Viking Sky was less than a ship length from running aground in harsh weather and cold waters with more than 1,300 persons on board.
In the 10 seconds immediately following the blackout, a total of approximately 1,000 alarms went off in the IAS. Recovery from a blackout without a standby generator had never been drilled on board. The engineers were therefore faced with a situation they could not readily recognise and were not practised in managing.
It took about 14 minutes from the blackout until refilling of lube oil was started. The engineers
struggled to restart and connect the DGs, and the first DG was connected to the MSB almost 24 minutes after the blackout, and it took another 9 minutes further to restore any propulsive power.During this time, the vessel drifted to within a ship’s length of running aground despite the attempt to arrest its drift by deploying both anchors. The blackout recovery is analysed in section 2.9 and the evacuation and rescue operation is analysed in section 2.10.
The term alarm or alarms appears 327 times in the report. Basically sounds like the alarm system was poorly designed under normal conditions and in this incident the alarm system turned into a pile of dogshit.
The design and configuration of the alarm interface produced unacceptable
workload which would have had a negative effect on engineers’ processing ability to the extent that it is very likely to have decreased their problem-solving and decision making ability. In situations like a blackout where the alarm burden is extremely high, priority and grouping of alarms are of specific importance.The NSIA’s observations are also supported by the internal report by the ship management
company where it is stated that the configuration of the alarm system provided an incomplete
understanding of the risks. As they found there were too many alarms and lack of criticality
indicators, they stated that a further study into configuration of the alarm system was
recommended.