Scandinavian Shipyard / 2011 Vessel Fire whilst in Dry Dock Major Incident Investigation 1
Slide Agenda 1. Introduction 2. Sequence of Events 3. Investigation Analysis 4. Recommendations 5. Recommendations for the Industry. 2
Introduction 1. Introduction High level major events Consequences 2. Sequence of Events 3. Investigation Analysis 4. Recommendations 5. Recommendations for the industry 3
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 4
Consequences Actual Potential Human (P) C1 (P) C5 Environment - - Assets (A) C3* (A) C5 # Final Classification: Major Asset Damage Potential Multiple Fatalities * Severity 3 = above 50 KUSD but less than 500 KUSD # Severity 5 = above 5 MUSD 5
Sequence of events 1. Introduction 2. Sequence of Events Location map Detailed sequence 3. Investigation Analysis 4. Recommendations 5. Recommendations for the Industry. 6
Location Map Major Scandinavian Shipyard, Dock 4 7
Location on board 8
Location on board 9
Hot Work Task 10
Detailed Sequence of Events Some Pictures & Diagrams first.. Followed by 2 pages of time line 11
Yard s Contractors Yard Welders Fire Watch Carpenters 12
New Weld Forepeak side 13
PPE Store : Ignited foam 14
Looking up, above Weld seam 15
Ceiling of PPE Store Route of Fire Route of Smoke 16
Route of smoke Route of Fire Route of Smoke 17
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Investigation analysis 1. Introduction 2. Sequence of Events 3. Investigation Analysis Analysis Methodology Relevant Diagrams Main causes 4. Recommendations 5. Recommendations for the Industry. 20
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) 21
Diagrams Why? Why? Fire Watch departed area Fire In PPE Store Foam Ignited Hot Work ongoing Foam scrapings not totally removed 23
Diagrams Why? Why? Why? Why? Left with Supervisor F.W. Supervisor unable to contact Welder s Supervisor No Radio s & No mobile signal Yard s Comms procedures not adequate No direct contact with Welder Fire Watch departed area 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 24
Diagrams Why? Why? Fire Watch departed area Fire In PPE Store Foam Ignited Hot Work ongoing Foam scrapings not totally removed 25
Diagrams Why? Why? Why? Why? 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 shotblasting Previously treated with concrete wash 26
Diagrams Why? Why? Fire Watch departed area Fire In PPE Store Foam Ignited Hot Work ongoing Foam scrapings not totally removed 27
Diagrams Why? Why? Why? Why? Foam scrapings not totally removed Hot Work checklist not followed Previous lessons learned were not remembered No Hot Work checklist was completed Yard HSE Plan template not updated Hot Work PTW not fully completed Yard s own procedures not followed 28
Diagrams Why? Why? Why? Casualties with Smoke inhalation Automatic Fire Alarm too late Not Optimal setting for unmanned Bridge Unmanned Bridge Settings not reviewed before Yard stay No Policy for 24hr Manned Bridge whilst in Yard Use not regularly drilled Smoke Hood not properly used Their use was not part of new-hire Induction 29
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 30
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 31
Recommendations 1. Introduction 2. Sequence of Events 3. Investigation Analysis 4. Recommendations 1. Immediate actions taken 2. Recommendations 5. Recommendations for the Industry. 32
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 33
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 34
Recommendations 1. Introduction 2. Sequence of Events 3. Investigation Analysis 4. Recommendations 5. Recommendations for the Industry. 35
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. 36