Accident to Jetfoil Funchal, 16th October 1988.

HONG KONG GOVERNMENT - MARINE DEPARTMENT
Summary
IM TOBY- INQUIRY
REPORT
CONCERNING THE GROUNDING
OF THE BRITISH JETFOIL
"FUNCHAL" ON 16 OCTOBER 1988
Sister ship to Jetfoil FUNCHAL close to position of casualty in MACAU Access Channel
MftNQ.
UNIVERSITY OF HONG KONG
LIBRARY
Hong Kong Collection
Gift from
Hong Kong. Marine Dept.
Accident to Jetfoil Funchal, 16th October
1988.
On the evening of 16 October 1988 the Hong Kong registered
Jetfoil Funchal, Official Number 388142, was reported to have
grounded in the Macau Outer Harbour Access Channel, with several
persons injured. On the 18 October 1988 the Director of Marine, in
accordance with Section 51(1) of the Merchant Shipping Ordinance
(Cap. 281), appointed Paul Richard Owen, Master Mariner, to carry out
a Preliminary Inquiry into the circumstances attending this casualty.
Sequence of Events
The Jetfoil Funchal departed from Macau on 16th October 1988
at 1842 hours after a short delay due to other ferries occupying the
access channel. All the normal equipment checks and inspections had
been carried out and found satisfactory, the Funchal was properly
manned and there is no reason why the Funchal should not have set
out on this voyage from Macau to Hong Kong. There were 248
passengers on board, with maximum capacity at 268, in addition there
were nine crew who consisted of the Captain, Engineer, First Mate
and Second Mate, who manned the wheelhouse. The crew in the
passenger cabin consisted of two Cabin Attendants and three Sailors.
Routine pre-departure checks are recorded on a voice tape
recorder, the recording of this particular voyage confirms that these
procedures were carried out which include verifying the performance
of the radars, night vision equipment, headset communications system
between the officers and other important equipment in the
wheelhouse.
Approximately four minutes after leaving the berth in Macau the
Captain was satisfied that the Funchal had achieved full speed and
everything was normal as the end of the inner breakwater was being
passed. Two minutes after this, at about 1848 hours, the Jetfoil
sheered unexpectedly to port and within five seconds went out of the
channel into the shallow water between the dredged channel and the
breakwater.
These first five seconds were critical, it is possible that during
this time the Captain glanced down to check his instruments and the
Chief Officer was recording a time in the logbook. It is known,
however, that the Second Officer reported a 'contact' on the night
vision equipment to the Captain during these five seconds which
would have occupied his attention for at least two seconds.
Once out of the channel the Captain knew the depth of water
was too shallow to land the Jetfoil and took every possible action to try
and return the Funchal to the deep water in the channel. The Jetfoil
began responding to this action and started to turn back towards the
channel when the Jetfoil sheered to port for the second time.
At this stage the Captain concluded that he could not control the
direction of the Funchal sufficiently to regain the channel and because
a large concrete navigation beacon was closing fast from right ahead
and the breakwater was very close on the port side, he decided to stop
the Jetfoil by placing the throttles into full reverse to avoid these
immediate dangers. See track chart in Appendix A.
The impact of grounding had two effects, first the aft or back
end of the Funchal was driven upwards, secondly as the weak link
broke on the aft strut and it folded backwards, it had a braking effect
and the Funchal decelerated rapidly. The forward strut also has a weak
link and as this parted on impact the forward strut also folded
backwards puncturing one of the watertight compartments. This was
not a serious problem as Jetfoils have many separate watertight
compartments.
The passengers and crew were also subjected to the two forces
described above, first upwards and then forwards as the Fur^chal
decelerated. Four of the crew who were standing up at the back end of
the passenger cabin all hit their heads on the ceiling and the three
sailors lost consciousness and received various injuries such that they
were all incapacitated. Many passengers were injured, with altogether
71 persons seeking hospital treatment in Macau, however many of
these injuries were minor in nature and these persons were treated
and discharged. The injuries received were mostly caused from
passengers hitting the back of the seat in front of them and from leg
injuries where passengers had stretched out their legs under the seat
in front. The most seriously injured was sailor Leung Tak-yin with a
head injury, he remained unconscious for several weeks after the
accident.
The remaining crew members who were not injured attended to
the passengers and treated their injuries using the medical supplies
carried on board.
The Funchal came to rest about two metres from the breakwater
and adjacent to Macau No. 3 Beacon. The engineer stopped all
machinery and checked the various compartments for damage. The
Captain was satisfied that the Funchal was in a relatively safe and stable
condition and was in no imminent danger. The emergency batteries
were working and supplying the essential emergency equipment
including radios and emergency exit lights. Contact was established
with Macau Radio within one minute of the accident by the officers
and the first rescue tug left Macau at 1852 hours arriving at the
Funchal at 1907 hours. Altogether four tugs went to assist the Funchal
by either towing her back to the berth or ferrying some of the
passengers to shore for earlier medical treatment.
The Funchal arrived back alongside the berth in Macau at 1945
hours. By 2000 hours all the injured had left the Funchal.
Scope of Investigation
Several days after the accident a detailed inspection of the
Funchal and its1 equipment did not identify any malfunction. In
particular the steering system and automatic control computers were
given a very searching examination by removing them from the vessel
and linking them up to a testing machine. The comprehensive test
procedures showed that all components controlling the steering of
Funchal were operating correctly.
Tape transcripts were made from the voice tape recording on
the Funchal and from the tape recording from the Macau Port Radio
Station supplied by the Macau authorities. The voice tape recording
which was operating throughout the voyage shows the officers in the
wheelhouse were following correct procedures and there were no
indications of malfunctioning equipment.
These tests, together with other investigations, show that it was
extremely unlikely that the accident was caused by equipment
malfunction or crew negligence.
Comparisons were made with previous similar accidents to find
any repetition in defects or causes, in particular the accident to the
Jetfoil Rco in March 1981 and the subsequent findings of the Marine
Court. This accident may be considered to be of a similar magnitude
when considering damage and injuries, however, the circumstances of
the accident were found to be quite different.
Findings
The most probable cause of the accident is a phenomena called a
Strut Ventilation or Foilborne Skid. This can happen through several
causes the most common of which is rubbish, such as discarded ropes
or plastic sheeting, being caught on the forward strut, see Appendix B.
Normally this will not cause any serious effect to the steering and
there are procedures laid down for the crew to correct the problem.
On rare occasions, when the rubbish is substantial, it will have a
serious effect on the steering. Once again procedures are laid down for
recovery from this problem, however, on this particular occasion it
happened so fast that the Captain was unable to take any action, which
includes stopping, before the Funchal entered the shallow water,
when such action was not possible.
The frequency of Strut Ventilations and Foilborne Skids is
estimated at about 25 occurrences a year for each Captain.
Approximately 10% of these require some action by the crew to
remove the rubbish from the strut by manipulating the controls, and
1% require the Jetfoil to stop and move backwards to remove the
rubbish from the strut before the voyage can be continued. The
remainder are minor in nature and require no special action from the
crew to remove the rubbish as it is quickly washed off after a few
seconds and will, in any case, not affect the steering. Each Captain will
operate up to 1,500 voyages between Hong Kong and Macau each year.
Recommendations
A detailed investigation was conducted into every aspect of this
casualty and several areas requiring attention were uncovered and
appropriate recommendations have been made. In addition, and most
important of all, investigations are being carried out into the feasibility
of fitting an alarm to all Jetfoils to warn Captains at the initiation of a
Strut Ventilation or Foilborne Skid. During these incidents one of the
difficulties the Captains have is identifying exactly what is going wrong
so the appropriate action can be taken, this alarm system will help to
solve this problem by eliminating the delay in identification.
Some recommendations were formed bearing in mind the
consequences of a foilborne skid in narrow channels where normal
action could not be taken.
Recommendations directly relating to casualty:T,
1. A Strut Ventilation or Foilborne Skid alarm should be
installed on Jetfoils, if possible;
2.
Seat belts should be fitted to all passenger seats and
announcements made to recommend that they should be
worn. Also a mandatory requirement to wear seat belts in the
higher risk areas of the harbours should be carefully
considered;
3. The cabin crew should be provided with seats, fitted with
safety belts, for use in the Macau Channel and Hong Kong
Harbour to ensure that, in the event of a similar casualty, they
have the best chance of avoiding injury and be in a position to
render assistance to the passengers;
4.
The public address system, although supplied from two
alternative independent electrical sources, failed to work
after the accident, it should be connected to the emergency
batteries;
5. The Confectionery and Drinks trolleys should not be used
while Jetfoils are in high risk areas such as Harbours;
6.
The company should review the crew uniforms to see if they
are distinctive enough.
7.
It should be reconsidered whether the orange smoke signals
are required for these vessels in view of the panic they caused
during this casualty. If they can be dispensed with then they
should be removed from all similar craft;
8.
The Chief Officers should not write down times while they
are keeping a lookout in the confined waters of the Macau
Channel and Hong Kong Harbour. If it is necessary to record a
time then this should be done by^the Engineer Officer;
Recommendations concernings other matters discovered during
investigations :9.
Negative Reporting practices by the crews should be brought
to the attention of the company;
10.
With the agreement of the Macau Authorities, Captains
should be advised to follow a track down the centre of the
access channel to Macau when it is safe to do so;
11. Damage occurred to some of the engine room fire insulation
as a result of the accident, action should be taken to prevent
recurrence;
12. As a result of this accident the crew First Aid Training course
and the initiation of refresher courses should be reviewed and
if necessary special River Trade Passenger Vessel Syllabuses
introduced;
i
13. The contents of the First Aid supplies should be reviewed as
this is the first major accident since they were last reviewed
in 1986;
14. The lessons learnt from the casualty should be incorporated
into any future crew training, such as passenger control
techniques;
15. Because of the seriousness of this accident the instructions in
the Boeing Jetfoil Operators Manual for Foilborne Skids
should be promoted from the Normal to Emergency section;
16. The Far East Hydrofoil Company should be informed that
some of their officers are not complying with the
recommendations of the various fatigue studies with regard to
annual leave;
17. Announcements to the passengers when approaching the
destination to ask them to remain seated should cease. If this
reminder is considered necessary then it should be made at
the mid-point of the voyage and also remind them to keep
their seat belts fastened;
18. Any person from the company who is not a passenger must
inform the master or officers when they board a Jetfoil while
the master or officers are on board;
19. Research should be conducted to find out why the bilge
alarms came on during this casualty for compartments that
were not flooded and to find a way to prevent this in the
future.
Recommendation relating to the holding of a Marine Court:20. Because of the depth this inquiry has been able to go and the
results of this inquiry, the appointment of a Marine Court is
not recommended.
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