onnettomuustutkintakeskus centralen för undersökning av

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onnettomuustutkintakeskus centralen för undersökning av
ONNETTOMUUSTUTKINTAKESKUS
CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR
ACCIDENT INVESTIGATION BOARD FINLAND
Sörnäisten rantatie 33 C, 00580 Helsinki, Finland
www.onnettomuustutkinta.fi
A COLLISION WITH PONTOON BRIDGE AND
CONSEQUENCES FOR OPERA FESTIVAL
Martti Heikkilä
EMAIIF 5
Budapest
p
29 - 31 March 2009
The Finnish inland
waterways
ate a s
ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND
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Partt 1
P
The KRASNOVIDOVO accident
•
Russian flagged river-sea vessel
•
Built
1980
•
L
Length
th
78 10 m
78,10
•
Draft
3,338 m
•
GT
1522
•
Displacment
2684 t
•
Machine effect 2 x 441 kW
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The KRASNOVIDOVO accident
ms KRASNOVIDOVO was on 18
18.7.2004
7 2004 on its
way to Varkaus nearly fully laden with timber.
The Master of the vessel had been changed in
St. Peterburg, and the Master now onboard was
making this voyage on the KRASNOVIDOVO for
the first time. This was also his and the Chief
Officer’s first voyage
y g to the Saimaa Lake
District.
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The town
Savonlinna in lake
district in eastern
Finland
SAVONLINNA
ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND
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The KRASNOVIDOVO accident
Three Finnish pilots had piloted the vessel from
the Saimaa Canal to Savonlinna. The new pilot
carrying out the piloting from Savonlinna had
embarked the vessel 20 minutes before the
vessel entered the Kyrönsalmi strait which
passes the Olavinlinna Castle.
ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND
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The Olavinlinna castle and the pontoon bridge
ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND
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Road bridge
Railway bridge
Pontoon bridge to Olavinlinna
Olavinlinna
Törninpyörä
Mallatsaari
Rapaluoto
Uuraanpää
Place the pilot
got onboard
© merenkulkulaitos
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The KRASNOVIDOVO accident
The pilot took over the manoeuvring of the
vessel by manual steering. The vessel type was
not familiar to the pilot
pilot, and he did not have time
to get enough feel for the manoeuvring of the
vessel before it reached Kyrönsalmi.
The pilot and the crew discussed neither the
manoeuvring characteristics of the vessel in
greater detail nor the earlier stages of the
voyage.
ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND
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The KRASNOVIDOVO accident
When the KRASNOVIDOVO approached
Kyrönsalmi, the pilot noticed that the current
was very strong in the strait
strait. The vessel entered
the inhomogeneous current field of Kyrönsalmi
at an angle after a turn which had been too long.
At the same time the pilot handed the
manoeuvring over to the Chief Officer without
informing about it in advance.
ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND
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The currents in
the Kyrösalmi
sound
1 m/s
(2knots)
Olavinlinna
castle
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Pilot information
about the currents
in Kyrönsalmi
ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND
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The buoy (right) used as current meter by pilots
ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND
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The KRASNOVIDOVO accident
The Chief Officer took over the helm
helm, and the
Master started to handle the engine. After the
vessel had started to take a strong turn in the
opposite direction, the Master could not stop this
turn quickly enough. The vessel first hit the
Olavinlinna pontoon bridge, which was open,
and then the cliffs of the island at a speed
p
of a
little less than three knots.
ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND
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Correct angle of approach to Kyrönsalmi
( h t taken
(photo
t k on reconstruction
t ti run))
ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND
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KRASNOVIDOVO ttrack
k lleading
di tto collision
lli i
extracted from VTS recorded AIS data
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KRASNOVIDOVO
colliding the pontoon
bridge and hitting the
cliffs of the island at 3
knots
Tallisaari
Olavinlinna
ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND
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The damages on the KRASNOVIDOVO were
minor, and a few minutes after the collision the
vessell was manoeuvred
d th
through
hK
Kyrönsalmi.
ö
l i
ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND
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The KRASNOVIDOVO accident
The KRASNOVIDOVO entered the Kyrönsalmi
fairway at an angle, and the pilot handed over
the manoeuvring without any prior notice
notice. These
two incidents together were the direct causes of
the accident.
In a narrow fairway with a current even slight
deviations in the steering of the vessel require
good knowledge about the conditions in the
fairway and excellent manoeuvring of the vessel.
ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND
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Part 2
The Opera Festival public safety
In the collision the fastening of the fixed part of
the pontoon bridge came partly loose, and it
was no longer possible to use the bridge as a
traffic route.
The first round of the Timo Mustakallio song
contest was about to begin in the Olavinlinna
Castle At decision was quickly made to convey
Castle.
passengers on a transport ferry, which had not
been inspected as a passenger-vessel.
passenger vessel.
ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND
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Transportation of the festival public to the castle
on a ferry
f
nott approved
d for
f passengers
ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND
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The KRASNOVIDOVO accident occured in the
summer when the use of the Olavinlinna Castle
for big events for the general public is most
active. The accident also showed that the only
planned route for a great number of people back
t the
to
th mainland
i l d ffrom th
the Ol
Olavinlinna
i li
C
Castle
tl iis
very vulnerable to disturbances.
The historical constructions of the Olavinlinna
Castle and its current usage as festival
premises
i
ffor thousands
h
d off people
l are
inconsistent with current requirements on public
safety.
f t
ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND
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The safety arrangements at the Olavinlinna
Castle constitute a whole, which is not restricted
only to the usability of the pontoon bridge or the
vessel accident. In 1989 the maximum allowed
number of persons on the castle yard was
established
t bli h d tto 560.
560
The combined width of the traffic routes to and
from the castle is according to the current
building regulations too small for the number of
persons temporarily
il allowed
ll
d at the
h gallery
ll
(2257) or at the whole castle (2777).
ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND
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The gallery is
constructed for the
festivals in each year.
Below the new gallery
designed in 2000 and
accommodating 2260
2260.
1975
2000
ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND
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Escape routes from the gallery
ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND
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Escape routes from the gallery
ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND
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Escape routes from the gallery
ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND
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31.3.2009
Escape routes from the gallery
ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND
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Poistumisaika
0:00
00:05
2260 henkilöä
2260 pers
katsomossa
Poistumisaika
0:41
00:41
2000 henkilöä
2000 pers
katsomossa
Poistumisaika
02:30
2:30
1190 henkilöä
1190 pers
katsomossa
Poistumisaika
03:53
3:53
730 henkilöä
730 pers
katsomossa
Poistumisaika
01:33
1:33
Poistumisaika
6:13
06:13
1700 henkilöä
1700 pers
katsomossa
200
henkilöä
200
pers
katsomossa
ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND
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Escape simulations, the gallery fully occupied
The decisions on the maximum number of
persons are based on a practice which has
continued for a long time
time, and the situation has
not been reassessed when there have been
rebuilding of the gallery and stage structures in
2000.
ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND
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The KRASNOVIDOVO accident safety recommendations
•
•
•
•
•
better information about the currents in the strait
to the users of the Kyrönsalmi fairway
the transfer of the deep-water
deep water channel
the development of piloting practices
the special requirements on pilots navigating the
more demanding fairway sections
a thorough investigation of the public safety of
the Olavinlinna Castle.
ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND
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Thank you
for
your attention
www onnettomuustutkinta fi
www.onnettomuustutkinta.fi
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The Finnish waterways
y
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