Report on marine accident, fall on board the ferry 'Skagastøl' in the Nærøyfjord, Sogn og Fjordane county, 19 July 2013
Marine report 2015/04
A few minutes before arrival in Gudvangen, a passenger fell down a stairway at the tourist ferry. The passenger died two days later as a result of extensive head injuries. The accident happened while the passengers where watching the surroundings around the fjord. The AIBN points at the design of the strairway and rails as a special danger. The investigation has focused on how passenger safety in stairways is attended during planning, building and operation of the ferry.
The accident happened on board 'Skagastøl', a tourist ferry operating a summer route on the Nærøyfjord and Aurlandsfjord in Sogn og Fjordane county. When the accident happened, the ferry had about five minutes left before arriving in Gudvangen. Many of the passengers were standing on the wheelhouse deck looking at and photographing the steep mountainsides surrounding the narrow Nærøyfjord. The passenger involved in the accident was on the wheelhouse deck near the starboard stairs, which she fell down at one point. The passenger died in hospital two days later as a result of extensive head injuries.
The investigation has found that the stairs were so designed that they could entail a risk of falling down them. The angle of the stairs was steep, the first step down was placed 35 cm in past the edge of the wheelhouse deck, and the railing on the starboard side did not extend all the way to the last step. In the AIBN's view, this constituted a hazard zone for people standing on the wheelhouse deck who were not aware of the unusual way the stairs were designed.
The vessel was converted into a tourist ferry in 1994. The drawings, which were approved by the Norwegian Maritime Authority, show that the plan was that the railing would extend down the full length of the stairs on both sides. However, the railing was not built in accordance with the drawings. The Norwegian Maritime Authority did not discover this during inspection.
The investigation has shown that the shipping company's safety management system and mapping of risks had not identified falling on the stairs as a risk factor on board 'Skagastøl'. Since the accident, the shipping company has extended the railing beside the stairs on this ferry and another ferry with a corresponding design. The shipping company has further emphasised passenger safety and fall injuries in its safety management system. The Norwegian Maritime Authority has also defined fall injuries as a focus area in its risk-based inspections.
The AIBN submits no safety recommendations in connection with the investigation.
Facts
| Location | Nærøyfjorden, Sogn og Fjordane County |
| Occurrence date | 19.07.2013 |
| Accident category | Personal injury |
| Area | Norwegian Territorial Waters |
| IMO number | 7024146 |
| Name of vessel | Skagastøl |
| Accident type | Fatal Accident, Fall on board, Passenger accident |
| Vessel type | Passenger Ship - Ferry |
| Register | The Norwegian Ship Register |