on board. A full-scale emergency was only declared at 02:30. Ships rescued 34 people and helicopters...

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on board. A full-scale emergency was only declared at 02:30. Ships rescued 34 people and helicopters 104; the ferries played a much smaller part than the planners had intended because it was too dangerous to launch their man-overboard (MOB) boats or lifeboats. Most passengers died from drowning and hypothermia, as the water temperature was 10 to 11 C/50 to 52 F. About 650 people were still inside the ship when it sank. It was estimated that up to 310 passengers reached the outer decks, 160 of whom boarded the life-rafts or lifeboats. According to the official report, the bow door had separated from the vessel, pulling the ramp used to upload and download vehicles ajar. In addition, the ship also started listing/tilting because of poor cargo distribution. The ship rapidly took on water and started to tilt to one side due to the damaged/open bow door, causing the flooding of other decks and the cabins. Following the flooding, the power failed altogether, inhibiting rescue efforts and caused that a full-scale emergency was only declared after 90 minutes. This also initiated criticism regarding the passive attitude of the crew, who failed to notice that water was entering the vehicle deck, which delayed the alarm and caused a shortcoming in providing guidance from the bridge during the SECTION A Instructions: Consider the case study and answer ALL the questions related to the case study. [60] Case study The MS Estonia was a cruise ferry built in 1980 at a German shipyard, with almost 15 years of successful ferrying service for four different owners and operators. The ferry was sold to Nordstrm & Thulin on the Estline's Tallinn-Stockholm route in 1993. The MS Estonia consisted of 11 decks. Passenger facilities were located on decks one, four, five and six, while the crew members occupied decks seven and eight. Decks two and three were dedicated to the respective cargo. The MS Estonia was also a car ferry with large external doors close to the waterline. These ferries with open vehicle According to the official report, the bow door had separated from the vessel, pulling the ramp used to upload and download vehicles ajar. In addition, the ship also started listing/tilting because of poor cargo distribution. The ship rapidly took on water and started to tilt to one side due to the damaged/open bow door, causing the flooding of other decks and the cabins. Following the flooding, the power failed altogether, inhibiting rescue efforts and caused that a full-scale emergency was only declared after 90 minutes. This also initiated criticism regarding the passive attitude of the crew, who failed to notice that water was entering the vehicle deck, which delayed the alarm and caused a shortcoming in providing guidance from the bridge during the identified as the leading cause of the capsizing and sinking of the ship. An incident report was critical of the crew's actions, particularly for failing to reduce speed before investigating the noises emanating from the bow and being unaware that the list was being caused by water entering the vehicle deck. There were also general criticisms of the delays in sounding the alarm, the passivity of the crew, and the lack of guidance from the bridge. The sinking of the MS Estonia remains the worst European peacetime maritime disaster and the second-worst maritime disaster involving a European-made boat since the Titanic. Due to the costs and complex logistics involved with raising such a large vessel, the MS Estonia has been declared a memorial site. Further exploration of the wreck was prohibited (a treaty was declared in 1994). This resulted in a lot of ferry with large external doors close to the waterline. These ferries with open vehicle decks with few internal bulkheads have a reputation for being a high-risk design. An improperly secured loading door can cause a ship to take on water and sink, which happened in 1987 with the MS Herald of Free Enterprise. Water sloshing on the vehicle deck can set up a free surface effect, making the ship unstable and causing it to capsize. On 28 September 1994, in the Baltic Sea, the MS Estonia sank off Finland's coast and was recorded as one of the worst maritime disasters of the 20th century, claiming 852 lives of the 989 passengers and crew on board. Headline news worldwide reported the massive loss of life; only 137 people survived. Free surface water on the vehicle deck was determined to contribute to the sinking of MS Estonia. Question 2 (8) Discuss in detail four reputational risks that resulted from the sinking of the MS Estonia. Question 3 (4) Discuss two critical risk decisions made by the captain that potentially led to the disaster and how these decisions could have been prevented. rumours and conspiracy theories circulating. In 2020, a Swedish TV channel released a documentary indicating a large hole in the hull due to a collision. The Estonia government announced on 28 September 2020 that a new "technical investigation" will be undertaken to investigate the disaster. Survivors of the disaster and the relatives of those who died have petitioned for more than 20 years to re-open and expand the investigation into the disaster. The official report indicated that the locks on the bow door had failed from the strain of the waves, and the door had separated from the rest of the vessel, pulling the ramp behind it ajar. The bow visor and ramp had been torn off at points that would not trigger an "open" or "unlatched" warning on the bridge, as is the case in normal operation or failure of the latches. The bridge was also situated too far back on the ferry for the visor to be seen from there. While there was video monitoring of the inner ramp, the monitor on the bridge was not visible from the conning station. The bow visor was under-designed, as the ship's manufacturing and approval processes did not consider the visor and its attachments as critical items regarding ship safety. The first metallic sound was believed to have been that of the visor's lower locking mechanism failing and that the subsequent noises would have been from the visor "flapping against the hull as the other locks failed before tearing free and exposing the bow ramp. The subsequent failure of the bow ramp allowed water into the vehicle deck, which was Question 4 (10) Risk-based decisions are dependent on accurate risk information. Key risk indicators are an operational risk management methodology that generates risk information. The height of the swells can be regarded as risk information that could have been used to decide whether to leave the harbour or not. You must explain the concept of risk indicators as an operational risk management methodology and provide a graph using the information in table 1 to illustrate the height of the swells on 27/28 September 1994. Clearly indicate the threshold and state whether you agree with the captain's decision to sail at 19:15. Question 5 (6) People are frequently the cause of risks. This can be clearly identified in the case study. Identify four incidents where the crew can be held responsible for the ensuing disaster and identify possible solutions to prevent similar disasters. Question 6 (12) The case study shows the importance of a risk management policy. According to Blunden and Thirlwell, policy and governance form the cornerstone of business continuity management. Discuss the policy statement concept and identify three focus areas/procedures where a clear policy statement/operating procedure was lacking during the MS Estonia disaster. For training purposes, some fictitious information is included in the case study. Analyse the case study and answer the related questions below. Source: Most of the information was retrieved from: https://en.wikipedia.org/wiki/Sinking_of_the_MS_Estonia and Documentary Claims a Sub May Have Caused the Sinking of the Ferry MS Estonia (warhistoryonline.com) - accessed 14 September and 29 November 2021. Blunden, T & Thirlwell, J. 2013. Mastering operational risk: A practical guide to understanding operational risk and how to manage it. 2nd edition. Harlow: Pearson Education Limited. Question 1 (20) Define operational risk and explain each operational risk factor in detail. Analyse the case study and use the operational risk factors to identify operational risk examples for each factor and the mitigation measures that MS Estonia could have taken. Table 1: Height of swells/waves Time: 27/28 September 1994 15:00 Height of the swells in metres Source: Fictitious data 2 20:00 21:00 02:00 8 8 m 6 m m A safe height of the swells for a passenger liner is 2 to 3 metres. If the swells are 4 to 5 metres, it becomes risky and higher than 6 metres becomes dangerous for passenger ships. However, despite the 6-metre swells, the captain decided to depart at 19:15. The first sign of trouble aboard the MS Estonia was when a loud metallic sound was heard, presumably caused by a heavy wave hitting the bow doors around 01:00, when emergency. It seems as if the responsible crew were not adequately trained to sound the alarm during emergencies. There was a general lack of standing operating procedures when a problem was encountered with the bow door. In addition, the loading crew failed to identify the incorrect loading of vehicles which caused the ship to list/tilt over. However, there were also other factors involved that should have been considered and which contributed directly or indirectly to the disaster. The MS Estonia disaster occurred on Wednesday, 28 September 1994, between 00:55 and 01:50 (UTC+2) as the ship was sailing across the Baltic Sea from Tallinn to Stockholm, Sweden. The ship departed behind schedule at 19:15 on 27 September and was expected to doc in Stockholm on 28 September at 09:00. The ship was fully loaded and was listing slightly to starboard because of poor cargo distribution. The captain failed to notice or question The first sign of trouble aboard the MS Estonia was when a loud metallic sound was heard, presumably caused by a heavy wave hitting the bow doors around 01:00, when the ship was on the outskirts of the Turku archipelago. However, an inspection, which was limited to checking the ramp and bow door indicator lights, showed no problems. It seems the responsible crew did not perform a physical inspection of the bow doors. Over the next 10 minutes, similar noises were reported by passengers and other crew members. At about 01:15, the bow doors are believed to have separated and torn open the loading ramp behind them. The ship immediately took on a heavy starboard list (initially around 15 degrees, but by 01:30, the ship had rolled 60 degrees, and by 01:50, the list was 90 degrees) as water flooded into the vehicle deck. The captain subsequently ordered the ship to turn to port, but it slowed down before her four engines ceased completely. bearing 157 from Ut island, Finland, to the depth of 74 to 85 metres (243 to 279 ft) of water. According to survivor accounts, the ship sank stern first after taking a list/tilt of 90 degrees. Search and rescue followed arrangements set up under the 1979 International Convention on Maritime Search and Rescue (the SAR Convention). The nearest Maritime Rescue Co-ordination Centre, MRCC Turku, coordinated the effort in accordance with Finland's plans. The Baltic is one of the world's busiest shipping areas, with 2,000 vessels at sea at any time, and these plans assumed the ship's own boats and nearby ferries would provide immediate help and that helicopters could be airborne after an hour. This scheme had worked for the relatively small number of accidents involving the sinking of vessels, particularly as most ships have few people on board. A full-scale emergency was only declared at 02:30. Ships rescued 34 people emergency. It seems as if the responsible crew were not adequately trained to sound the alarm during emergencies. There was a general lack of standing operating procedures when a problem was encountered with the bow door. In addition, the loading crew failed to identify the incorrect loading of vehicles which caused the ship to list/tilt over. However, there were also other factors involved that should have been considered and which contributed directly or indirectly to the disaster. The MS Estonia disaster occurred on Wednesday, 28 September 1994, between 00:55 and 01:50 (UTC+2) as the ship was sailing across the Baltic Sea from Tallinn to Stockholm, Sweden. The ship departed behind schedule at 19:15 on 27 September and was expected to doc in Stockholm on 28 September at 09:00. The ship was fully loaded and was listing slightly to starboard because of poor cargo distribution. The captain failed to notice or question 01:22 but did not follow international formats. The MS Estonia directed a call to Silja Europa, and only after making contact with her did the radio operator utter the word "mayday". The radio operator on Silja Europa, chief mate Teijo Seppelin, replied in English: "Estonia, are you calling mayday?" After that, the voice of the third mate took over on the MS Estonia, and the conversation shifted to "Finnish. At first, there seemed to be a language problem, but the third mate was able to provide some details about their situation. However, due to a loss of power, he could not give their position, which delayed rescue operations. Some minutes later, power returned (or somebody on the bridge managed to lower himself to the starboard side of the bridge to check the marine GPS, which will display the ship's position even in blackout conditions), and the MS Estonia was able to radio its position to Silja Europa and Mariella. The ship disappeared from the radar screens of other ships at around 01:50 and sank at 01:22 but did not follow international formats. The MS Estonia directed a call to Silja Europa, and only after making contact with her did the radio operator utter the word "mayday". The radio operator on Silja Europa, chief mate Teijo Seppelin, replied in English: "Estonia, are you calling mayday?" After that, the voice of the third mate took over on the MS Estonia, and the conversation shifted to "Finnish". At first, there seemed to be a language problem, but the third mate was able to provide some details about their situation. However, due to a loss of power, he could not give their position, which delayed rescue operations. Some minutes later, power returned (or somebody on the bridge managed to lower himself to the starboard side of the bridge to check the marine GPS, which will display the ship's position even in blackout conditions), and the MS Estonia was able to radio its position to Silja Europa and Mariella. The ship disappeared from the radar screens of other ships at around 01:50 and sank at 5923N 2142'E in international waters, about 22 nautical miles (41 km; 25 mi) on At about 01:20, a quiet female voice called "hire, hire, laeval on hire", Estonian for "alarm, alarm, there is an alarm on the ship over the public address system, which was followed immediately by an internal alarm for the crew, then one minute later by the general emergency signal. The vessel's rapid list and the flooding prevented many people in the cabins from ascending to the boat deck, as water flooded the vessel via the car deck and through windows in cabins and the massive windows along deck six. The windows gave way to the powerful waves as the ship listed/tilted and the sea reached the upper decks. Survivors reported that water flowed down from ceiling panels, stairwells and along corridors from decks that were not yet underwater. This contributed to the rapid sinking. A mayday was communicated by the ship's crew at on board. A full-scale emergency was only declared at 02:30. Ships rescued 34 people and helicopters 104; the ferries played a much smaller part than the planners had intended because it was too dangerous to launch their man-overboard (MOB) boats or lifeboats. Most passengers died from drowning and hypothermia, as the water temperature was 10 to 11 C/50 to 52 F. About 650 people were still inside the ship when it sank. It was estimated that up to 310 passengers reached the outer decks, 160 of whom boarded the life-rafts or lifeboats. According to the official report, the bow door had separated from the vessel, pulling the ramp used to upload and download vehicles ajar. In addition, the ship also started listing/tilting because of poor cargo distribution. The ship rapidly took on water and started to tilt to one side due to the damaged/open bow door, causing the flooding of other decks and the cabins. Following the flooding, the power failed altogether, inhibiting rescue efforts and caused that a full-scale emergency was only declared after 90 minutes. This also initiated criticism regarding the passive attitude of the crew, who failed to notice that water was entering the vehicle deck, which delayed the alarm and caused a shortcoming in providing guidance from the bridge during the SECTION A Instructions: Consider the case study and answer ALL the questions related to the case study. [60] Case study The MS Estonia was a cruise ferry built in 1980 at a German shipyard, with almost 15 years of successful ferrying service for four different owners and operators. The ferry was sold to Nordstrm & Thulin on the Estline's Tallinn-Stockholm route in 1993. The MS Estonia consisted of 11 decks. Passenger facilities were located on decks one, four, five and six, while the crew members occupied decks seven and eight. Decks two and three were dedicated to the respective cargo. The MS Estonia was also a car ferry with large external doors close to the waterline. These ferries with open vehicle According to the official report, the bow door had separated from the vessel, pulling the ramp used to upload and download vehicles ajar. In addition, the ship also started listing/tilting because of poor cargo distribution. The ship rapidly took on water and started to tilt to one side due to the damaged/open bow door, causing the flooding of other decks and the cabins. Following the flooding, the power failed altogether, inhibiting rescue efforts and caused that a full-scale emergency was only declared after 90 minutes. This also initiated criticism regarding the passive attitude of the crew, who failed to notice that water was entering the vehicle deck, which delayed the alarm and caused a shortcoming in providing guidance from the bridge during the identified as the leading cause of the capsizing and sinking of the ship. An incident report was critical of the crew's actions, particularly for failing to reduce speed before investigating the noises emanating from the bow and being unaware that the list was being caused by water entering the vehicle deck. There were also general criticisms of the delays in sounding the alarm, the passivity of the crew, and the lack of guidance from the bridge. The sinking of the MS Estonia remains the worst European peacetime maritime disaster and the second-worst maritime disaster involving a European-made boat since the Titanic. Due to the costs and complex logistics involved with raising such a large vessel, the MS Estonia has been declared a memorial site. Further exploration of the wreck was prohibited (a treaty was declared in 1994). This resulted in a lot of ferry with large external doors close to the waterline. These ferries with open vehicle decks with few internal bulkheads have a reputation for being a high-risk design. An improperly secured loading door can cause a ship to take on water and sink, which happened in 1987 with the MS Herald of Free Enterprise. Water sloshing on the vehicle deck can set up a free surface effect, making the ship unstable and causing it to capsize. On 28 September 1994, in the Baltic Sea, the MS Estonia sank off Finland's coast and was recorded as one of the worst maritime disasters of the 20th century, claiming 852 lives of the 989 passengers and crew on board. Headline news worldwide reported the massive loss of life; only 137 people survived. Free surface water on the vehicle deck was determined to contribute to the sinking of MS Estonia. Question 2 (8) Discuss in detail four reputational risks that resulted from the sinking of the MS Estonia. Question 3 (4) Discuss two critical risk decisions made by the captain that potentially led to the disaster and how these decisions could have been prevented. rumours and conspiracy theories circulating. In 2020, a Swedish TV channel released a documentary indicating a large hole in the hull due to a collision. The Estonia government announced on 28 September 2020 that a new "technical investigation" will be undertaken to investigate the disaster. Survivors of the disaster and the relatives of those who died have petitioned for more than 20 years to re-open and expand the investigation into the disaster. The official report indicated that the locks on the bow door had failed from the strain of the waves, and the door had separated from the rest of the vessel, pulling the ramp behind it ajar. The bow visor and ramp had been torn off at points that would not trigger an "open" or "unlatched" warning on the bridge, as is the case in normal operation or failure of the latches. The bridge was also situated too far back on the ferry for the visor to be seen from there. While there was video monitoring of the inner ramp, the monitor on the bridge was not visible from the conning station. The bow visor was under-designed, as the ship's manufacturing and approval processes did not consider the visor and its attachments as critical items regarding ship safety. The first metallic sound was believed to have been that of the visor's lower locking mechanism failing and that the subsequent noises would have been from the visor "flapping against the hull as the other locks failed before tearing free and exposing the bow ramp. The subsequent failure of the bow ramp allowed water into the vehicle deck, which was Question 4 (10) Risk-based decisions are dependent on accurate risk information. Key risk indicators are an operational risk management methodology that generates risk information. The height of the swells can be regarded as risk information that could have been used to decide whether to leave the harbour or not. You must explain the concept of risk indicators as an operational risk management methodology and provide a graph using the information in table 1 to illustrate the height of the swells on 27/28 September 1994. Clearly indicate the threshold and state whether you agree with the captain's decision to sail at 19:15. Question 5 (6) People are frequently the cause of risks. This can be clearly identified in the case study. Identify four incidents where the crew can be held responsible for the ensuing disaster and identify possible solutions to prevent similar disasters. Question 6 (12) The case study shows the importance of a risk management policy. According to Blunden and Thirlwell, policy and governance form the cornerstone of business continuity management. Discuss the policy statement concept and identify three focus areas/procedures where a clear policy statement/operating procedure was lacking during the MS Estonia disaster. For training purposes, some fictitious information is included in the case study. Analyse the case study and answer the related questions below. Source: Most of the information was retrieved from: https://en.wikipedia.org/wiki/Sinking_of_the_MS_Estonia and Documentary Claims a Sub May Have Caused the Sinking of the Ferry MS Estonia (warhistoryonline.com) - accessed 14 September and 29 November 2021. Blunden, T & Thirlwell, J. 2013. Mastering operational risk: A practical guide to understanding operational risk and how to manage it. 2nd edition. Harlow: Pearson Education Limited. Question 1 (20) Define operational risk and explain each operational risk factor in detail. Analyse the case study and use the operational risk factors to identify operational risk examples for each factor and the mitigation measures that MS Estonia could have taken. Table 1: Height of swells/waves Time: 27/28 September 1994 15:00 Height of the swells in metres Source: Fictitious data 2 20:00 21:00 02:00 8 8 m 6 m m A safe height of the swells for a passenger liner is 2 to 3 metres. If the swells are 4 to 5 metres, it becomes risky and higher than 6 metres becomes dangerous for passenger ships. However, despite the 6-metre swells, the captain decided to depart at 19:15. The first sign of trouble aboard the MS Estonia was when a loud metallic sound was heard, presumably caused by a heavy wave hitting the bow doors around 01:00, when emergency. It seems as if the responsible crew were not adequately trained to sound the alarm during emergencies. There was a general lack of standing operating procedures when a problem was encountered with the bow door. In addition, the loading crew failed to identify the incorrect loading of vehicles which caused the ship to list/tilt over. However, there were also other factors involved that should have been considered and which contributed directly or indirectly to the disaster. The MS Estonia disaster occurred on Wednesday, 28 September 1994, between 00:55 and 01:50 (UTC+2) as the ship was sailing across the Baltic Sea from Tallinn to Stockholm, Sweden. The ship departed behind schedule at 19:15 on 27 September and was expected to doc in Stockholm on 28 September at 09:00. The ship was fully loaded and was listing slightly to starboard because of poor cargo distribution. The captain failed to notice or question The first sign of trouble aboard the MS Estonia was when a loud metallic sound was heard, presumably caused by a heavy wave hitting the bow doors around 01:00, when the ship was on the outskirts of the Turku archipelago. However, an inspection, which was limited to checking the ramp and bow door indicator lights, showed no problems. It seems the responsible crew did not perform a physical inspection of the bow doors. Over the next 10 minutes, similar noises were reported by passengers and other crew members. At about 01:15, the bow doors are believed to have separated and torn open the loading ramp behind them. The ship immediately took on a heavy starboard list (initially around 15 degrees, but by 01:30, the ship had rolled 60 degrees, and by 01:50, the list was 90 degrees) as water flooded into the vehicle deck. The captain subsequently ordered the ship to turn to port, but it slowed down before her four engines ceased completely. bearing 157 from Ut island, Finland, to the depth of 74 to 85 metres (243 to 279 ft) of water. According to survivor accounts, the ship sank stern first after taking a list/tilt of 90 degrees. Search and rescue followed arrangements set up under the 1979 International Convention on Maritime Search and Rescue (the SAR Convention). The nearest Maritime Rescue Co-ordination Centre, MRCC Turku, coordinated the effort in accordance with Finland's plans. The Baltic is one of the world's busiest shipping areas, with 2,000 vessels at sea at any time, and these plans assumed the ship's own boats and nearby ferries would provide immediate help and that helicopters could be airborne after an hour. This scheme had worked for the relatively small number of accidents involving the sinking of vessels, particularly as most ships have few people on board. A full-scale emergency was only declared at 02:30. Ships rescued 34 people emergency. It seems as if the responsible crew were not adequately trained to sound the alarm during emergencies. There was a general lack of standing operating procedures when a problem was encountered with the bow door. In addition, the loading crew failed to identify the incorrect loading of vehicles which caused the ship to list/tilt over. However, there were also other factors involved that should have been considered and which contributed directly or indirectly to the disaster. The MS Estonia disaster occurred on Wednesday, 28 September 1994, between 00:55 and 01:50 (UTC+2) as the ship was sailing across the Baltic Sea from Tallinn to Stockholm, Sweden. The ship departed behind schedule at 19:15 on 27 September and was expected to doc in Stockholm on 28 September at 09:00. The ship was fully loaded and was listing slightly to starboard because of poor cargo distribution. The captain failed to notice or question 01:22 but did not follow international formats. The MS Estonia directed a call to Silja Europa, and only after making contact with her did the radio operator utter the word "mayday". The radio operator on Silja Europa, chief mate Teijo Seppelin, replied in English: "Estonia, are you calling mayday?" After that, the voice of the third mate took over on the MS Estonia, and the conversation shifted to "Finnish. At first, there seemed to be a language problem, but the third mate was able to provide some details about their situation. However, due to a loss of power, he could not give their position, which delayed rescue operations. Some minutes later, power returned (or somebody on the bridge managed to lower himself to the starboard side of the bridge to check the marine GPS, which will display the ship's position even in blackout conditions), and the MS Estonia was able to radio its position to Silja Europa and Mariella. The ship disappeared from the radar screens of other ships at around 01:50 and sank at 01:22 but did not follow international formats. The MS Estonia directed a call to Silja Europa, and only after making contact with her did the radio operator utter the word "mayday". The radio operator on Silja Europa, chief mate Teijo Seppelin, replied in English: "Estonia, are you calling mayday?" After that, the voice of the third mate took over on the MS Estonia, and the conversation shifted to "Finnish". At first, there seemed to be a language problem, but the third mate was able to provide some details about their situation. However, due to a loss of power, he could not give their position, which delayed rescue operations. Some minutes later, power returned (or somebody on the bridge managed to lower himself to the starboard side of the bridge to check the marine GPS, which will display the ship's position even in blackout conditions), and the MS Estonia was able to radio its position to Silja Europa and Mariella. The ship disappeared from the radar screens of other ships at around 01:50 and sank at 5923N 2142'E in international waters, about 22 nautical miles (41 km; 25 mi) on At about 01:20, a quiet female voice called "hire, hire, laeval on hire", Estonian for "alarm, alarm, there is an alarm on the ship over the public address system, which was followed immediately by an internal alarm for the crew, then one minute later by the general emergency signal. The vessel's rapid list and the flooding prevented many people in the cabins from ascending to the boat deck, as water flooded the vessel via the car deck and through windows in cabins and the massive windows along deck six. The windows gave way to the powerful waves as the ship listed/tilted and the sea reached the upper decks. Survivors reported that water flowed down from ceiling panels, stairwells and along corridors from decks that were not yet underwater. This contributed to the rapid sinking. A mayday was communicated by the ship's crew at