brazilian navy

BRAZILIAN NAVY

Directorate of Ports and Coasts WATERWAY TRAFFIC SAFETY SUPERINTENDENCY

Department of Inquiries and Investigations of Navigation Accidents Explosion on board Vessel “RENASCER IV” Maritime Safety Investigation Report

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BRAZILIAN NAVY

DIRECTORATE OF PORTS AND COASTS

WATERWAY TRAFFIC SAFETY SUPERINTENDENCY

DEPARTMENT OF INQUIRIES AND INVESTIGATIONS

OF NAVIGATION ACCIDENTS

VESSEL “RENASCER IV”

EXPLOSION ONBOARD

5TH OF NOVEMBER OF 2011

MARITIME SAFETY INVESTIGATION REPORT

Vessel “RENASCER IV” before the accident (photograph ceded by Owner)

Reference: Code of Investigation of Accidents of the

International Maritime Organization (CIA)

MSCMEPC.3/Circ. 2, 13 June 2008/ Resolution MSC.255(84)

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INDEX

LIST OF ABBREVIATIONS…………………………………………………….……3

1-INTRODUCTION.......…………………………………………………………..….4

II- SYNOPSIS….………………………………………………………………….…...5

III- GENERAL INFORMATION…………………………………………………….8

IV- DETAILS OF LOCATION OF THE ACCIDENT……...…………………….11

V- HUMAN FACTORS AND CREWMEMBERS………………………………...13

VI- SEQUENCE OF OCCURRENCES…….……………………………………...13

VII-PROCEDURES AFTER THE ACCIDENT…………………………………...15

VIII- CONSEQUENCES OF THE ACCIDENT…………………………………...15

IX – EXPERT EXAMINATIONS…………………………………………………..15

X -ANALYSIS OF THE DATA OBTAINED AND CAUSAL FACTORS………18

XI – PRELIMINARY LESSONS LEARNT AND CONCLUSIONS ……………19

XII - RECOMENDATIONS OF SAFETY …………………………………………20

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LIST 0F ABBREVIATIONS

AMB – Brazilian Maritime Authority

BADE – Bulletin of the up-to-dating of the vessel

BB - Port side

BE – Starboard side

CFAOC – Fluvial Captaincy of Western Amazonia

DOC – Document of conformity

DPC - Directorate of Ports and Coasts

DPEM – Obligatory Insurance of Personal Damages Caused by Vessels or their

Cargoes

EPI – Individual Protection Equipment

IMO – International Maritime Organization

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I - INTRODUCTION

With purpose of collecting and the analysis of evidence, the elaboration of the

recommendations for safety that may be necessary, in order to impede that in future

occur similar accidents or incidents, the Fluvial Captaincy of Western Amazonia

(CFAOC) carried out the present Investigation of Safety of Maritime Accidents and

Incidents (ISAIM) in compliance with that laid down in the Code of Investigation of

Maritime Accidents of the International Maritime Organization (IMO), adopted by

Resolution MSC.255(84).

This Final Report is a technical document that reflects the result obtained by the

CFAOC in relation to the circumstances that contributed or may have contributed to

release the occurrence and does not resort to any procedure for proof for establishing

responsibility civil or criminal.

Furthermore, it should emphasize the importance of protecting the people

responsible for supplying of information relative to the occurrence of the accident, it

being that the use of constant information in this report for ends other than the

prevention of future similar accidents could lead to erroneous interpretation and to

erroneous conclusions.

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Place where the wreckage was found

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II – SYNOPSIS

On the fourteenth day of the month of November of the year two thousand and

eleven, in this city of Manaus, were commenced the procedures to establish the

possible causes that competed for the explosion followed by shipwreck, occurred on a

Brazilian flag vessel named “RENASCER IV”, on 5th

November of 2011 around 06:15

hours, at Latitude 04o 18’ 10.4 S and Longitude 063°50`53” W, in the Community São

João da Chapada on the River Urucu, in the city of Coari, state of Amazonas, when

the referred vessel was in process of preparation to continue voyage, carrying 19

thousand litres of gasoline.

As a result of the accident, were injured three people that were on board. one of

whom died on 20th

November, in the Hospital and First Aid “23rd

AUGUST”, in the

city of Manaus, to where the victims were removed.

The vessel caught fire and was destroyed, foundering in the banks of the river at

latitude 04° 16`36.8” S and longitude 063o 45’ 42,7” W. There was no registry of

pollution in the waters of the River Urucu,

The present procedure was started as from the sending of the communication of the

occurrence by the company HRT Exploração e Petróleo Ltda, on 07 of November of

2011.

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Wreckage of the craft

III – GENERAL INFORMATION

Vessel Name: RENASCER IV;

Brazilian Flag;

Gross Tonnage: 17;

Area of navigation: interior;

Type: for transport of liquid in bulk (charuto);

Propulsion: diesel motor;

Hull: wood;

Year built: 2010;

Classification Society; not classified;

Owner: EVADY SATURNINO DE LIMA:

Operator; xxx;

Crewmembers: 03;

Port of origin: Coari, State of Amazonia;

Previous name: xxx;

Motor: Mercedes Benz - 25 HP, model 352, serial number 344.94410671370,

2.000 rpm, combustible: diesel oil;

Molded depth: 1.3m;

Hull : simple;

Builder: Juarez Menezes de Oliveira

Place: Acajatuba – Rio Negro, AM

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Explosion site

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Photo of the vessel ceded by the Owner

b) Documentation (Certificates):

The vessel does not possess statutory certificates.

The vessel was in initial phase of the process of registration and presented the

following documents;

-BADE filled out.

- Signed Undertaking

- Receipt for the building of one Wooden Hull

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- Receipt for the purchase of one motor.

- Copies of the Owners personal documents

- Copy of Obligatory Insurance for Personal Damages Caused by Vessels (DPEM),

dated 18/10/2011.

All Owners or Operators are obliged to contract this insurance, by law nº 8374, of

30/12/1991, all owners or operators in general, national or foreign, subject to registry

in the Port Captaincies or Delegacies and subordinate Agencies. The DPEM

Insurance and the obligatory insurance that have the object go grant coverage to

people, transported or not, including the Owners, crewmembers and/ or conductors of

the vessels, and their respective beneficiaries or dependents.

On the occasion of carrying out the initial inspection of this investigation, the vessel

was overturned on its side on the right side of the Urucu river, in latitude 04o

16’36.8”S and Longitude 063o

45’42.7W, around six miles downstream from the point

where occurred the explosion. It is emphasized that the vessel was in the process of

registration and does not possess a Safety Manning Card.

IV-DETAILS OF LOCATION OF THE ACCIDENT

1 - Location: coordinates 04°18'10, 04” S / 063° 51'01, 86" W, Community of St.

Joseph's Chapada - Coari / AM.

2 - Environmental conditions - the time of the accident, according to witnesses, the

sky was clear, the river in its bed normal for the season, moderate temperature, no

rain and wind.

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Forest burned by explosion

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V- HUMAN FACTORS AND CREWMEMBERS

The crew was composed of three men, who were not seamen, who were recruited

for that voyage for their practical knowledge of navigating in that region.

One of them possessed some knowledge of mechanics and was who descended to the

engine room and tried to make the electrical connection for the motor of the vessel,

whilst the others watched him from the deck, close to the access to the engine room.

Before the accident the crew has rested during the night. There was no report of

use of alcoholic drinks, drugs or of medicines with or without medical prescription.

In this manner, the human factor only influenced with the unpreparedness and the

lack of experience of the crew in treating the difficulties encountered: leakage of the

cargo of gasoline and the starter battery not operating.

VI – SEQUENCE OF OCURRENCES

In accordance with the information obtained in the report of the accident sent by

the company HRT Oil & Gas, dated 07/11/2011, and confirmed by the experts in the

place of the accident, occurred an explosion when a crewmember of the vessel

RENASCER 1V attempted to connect the Motor using a “dummy’ (utilization of a

movable battery in assistance of the battery of the motor) on the occasion of the “dis-

banking” (process utilized by the navigators of the rivers of the Amazon region, after

spending overnight tied to trees on the bank commence leaving) generating an electric

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spark in the engine room which, according to the reports of one of the survivors,

presented a strong smell of gasoline and there is no type of ventilation, provoking an

accumulation of that combustible.

A team of experts of the Fluvial Captaincy of Western Amazonia came to the

place of the accident to arrange the initial raising of data, documents and information

for the conduction of the present investigation and elaboration of the Report. Also

were obtained various documents for analysis, in an attempt to identify the cause of

the explosion.

According to information of one of the surviving crewmembers, confirmed by

the owner of the vessel, it was contracted verbally to undertake voyage to the city of

Coari to the base of support to prospection of petroleum on the Urucu river, carrying

19,000 litres of gasoline, a voyage that started on 04/11/2011 at 11.00 hours in the

morning, with three crewmembers, it being that was not one of them was qualified

with the maritime authority going up the Urucu river. The sailing was interrupted at

21.00 hours in view of the lack of visibility due to nightfall. The ship was dis-banking

close to the Community São José da Chapada (a small settlement on the banks of the

Urucu river). Around 06:00 hour on the morning of 5th

November of 2011, when

trying to start the motor it was found that it was not sufficiently charged. At that

moment was passing a local vessel called ”CAUAME”, to whom was solicited the loan

of a battery to help in starting the motor. Promptly the equipment was provided and

one of the crewmembers took the battery and made for the engine-room to start the

procedures, whilst the other two watched him from the entrance. When closing the

contacts of the reserve battery with those of the motor, occurred the explosion, which

projected the three crewmembers off the ship, making everyone to fall in the water.

To follow fire broke out on the ship which was drifting downstream going to the other

side where it started a small fire afterwards and continued going down the river ,

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stopping in the position informed above, where were found the wreckage by the team

of experts of the Fluvial Captaincy of Western Amazonia (CFAOC)

VII – PROCEDURES AFTER THE ACCIDENT

The three crewmembers fell into the water all with 1st, 2

nd or 3

rd degree burns.

They were rescued by an organic launch from the vessel “CAUAME” that was in the

area of the accident and taken to that vessel, where they received first aid treatment

and afterwards, removed, by helicopters to the town of Coari. To follow they were

transported by plane to the city of Manaus, were one of the crewmembers of 28 years

of age, a native of Coari/AM, died on 20/11/2011 at 00:10 hours, according to his

death certificate, from septic shock and grave burning. The other crewmembers

received treatment of the wounds suffered.

VIII – CONSEQUENCES OF THE ACCIDENT

Personnel damages: three crewmembers were hurt with burns, one of them

died.

Ambience damages: the bush in the proximities of the burning vessel was

burnt.

IX-EXPERT EXAMINATIONS

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The steps for raising the data and information for the conduction of the present

investigation were commenced on 17/11/2011, after the arrival by air of the team to

the city of Coari and from there by the river to the place where occurred the accident,

place which was not preserved and presented signs of violation of a possible isolation

carried out before the arrival of the team. The place where the explosion occurred is

distant from the place where was found the wreckage of the ship around about nine

miles up the river; which competed to make difficult a possible total isolation of the

wreck.

The wreckage of the ship were found various miles downstream from the place of

the accident, totally burnt and presenting only part of the bow of the ship. The area

was not preserved, the periodical examinations being made on the wreckage as is.

Afterwards, on the same day, in the exact place of the accident were found vestiges of

burnt bush, some wood from the ship and one small ship totally carbonized.

The inspectors of Safety received the information that the vessel left Coari at 11.00

hours on 04/112011 bound for the base of Urucum and the explosion occurred at

06:15 hours on the morning of 05/11/2011. The vessel was employed in the transport

of bulk combustible, it being considered dangerous this transport of combustible

products; it had not been examined for verifying its conformity for the transport of

petroleum derivatives.

. During the examination it was ascertained that really occurred an attempt to

start the motor of the vessel using an artifice called “dummy” which consists of

employing one battery interconnected to the other, in series, with the intent of starting

the motor of the vessel. However, with the compartment impregnated with

combustible vapors (gasoline), occurred an electrical spark and the consequent

explosion. The vessel carried 19.000 liters of gasoline.

The investigators verified that the crewmembers did not have technical

knowledge for carrying out the service of transport of dangerous cargoes and also of

the procedures for entering confined spaces as well as the care to be taken for

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carrying out services involving electricity in spaces with possible vestiges of

combustible liquids. According to witnesses, the accident would have occurred on

account of a leak of gasoline which was being transported, that accumulated in the

engine room, coming to explode. The investigators verified through the testimony of

crewmembers, that there were no ventilators or exhausters installed in the area of the

accident and they had not observed the existence of alarms, or measurers of gas

belonging to the vessel.

X -ANALYSIS OF THE DATA OBTAINED AND CAUSAL FACTORS

By analysis of the evidences, observations and indications, one may conclude that

occurred an undue accumulation of vapors in the engine room coming from a leakage

of a cargo tank of the vessel, which, in the presence of an electric spark produced by

an un-experienced operator when attempting to connect provoked the explosion.

Testimonial proofs point out the strong smell of gasoline at the entrance of the

engine room and the non-existence of an apparatus for measuring the concentration

of gases.

The following contributing factors were analyzed:

a) Human factor – there are no indications that the human factor, from the bio-

psychological point of view, could have contributed to the accident;

b) Material factor- contributed to the accident the leakage of gasoline from the

cargo tank and the low charge of the battery used to start the diesel motor of the

vessel.

c) Operational factor- contributed for the accident the lack of monitoring of the

air to verify the existence of explosive mixture in the engine room and further,

the undue use of batteries connected in an unsafe manner providing the

production of an electrical spark in a confined compartment and with the

presence of an explosive mixture in the air. Joining that already narrated

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mention should be made of the lack of training and knowledge on the part of the

un-experienced operator.

One concludes that the determinant cause of the accident was the accumulation of

explosive vapors in the engine room from possible leakages of gasoline from cargo

tank of the ship, associated with the ignorance of the operator making a maneuver

involving electric sparks without observance of the conditions of safety for its

completion.

XI – PRELIMINARY LESSONS LEARNT AND CONCLUSIONS

The investigations of the circumstances of the accidents have shown that the

accidents onboard ships are in the majority of cases provoked by insufficient

knowledge or disrespect of the necessity to adopt safety precautions.

The atmosphere in any confined space can be deficient in oxygen and/or contain

inflammable gases and/or toxic vapors. An insecure atmosphere can occur afterwards

in a space previously considered safe. An adequate ventilation can annul the risks of

accidents and could have been provided by means of lids to be opened in the engine

room whenever necessary. Besides this, the spaces adjoining tanks with volatile fuel

(such as gasoline, etc.) should be monitored to detect leakages.

From the analysis of the data obtained, it was verified that the determinant cause

of the explosion was the accumulation of vapors of gasoline from the cargo tank of the

vessel associated with the production of an electric spark in an operation denominated

“dummy”.

One can underline that the vapor of gasoline, being heavier than the air,

accumulates in the lowest part of the compartment. It also remains evident that the

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safety precautions should be observed and the operators of the vessel should possess

ample knowledge of these precautions.

The safety precautions cannot be banished to second level in the work in confined

spaces.

During the execution of work in confined spaces exists the necessity of

accompaniment and supervision of same by crewmembers of the vessel.

The members of the crew of a vessel should have minimum professional

knowledge to prevent accidents. In this case, the crew did not have the minimum

necessary.

XII - RECOMENDATIONS OF SAFETY

In view of the lessons learnt and the conclusions formulated, the following

recommendations are presented for the prevention of a similar accident:

a) Every vessel should be conducted by professionals, qualified and holders of

specific knowledge of their profession;

b) The warehousing tanks should be tested at regular intervals to verify

if watertight, principally in wooden vessels.;

c) The air in the interior of confined compartments should be permanently

renewed by ventilators or adequate openings, to not allow an accumulation of gases

forming an explosive mixture

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State that was found the vessel

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