Accident Investigation report 18/2014
The UK MAIB has issued Accident Investigation Report No.18of the fire on board Celtic Carrier 24 miles west of Cape Trafalgar, Spain on 26 April 2013.
At0315(UTC+2)on26April2013,afirebrokeoutinacrewcabinonboardtheUK registered general cargo ship Celtic Carrier.TheshipwasonpassagefromGibraltar to Belfast with a cargo of cement.
Thecrewmember,inwhosecabinthefirestarted,hadbeenconsumingalcohol andsmokingcigarettes.Hehadcontinuedtosmokeafterclimbingintobedand hadfallenasleepwhileholdingalitcigarette.Itisprobablethatthelitcigarettethen meltedanadjacentsofasvinylcoveringandignitedthefoamseatingbeneath.
Thecrewmemberawoke,discoveredthefire,proceededtothebridgeandinformed thesecondofficer,whothensoundedthefirealarm.Thecrewmusteredandthen attemptedtocontainandfightthefire.However,thefirewasnotfinallybrought undercontroluntil1226,aftertwofire-fightingteamshadtransferredtotheshipfrom aSpanishnavalvessel.ThefirewassubsequentlyextinguishedandCeltic Carrier wasthentowedtoCadiz,arrivingat0545on27April.Threecrewcabinswere damagedbythefire,whichhadcausedanelectricalfailureoftheshipssteering gear,andthemajorityoftheaccommodationspacesweredamagedbyheat,smoke and water.
TheinvestigationidentifiedthatCeltic Carriers crew were ill-prepared for the emergency;therewasalackofleadership,andsub-standardfire-fightingtechniques resultedincrewmembersbeingunnecessarilyexposedtodanger.Itwasfound thattheofficialrecordsofsomeemergencydrillshadbeenfalsified,andthata complacentapproachtosafetyexistedonboard.
Theshipsowner,CharlesM.Willie&Co.(Shipping)Ltd(CMW),wasawareofa numberofweaknessesrelatingtoitssafetymanagementsystem(SMS)thatneeded tobeaddressedbothashoreandafloat.However,theneedtoinvolveitscrews in the application of the SMS to ensure its success was not fully recognised. The investigationalsoidentifiedweaknessesintheMaritimeandCoastguardAgencys (MCA)paper-basedsystemformonitoringitsInternationalSafetyManagement (ISM)Codeauditactivity.ThelackofanationaldatabaseforISMCodeaudits hamperedtheMCAsabilitytoconductfleetperformancetrendanalysis,andto ensure that a consistent approach to auditing was carried out.
CMWandtheMCAhavetakenarangeofactionsinresponsetothefireonboard Celtic Carrier, which should reduce the likelihood of a similar accident occurring inthefuture.Inaddition,theMAIBhasmaderecommendationstoCMWaimedat developingarobustsafetyculturebothashoreandacrossitsfleet.TheMCAhas beenrecommendedtoreviewitsprocessesformanagingtheinformationgained from surveys, audits and inspections relating to the ISM Code.
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Safety issues directly contributing to the accident that have been addressed or resulted in recommendations
- AB2fellasleepholdingalitcigarette,whichmeltedthevinylcoveringofhiscabin sofaandignitedthefoamseatingbeneath.Designatedsmokingareashadnotbeen specifiedbythemaster,whichgavetacitpermissionforthecrewtosmokeintheir cabins.
- Thesofasupholsteredfoamseatingwasnotfire-resistant.Consequently,once alight,thefoamburnedquicklyandgaveoffintenseblacksmoke.
- Cabinportholesandinternaldoorswerecommonlyleftopen,whichassistedthe firesdevelopmentbyprovidingareadysupplyofoxygen.
Other safety issues directly contributing to the accident
- AB2sconsumptionofalcoholprobablyinfluencedhisdecisiontosmokeinbed onthisoccasionandcontributedtohisfallingasleepholdingalitcigarette,which meltedthevinylcoveringofhiscabinsofaandignitedthefoamseatingbeneath.
- TherewasasufficientquantityofflammableproductsstoredinAB2scabinto ensurethatthefirewasreadilysupported.Thedangerofstoringanundesignated plasticcontainerofpaintthinnersinacabinwasevidentlynotunderstoodor managed.
- ItisprobablethatAB2sconsumptionofalcoholimpairedhisabilitytowake-upand thenadverselyaffectedhisperformanceinreactingtothedevelopingfire.
- Althoughallcrewmemberswouldhaveexperiencedaninitialdipintheir performance from having woken up and the stressful situation in which they found themselves, they were nevertheless ill-prepared for the emergency.
- Thenecessaryleadershipexpectedfromthemasterandchiefofficerforplanning andexecutingthefire-fightingeffortwasmissingandresultedinaconfused commandandcontrolstructureonboard.
- Sub-standardfire-fightingtechniquesresultedininternaldoorsnotbeingclosedand crewmembersbeingunnecessarilyexposedtothepossibilityofabackdraughtand spontaneousre-ignitionofthefire.
- TherecordsofsomeemergencydrillsintheOfficialLogBookwerefalsified,which callsintoquestionthevalidityofotherrecordsanddemonstratesthatacomplacent approachtosafetyexistedonboard.
- TheEmergencyMusterListdidnotmakeprovisionforasubstituteintheeventofa crewmemberbeingunabletocarryouttheirduties.
Safety issues not directly contributing to the accident that have been addressed or resulted in recommendations
- Theprovisionanduseofaportableelectricfanheaterinacabinwasan unnecessaryfirehazard,particularlywhentheshipwasatsea.
- SimilarsafetyissuestothoseidentifiedonCeltic Carrier highlighted during recent SMCauditsconductedonotherUK-flaggedCMWships,suggestthatcomplacency mighthavebeenmorewidespreadacrossCMWsfleet.
- AlthoughCMWwasawareofanumberofcommonSMSissuesthatneededto beaddressedbothashoreandafloat,itsshoremanagementcontinuedtoaccept the veracity of Celtic Carriers records without critical examination, and viewed the resultsofauditsandinspectionsasareflectionofthedecreasingqualityofthe crews it was employing to operate and survive economically.
- In taking a micro-management and authoritarian approach to the operation of its ships,itisapparentthatCMWsshoremanagementdidnotfullyrecognisetheneed to fully involve its crews in the application of the SMS to ensure its success, and demonstratesthatthecompanyhadnotyetdevelopedarobustsafetycultureboth ashoreandacrossitsfleet.
- The MCAs ISM Code instructions for the guidance of surveyors currently do not requirethefindingsofpreviousauditandPSCinspectionreportsforacompanyand itsUK-flaggedshipstobereviewedpriortoconductinganSMCaudit.
- The fact that Celtic CarriernolongermettwoACSeligibilitycriteria,didnotprompta reviewoftheshipscontinuedeligibilitybecausenoformalexitcriteriawereinplace to cover this eventuality.
- TheMCAspaper-basedsystemformonitoringitsISMCodeauditactivitymeant that a comprehensive overview of the audit and inspection history of a company and itsfleetbyanMCAsurveyorunfamiliarwiththatcompanyorship,wasnotalways feasiblebeforeconductingascheduledSMCorDOCaudit.
- ThelackofanationaldatabaseforISMCodeauditshamperedtheMCAsabilityto conductfleetperformancetrendanalysis,andtoensurethataconsistentapproach to auditing was carried out.
- AsthereportsummaryofCMWsDoCauditon30May2012didnottakeaccount ofandreiteratetheissuesidentifiedinthesummaryreportofCeltic Carriers SMC auditon18April2012,theMCAmissedanopportunitytoreinforcetheneedfor CMWtoaddressthoseissuesasamatterofpriority.
Other safety issues not directly contributing to the accident
- Itwascommonplaceforbridgelookoutsnottobepostedatnightdespitecompany instructions to do so.
- Thereweredifferencesbetweenthefire-fightingequipmentshownontheships fireplanandthatrequiredbyapplicableregulations.However,itisunlikelythatthe differences were relevant to the outcome of the accident.
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Further details may be found by reading the UK MAIB report (please click at image below)
