ferry operators are unable to raise
revenues by increasing fares, they are likely to increase revenues
simply by allowing many more passengers on the vessel.
 Artificially low fares may have a significant effect on safety;
these impacts have been overcome in some countries (e.g. by
subsidies).

27. WFSA – Safe Affordable Design Competition
(Papua New Guinea & Bangladesh)
 Bangladesh Ferry
University student
proposals for simple safe
ferries based on statement
of requirements from the
host country.
 Papua New Guinea Ferry

28.  “Time & time again we are shocked by a new
disaster…”
 “We say we will never forget”
 “Then we forget”
 “And it happens again”
‘The Ocean Ranger’ - Prof. Susan Dodd, University of Kings College, 2012
The Ocean Ranger
Feb 15, 1982 – Newfoundland – 84 lives lost

29.  “the many socio-political forces which
contributed to the loss, and which conspired to
deal with the public outcry afterwards.”
 “Governments will not regulate unless ‘the
public’ demands that they do so.”
‘The Ocean Ranger’ - Prof. Susan Dodd, University of Kings College, 2012
The Ocean Ranger
Feb 15, 1982 – Newfoundland – 84 lives lost

30. Thank you for your attention!
I acknowledge the inspiration given by many of my
colleagues in the Marine Industry who have consistently
put the public safety ahead of their own careers.

31. Domestic Ferry Safety in the Developing World
Some Questions for the Workshop Attendees (1)
1. How can Search & Rescue response issues best be addressed,
given the limited resources in many of these countries - e.g. -
resources, communication, Co-ordination / Co-operation?
2. Preventative measures – to improve ferry safety and reduce
fatalities when incidents occur. – e.g. – pro-active publicity,
education (public & industry), accident investigation (following
principles of IMO Casualty Investigation Code)?
3. Economic impact on ferry safety – can the effects of marginal
economics be mitigated?

32. Domestic Ferry Safety in the Developing World
Some Questions for the Workshop Attendees (2)
Suggested Outcomes
4. For Domestic Ferry Incidents, should the IMRF encourage flag
states to investigate and analyze the causes and SAR response
in accordance with the principles of the IMO Casualty
Investigation Code – for individual incidents where possible -
for ‘generic’ cases (such as small river ferries) where little
information is available?
5. Should the IMRF consider initiating a ‘Project’ to deal with
‘Domestic Ferry Safety in the Developing World’?

33. Domestic Ferry Safety in the Developing World
Some Questions for the Workshop Attendees (3)
6. Personal professional ethics – hypothetical case - you are
an experienced marine professional at a responsible level
in a shipping organization – you are aware of significant
violations of safety standards – yet no action is taken by
the appropriate managers or regulatory personnel.
1. What would you do?
2. What would you do if you knew that your best friend’s
children regularly travelled on the vessel?

34. Worldwide Ferry Safety Association
Contact Information
Email Contact:
ferrysafety@gmail.com
Web links:
www.ferrysafety.org
www.ferrysafetyconference.squarespace.com/presentations

35. Additional Information
Ao Nang Princess 5, Thailand, April 2015.

36. Le Joola – Senegal (West Africa) – 26 Sept 2002
1,800 + Dead / Missing
 Issues:
 Overloading
 Suitability of the ship
 Stability & loading
 Understanding of stability
 Regulatory regime
 Regulatory enforcement
 Weather reporting
 Rescue response
(source – official inquiry report)

37. Spice Islander I – Zanzibar – 10 Sept 2011
1,600 Dead / Missing
 “Overloading was the main
factor behind the sinking of
the ship, noting that the
vessel carried passengers
and cargo beyond its
capacity”
 “The ship had technical
problems, but was allowed
to continue providing marine
transport services,…”

38. Skagit – Zanzibar – 18 July 2012
100 + Dead / Missing
 “They were not meant to carry
passengers on long distances.
But the two boats have since
their registration in the country
in October last year, been
carrying passengers from the
mainland to Zanzibar,” said the
second vice president, adding:
“Until it sank, MV Skagit had
remained with only two years of
operational life.”
 “crew gave them no instructions
on how to evacuate and merely
told them to calm down.”

39. Congo River Ferries – 5 Sept 2010
200 + Dead / Missing
 Heavily loaded boats operated with few safety measures,
officials said Sunday.
 Early Saturday, a boat on the Rupi River in northwest Equateur
Province hit a rock and capsized, … more than 70 people are
believed dead among 100 estimated passengers. Officials are
investigating why the boat was traveling through the darkness
without a light.
 Another boat tipping in Kasai Occidental Province left 200
people feared dead after the boat loaded with passengers and
fuel drums caught fire and capsized in southern Congo,
 The boats that traverse Congo’s rivers are often in poor repair
and filled beyond capacity. The industry is not well-regulated and
boat operators are known to fill boats to dangerous levels.
(source – France 24.com)

40. Tour Vessel Bulgaria – Russia , Volga River – 10 July 2011
120 + Lives Lost (including many children)
 “ the ship's Canadian-based owner said it
could only assume "moral responsibility"
for the worst disaster in Russian waters
in post-Soviet history.”…
 The Bulgaria is believed to have sunk due to
its poor technical condition. The operator
apparently saved money by not maintaining
the vessel and the regulator was coerced to
turn a blind eye to the state of the ship,
witnesses said….
 Also, the riverine shipping register was
found to have certified sub-standard vessels
and extended validity periods unlawfully.
The office has begun enforcement and
penalty actions in 550 cases involving 800
individuals.

41. Lady D – Baltimore, USA – 6 March 2004
5 Lives Lost
USA – NTSB Report
• The Lady D was erroneously granted
sister status by the U.S. Coast Guard
to a pontoon vessel with different
design characteristics;
• The Coast Guard certificated the Lady
D to carry too many people as a
result of an inappropriate stability
test on the vessel to which it was
granted sister status;
and
• The Coast Guard’s regulatory stability
test standards on which the Lady D’s
passenger allowance was based use
an out-of-date average passenger
weight.

42. Tour Boat ‘Ethan Allen’
USA, Lake George, New York – 2 October 2005
20 Lives Lost
USA – NTSB Report
The combination of too many
passengers, as permitted by the
Ethan Allen’s inappropriate
certificate of inspection, and the
use of an out-of-date average
weight standard for passengers
on public vessels resulted in the
Ethan Allen carrying a load that
significantly reduced its stability,
which made it more susceptible
to capsizing on the day of the
accident.

43. TRUE NORTH II
Canada, Georgian Bay - 16 June 2000
2 Lives Lost
Chairman of Transportation Safety Board:
 “One, the safety of the vessel was not
challenged.”
 “Two, the status quo should always be
challenged in order to safely operate every
vessel, especially those carrying passengers.”
 “Specifically, inspections should not be
limited only to compliance with the rules. We
believe there is an intent behind those rules,
and that intent is to keep crew members and
passengers safe, by recognizing and
addressing unsafe practices and conditions
not necessarily proscribed by regulations.”

44. Rabaul Queen – Papua New Guinea
2 February 2012
161 Dead / Missing

45. Princess Ashika, Tonga
Reliance on Falsified Certification
As Engineers we must often rely on certification from third-parties
Is it enough to rely on such certification when the evidence
indicates otherwise? A decision of the Supreme Court of
Tonga points out that it may not.
 The ship-operator argued it relied on certificates “issued by the
appropriate authority”.
 “any fool (could) tell how bad the ship was”.
 “defence was improperly hiding behind an unlawful Provisional
Certificate of Survey”
 The accused were found guilty – including manslaughter by
negligence
(Ref – Engineers NS – ‘The Engineer’ Fall 2011, p 15-17)

46. Lives Lost due to
Lack of Communication
Uean Te Raoi II – Kiribati – 13 July 2009
19 Dead / 16 Missing
 ... Consequently the search was
undertaken in the wrong area for
about 2½ days.
 Had an EPIRB been on-board and
activated, the exact location and
plight of the Uean Te Raoi II would
have been known almost
immediately. In this event it is highly
likely that all of those on-board would
have been rescued that night,
meaning the number of fatalities
would have been kept at 2.

47. Lives Lost due to
Lack of Communication
Manitoba, Canada – 2008 / 2011
 Island Lake River – northern
Manitoba – Canada – 5 Nov
2011
 Boat stuck in rapids – 3
day delay in rescue - 3 lost,
1 survivor
 Lake Manitoba – Canada – 21
October 2008
 Vessel broken down, 1 day
delay in communication –
1 lost, 2 survivors