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SAFETY4SEA

UK MAIB issues investigation report of the fire on Celtic Carrier

by The Editorial Team
July 17, 2014
in Accidents
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Accident Investigation report 18/2014

Celtic-Carrier

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.

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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.


Conclusions

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.

Further details may be found by reading the UK MAIB report (please click at image below)

UK-MAIB-Celtic-Carrier-cover

UK MAIB issues investigation report of the fire on Celtic Carrier
UK MAIB issues investigation report of the fire on Celtic Carrier
Tags: fire onboardincident investigationlessons learnedUK MAIB
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