This first step involved identifying and outlining all the key controllers involved in the propagation of the ferry accidents. These controllers included individuals, institutions, and regulatory bodies mandated to monitor, operate, and make crucial decisions that affected the safety and efficiency of the ferries in the Mombasa Channel as illustrated in Fig. 1. Comprehending their roles and responsibilities was important in evaluating how their actions and decisions led to the accidents occurring.

At the Government Policy and Budgeting Level, the controller was the Government of Kenya, which was responsible for financial support for ferry maintenance. This support influenced the operational capabilities of the ferries. At the Regulatory Bodies and Associations level, the component was the Kenya Maritime Authority tasked with enforcing safety regulations from the local Merchant Shipping Act(National Council for Law Reporting, 2023a), and international regulations from the International Maritime Organization(2024) to ensure domestic ferry safety. At the organizational level, the defunct KFSL was the controller mandated for managing and operating the ferries. KFSL’s duties comprised proper maintenance of the ferries, ferry crew recruitment, and ensuring the operational availability of the ships. The company’s management procedures, decisions concerning ferry maintenance, training and recruitment of ferry operators, other technical and operational processes, and adherence to safety protocols played a direct role in ferry operations and safety. The Physical/ Actor events, processes, and conditions level were represented by controllers such as the ferry operators’ and engineers’ actions and decisions, the environmental conditions in the Mombasa channel, and the conditions of the equipment and machinery. The Outcome Level comprised the culmination of the above levels and the interactions of the factors, and this determined the result which was ferry navigation accidents in the channel.

This section provides a synopsis of ferry accidents officially recorded in the Channel between the years 2011 and 2020 as illustrated in Fig. 2 and Fig. 3.

A safety inquiry was conducted in 2019 by the Public Investment Committee(Government of Kenya) to investigate the safety of ferries operated by the KFSL following an incident on one of its ferries, MV Harambee, that resulted in the death of two Kenyans(Public Investments Committee, 2019). A subsequent report detailed the deficiencies of ferry operations within its socio-technical system as consolidated in Table 2.

The next phase of AcciMap analysis was to combine the identified contributory factors from Table 1 and Table 2 and systematically code and classify them into their thematic areas by the respective AcciMap Levels: Government Policy & Budgeting, Regulatory Bodies & Associations, Organization, Physical/Actor Events, Processes & Conditions as outlined by Salmon et al.(2020), as categorized in Table 3.

At the government level, the theme of the causal factors reflected the all-encompassing governmental influence on ferry safety through policy and funding. Moreover, coding in the regulatory category exposed the gaps in regulatory frameworks and enforcement. Furthermore, the coded organization level revealed safety issues within ferry operations that heightened the risk of accidents and lastly, coding at the physical/actor events levels highlighted the roles of these conditions as the immediate triggers of the accident.

At the Government of Kenya level, the key factor analyzed was the inadequate financial allocation for ferry maintenance. This lack of sufficient budget led to a systemic failure to ensure the availability of resources required for regular upkeep and upgrade of the ferries by KFSL. This financial deficit developed conditions for poor ferry maintenance management and inadequate seaworthiness that led to high navigation risks for the ferries.

The Government of Kenya plays a crucial role in promoting maritime safety. Therefore, it is recommended that the allocation of the budget for ferry maintenance be increased to provide the requisite resources for maintaining ferry infrastructure and enhancing safety standards. Furthermore, domestic ferry safety policies and regulations should be updated and strengthened to address the gaps in enforcement and regulations.

At the regulatory level controlled by the KMA, factors that contributed to the ferry navigation accidents centered on the failure of the regulatory body to enforce safety standards on crew certification and vessel seaworthiness. The shortage of ferry inspection officers exacerbated the deficiencies in ferry inspections without a clear succession plan to ensure the continuity of ferry inspections even after the retirement of the safety officers.

The Kenya Maritime Authority(KMA) as the regulatory body should recruit and train more safety officers to oversee ferry inspection and certification duties. Moreover, regular, and thorough inspections should be done to determine latent safety risks. Finally, stricter adherence to ferry safety standards should be enforced to hold the ferry company and ferry operators accountable for promoting passenger safety.

At the KFSL level, various managerial and operational inadequacies were determined. Employing unqualified ferry operators was a critical factor that contributed to navigation errors and poor decision-making during ferry transits. Moreover, inefficient ferry maintenance management led to continuous mechanical failures that impacted the ferries’ maneuverability in the channel leading to stalling and eventual drifting which led to various ferry accidents. Furthermore, the overreliance on limited ferries meant that the available ferries were overburdened and frequently subjected to wear and tear in the absence of adequate downtime for maintenance. Lastly, the ferry company encouraged overloading practices to meet the ferry demand, which increased navigation risks by operating ferries exceeding their capacity limits.

Kenya Ports Authority(KPA) as the current organization responsible for ferry operations in the Mombasa channel should hire qualified ferry crew members and implement strict routine preventive maintenance schedules to keep the ferries in optimal condition. As for overloading, the organization can enforce stringent capacity regulations ensuring that the ferries maneuver within safe limits.

At this level, the human, environmental, and equipment conditions performed a critical role as the immediate precursors to the ferry accidents. The unqualified ferry operators made significant navigation errors under low water tide conditions and in the presence of coral reefs in the Channel leading to loss of control of the vessel. These navigation errors also contributed to poor docking procedures of the vessels at high speeds and in overloaded conditions. Furthermore, inadequate ferry maintenance led to inadequate seaworthiness which contributed to the prevalent mechanical breakdowns of the ferries.

To mitigate the safety risks at the last level comprising of Physical/Actor Events, Processes, and Conditions, proper docking procedures should be implemented and training of the ferry operators to safely navigate environmental hazards such as low water tides should be enforced.