onnettomuustutkintakeskus centralen för undersökning av
Transcription
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 2 31.3.2009 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 ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND 3 31.3.2009 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. ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND 4 31.3.2009 The town Savonlinna in lake district in eastern Finland SAVONLINNA ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND 5 31.3.2009 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 6 31.3.2009 The Olavinlinna castle and the pontoon bridge ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND 7 31.3.2009 Road bridge Railway bridge Pontoon bridge to Olavinlinna Olavinlinna Törninpyörä Mallatsaari Rapaluoto Uuraanpää Place the pilot got onboard © merenkulkulaitos ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND 8 31.3.2009 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 9 31.3.2009 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 10 31.3.2009 The currents in the Kyrösalmi sound 1 m/s (2knots) Olavinlinna castle ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND 11 31.3.2009 Pilot information about the currents in Kyrönsalmi ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND 12 31.3.2009 The buoy (right) used as current meter by pilots ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND 13 31.3.2009 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 14 31.3.2009 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 15 31.3.2009 KRASNOVIDOVO ttrack k lleading di tto collision lli i extracted from VTS recorded AIS data ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND 16 31.3.2009 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 17 31.3.2009 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 18 31.3.2009 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 19 31.3.2009 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 20 31.3.2009 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 21 31.3.2009 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 22 31.3.2009 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 23 31.3.2009 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 24 31.3.2009 Escape routes from the gallery ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND 25 31.3.2009 Escape routes from the gallery ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND 26 31.3.2009 Escape routes from the gallery ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND 27 31.3.2009 Escape routes from the gallery ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND 28 31.3.2009 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 29 31.3.2009 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 30 31.3.2009 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 31 31.3.2009 Thank you for your attention www onnettomuustutkinta fi www.onnettomuustutkinta.fi ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND 32 31.3.2009 The Finnish waterways y ONNETTOMUUSTUTKINTAKESKUS – CENTRALEN FÖR UNDERSÖKNING AV OLYCKOR – ACCIDENT INVESTIGATION BOARD FINLAND 33 31.3.2009