On Sunday, August 11, 2024, while operating the regular ferry route 401 from the port of Zadar (Gaženica), the RO-RO passenger ship Lastovo docked at the Mali Lošinj ferry terminal at approximately 02:55 pm. After disembarking passengers and vehicles, and with the bow visor already raised, the bow ramp was lifted to allow the crew to inspect the sealing condition of the bow visor. At approximately 15:07, the bow ramp suddenly, abruptly, and uncontrollably collapsed, resulting in the tragic deaths of three crew members and one seriously injuried.
The Agency for the Investigation of Accidents in Air, Marine, and Railway Transport conducted a thorough investigation, collecting all relevant materials and documentation related to the incident. The investigation included an on-site inspection, interviews with the crew members present on the day of the accident, other crew members with experience on the vessel, company officials, and other relevant experts. International and domestic safety regulations, company procedures related to work processes, vessel maintenance, technical specifications of ship equipment, and crew operational practices were all analyzed to identify direct and contributing factors to the accident.
This marine accident resulted from multiple factors that, cumulatively, led to the tragic outcome. The primary causal factor was an incomplete understanding of the bow ramp system’s design and technical characteristics. This was due to the absence of detailed instructions and documented information on the associated hydraulic system, leaving the crew insufficiently aware of its capabilities, limitations, and related operational risks.
The safety recommendations are intended for the most relevant authorities responsible for their implementation, with the goal of preventing future marine accidents and improving navigation safety. These recommendations do not assign responsibility or blame for the accident.
All parties involved in the safety investigation cooperated fully, contributing to an objective and comprehensive determination of the circumstances surrounding this accident.
The safety recommendations are intended for the most relevant authorities responsible for their implementation, with the goal of preventing future marine accidents and improving navigation safety. These recommendations do not assign responsibility or blame for the accident.
Safety Recommendations to company “Jadrolinija”
✓ AIN05-SR-1/2025
The Agency recommends that Jadrolinija ensure that operating procedures for handling, closing, and securing hull doors, created according to the specific technical design of the system, are available on board and placed at appropriate control locations.
✓ AIN05-SR-2/2025
The Agency recommends that Jadrolinija ensure that crew members are familiar with the correct procedures for handling, closing, and securing hull doors during both regular operations and emergency situations, according to the specific technical design of each vessel.
✓ AIN05-SR-3/2025
The Agency recommends that Jadrolinija install dedicated visual indicators and audible alarms on the bridge and at each control panel on ships that do not have them, to indicate that the hull doors are closed and that the securing and locking mechanisms are properly engaged, in compliance with classification society rules.
✓ AIN05-SR-4/2025
The Agency recommends that Jadrolinija implement and promote the “Stop Work Authority” (SWA) principle within its Safety Management System (SMS), allowing any crew member, regardless of rank, to halt any operation they believe is being carried out in an unsafe manner or under unsafe conditions, which could endanger people, the ship, or the environment.
✓ AIN05-SR-5/2025
The Agency recommends that Jadrolinija establish a methodology for identifying critical ship systems and equipment, in accordance with the ISM Code and its implementation standards. The list of critical ship systems and equipment should be reviewed and updated, and for RO-RO passenger vessels, bow visor systems, and bow and stern ramps should be included in the list of “Critical Ship Equipment and Systems.”
✓ AIN05-SR-6/2025
The Agency recommends that Jadrolinija improve maintenance records, including data on repairs, replacements, inspections, and incidents involving ship devices, equipment, and components. The system should allow access to such records for responsible personnel on board and company staff in charge of technical support. Functional requirements for the maintenance database should align with the “IACS – A Guide to Managing Maintenance in Accordance with the Requirements of the ISM Code” and should be implemented on an e-platform with real-time access.
✓ AIN05-SR-7/2025
The Agency recommends that Jadrolinija provide crew members with a sufficient number of portable VHF communication devices, along with appropriate personal accessories (headsets for noisy environments, holsters, microphone extensions, etc.) to ensure effective internal communication and coordination during ship operations. The SMS should include procedures for regular inspection and maintenance of these communication devices.
✓ AIN05-SR-8/2025
The Agency recommends that Jadrolinija conduct a review of the officer staffing levels on deck to ensure that the assigned personnel can effectively perform their duties and responsibilities at the management level, with a primary focus on ensuring the safety of crew members, passengers, and the ship. The required number of deck officers should be determined based on each vessel’s specific characteristics while considering work and rest time regulations.
✓ AIN05-SR-9/2025
The Agency recommends that Jadrolinija introduce an internal rule requiring that rotating management personnel within the same department (deck and/or engine) meet a minimum cumulative experience criterion for a specific vessel (“Officer Matrix”). A minimum of six months of cumulative sailing experience in the current rank is recommended.
✓ AIN05-SR-10/2025
The Agency recommends that Jadrolinija clearly define, structure, and align work procedures, task planning, and risk assessment within the Safety Management System (SMS) to ensure that responsible personnel on board properly apply prescribed procedures when organizing work tasks, considering the specific characteristics of each vessel.
✓ AIN05-SR-11/2025
The Agency recommends that Jadrolinija improve internal audit mechanisms within the SMS, as required by the ISM Code, to effectively identify root causes of non-conformities, eliminate them, and prevent recurrence. This includes refining the definitions of “corrective actions” and implementing “preventive measures” in accordance with ISO 9000 and ISO 9001 quality management standards, in their latest versions.
✓ AIN05-SR-12/2025
The Agency recommends that Jadrolinija ensure continuous training and competency enhancement for internal auditors responsible for SMS evaluations, focusing on ISM Code compliance and internal audit procedures. Training should align with the ISO 9001 quality management standard, in its latest version, to strengthen critical assessment capabilities and foster continuous improvement of the SMS.
Safety Recommendations to Croatian Register of Shipping
✓ AIN05-SR-13/2025
The Agency recommends that the Croatian Register of Shipping (HRB) align technical supervision of hull door safety systems on RO-RO passenger ships in domestic navigation with both international and national regulations, particularly regarding inspections of ships built before June 30, 1996.
✓ AIN05-SR-14/2025
The Agency recommends that the Croatian Register of Shipping (HRB) ensure additional training for ISM auditors on the principles and guidelines outlined in IACS “Guidance for Auditors to the ISM Code 41” to enhance external audits under the ISM Code and to reduce the risk of non-conformities and observations being overlooked during audits.
✓ AIN05-SR-15/2025
The Agency recommends that the Croatian Register of Shipping (HRB) enhance the existing ISM audit checklists (“ISM Audit Checklist QF-PRP-54” for ships and “ISM Audit Checklist” for companies) by providing more detailed specifications for inspection components within the respective ISM Code sections. This will increase transparency on what was examined and sampled during audits, complying with the IACS “Guidance for Auditors to the ISM Code 41”.
These recommendations do not assign responsibility or blame for the accident.
Based on the findings of the safety investigation into the marine accident involving the RO-RO passenger ship Lastovo, and following the analysis and conclusions of this report, the Accident Investigation Agency for Air, Marine, and Railway Transport issues the following safety recommendations:
✓ AIN05-SL-1/2025
Crew members operate and manage various ship systems, devices, and equipment. When transferring to a new ship, seafarers often encounter different system designs that are specific to each vessel. Understanding the technical design and operating principles of these systems is essential for safe handling and work execution.
To ensure the safe and proper use of ship systems, devices, and equipment, the following measures are recommended:
Clear and accessible operating and maintenance instructions must be available on board.
Instructions should be written in the working language of the ship in a format understandable to all crew members.
Crew training should align with manufacturer guidelines and reflect the actual technical setup of the ship’s systems.
Identified capabilities, limitations, and associated risks of each system must be included in the instructions.
Coordinated handling procedures should be established, especially for systems that require operation from multiple locations on the vessel.
Recipients: This safety advisory is intended for shipowners, shipping companies, classification societies, and seafarers.