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Scandinavian Shipyard / 2011Vessel Fire whilst in Dry Dock

Major Incident Investigation

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Slide Agenda

1. Introduction2. Sequence of Events3. Investigation Analysis4. Recommendations5. Recommendations for the Industry.

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Introduction

1. IntroductionHigh level major eventsConsequences

2. Sequence of Events3. Investigation Analysis4. Recommendations5. Recommendations for the industry

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High Level Major Events

• Vessel in Dry Dock

• Blasting in Forepeak tank revealed a missing seam weld

• Remedial work required hot work (not in original yard plan)

• Fire and smoke damage through 2 decks

• All crew admitted to local hospital: smoke inhalation

checks for unknown toxic gas

• Accommodation areas rebuilt: 5 days delay in yard

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Consequences

Actual PotentialHuman (P) C1 (P) C5Environment - -Assets (A) C3* (A) C5#

Final Classification: Major Asset DamagePotential Multiple Fatalities

* Severity 3 = above 50 KUSD but less than 500 KUSD# Severity 5 = above 5 MUSD

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Sequence of events

1. Introduction2. Sequence of Events

Location mapDetailed sequence

3. Investigation Analysis4. Recommendations5. Recommendations for the Industry.

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Location Map

• Major Scandinavian Shipyard, Dock 4

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Location on board

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Location on board

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Hot Work Task

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Detailed Sequence of Events

Some Pictures & Diagrams first..

Followed by 2 pages of time line

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Yard

Welders Fire Watch Carpenters

Yard’s Contractors

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New Weld – Forepeak side

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PPE Store : Ignited foam

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Looking up, above Weld seam

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Route of FireRoute of Smoke

Ceiling of PPE Store

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Route of Fire

Route of smoke

Route of Smoke

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Investigation analysis

1. Introduction2. Sequence of Events3. Investigation Analysis

Analysis MethodologyRelevant DiagramsMain causes

4. Recommendations5. Recommendations for the Industry.

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Analysis Methodology

• Full TOPSET Incident Investigation

• Investigation Team of 2 x QHSE and VM

• Separate interviews of entire crew

• Supervised interviews of Yard Workers & Foremen

• Immediate Underlying Root Causes

• Reviewed by Ship Managers and Seismic Contractor

• Root Causes QHSE MS Weaknesses

• Report distributed across fleet(s)

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Fire In PPE Store Foam Ignited

Fire Watch departed area

Hot Work on-going

Foam scrapings not totally removed

Diagrams

Why? Why?

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Fire Watch departed

area

Left with Supervisor

F.W. Supervisor unable to contact

Welder’s Supervisor

No Radio’s & No mobile signal

Yard’s Commsprocedures not

adequate

No direct contact with Welder

F.W. did not think Hot Work was

continuing

No Activity for > 1 hour

Welder took a meal break @ 18:00

Resumed work in another part of Forepeak Tank

Other Hot Work not known about

Single PTW covered multiple

locations

Diagrams

Why? Why? Why? Why?

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Fire In PPE Store Foam Ignited

Fire Watch departed area

Hot Work on-going

Foam scrapings not totally removed

Diagrams

Why? Why?

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Hot Work on-going

Seal Reference Hole

Pilot/Locator hole drilled through

Bulkhead

Verification of location of plate

seam

Working opposite sides of a Bulkhead

To see how much combustibles had

to be removed

Repair Seam from Tank-side

Previously only tack-welded

Only became visible after shot-

blastingPreviously treated

with concrete wash

Diagrams

Why? Why? Why? Why?

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Fire In PPE Store Foam Ignited

Fire Watch departed area

Hot Work on-going

Foam scrapings not totally removed

Diagrams

Why? Why?

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Foam scrapings not totally removed

Hot Work checklist not

followed

No Hot Work checklist was

completed

Hot Work PTW not fully

completed

Yard’s own procedures not

followed

Previous lessons learned were not

remembered

Yard HSE Plan template not

updated

Diagrams

Why? Why? Why? Why?

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Diagrams

Casualties with Smoke inhalation

Automatic Fire Alarm too late

Not Optimal setting for

unmanned Bridge

Settings not reviewed before

Yard stay

Unmanned BridgeNo Policy for 24hr

Manned Bridge whilst in Yard

Smoke Hood not properly used

Use not regularly drilled

Their use was not part of new-hire

Induction

Why? Why? Why?

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Findings

• Inadequate Hot Work Procedures

o Did not address multiple HW tasks within same tank

o Ineffective communication methods/tools

o Carpenters did not clear combustibles as per procedure

• Inadequate sub-contractor communication

• Sub-Optimal Fire Alarm configuration during Yard stay

o Ship-wide alarm sounded too late (Pre-Alarm not heard)

• Use of smoke Hoods unfamiliar to some of crew

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Other Observations

• Test residual main water pressure from yard

• Ensure Fire Plans are posted on gang-way

• Mobile phones useless under MSL, in metal! Use UHF

• 2 of 4 smoke hoods used were not activated

• Investigators - Download event logs immediately!

o FiFo buffer of Fire Alarm no longer held history far enough back

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Recommendations

1. Introduction2. Sequence of Events3. Investigation Analysis4. Recommendations

1. Immediate actions taken2. Recommendations

5. Recommendations for the Industry.

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Immediate actions taken

• Crew tested at Hospital for possible inhalation of toxins

• All clear and back at work the next morning (Hotel-based)

• 24 hour Bridge watch

• Accommodation rebuild

• Air Quality measured before crew returned to ship

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Recommendations

• Familiarisation of Fire Alarm settings by OOW

• Familiarisation of Smoke Hoods with more realistic Drills

• 24 hour Bridge watch during all future yard stays

• Pre-Yard, 2-way presentations of recent “lessons learned”

• Hot Work Permit process more rigorous (by task, not area)

• Audit Yard’s contractor management wrt communication

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Recommendations

1. Introduction2. Sequence of Events3. Investigation Analysis4. Recommendations5. Recommendations for the Industry.

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Recommendations for the Industry

• Your Yard HSE Plans to include reference to:

o Yard’s contractor communications (our sub-contractor management!)

o HWP should be issued by task, not by area, and be risk-assessed

o Use UHF Radios – do not rely on mobile phones

o Optimise Fire Alarm settings before entering yard (e.g. pre-alarm)

o Residual water pressure for fire hoses

• Consider retaining 24 hr Bridge Watch during any Yard.

• More regular drills involving the use of smoke-hoods.