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SERIOUS MARINE CASUALTY REPORT NO 17/2014 JULY 2014

Report on the investigation of

the fire on the main deck of the ro-ro cargo ferry

Corona Seaways

in the Kattegat, Scandinavia

on 4 December 2013

This investigation has been conducted with the co-operation and assistance of the Danish,

Swedish and Lithuanian accident investigation branches.

Extract from

The United Kingdom Merchant Shipping

(Accident Reporting and Investigation)

Regulations 2012 – Regulation 5:

“The sole objective of the investigation of an accident under the Merchant Shipping (Accident

Reporting and Investigation) Regulations 2012 shall be the prevention of future accidents

through the ascertainment of its causes and circumstances. It shall not be the purpose of an

investigation to determine liability nor, except so far as is necessary to achieve its objective,

to apportion blame.”

NOTE

This report is not written with litigation in mind and, pursuant to Regulation 14(14) of the

Merchant Shipping (Accident Reporting and Investigation) Regulations 2012, shall be

inadmissible in any judicial proceedings whose purpose, or one of whose purposes is to

attribute or apportion liability or blame.

© Crown copyright, 2014You may re-use this document/publication (not including departmental or agency logos) free of charge in any format or medium. You must re-use it accurately and not in a misleading context. The material must be acknowledged as Crown copyright and you must give the title of the source publication. Where we have identified any third party copyright material you will need to obtain permission from the copyright holders concerned.

All MAIB publications can be found on our website: www.maib.gov.uk

For all enquiries:Marine Accident Investigation BranchMountbatten HouseGrosvenor SquareSouthampton Email: maib@dft.gsi.gov.ukUnited Kingdom Telephone: +44 (0) 23 8039 5500SO15 2JU Fax: +44 (0) 23 8023 2459

SECTION 1 CONTENTS

SECTION 1 – FACTUAL INFORMATION 2

1.1 Particulars of Corona Seaways and accident 21.2 Background – overview of route and cargo shipping procedures 41.3 Narrative 4

1.3.1 Eventsleadinguptothediscoveryofthefire 41.3.2 Fire-fightingatsea 71.3.3 Fire-fightinginHelsingborg 8

1.4 Vesselandcargodamage 81.4.1 Vessel’sstructureandsystemsdamage 81.4.2 Cargo damage 9

1.5 Description and history of primary vehicles 91.5.1 RenaultPremium250.18truck 91.5.2 Renault Mascott-Master van 10

1.6 RenaultPremium250.18truck–overviewofelectricalandenginestartingarrangements 101.6.1 Electrical system 101.6.2 Engine starting arrangements 11

1.7 ExaminationofRenaultPremium250.18truck 121.7.1 Structure 121.7.2 Electricalandmechanicalsystems 12

1.8 ExaminationofRenaultMascott-Mastervan 131.9 Low-pressurefixedCO2fire-extinguishingsystem 131.10 Cargo decks’ ventilation arrangements 151.11 Regulation and guidance 161.12 Similaraccident 16

SECTION 2 – ANALYSIS 17

2.1 Aim 172.2 Causeofthefire 17

2.2.1 RenaultMascott-Mastervan 172.2.2 RenaultPremium250.18truck 17

2.3 Firedevelopment 182.4 Risksofthecarriageofusedvehicles 18

2.4.1 Usedvehicles–fireignitionrisk 182.4.2 Vehiclechecks 182.4.3 Vessel’s safety instructions 19

2.5 Crew’sfire-fightingpractice 192.6 Muster stations 192.7 FunctionalityofthelowpressurefixedCO2 fire-extinguishingsystem 202.8 Cargodeckventilationissues 20

2.8.1 Isolationofventilationsupplies 202.8.2 Operationofcargodeckventilationfans 20

2.9 Drug and alcohol policy and passengers 21

SECTION 3 - CONCLUSIONS 22

3.1 Safetyissuesdirectlycontributingtotheaccidentthathavebeenaddressedorresulted in recommendations 22

3.2 Othersafetyissuesdirectlycontributingtotheaccident 223.3 Safetyissuesnotdirectlycontributingtotheaccidentthathavebeenaddressedor

resulted in recommendations 223.4 Othersafetyissuesnotdirectlycontributingtotheaccident 23

SECTION 4 - ACTIONS TAKEN 24

SECTION 5 - RECOMMENDATIONS 25

FIGURES

Figure 1 - Accident position

Figure 2 - Corona Seaways – general arrangement

Figure 3 - Fire-damagedRenaultPremium250.18truckandRenault Mascott-Master van following their removal from the vessel

Figure 4 - Damaged vehicles and trailers on the main deck

Figure 5 - SchematicofRenaultPremium250.18truckenginestarting arrangements

Figure 6 - Fire damaged engine components

Figure 7 - Schematicofenginestartermotormainsolenoid

Figure 8 - DamagedRenaultPremium250.18truckenginestartermotor main solenoid

Figure 9 - Main deck ventilation jalousie

ANNEXES

Annex A - DFDS/ASInstruction-InformationtoCarCarriersdated28 January 2014

Annex B - DFDSA/AInstruction-InformationtoUnregisteredSecond HandSegmentdated28January2014

Annex C - DFDSA/SInstruction–DeliveryNote,Single/EmptyUnitdated6 January 2014

GLOSSARY OF ABBREVIATIONS AND ACRONYMS

AB - Ableseaman

AB - Aktiebolag

A/S - Aktieselskab

BA - Breathing Apparatus

C - Celsius

CCTV - Closed-Circuit-Television

CO2 - CarbonDioxide

COSWP - CodeofSafeWorkingPracticesforMerchantSeamen

CSMM - CompanySafetyManagementManual

DFDS - DetForendeDampskibs-Selskab

FRS - FireandRescueService

hp - horsepower

JRCC - Joint Rescue Co-ordination Centre

km - kilometre

m - metre

mm - millimetre

MCA - Maritime and Coastguard Agency

MGN - Marine Guidance Note

nm - nautical mile

OOW - OfficeroftheWatch

Ro-Ro - Rollon,Rolloff

SOLAS - InternationalConventionfortheSafetyofLifeatSea1974,as amended

SSMM - ShipSafetyManagementManual

t - tonne

UTC - Universal Co-ordinated Time

VHF - VeryHighFrequency

Volt - V

TIMES: All times in this report are UTC+1 unless otherwise stated

TERMS:

Aktiebolag - Swedishlegaltermassociatedwithcompanyliabilityand equivalenttotheEnglish“Limited”.

Aktieselskab - Danishlegaltermassociatedwithcompanyliabilityand equivalenttotheEnglish“Limited”.

Jalousie - Astructurecomprisingaseriesoflouvreswhichcanbe opened or closed for ventilation purposes.

MAFI - TheGermancompanynameMAFIiswidelyusedfordescribinglow, heavy-duty trailers in the freight industry. The name originates from oneofthecompany’sfoundermembers,Martin Fila.

Nearside - Thepartofavehiclewhichisnearesttothekerb(foraleft-handdrive vehicle this is the right-hand side).

Offside - Thepartofavehiclewhichisfurthestfromthekerb(foraleft-hand drive vehicle this is the left-hand side).

1

SYNOPSIS

At0215on4December2013,afirewasdiscoveredonthemaindeckofthero-rocargo ferry Corona Seaways while the vessel was on passage from Fredericia toCopenhagen,Denmark.Thecrewmustered,closedtheventilationlouvres,establishedboundarycoolingandoperatedthefixedCO2fire-extinguishingsystem.Althoughsmokecontinuedtoescapefromthelouvres,steadytemperaturesinthevicinityofthefireindicatedthattheCO2hadbeeneffectiveincontrollingit.At0640,thevesselenteredtheSwedishportofHelsingborg,whereassistancewasprovidedbythelocalFireandRescueService.

The vessel suffered light structural damage and the loss of some minor electrical supplies.Threevehiclesandsixtrailerswereseverelyfire-damagedandothervehiclessufferedminorradiantheatdamage.Thefirewascausedbyanelectricaldefect on one of the vehicles’ engine starting system.

Recommendationstothemanagementcompanyincludeareviewofitsonboardinstructionstotakeaccountoftherevisedproceduressinceintroducedbytheoperator for the carriage of used and unregistered vehicles.

2

SECTION 1 – FACTUAL INFORMATION1.1 PARTICULARS OF CORONA SEAWAYS AND ACCIDENT

SHIP PARTICULARSVessel’s name Corona Seaways

Flag United KingdomClassificationsociety AmericanBureauofShippingIMOnumber 9357597Type Ro-Ro cargo shipRegistered owner SnowdonLeasingCompanyLimitedManager EllingsenShipManagementABConstruction SteelYearofbuild Keellaid20October2006Length overall 187mRegistered length 169.85mGross tonnage 25,609.00Minimum safe manning 12Authorised cargo Passengers and vehicles

VOYAGE PARTICULARSPort of departure Fredericia,DenmarkPort of arrival Copenhagen,Denmark(intended),

Helsinborg,Sweden(actual)Type of voyage ShortinternationalCargo information 170units,10accompaniedManning 19

MARINE CASUALTY INFORMATIONDate and time 4December2013at0215Type of marine casualty or incident SeriousmarinecasualtyLocation of incident 56º08’N011º41’E,59nmwestof

Helsingborg,SwedenPlaceonboard StarboardsideofthemaindeckInjuries/fatalities NoneDamage/environmentalimpact Severedamageto3vehiclesand6trailers.

Smokedamagetomaindeck,heatdamageto 15m2 ofsteeldeckand8longitudinalsbetweenframes131and134.Firedamagetotheforwardmooringwinchsupplycablesand to minor electrical circuits

Shipoperation Onpassage

3

Voyage segment Mid-waterExternal&internalenvironment Cloudy,visibilitygood,windsouth-westerly

force4,waveheight0.5-1.0m,airtemperature7ºC

Personsonboard 19 crew and 10 vehicle drivers

Corona Seaways

4

1.2 BACKGROUND – OVERVIEW OF ROUTE AND CARGO SHIPPING PROCEDURES

Corona SeawayswascharteredbyDetForendeDampskibs-Selskab(DFDS)A/Stooperateanaverage6-daycircular,BalticSeafreightferryroutebetweenFredericiaandCopenhagen,DenmarkandKlaipeda,Lithuania.Kiel,Germanywasoccasionallyincludedintheschedule.Thevessel’spositionwhenthefirewasdiscovered is shown at Figure 1.

Thecargoroutinelyincludeduseddriveableandnon-driveablevehicles,loadedMAFIs,trailers,cartransporters,andagriculturalandheavyplantmachinerypredominantlyforexporttoEasternEurope.Onaverage,about15%ofthevehicleswerepushedortowedonboardbecauseofmechanicaldefects.

Usedvehiclesweresubjecttorandomcheckstodeterminetheirsuitabilityforshipment(i.e.checkingforoilandfuelleaks).Stevedoresloadedthevehiclesandthevessel’screwwereresponsibleforsecuringthem.Onceavehiclewasinposition,theignitionkeywasleftintheignitionbarrelinthe‘stop/park’positioninaccordancewiththeoperator’srequiredprocedures.

1.3 NARRATIVE

1.3.1 Events leading up to the discovery of the fire

At2100on3December2013,Corona Seaways finishedcargoloadingoperationsinFredericia.Atotalof170unitsweretightlystowedinthelowerhold,onthemain,upperandweatherdecks,andontheaccessramps.Thecargoincluded10vehiclesthatwereaccompaniedbytheirdrivers,whowereamixofLatvianandLithuaniannationals.

At2110,withthecargosecuredandallcargospacefansstopped,Corona Seaways sailedforKlaipedaviaCopenhagen.At0130on4December,theon-watchableseaman(AB)informedtheofficerofthewatch(OOW)thathehadcompletedhisfireandsecurityrounds,includingrudimentarychecksofthecargodecks,andthatallwas satisfactory.

At0215,thefiredetectionalarmsystemsoundedonthebridge,indicatingafireinZone12(starboardside)onthemaindeck.TheOOWinformedthemasterandsenttheon-watchABtothemaindecktocarryoutchecks.TheOOWviewedthemaindeckontheClosed-Circuit-Television(CCTV)monitorandsawnoevidenceofafire.TheABopenedthemaindeckportaftdoorbutdidnotenterthespacebecauseofthetightlypackedvehicles.HereportedtotheOOWonhisVeryHighFrequency(VHF)radiothathecouldnotseeanyevidenceofafire,andhethenclosedthedoor.TheOOWinstructedtheABtoreturntothebridgeasthefirealarmsoundedagain.Onenteringthebridge,themasterlookedattheCCTVmonitor.Hesawsmokeand,shortlyafterwards,flames,whichappearedtocomefromvehiclesinthevicinityofframe131onthestarboardsideofthemaindeck(Figure 2). The general alarmwassoundedassmokeandflameswereseentorapidlyincreasebeforetheCCTVcameralensbecameobscured.

5

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1.3.2 Fire-fighting at sea

Afterarrivingatthemusterstation,twopre-designatedteamsstartedtoclosethemanually operated louvres of the 36 ventilation jalousies located on the upper and weather decks. Because of the high levels of smoke coming from the ventilation openings,somecrewmembershadtodonBreathingApparatus(BA)forprotection.Althoughthelouvreswerereportedclosedtothechiefofficer,aconsiderableamountofsmokecontinuedtoemitfromthem.Inthemeantime,themasterinstructedthechiefengineertopreparethefixedCO2fire-extinguishingsystemfordischarge into the main deck cargo space.

At0225,thechiefofficerreportedtothemasterthattheventilationlouvreshadbeenclosedandthatallpersonnel,withtheexceptionofthefitter,hadbeenaccountedfor.Notknowingthefitter’swhereabouts,themasterdecidedtodelayuseoftheCO2 incasehewasonthemaindeckand,ashewasnotequippedwithaVHFradio,hecouldnotbereadilyaccountedfor.At0230,thefitterarrivedatthemusterstationhavingreportedlybeenclosingupperdeckventilationlouvres.

ThemasterthenapprovedtheinjectionofCO2 into the main deck using the forward CO2 fire-extinguishingsystemcontrolpositionlocatedintheaccommodationsuperstructure.

The10vehicledrivers,whohadconsumedalcoholandwerenowlocatedatthemusterstation,startedtobecomedisruptive.Asthiswasaffectingthechiefofficer’sabilitytomanagetheincident,hedecided,inconsultationwiththemaster,torelocatethemtothepassengerloungefromwheretheycouldbereadilyevacuatedif necessary.

Meanwhile,themasterreportedhissituationtoLyngbyRadio,whotransferredtheinformationtotheDanishJointRescueCo-ordinationCentre(JRCC)atBrabrand.At0248,theGermanFederalNavycorvetteBraunschweig offered to assist in evacuatingthecrewifthisbecamenecessary.

Bynow,Corona Seaways’upperdeckwasbeingboundary-cooledusingwaterfromopenfirehydrants.At0300,thechiefofficerinstructedtheupperdeckwaterdrenchingsystemtobeoperatedasheconsideredthatthiswouldbeamoreeffective method of cooling the deck.

At0310,thechiefengineeradvisedthemasterthattheCO2 storage tank contents gaugewasregisteringabout12t.Thissuggestedthatonly9tonnes(t)ofthe21.3tofCO2storedinthetankhadbeenreleasedintothemaindeckinsteadoftherequired19.8t.Unsureofthetruesituation,themasterauthorisedthechiefengineertooperate the system once more from the forward control position.

FollowingthesecondreleaseofCO2,themaster,inconsultationwiththechiefofficerandchiefengineer,determinedthatthefireappearedtobeundercontrolasnootherfiredetectorshadoperatedandthetemperatureontheupperdeck,abovethefire,hadnotincreased.

Inthemeantime,arrangementsweremadeforCorona SeawaystoberthatHelsingborg,Sweden.Accordingly,co-ordinationoftheemergencywastransferredtotheSwedishJRCCbasedinGothenburg.

8

At0400,thechiefengineeradvisedthemasterthatthecontentsgaugeindicatedthatover10tofCO2 was still remaining in the storage tank. The master authorised thechiefengineertomanuallyoperatethesystemfromtheCO2 storage tank compartment,whichhedid,leavingthedischargevalvetothemaindeckfullyopen.

Ashorttimelater,thefiredetectionsystemalarmagainsounded,indicatingafireintheupperdeckforwardstaircase,whichprovidedaccesstothemaindeckviaaslidingwatertightdoor.ThechiefofficersentaBAteamtoinvestigate.TheBAteamreportedthatsmokewaswispingthroughthedoorsealbutthatthedoorwascoldtothetouch,indicatingthatthefirehadnotspreadtotheforwardsectionofthemaindeck.

1.3.3 Fire-fighting in Helsingborg

At0445,aSwedishcoastguardlaunch,equippedwithaninfra-redthermalimagingcamera,scannedCorona Seaways andconfirmedthattemperaturesweresteady,indicatingthattheuseofCO2hadbeeneffectiveincontrollingthefire.

At0640,Corona Seaways wassecuredalongside704berthatHelsingborg.The10vehicledriversandsurpluscrewwereevacuatedbytheFireandRescueService(FRS)whileaharbourtugboundary-cooledthevessel’ssidewithwaterusingitsfire-fightingmonitor.

Followingabriefingbythechiefengineer,FRSpersonnelenteredthemaindeckthroughtheportaftdoorat0704.However,theirprogresswashamperedbypoorvisibility,restrictedaccessbetweenthestowedvehiclesandtheneedtoextendandre-laythefire-fightinghoses.

At0805,someofthemaindeckexhaustfanswerestartedtohelpimprovevisibility.At0914,itwasagreedtolowerthemaindeckaccessrampanddischargesomeofthecargotoprovidetheFRSaccesstotheseatofthefire.Thevesselwasre-positionedtoallowtheramptobesafelylocatedonthequaysideand,at1208,cargo unloading started. Following access to and dampening down of the main deck,theFRSdeclaredthefireoutat1325.At2110,afterfurtherdampeninganumberof‘hotspots’,theFRSpassedresponsibilityformonitoringthefirescenetothe vessel’s crew.

FollowingrepairsatnearbyLandskrona,Corona Seaways re-entered service on 29 December2013.

1.4 VESSEL AND CARGO DAMAGE

1.4.1 Vessel’s structure and systems damage

Themajorityofthestructuraldamagewaslocatedabovethefireontheundersideoftheupperdeckbetweenframes131and134.Approximately15m2 of the steel deck requiredreplacing,asdidsevenslightlydistortedlongitudinaldeckheadstiffeners.

Electricalcablingsupplyingtheforwardmooringwinch,lighting,ballasttankventilationpipeheatingandfiredetectionequipmentwasfire-damaged.OtherthansootcontaminationofthefixedCO2fire-extinguishingsystemnozzles,nomechanical or pipework systems were affected.

9

1.4.2 Cargo damage

ThetwovehiclesatthelocusofthefirewereaRenaultPremium250.18truckanda Renault Mascott-Master van that it was carrying; these are termed the primary vehicles and were totally destroyed (Figure 3).TheywerepositionedinLane8andadjacent to frame 131 on the main deck.

ARenaultPremium410cabunitlocatedalongsideandinboardoftheprimaryvehicles,inLane7,sufferedseverefiredamagetoitsnearside.Two3-axletrailerunits,eachcarryingtwotrailers,positionedinLanes7and8anddirectlyaftoftheprimaryvehicleswerealsobadlyfire-damaged.Eighteenofthetrailertyreshadbeentotallyconsumedbythefire.Otherunitsforwardoftheprimaryvehiclessuffered minor radiant heat damage (Figure 4).

1.5 DESCRIPTION AND HISTORY OF PRIMARY VEHICLES

1.5.1 Renault Premium 250.18 truck

Manufacturedin1996,theleft-handsidedriveRenaultPremium250.18truckwasfittedwitha6-cylinder,250horsepower(hp)turbo-chargeddieselengine.Thecargocompartment sides and roof were made from light aluminium sheeting and the deck from aluminium checker plate laid over plywood sheeting. There was a rear-mounted electrically operated steel ramp.

FromFebruary2013until28November2013,thetruckwaslocatedatausedvehicledealershipbasedinChristiansfeld,Denmark.Duringthisperiod,itsenginewasreportedtohavebeenoccasionallystartedusingaportablebatterypackasthetruck’sbatterieshadbeenremoved.

Figure 3:Fire-damagedRenaultPremium250.18truckandRenaultMascott-Mastervanfollowingtheirremoval from the vessel

Renault Mascott-Master van

Renault Premium 250.18truck

10

AttheendofNovember2013,thetruckwaspurchasedbyLithuanian-basedUABAmerijaforimporttoLithuania.On1December2013,two12volt(V)batterieswerefittedtothetruck.Itwasthendriven240kmtoFredericia,arrivingthefollowingdayafterpickinguptheRenaultMascott-MastervaninSkjern,Denmark.Thetruckanditsvancargowereleftattheportovernighttoawaitloadingbythestevedoresthefollowing afternoon.

1.5.2 Renault Mascott-Master van

Therear-wheeldriveRenaultMascott-Mastervanwasmanufacturedin2005.Itwasfittedwitha63hpnaturallyaspiratedengine,drop-downwoodensidesandasmallhydraulicallypoweredcranepositionedimmediatelybehindthecab.ItsufferedenginefailurewhenitwaslastruninaboutDecember2012,afterwhichthecylinderhead was removed.

1.6 RENAULT PREMIUM 250.18 TRUCK – OVERVIEW OF ELECTRICAL AND ENGINE STARTING ARRANGEMENTS

1.6.1 Electrical system

A schematic of the electrical and engine starting arrangements is at Figure 5. The 24Velectricalsystemwasprovidedbytwo12Vbatteries,connectedinseries,whichwerelocatedonaplatformbehindthefrontoffsidewheelarch.Powerwas

Figure 4: Damaged vehicles and trailers on the main deck

Renault 410 cabunit

RenaultPremium250.18truck and Renault Mascott-Master van

Trailers

11

distributedthroughabatteryrotaryisolatingswitch.Afusedprotectedelectricalsupplyforoperatingtherearrampwasarrangedtoby-passthemainisolatingswitch.

Whentheignitionkeywasremovedorinthe‘stop/park’position,anumberoffusedcircuitsremainedlive,includingthoseforthetachograph,hazardwarninglightsandcentrallockingsystem.Non-fusedcircuitsthatremainedliveincludedsuppliesto/fromtheremoteenginestartsolenoid,enginepre-heatsolenoidandenginestartermotormainsolenoid,anditsconnectiontothealternatoroutputsupply.

1.6.2 Engine starting arrangements

Whenthegearboxwasintheneutralposition,theneutralswitchwasclosed,whichcompletedtheearthcircuitfortheremoteenginestartsolenoidcoil.Whentheignitionkeywasturnedtothe‘start’position,theremoteenginestartsolenoidwasenergisedthroughwire205,whichclosedthecircuittoprovidepowerthroughwire

Figure 5:SchematicofRenaultPremium250.18truckenginestartingarrangements

Engine starter motor and main solenoid

Remote enginestart solenoid

24V supply from ignition switch

205

Neutralswitchongearbox

21

24V supply from remote engine start solenoid

Battery rotary isolating switch Fused suppliesSupplytorearramp

Connection from alternator

12

21toenergisetheenginestartermotormainsolenoid.Whenenergised,theenginestartermotorsolenoidconnectedthebattery24Vsupplytothestartermotorwhichturned the engine over.

Asecondsolenoidwasfittednexttotheremotestartingsolenoidtoprovide24Vpower to two resistance-type engine pre-heaters. These were positioned in the engine air intake manifold to assist in engine starting in cold conditions. The pre-heatersolenoidwasactivatedbyadriver-operatedswitchonthedashboardwhich was fed from the ignition circuit when the ignition was turned on.

Thevehiclewasalsofittedwithathree-element,resistance-typedieselfueloilpre-heater.Theheater,whichwasfittedtotheoffsidetopoftheengineblock,wasautomatically activated once the engine was running.

1.7 EXAMINATION OF RENAULT PREMIUM 250.18 TRUCK

1.7.1 Structure

Theinternalcomponentsofthetruck’scabweretotallyconsumed.Althoughthetruck’signitionkeybarrelwaspartiallymelted,thekeywasfoundinthebarrelinthe‘stop/park’position.

Fiveofthesixfittedtyresandthesparetyrewerealsoconsumed.Mostofthetruck’soffsideglassfibrecabfrontandwinddeflectoronthecabroofhadburntaway,ashadabout60%ofthetruck’soffsideandabout30%ofthenearsidealuminium cargo compartment shell. A large amount of the truck’s cargo compartmentaluminiumcheckerfloorplatehadalsomelted.However,abouta2.5msectionoftheoffsidechassisrailandtheairbrakereservoirswereundamagedwiththepaintschemebeingunaffected.Asimilarpatternwasnotedonthenearsideexceptthatthefrontofthefueltankprotectiveplasticfacinghadmelted;however,aquantityofdieseloilfuelremainedinthetank.

1.7.2 Electrical and mechanical systems

Mostofthevehicle’selectricalcableinsulationwasmissingandthebatterycasingshadpartiallymelted.Oneofthebattery’spositivecableshadbecomedisconnectedandtherewasevidenceofpartialmeltingoftheleadterminalposts.Thebatteryisolatingswitchwasfoundtobeinthe‘on’position,indicatingthatthebatterywasnot isolated.

The rear part of the engine’s aluminium rocker cover had melted and the upper partofthealuminiumengineintakemanifoldhadbeenburntaway,exposingthepre-heaters (Figure 6). The diesel oil fuel unit had melted. The three heating elementswerestillconnectedtotheirelectricalcables,althoughthemainsupplyelectricalcableconnectionwasloose,withabouta3mmgapbetweenthenutandconnectiontab.Thebatterymainsupplycableinsulationhadbeendestroyedandthecablehadweldedtothechassis.

Themainterminalpostoftheenginestartermotormainsolenoidwasfoundtobeextremelyloose.TheendBakelite-typecapappearedbrittle,andtherewerecopperglobulesinthevicinityofthestartermotor.

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Ondismantlingthesolenoid,themaincontactpostconnectingthesolenoidtothebatteryseparatedfromtheendcap,whichexposedheavyarcingdamagetotheinternalsurfaces.Themaincontactshadsufferedsignificantsparkerosionandpitting.Themovingcontacthadseparatedfromitscarrier,meltedcopperglobuleswerefoundinthebodyofthesolenoid,andthealternatorconnectingcablehadmelted through (Figures 7 and 8).

Theremoteenginestartsolenoidwasdismantledandfoundtobefullyworking.However,theenginepre-heatsolenoidironcorewasfoundseizedwithintheelectro-magneticarmature,andthecontactswereinthe‘open’position.Continuitytestingconfirmedtherewasnoelectricalpathacrossthecontacts.

1.8 EXAMINATION OF RENAULT MASCOTT-MASTER VAN

Thevan’scabwastotallydestroyedaswereallofthetyresandthehingeddrop-downsides.Thevan’sfueltankcradlewasinplacebuttherewasnoevidenceofthefueltank.Itisunclearwhetherthetankwasfittedatthetime.Theenginestartingbatteryhadpartiallymeltedandthecableshadbeendisconnected,probablyatthetimethattheenginecylinderheadhadbeenremoved.Therewasalso other loose steel framework in the van’s cargo area.

1.9 LOW-PRESSURE FIXED CO2 FIRE-EXTINGUISHING SYSTEM

Corona Seaways wasfittedwithaDanfoss-Semcolow-pressurefixedCO2fire-extinguishingsystem.TheCO2 was held in a 21.3t capacity storage tank located in theCO2 storagecompartmentinthevessel’sportquarter.Thecompartmentwasequippedforlocaloperationofthesystem.Thesystemcouldalsobeoperated

Figure 6: Fire damaged engine components

Air intake manifold pre-heaters

Inletmanifold

Startermotor

Startermotormain solenoid

14

Figure 7:Schematicofenginestartermotormainsolenoid

Electro-magnetic coil 24Vsupplyfrom/tobattery Supplyfromalternator

Return spring

24V supply to starting motorMoving contactHeavydutycontacts

Ironplunger

1

1

1

Figure 8:DamagedRenaultPremium250.18truckenginestartermotormainsolenoid

Sparkerosiondamage

Moving contact

Cableconnectingalternator

Copperglobule

24V electro-magnetic coilIronplunger

Arcingdamagetosolenoidbody

Supplytostarter motor terminal

24Vsupplyfrombattery

15

from the remote operating station in the forward superstructure. Each of the compartments displayed a comprehensive system mimic diagram and operating instructions.

ThetimeddischargeratewasdesignedtoachievethecorrectCO2 concentration bycompartmentvolumetoextinguishafire.Thefollowingcompartmentswereprotected: engine room; emergency generator room; separator room; paint store (between0.3and4tofCO2wererequiredover2minutes);lowerholdandmaindeck(9and19.8trespectivelyover15minutes).

1.10 CARGO DECKS’ VENTILATION ARRANGEMENTS

Therewasatotalof38maindeckventilationjalousies.Sixwerelocatedonthestarboardsideoftheupperdeckand15oneachoftheportandstarboardsidesoftheweatherdeck.Thejalousiesservingthemaindeckwereeasilyidentifiablebyayellow-paintedstripacrosstheirmiddlesection1. Each jalousie comprised 11 manuallyoperatedlouvresfittedwithrubbersealingstrips(Figure 9).

There were also two automatically operated jalousies on the upper deck level at the portandstarboardcornersofthesuperstructure.Thesewerelinkedtothefirealarmsystemandservedboththemainandupperdecks.

The 14 fans servicing the main deck were controlled from the cargo control room. Onewasadedicatedexhaustfan,threeweresupplyfansandtheremainderweredual-purposesupplyandexhaustfans.

Itwasnormalpracticetostopallcargodeckventilationfansonceloadingwascompleted.

1 Jalousiesservingthelowerholdandtheupperdeckwereidentifiedbyayellow-paintedstripontheirlowerandupper sections respectively

Figure 9: Main deck ventilation jalousie

1.5cmgapbetweeneachlouvre

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1.11 REGULATION AND GUIDANCE

TheInternationalConventionfortheSafetyofLifeatSea1974,asamended(SOLAS)ChapterII-2–Fireprotection,firedetectionandfireextinction,Regulation20,paragraph3.1.2.2states:

‘In cargo ships, ventilation fans shall normally be run continuously whenever vehicles are on board. ….’.

Theinstructionisreiteratedinparagraph8.7ofMarineGuidanceNote(MGN)341(M)Ro-RoShipsVehicleDecks–AccidentstoPersonnel,PassengerAccessandtheCarriageofMotorVehicles,whichstates:

‘…. ventilation systems serving the vehicle decks should be in operation during any loaded voyage……’

TheCodeofSafeWorkingPracticesforMerchantSeamen(COSWP)–Chapter32Ro-Ro Ferries paragraph 32.3.2 also covers the need to run ventilation fans while vehiclesareonboard.Section32.7–InspectionofVehiclesstates:

‘Before being accepted for shipment, every freight vehicle should be inspected externally by a competent and responsible person or persons to check that it is in a satisfactory condition for shipment….’

TheMaritimeandCoastguardAgency’s(MCA)publication-TheCodeofPractice–Roll-On/Roll-OffShips–StowageandSecuringofVehicles,Section1.1identifiesthat a principal source of danger to ships and persons is the unsatisfactory condition ordesignofvehiclespresentedforshipment.Section2.2states:

‘Before being accepted for shipment, every freight vehicle should be inspected externally by a responsible person or persons appointed by the ship owner, the ship manager and/or the master, to check that it is in a satisfactory condition for shipment.’

1.12 SIMILAR ACCIDENT

At0153on23April2013,afirewasdiscoveredonNo3cargodeckoftheLithuanianregistered,andDFDSA/Soperated,passengerro-rocargoferryVictoria Seaways while on passage from Kiel to Klaipeda. Atthetime,therewere37crewand309passengersonboard.Thefirewasdealtwithbythecrewandwasdeclaredtobeextinguishedat0400.Thecargoincludedsecond-handcarsforexporttoLithuania.Sixcarsandacartransporterweredestroyedinthefirebuttherewerenoinjuries or structural damage to the vessel.

TheLithuanian-ledinvestigationidentifiedthatthefirewascausedbyanelectricalfault on a second-hand car that was in poor condition.

Thereportincludedarecommendationtotheeffectthatbatteriesofsecond-handcarsshouldbedisconnectedandthatconfirmatorychecksshouldbemadebythevessel’s crew.

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SECTION 2 – ANALYSIS

2.1 AIM

Thepurposeoftheanalysisistodeterminethecontributorycausesandcircumstancesoftheaccidentasabasisformakingrecommendationstopreventsimilar accidents occurring in the future.

2.2 CAUSE OF THE FIRE

2.2.1 Renault Mascott-Master van

Anumberofpotentialcausesofthefirewereexamined.TheRenaultMascott-Mastervanwasconsidered.However,itsenginecylinderheadhadbeenremovedandthebatterywasdisconnected.Astherewasnoviableignitionsourceonthevan,itisnotconsideredtobetheoriginofthefire.

2.2.2 Renault Premium 250.18 truck

TheRenaultPremium250.18truckhadbeendrivenabout240kmbeforearrivingatFredericia and then onto the vessel. Neither the drivers nor stevedores reported any mechanical,electricalorinstrumentationissues.However,thetruckhadnotbeendriven for the previous 11 months and there was no evidence that any checks had beencarriedouttoproveitsroadworthinessorgeneralsafety,includingtheintegrityof its electrical and mechanical systems.

Thetruckwaslasheddownabout8hoursbeforethefirewasdiscovered.Ithadonlybeenrunforashorttimeduringloading,andthechancesofthefirestartingfromresidualheatfromtheengine,exhaustorturbo-chargerwerenegligible.

Althoughoneofthetruck’spositivebatterycableswasdisconnectedandthebatterieswereheavilyfire-damaged,therewasnoevidenceofarcinginthisarea.Cablestotheremoteenginestartandenginepre-heatsolenoids,whichwereintheimmediatevicinity,werevirtuallyundamagedandcanthereforebediscountedasthecauseofthefire.Itisconsideredthatthebatterycablebecamedisconnectedastheterminalpostmeltedandreducedindiameter,whichreleasedthecablesecuringclamp.

Alltheevidence,includingtheareaofhighheatenergyandtheburningandheavyradiantheatdamagetotheengineandtothefrontofthecab,indicatedthattheseatofthefirewaslocatedaroundtheupperhalfoftheengine.Theenginestartermotormainsolenoidwasseverelydamagedbyinternalarcing,whichhaddestroyedthemovingcontact.Astheenginepre-heatsolenoidwasdefective,theairchargecouldnotbepre-heatedandtheenginewouldhavebeendifficulttostart:therewasanecdotalevidencethattheenginehadtoberepeatedlycrankedovertostartit.Itisprobablethattheinternalarcinganddamagetotheenginestartermotormainsolenoid’sfixedandmovingcontactswereinitiallyduetorepeatedattemptstostarttheengine.Thiswouldhaveresultedinacontinualcurrentflowintheheavydutycablefromthebatterywhichwouldhaveremainedlivedespitetheignitionswitchbeinginthe‘stop/park’position.Overtime,continualarctrackingwithinthesolenoidwouldhavecausedfurtherdamageand,togetherwiththehighcurrentflow

18

experiencedduringenginestarting,wouldhavecausedthecabletooverheat,ignitetheinsulationandinitiatethefire.Astheinsulationburnt,thenowbarecablewouldhaveshorted,causingfurthersparksandforittoweldagainstthechassis.

2.3 FIRE DEVELOPMENT

Oncethefirehadstartedontheengine,itconsumedinsulation,plasticfittingsandrubberhoses,andspreadintothecababoveandforwardtodestroytheglassfibrecabfront.The‘V’shapedburnpatternattherearofthecabindicatedthatthefirespreadupwards.Asthefireignitedthetruck’styres,theheatwouldhaveintensified,causingthefiretomoveaftandengulfthevananditstyres,andmeltthetruck’saluminiumcheckerplateflooring.Thelocationofthepartiallyopenventilationlouvres on Corona Seaways’ upper deck was such that as the vessel made headway,aslightoverpressurewascreatedforward,resultinginaforwardtoaftair-flowonthemaindeck.Thiswouldexplainwhythevehiclesforwardofthetrucksufferedonlyminordamageandthosebehindwereengulfedinthefire.Whiletherewasverylittleflammablematerialonthesixtrailersinvolved,theirtyreswouldhaveaddedsignificantlytothegeneratedheatenergy.

2.4 RISKS OF THE CARRIAGE OF USED VEHICLES

Thecarriageofusedvehiclesandequipmentthatdonothaveappropriateroadworthinesscertificationandwhosehistoryandconditionareunknown,bringsincreased risks when compared with the carriage of well maintained vehicles that are in regular use.

2.4.1 Used vehicles – fire ignition risk

ThevehiclesroutinelyshippedonDFDSA/S’sBalticSearoutehadoftenbeenlaidupforlongperiodsduringwhichelectricalinsulationcouldbecomebrittle,componentscouldseize,andsealsonfuelandoilsystemscouldbecomeineffective,allcontributingtoanincreasedfirerisk.Electricalsystemsthathavebeenidleandarethenconnectedtochargedbatteriesareparticularlyvulnerable.Theproceduretoleavetheignitionkeyinthe‘stop/park’positiondidlittletoreducetheriskasmanycircuitsstillremainedlive.Whiletherewereotherpotentialsourcesofignition,includingengineandturbo-chargerresidualheattransfer,anddiscardedlitcigarettesandheatingequipmentleftinthecab,theprominentriskwaselectricallybased.Ifthebatteryhadbeentotallyisolated,theriskwouldhavebeenconsiderablyreduced.

2.4.2 Vehicle checks

FollowingacarfireonboardtheLithuanianregisteredro-roferryVictoria Seaways on23April2013,DFDSA/Sintroducedprocedurestoreducetheriskoffire.Theseincludedremovingthebattery,prohibitingthecarriageofsparefuelorflammables,andrequiringthevehicle’ssystemstobeleak-free.However,theinstructionappliedonly to used vehicles carried on designated car transporters.

Theinstructionwasre-iteratedbythemaster’sundated‘UnsafeCargo’noticedisplayedinseverallocationsonboard,includingthecargocontrolroom.Inaddition,thenoticestatedthatforused,self-movingvehicles(notjustthosecarriedon

19

designatedcartransporters)loadedonboard,thebatterywastobedisconnectedorisolatedbyaswitch,onlyaminimalamountoffuelwastobecarried(approximately5litres),andthehandbrakewastobeengaged.

DriversofdesignatedcartransporterssignedaDFDSA/Schecksheettostatethattherequisiteshippingconditionshadbeencompliedwith.However,anecdotalevidencesuggeststhatDFDSA/Scontractors,whoshouldhavebeenverifyingthis,onlyoccasionallycarriedoutchecks,butnodocumentedevidencewasidentifiedorcouldbeprovidedtocorroboratethis.

Furthermore,contrarytotheMCA’sCodeofPracticetherewasnoevidencethatthevessel’s crew made any vehicle electrical system isolations or other vehicle safety checks.Indeed,itwouldbeverydifficultforcrewtosafelyisolateorremovebatteryconnections in addition to their routine tasks of loading and securing the vehicles.

2.4.3 Vessel’s safety instructions

Thevessel’sShipSafetyManagementManual(SSMM)SectionSM11-11–CargoOperations,providedgeneralinstructionsonstowing,lashing,ballastingandsafetyprecautions. Corona Seaways also held risk assessments covering lashing and unlashingcargo,ro-rocargooperations,andtheloading/unloadingofextraordinarycargo.However,neithertheSSMMnortheriskassessmentsprovidedguidanceonthespecificrisksassociatedwiththecarriageofusedvehiclesandequipment.

2.5 CREW’S FIRE-FIGHTING PRACTICE

TheOOW’sdecisiontosendtheon-watchABtocheckthestatusofthemaindeckafterthefirstfirealarmwasreasonableandappropriate.HehadnoindicationofafireontheCCTVmonitor,andheneededtoclarifythesituation.TheABalsoreasonablyoptedtocheckthemaindeckfromthedoor.HadtheABventuredbetweentheclosely-packedcargotowardstheseatofthefirehemighthavebecometrappedwhenthefirerapidlyescalated,asobservedbythemasterontheCCTV monitor.

Thepromptuseoftheupperdeckhydrantsand,later,thedrenchingsystemtoboundarycooltheareaabovethefirewasalsowellconsideredandhelpedtolimitstructuraldamageandthepotentialspreadofthefire.

ThespeedatwhichthefiredevelopedgavenoopportunitytofightitwithanythingotherthanthefixedCO2fire-extinguishingsystem.Itwasthereforeoftheutmostimportancethatoncethecompartmentwascloseddownthesystemwasused,withoutdelay,tomaximisethechanceofsuccess.

Overall,thefire-fightingeffortwaswellconsidered,effectiveandsafelymanaged.

2.6 MUSTER STATIONS

Whilethecrewwerepromptlyorderedtotheirmusterstationsfollowingtheoutbreakofthefire,itwas15minutesbeforethechiefofficerwasabletoreporttothebridgethatthecrewhadbeenfullyaccountedfor.TheCO2 systemwasreadytobeusedafter10minutes,buttherewasa5minutedelayindischargingthegasbecausethefitter’swhereaboutswereunknown.Thisallowedthefiretodevelopanddemonstrates the importance of the crew reporting to their muster station promptly.

20

Inothercircumstances,thedelaycouldhavebeencritical.Manycompaniesissueallcrewmemberswithportableradiostoeasecommunicationproblems.Hadthefitterbeenequippedwitharadio,hecouldhavebeenquicklyaccountedfor.

2.7 FUNCTIONALITY OF THE LOW PRESSURE FIXED CO2 FIRE-EXTINGUISHING SYSTEM

AlthoughtherewasconfusionabouttheactualamountofCO2 discharged onto the maindeckduetotheinformationindicatedonthestoragetankcontentsgauge,thedecisionstore-injectCO2weresensiblyjudged.

On6December,theCO2systemwasservicedbyWilhemsenShipsService.Thesystemwasre-chargedandunderwentacomprehensiverangeofchecks,includingconfirmationthatthestoragetankcontentsgaugewasworkingcorrectly.However,therewasnoexplanationforwhythesystemapparentlyfailedtodischargetheallottedquantityofCO2asdesigned.ItisvitallyimportantthatthecrewhavetotalconfidenceintheCO2systemasthereisnobackupfixedfire-extinguishingsystemfor the cargo decks.

2.8 CARGO DECK VENTILATION ISSUES

2.8.1 Isolation of ventilation supplies

ItisimportantthatacompartmentisfullycloseddownbeforeCO2 isinjectedbothtoreduceanyinflowofoxygenfeedingthefireandtoensurethecorrectconcentrationofCO2ismaintainedtoextinguishafire.AlthoughCO2 is denser than air and will taketimetodissipatethroughventilators,thetighteracompartmentissealedthebetterthechanceofsuccess.

Whiletheventilationlouvreswerereportedclosed,smokecontinuedtoemitfromthemformostoftheincident.Oninvestigation,itwasfoundthattherewasamisunderstandingonboardonhowtolockthelouvresinthe‘closed’position.Notallcrewwereawarethattwopersonswererequiredoroftheneedtorotatetheoperatingspindlepasttheapparent‘closed’pointtolockthelouvresshutagainstthecamsystem.Itwasalsonotedthatthevessel’sTrainingManualdidnotcovertheprocess.

Duringtrials,itwasfoundthattherewasanaveragegapofabout1.5cmbetweeneachoftheelevenlouvresineachofthe34,1-metrewidejalousieswhenthelouvreswereinthe‘closed’butnot‘locked’position.Thisequatedtoaholeofapproximately5m2 throughwhichCO2 couldescape,orair(oxygen)couldbedrawnin.

2.8.2 Operation of cargo deck ventilation fans

Flammablevapoursthatevolvefromvehiclesstowedonro-rocargodeckscreateaninherentfirerisk.Duringtheinvestigation,itwasnotedthatitwasusualpracticeon Corona Seaways forthecargofanstobestoppedoncecargooperationswerecompleted.SOLAS,COSWPandMGN341(M)highlighttheneedforventilationtobemaintainedwhilevehiclesareonboardtoremovevapoursandsominimisetheriskoffire.

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2.9 DRUG AND ALCOHOL POLICY AND PASSENGERS

The management company’s drug and alcohol policy was set out in Document CSMM02-06oftheCompanySafetyManagementManual.Thepolicycoveredthecompany’sshorepersonnelandcrew,butnotpassengers.

Itisdifficulttodevelopapolicypreventingvehicledrivers/passengersfrombringingalcoholonboardforpersonalconsumption.Thecontrolofvehicledrivers/passengersthathaveconsumedalcoholrequirescarefulmanagement,especiallyduringanemergency.Thechiefofficerstruckanappropriatebalanceinremovingthemfromthemusterstationtothepassengerloungewheretheyweresafe,couldbeeasilyevacuatedandwerenotdisruptivetothemanagementoftheemergency.

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SECTION 3 - CONCLUSIONS

3.1 SAFETY ISSUES DIRECTLY CONTRIBUTING TO THE ACCIDENT THAT HAVE BEEN ADDRESSED OR RESULTED IN RECOMMENDATIONS

1. Therewasnoevidencethatanycheckshadbeencarriedouttoprovethetruck’sroadworthinessorgeneralsafety,includingtheintegrityofitselectricalandmechanical systems. [2.2.2]

2. Thecarriageofusedvehiclesandequipmentthatdonothaveappropriateroadworthinesscertificationandwhosehistoryandconditionareunknownbringsincreased risks when compared to the carriage of well maintained vehicles that are in regular use. [2.4]

3. DFDSA/S’sfireriskcontrolmeasuresintroducedafterthefireonboardVictoria Seaways applied only to used vehicles carried on designated car transporters. There was no documented evidence that these control measures were carried out. [2.4.2]

4. ContrarytothespiritoftheMCA’sCodeofPracticeandthemaster’s‘UnsafeCargo'notice,therewasnoevidencethatthevessel’screwcarriedoutvehiclesafetychecks. [2.4.2]

5. NeithertheSSMMnortheonboardriskassessmentscoveredthecarriageofusedvehiclesandequipment.[2.4.3]

3.2 OTHER SAFETY ISSUES DIRECTLY CONTRIBUTING TO THE ACCIDENT2

1. Theenginestartermotormainsolenoidwasseverelydamagedbyinternalarcing,which had destroyed the moving contact. [2.2.2]

2. Theheavydutycableconnectingthebatterytotheenginestartermotormainsolenoid was live and permitted unintended electrical arcing inside the solenoid which,togetherwithhighcurrentflowexperiencedduringenginestarting,causedthecabletooverheatandinitiatethefire.[2.2.2]

3. Thedefectiveenginepre-heatsolenoidpreventedtheairchargefrombeingpre-heated,makingtheenginedifficulttostart.[2.2.2]

3.3 SAFETY ISSUES NOT DIRECTLY CONTRIBUTING TO THE ACCIDENT THAT HAVE BEEN ADDRESSED OR RESULTED IN RECOMMENDATIONS

1. InjectionofCO2intothemaindeckwasdelayed,allowingthefiretodevelop,becauseittooktimetoestablishthefitter’swhereaboutsduringthecrewmuster.[2.6]

2. ThereasonwhytheCO2fire-extinguishingsystemapparentlyfailedtodischargetheallottedquantityofCO2asdesignedremainsunexplained.[2.7]

2 Thesesafetyissuesidentifylessonstobelearned.Theydonotmeritasafetyrecommendationbasedonthisinvestigationalone.However,theymaybeusedforanalysingtrendsinmarineaccidentsorinsupportofafuture safety recommendation.

23

3. The main deck ventilation louvres were not fully closed and some of the crew were unawarehowtocorrectlyoperatethem.Thisallowedair(oxygen)tofeedthefireandpotentiallyaffectedtheCO2concentrationlevelsneededtoextinguishthefire.[2.8.1]

4. Thecargodeckventilationfanswerenotoperatedasrequiredbythecurrentregulations.Thisincreasedthefireriskduetothepotentialbuild-upofflammablevapoursfromvehicles.[2.8.2]

3.4 OTHER SAFETY ISSUES NOT DIRECTLY CONTRIBUTING TO THE ACCIDENT3

1. Vehicledrivers/passengerswhohadconsumedalcoholweredisruptiveandstartedtoaffectthechiefofficer’smanagementoftheincident.[2.9]

3 Thesesafetyissuesidentifylessonstobelearned.Theydonotmeritasafetyrecommendationbasedonthisinvestigationalone.However,theymaybeusedforanalysingtrendsinmarineaccidentsorinsupportofafuture safety recommendation

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SECTION 4 - ACTIONS TAKEN

Ellingsen Ship Management AB has:

• DevelopedriskassessmentDE45-14-Ro-RoCargoOperation“ScrapVehicle”.

• Inrespecttotheventilationsystem:

◦ Developed risk assessment DE46-14 - Cargo and Engine Louvre Monthly Performance Test.

◦ Introduceda4-monthlymaintenanceitemtocheckthefulloperationoftheventilation louvres and to conduct a watertightness check.

◦ Provided instructions and illustrations on how to correctly operate the ventilation louvres for inclusion in the ship’s Training Manual Part 3.

• Instructedallvessels’masterstohighlighttheimportanceofpromptmusteringinanemergencyduringmonthlySafetyCommitteeMeetings.

DFDS A/S has:

• Promulgatedthefollowingrevisedprocedures,whichincludefullisolationofbatteriesandtheirterminals,andchecksforoilandoilleaks,toimprovethesafecarriage of used and unregistered vehicles:

◦ ‘InformationtoCarCarriers’dated28January2014(Annex A).

◦ ‘InformationtoUnregisteredSecondHandSegment’dated28January2014 (Annex B).

• Introducedasystemofsignedchecksbyatechnicianaspartofits‘Instruction–DeliveryNote,Single/EmptyUnits’dated6January2014,toensurecustomercompliance with the conditions of carriage (Annex C).

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SECTION 5 - RECOMMENDATIONS

Ellingsen Ship Management AB is recommended to:

2014/127 Reviewitsonboarddocumentationandthe‘UnsafeCargo’noticetotakeinto accountDFDSA/S’srevisedproceduresforthecarriageofusedand unregistered vehicles:

◦ ‘InformationtoCarCarriers’dated28January2014.

◦ ‘InformationtoUnregisteredSecondHandSegment’dated28 January 2014.

2014/128 Takeappropriateactionto:

◦ Ensure that cargo deck ventilation fans are run in accordance with current regulations.

◦ InvestigatewhytheCO2fire-extinguishingsystemapparentlyfailedtodischargetheallottedquantityofCO2 as designed.

Safetyrecommendationsshallinnocasecreateapresumptionofblameorliability

Annex A

DFDS/AS Instruction - Information to Car Carriers dated 28 January 2014

Safety precautions to be taken prior loading Car Carrier onboard the vessel 28.01.2014

Dear Customer,

DFDS A/S is committed to providing the best possible service to our customers and

to ensuring the comfort and safety of all passengers and crewmembers on board

our vessels. With that in mind, we are taking this opportunity to update all

customers using the routes in the Baltic Sea of the following mandatory safety

measures to be taken whenever second hand and/or damaged vehicles loaded on

Car Carriers are to be shipped.

To minimise the risk of fire accidents, it is your responsibility to ensure

that, apart from the previously introduced safety precautions (please refer

yourself to DFDS’ Newsletter dd. 29.04.2013), the following measures are

also to be taken prior to shipment:

- The batteries are completely disconnected - all cables

- The battery terminals are properly isolated

- The batteries have no visible damage

All Car Carriers with second hand and/or damaged vehicles will be inspected in the

port of loading and, based on the facilities available at the individual ports and on

the routes, an inspection fee will be imposed.

Any Car Carriers that do not comply with these essential requirements will not be

accepted for carriage on our vessels.

Your continuing co-operation in helping us to provide a safe travelling environment

is very much appreciated. If you have any questions, please contact your local

DFDS Seaways representative.

Sincerely yours,

DFDS A/S

Safety precautions

Annex B

DFDS A/A Instruction - Information to Unregistered Second Hand Segment dated 28 January 2014

Safety precautions to be taken prior loading onboard the vessel 28.01.2014

Dear customer,

DFDS A/S is committed in providing the best possible service to our customers and

to ensure the comfort and safety of all passengers and crew members on board our

vessels. With that in mind, we are taking the opportunity to update all customers

using the routes in the Baltic Sea of the following mandatory safety measures to be

taken whenever unregistered second hand and /or damages vehicles are to be

shipped.

To minimize the risk of fire accidents, DFDS will arrange for an pre-

shipment inspection of all vehicles within the segment mentioned above,

where the following measures will be carried out:

- The battery cables are disconnected completely

- The battery terminals are properly isolated

- The vehicle itself is determined in general condition not

compromising any safety requirements

All unregistered second hand vehicles, or other units carrying similar vehicles will be

inspected in the port of loading and, based on the facilities available at the

individual ports and on the routes, an inspection fee and/or a handling fee will be

imposed.

Any unregistered second hand vehicle that do not comply with these essential

requirements will not be accepted for carriage on our vessels.

Your continuing co-operation in helping us to provide a safe travelling environment

is very much appreciated. If you have any questions, please contact your local

DFDS Seaways representative.

Sincerely yours,

DFDS A/S

Safety precautions

Annex C

DFDS A/S Instruction – Delivery Note, Single/Empty Unit dated 6 January 2014

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