Viking Sky survivors

[JDincalif]

We just received this notification. Let's read it and let's discuss it!

 

The Norwegian Safety Investigation Authority has released a report:

 

Report on loss of propulsion and near grounding of Viking Sky, Hustadvika, Norway 23 March 2019

 

In the afternoon of 23 March 2019, the cruise vessel Viking Sky experienced a blackout, causing loss of propulsion and steering, during a storm in the Hustadvika area of the Norwegian coast. The vessel is estimated to have come within a ship’s length of running aground with 1,374 persons on board, and the accident had the potential to develop into one of the worst disasters at sea in modern times. The accident was caused by insufficient lubricating oil in all of the operating diesel generators’ lubricating oil sump tanks, in combination with pitching and rolling in rough seas. The investigation has identified operational, technical, and organisational safety issues that in different ways contributed to the blackout.

 

Read the full report at nsia.no

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[JDincalif]

Direct link to report:

 

https://www.nsia.no/Marine/Published-reports/2024-05

[JDincalif]

Of special interest to the survivors, from the report pdf linked to the recommendations summary:

 

The complex and extended helicopter operation was carried out effectively with no accidents or casualties, however both the first rescue helicopter and the first tug arrived after the vessel would have grounded if propulsion had not been regained.

 

Then this wise observation, with which we wholeheartedly agree:

 

This underlines the importance of not losing propulsion and steering and of avoiding situations where an evacuation is required. 

Edited March 19 by JDincalif
corrected spelling

[OnTheJourney]

Thanks so much for posting this! Long-awaited for sure. I see it is pretty lengthy and so saved it as a pdf (since I'll file it away for keeping along with the interim report). Should hopefully generate some interesting discussion. 5th anniversary coming up on Saturday!!!

[OnTheJourney]

4 hours ago, JDincalif said:

This underlines the importance of not losing propulsion and steering and of avoiding situations where an evacuation is required. 

Agreed! Even moreso relative to any evac scenarios (such as ours) that preclude the use of the lifeboats. Evac by helicopter is inherently dangerous but especially in the conditions we were in. Judging from the (many) pictures I looked at, I estimated that the ascent from deck 8 to the chopper was about 100 ft. Throw in some twisting and turning yet (yikes!). I was certain that my camera case would probably drop off into the ocean. Joan said a few prayers on the way up, while I was also saying a few for her while watching from below. Scariest moment of my life up until this past Christmas Eve with Joan's hospital / 911 event.

 

The first part of the quoted statement is, shall we say, pretty much a 'no brainer'  that pertains to operating any vessel!

 

Andy, I'll be anxiously awaiting your weigh-in on the report, as well as a few other expert mariners here.

Edited March 19 by OnTheJourney

[Heidi13]

I have only read a few pages of the report, so these are preliminary observations.

 

This incident meets the classic definition of the "Swiss Cheese Model" where numerous issues all aligned. To avoid the incident, all it would have taken is for 1 of the issues to be stopped. Assuming all Viking lub oil sump tanks are the same, this incident started many years before they even started cutting steel on the ship. The tank design not being in compliance with SOLAS is a serious error by the shipyard, which was compounded by Lloyds Register not identifying the deficiency during the plan approval.

 

The Ship Managers not including a sailing restriction for failure to meet the "Safe Return to Port" regulations, when 1 engine is out of service is another significant failure.

 

Ship Manager's "Designated Person Ashore" not following up with the email from one of the ships to the engine manufacturers, when they responded they couldn't provide a definitive answer, as the shipyard designed/built the sump tanks. This is another significant failure.

 

With the exception of the failure to comply with Safe return to Port Regulations, I don't see a problem with the Master's decision to sail, as the report states multiple times the conditions were well within the ship's design criteria.

 

As with most serious incidents, I expect the Lawyers will have a field day. I suspect the Owner probably provided the shipyard with a design/build, which usually contains boilerplate that it will be in accordance with SOLAS and all relevant International/Flag State Regulations. If the tank design is not in accordance with SOLAS, you have a potential breach of contract.

 

Lloyd's Register were also hired by the Owner/Ship Manager to oversee construction and to approve the plans. They again could be in breach of contract.

 

The Master sailed with 1 DG unavailable, which was in contravention of the Safe Return to Port Regulations, potentially rendering the vessel as not being fully seaworthy. Lawyers could potentially make an argument that it could limit the owners limitation of liability.

[SJD117]

16 minutes ago, Heidi13 said:

With the exception of the failure to comply with Safe return to Port Regulations, I don't see a problem with the Master's decision to sail, as the report states multiple times the conditions were well within the ship's design criteria.

 

Section 2.2 of the NSIA report discusses the decision to sail in detail. The following excerpt appears at page 101:

 

"Even though the SRtP regulations don't specifically address a scenario like the one the Viking Sky experienced, the NSIA is of the opinion that departing Tromso with one out of four DGs unavailable represented an unacceptable risk to the crew and passengers on board given the forecast weather conditions the vessel was to experience. As the vessel did not comply with the internationally agreed minimum safety standard as required by SOLAS, it should not have departed Tromso under the prevailing circumstances."

[Heidi13]

7 minutes ago, SJD117 said:

 

Section 2.2 of the NSIA report discusses the decision to sail in detail. The following excerpt appears at page 101:

 

"Even though the SRtP regulations don't specifically address a scenario like the one the Viking Sky experienced, the NSIA is of the opinion that departing Tromso with one out of four DGs unavailable represented an unacceptable risk to the crew and passengers on board given the forecast weather conditions the vessel was to experience. As the vessel did not comply with the internationally agreed minimum safety standard as required by SOLAS, it should not have departed Tromso under the prevailing circumstances."

 

Thanks, as I haven't got to Section 2 yet.

 

I'll suggest we should first consider the factual statement and NSIA opinion separately. As I noted, being in non-compliance with SRtP Regulations, in most situations, the vessel should not have sailed, as it wasn't fully seaworthy.

 

However, the Master has accountability and responsibility to manage the vessel in accordance with his/her best judgement and experience, with respect to safety and pollution prevention. With an impending significant storm, as per the forecasts, the Master could determine that remaining in port was not safe and heading out to sea was a safer option. The Master's overriding responsibility is outlined in the ISM Code Section 5.2. In accordance with ISM 5.2, that Master must take any action, in their professional judgement, to ensure the safety of the vessel, even if it contravenes the company SMS and regulations.

 

Note - I don't believe the Master used ISM 5.2 to justify sailing, but nothing in the report, I read so far, addresses this clause.

 

When the NSIA mention unacceptable risk due to forecast weather, they are getting away from facts and into subjective decisions. As with all after the fact inquiries, it is easy for the landlubber "Experts", to provide subjective opinions. When I went to sea, these type of positions were filled by experienced mariners, with many years of command experience. Sadly, these days, many are filled by those that can't handle command at sea.

 

I recall reading in Section 1 that the conditions were well within the design criteria of the ship, which is a factual statement. For the NSIA to later state "Unacceptable Risk" shows a complete lack of knowledge of risk analysis. Yes, sailing with only 3 engines, in any weather, results in a potential for increased risk. When the resultant risk of probability and severity reaches a certain level, you either incorporate risk mitigation strategies, to lower the risk, or don't sail. The risk is only unacceptable, if no risk mitigation strategies are used to lower the risk. Did the NSIA state that no risk assessment was completed with no risk mitigations incorporated into the plan prior to sailing?

 

I also note that most of the world's tonnage sail with only 1 engine, 1 propellor and no bow thrusters. Therefore, if the NSIA determined the vessel shouldn't sail due to the weather and  having only 3 engines, then every other vessel should not have been sailing.

[DGHOC]

Hi J and D, hope all good with you both. Thanks so much for posting this, we were beginning to think it would never appear.

 

Mmmm, it doesn't make for happy reading and I'm so glad Andy is here to offer his knowledge and experience, he was a huge help after the event. Even putting aside the frankly chilling 23 hours sitting in a chair in the theatre with the drama unleashed around us, it was shocking to see the evidence afterwards of how close we came to unimaginable disaster. 

 

When we were all together again on our gifted cruise in the Med, the issues of reason and responsibility were raised and much discussed by T H and others. One of the other guests who was on a pre-trip in Umbria with us, and who was still raging about the event, directly challenged TH about whether the Captain should have sailed in that storm, in that stretch of sea, knowing that one engine was out, he responded that he shouldn't have. This was witnessed by all around. We knew about the oil level issues then but not so much else that is detailed here. As Andy said, Swiss Cheese Model indeed!

 

I wonder when this report was received by TH and others responsible for the issues that need to be addressed. I wonder too whether action is underway to address these issues and concerns throughout the cruise industry.. 

 

Yep, no doubt this will be an enormous and hard fought legal battle to ascertain responsibility and blame; probably a massive money earner. Viking were extraordinarily generous and supportive of us passengers after the event, I suspect more generous with some with very serious injuries who were threatening to sue and who suddenly went quiet. Of course there was also the case of the couple from New Jersey who settled their multi million case against Viking. They were part of a large family group on the ship but weren't on the reunion cruise with the rest of the family.

 

We were all incredibly lucky to survive this event. On subsequent trips we met others who were still deeply affected by the experience; one chap we were talking to was openly weeping whilst discussing it. 

 

 

[TV Dad]

I cruised Viking Sky last October and enjoyed myself. But after reading this report, I will never cruise Viking again. The crew's incompetence put people's lives at risk. Totally unacceptable.

[JDincalif]

3 hours ago, DGHOC said:

One of the other guests who was on a pre-trip in Umbria with us...directly challenged TH about whether the Captain should have sailed in that storm, in that stretch of sea, knowing that one engine was out, he responded that he shouldn't have. This was witnessed by all around 

😳 Thank *you* for posting *this* 👆🏻

 

So good to hear from you, D - hope that you and C are well and happy.

[Goosebear Mum]

3 hours ago, TV Dad said:

I cruised Viking Sky last October and enjoyed myself. But after reading this report, I will never cruise Viking again. The crew's incompetence put people's lives at risk. Totally unacceptable.

 

I would hope Viking is now more risk adverse and would be very safe, maybe safer than companies that have not had an ‘incident’ yet… More safety processes followed, ships checked, etc.  I was on a boat (my parents) which exploded when I was 15, it's made me H&S aware, but not put me off, but I only ever book a balcony cabin, I’d have nightmares in an inside/seaview cabin.  

 

There were a couple of serious incidents in storms this Winter, injuring many passengers, with other cruise lines crossing the ‘Biscay’, again questions were raised about ‘should they have sailed?’.  Cruising will always be a ‘risk’, but companies have a responsibility to reduce that risk as much as possible. I am sure Viking will react to this, if not already ‘behind the scenes, before the report was publicised’.  

 

This was serious, It was horrifying.  I feel for those passengers who were onboard, and the relatives ‘watching’.  I remember the event clearly, though I was not onboard.  But, please don’t let it put you off.  I don’t believe the crew were incompetent, I have only ever read passengers praising the actual ‘crew’.  

 

I also will be interested to keep an ear open for any legal proceedings against captain, Viking, ship builder, etc.  

 

Out of interest, where is that Captain now? 

[JDincalif]

4 minutes ago, Goosebear Mum said:

Out of interest, where is that Captain now? 

Immediately following the incident, we set up news alerts for his name, yielding only a few hits in the first month; nothing since.

[OnTheJourney]

3 hours ago, TV Dad said:

But after reading this report, I will never cruise Viking again.

I don't believe this is a fully justifiable decision, but totally yours to make. It was undeniably a truly unfortunate set of circumstances (ala the "swiss cheese" model that Andy refers to). Probably safer sailing with Viking than flying with Boeing at the present time.

Edited March 20 by OnTheJourney

[OnTheJourney]

30 minutes ago, Goosebear Mum said:

Cruising will always be a ‘risk’

Of course, and yet far less of a risk than driving your car. Safer to fly than drive, and safer to cruise than fly, statistically speaking.

Edited March 20 by OnTheJourney

[OnTheJourney]

5 hours ago, DGHOC said:

he responded that he shouldn't have. This was witnessed by all around.

And, TH responded similarly during his presentation onboard the Mars, where he admitted to "human error" as the chief cause of the event.

[Heidi13]

4 hours ago, TV Dad said:

I cruised Viking Sky last October and enjoyed myself. But after reading this report, I will never cruise Viking again. The crew's incompetence put people's lives at risk. Totally unacceptable.

 

While I haven't read the entire report, I started with the conclusions (Section 3) and have read most of Section 1. In the areas I have read so far, the Master's and the crews actions were minor contributing factors compared to others.

 

Tank design - the shipyard designed tanks not complying with SOLAS and OEM guidelines. They further compounded this by installing an ineffective tank monitoring systems. These are not crew issues.

 

Plan Approval - The Flag State has delegated plan approval to Classification Societies, so Lloyd's Register were responsible for checking the shipyard design plans were in accordance with SOLAS and the Flag State (Norway). They were then responsible to approve the plans and ensuring the vessel was built according to said plans. Again, this was not a crew issue.

 

Remote Lub Oil Monitoring System - with fully integrated alarm and monitoring systems, this is a key component of any modern ship. This system was complex and not installed correctly, resulting in the Engineers receiving inaccurate and unreliable data. In this situation, the crew was not provided the correct tools to effectively manage the machinery.

 

Machinery Alarm Panel - modern ships have literally tens of thousands of sensors hooked up to the alarm panel. Modern diesel generators have automatic shut-downs for critical alarms, that include overspeed and loss of lub oil. On my last ships, these critical alarms were grouped separately, so my Chief Engineer could quickly advise why the engine automatically shut down. In the Viking system, they did not register by priority, so the Engineers had to scroll through 1,000 alarms on the screen. Faced with this type of challenge, I'll suggest the engineers did rather well, reasonably quickly identifying the issue and getting an engine restarted. The time interval was considerable, but with less experienced engineers, it could have been longer.

 

Lub Oil Management - this is a potential crew issue, but one must also take into consideration that no definitive minimum levels were provided by the OEM, upon request by another ship. The OEM declined to provide a definitive answer, as the tanks were designed/built by the shipyard and not to OEM recommendations. While the crew should have erred with higher levels, the Designated Person Ashore, should have taken action to solve the issue with the shipyard and OEM. The ship's SMS should have included clearly defined min and max levels for the engineers to follow.

 

Departure Decision - With 1 DG out of service, resulting in failure to comply with SRtP Regulations, the Master should not have sailed, unless he determined a higher risk to the vessel by staying in port, and sailing in accordance with the responsibility outlined in ISM 5.2. However, the constantly changing plethora of International, National and Local Acts and Regulations in the marine industry, make it impossible for every Master to know everything. Masters are provided detailed operational guidelines by the company in the Safety Management System (SMS). Many of the modern SMS include a sailing matrix outlining when the vessel cannot sail, and when it is Master's discretion. The SMS is developed by the Ship Management company and clearly did not include this key requirement.

 

Since cruise ships have routinely shut down an engine for maintenance during normal operations, for many years, this non-compliance with SRtP Regs should have been provided to the Master.

 

Post Incident - When drifting onto a lee shore, the Master quickly deployed both anchors by walking them down, which would be the preferred method. Mayday was issued in a timely manner and pax were mustered by the GES. When Assembly Station B was compromised they moved pax to an alternative location. The Master has effectively utilised the resources available, tasking 1 pilot to the con and another to communications, freeing the Master to focus on the emergency response.

 

In the engine room, considering the system challenges with the alarm system they identified the issue fairly quickly and responded accordingly. Once started, they faced a challenging situation getting the DG's to synchronise with the main board and operated them on manual control. Manual control is practiced, but not a common procedure, so in a stressful environment, the engineers response was effective.

 

With respect to evacuation, the Master correctly identified the risks of launching the survival craft in those seas and in close proximity of the lee shore. As most mariners are well aware, lifeboats have killed more people than have been saved by them. Therefore, while a traumatic experience, a helo evacuation was an excellent option. 

 

Yes, in hindsight, the crew could have prevented the incident, but I would hardly refer to them as incompetent. Many ships operate with less competent crews, which could have resulted in a worse outcome.

[SJD117]

@Heidi13 Let us know when you've read Section 2.

[OnTheJourney]

The one thing that will always bother me about the entire incident is that at no time were the pax informed of the impending situation, i.e. the weather forecast, what if any plans existed to deal with it, e.g. change in itinerary or not, and right up until the general alarm went and we were all told to go to muster stations, there was no communication - to the best of my memory - as to what was going on. Others on this thread (who were there) have a similar recollection. So there was no way to prepare - emotionally at least - for the situation. That made it more difficult. I guess the presumption was that - as has been stated - the ship SHOULD have, in normal operating conditions anyway, have been able to make it through safely. But even with that said, might have been good to tell everyone to report back to their staterooms awaiting further notice or at least inform us ahead of time (since the storm was forecasted days in advance) of what we could expect in the way of high seas and strong winds. I don't recall that anything was said. Instead, you still had people sitting in the lounge while stuff started falling out of the ceiling, loads of glass items smashing, lounge chairs sliding from one end to the other (with people in them) All of a sudden, a bit later, we were in an emergency situation and informed about the evac plans. I've mentioned before on this thread that another cruise we were on (actually the next one after the Sky) also encountered a (less severe) weather situation and the captain held a presentation in the theater to inform us of what was going on as well as the various itinerary changes, etc. that were being considered. It was most impressive and got us to thinking about the contrast between that level of communication and how I remember it on the Sky. All that said, I totally agree that following the general alarm the crew did an outstanding job for both those who were evacuated and stayed onboard. And, I can't say enough about how well things were handled ashore for the evacuees.

 

This was the weather report as listed on the room tv for 3/23/19. And yet the ship was rockin' and rollin' the evening before already.

Edited March 20 by OnTheJourney

[chengkp75]

I also have just done a quick read through of section 1, and agree with Andy on all points.

 

I will stress that from my readings the root cause of the incident was the failure of the shipyard and Lloyd's Register to adequately design the lube oil sump tanks.  Mitigating this, somewhat, is the note from the NSIA that there is no industry standard, or class procedure for evaluating whether the tank actually meets the requirements.

 

I've always been a bit critical of cruise ships that have only 4 diesel generators, but I never thought of the possible consequences to the SRtP regulations.  As Andy noted, and I have pointed out over the years here when folks complain about a ship not being able to make top speed, having one diesel down for maintenance, repair, or overhaul is quite common.  Overhauls in particular, happen every 2.5 years (about, actually 12,000 running hours), and for engines like the Sky has, they can take 4-5 weeks to complete.  This is exacerbated by having different sized generators, though this is common to allow maximum fuel efficiency by tailoring the generator capacity to the load required.  Ships with 5 or 6 generators, the individual generator is a much smaller percentage of the total load, so loss of one to maintenance, and loss of 2 or 3 in the other engine room (the SRtP scenario), does not present as significant a problem as the Sky had.  The fact that Viking has amended the SMS to show a SRtP scenario for two conditions now (one for loss of large engine and one for loss of small engine), will make this an industry standard (through the IACS), and may affect a lot of ships that have only 4 engines.

 

I also agree with Andy's assessment of the crew.  From an engineering standpoint, I have seen many, many ships operated with an SMS program that has too little detail, and non-specific procedures (both ship or class specific from the company, or ship specific based on the Chief Engineer's personal standing orders).  I have taken over such ships in the past.  I am, however, of the philosophy that I cannot write too much, nor get into the details of how a job is to be performed to much, in my standing orders.  They tend to be a 2" ring binder of policies and procedures.

 

As Andy said, this is the Swiss cheese model of an accident.  Even with the deficient design of the oil sump tanks, if the Chief had been more specific in his orders regarding lube oil consumption monitoring, level monitoring, and alarm/set point changes and monitoring, the incident would not have happened.  If, on the other hand, the tanks were designed properly, and the crew did not necessarily meet the proper procedures for maintaining oil level, the incident would also not have happened.  Misalign one hole in the Swiss cheese, and the accident never goes all the way through to the dangerous conclusion.

 

I would not have been happy with some of the equipment choices made (sending the oil level inputs out to a stability calculator to determine a volume and then use that volume back in the engine automation system for the alarms), or an alarm system that does not have a priority system (though virtually every system commercially available will output a thousand alarms at the moment of blackout), so either the shipyard or Viking can be held for those decisions.

 

 

[SJD117]

Articles about the NSIA report.

 

https://maritime-executive.com/article/report-contends-viking-sky-was-non-compliant-and-should-not-have-sailed

 

https://www.cruisehive.com/cruise-ship-which-lost-power-during-storm-should-have-never-sailed/126440

[Goosebear Mum]

1 hour ago, chengkp75 said:

I will stress that from my readings the root cause of the incident was the failure of the shipyard and Lloyd's Register to adequately design the lube oil sump tanks. 

 

 

So, out of interest, in your opinion, what do you think will/can/could potentially be done for all the current ships? 

Edited March 20 by Goosebear Mum

[chengkp75]

1 hour ago, Goosebear Mum said:

 

So, out of interest, in your opinion, what do you think will/can/could potentially be done for all the current ships? 

I haven't read the analysis or conclusion sections of the report, so I can't say what has been recommended and what has been done, but at the very least there is a new SRtP procedure in Viking's SMS that states different weather conditions depending on what engine is out for maintenance/repair.  There will also be amendments to Viking's SMS to delineate the proper assumed lube oil consumption rate, the new required minimum lube oil level, based on the new simulations done by NSIA, proper procedures for maintaining lube oil level while in heavy weather, and likely a few other procedural changes to the SMS.  There likely isn't anything that can be done to redesign/rebuild the sump tanks, given ship geometry, so there will have to be measures to mitigate any design deficiency.

[Goosebear Mum]

2 minutes ago, chengkp75 said:

There likely isn't anything that can be done to redesign/rebuild the sump tanks, given ship geometry, so there will have to be measures to mitigate any design deficiency.

 

Thanks, yes, I wondered as such. Mitigation. It’ll be interesting to see how TH and the industry as a whole responds, just as it had to do after Costa, etc.  Thanks. Sadly, it’s only through incidents like this, that the industry can sometimes learn, and improve safety further.  I know after my parent’s boat explosion (and others that followed over the next few years) that ‘bi yearly boat MOTs’ were introduced on the River Thames (UK)  The run of deadly explosions ended thankfully. 

[aungrl]

21 hours ago, Heidi13 said:

This incident meets the classic definition of the "Swiss Cheese Model" where numerous issues all aligned.

I remember this being your hypothesis early on when discussions about the situation first began.  This final report confirms your points of view, unsurprisingly, and I - along with many others, I'm sure - very much appreciate you coming back and giving even more details to help further explain and interpret the report.