marine safety investigation report 174 - … safety investigation report 174 independent...
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MARINE SAFETY INVESTIGATION
REPORT 174
Independent investigation intothe ballast tank explosion and subsequent fatalities
on board the Hong Kong registered bulk carrier
at Dampier WAon 18 November 2001
Nego Kim
In cooperation with the Hong Kong Marine Authority
Department of Transport and Regional Services
Australian Transport Safety Bureau
Navigation Act 1912Navigation (Marine Casualty) Regulations
investigation intothe ballast tank explosion and subsequent fatalities
on board the Hong Kong registered bulk carrierNego Kim
at Dampier WAon 18 November 2001
Report No 174
October 2002
ii
ISSN 1447-087XISBN 1 877071 11 0
Investigations into marine casualties occurring within the Commonwealth's jurisdiction are conductedunder the provisions of the Navigation (Marine Casualty) Regulations, made pursuant to subsections425 (1) (ea) and 425 (1AAA) of the Navigation Act 1912. The Regulations provide discretionarypowers to the Inspector to investigate incidents as defined by the Regulations. Where an investigationis undertaken, the Inspector must submit a report to the Executive Director of the Australian TransportSafety Bureau (ATSB).
It is ATSB policy to publish such reports in full as an educational tool to increase awareness of thecauses of marine incidents so as to improve safety at sea and enhance the protection of the marineenviroment.
To increase the value of the safety material presented in this report, readers are encouraged to copy orreprint the material, in part or in whole, for further distribution, but should acknowledge the source.Additional copies of the report can be downloaded from the Bureau’s website www.atsb.gov.au.
Australian Transport Safety BureauPO Box 967Civic Square ACT 2608AUSTRALIA
Phone: 02 6274 64781800 621 372
Fax: 02 6274 6699E-mail: [email protected]
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CONTENTS
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Sources of information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
Acknowledgment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
Narrative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Nego Kim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
The incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Emergency response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Comment and analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Previous painting activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
The explosion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
The fuel source . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
Tank ventilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
Source of ignition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
Material Safety Data Sheets (MSDS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
Crew exposure to fumes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
The International Safety Management Code (ISM Code) . . . . . . . . . . . . . . . . . . . . . . . . . . . .19
The on-board management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
The ship management company . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Ship management company remedial actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
Port communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
Response to the emergency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24
Search and rescue operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Submissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33
Nego Kim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
Figures
1. View towards port shoulder on Nego Kim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v
2. Ruptured tank on Nego Kim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v
3. Layout of Nego Kim (forward) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
4. Portion of chart Aus 57 showing anchored postion of Nego Kimin relation to Dampier Port Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
5. Area of explosion shown from boat deck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
6. Top of ballast tank viewed from hatch cover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
7. Interior of port topside ballast tank after the explosion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
8. Upper deck plan of Nego Kim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
9. Port shoulder after the explosion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
10. Similar fan rigged on 21 November . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15
11. Cargo light assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
12. Burnt light shade recovered from deck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
13. Nego Kim: Events and causal factors chart 18 November 2001 . . . . . . . . . . . . . . . . . . . . . . . .31
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v
FIGURE 1:View towards port shoulder on Nego Kim
FIGURE 2:Ruptured tank on Nego Kim
Photo: West Austalian Newspapers Limited
vi
SummaryAt about 0200 on Saturday 17 November 2001,the Hong Kong registered bulk carrier NegoKim arrived at the port of Dampier andanchored to await berthing instructions. Theship, which was on a time charter to load acargo of scrap iron at Fremantle, Adelaide andDampier, for discharge in Singapore, remainedat anchor through Saturday and Sunday. Atanchor, the crew continued tasks from the ship’splanned maintenance schedule, including thepreparation of the interior of no.1 port topsideballast tank for painting.
On Sunday morning the crew performed someroutine cleaning tasks. At about 1300, the matemonitored no.1 port topside ballast tank foroxygen content in accordance with safe entryprocedures. At about 1430, the eight-man deckcrew started work painting the steelwork insidethe tank. One man was engaged in painting withan airless spray gun while the other deck crewmaintained the paint reservoir, tended a cargolight lowered through the after manhole andassisted the painter as required. An open-endedcompressed air hose was led from the forecastle,along the deck and down through this aftermanhole, while an electrically driven fan waspositioned at an angle over the after manhole,which also provided access for the paint hose,light cable and a lanyard.
The mate supervised the initial stages of thetask. The paint used was a two-part epoxy mix,thinned as needed using the thinner productsupplied by the paint manufacturer. According
to the mate, the volume of thinner used wasbetween 30 and 50 percent of the total mixture.
At about 1530 the mate went to the bridge tostart his 1600 to 2000 anchor watch, leaving thebosun and deck fitter in charge at the site.
At about 1640 a large explosion ripped throughthe tank. The tank ruptured and three men wereblown down the length of the main deck, killingthem all instantly. The explosion also blew fourother men over the ship’s side. One man, whohad been inside the tank, was still alive althoughseverely burned. He was assisted out of the tank,through the ruptured maindeck plating, and laterairlifted ashore. Eighteen days later he died inhospital as a result of his burns and otherinjuries.
A search and rescue operation was initiated,using various surface vessels and aircraft as theybecame available, in the hope of finding thefour men who had been blown overboard. Thebody of one of the men was recovered from thewater at about 1325 the next day, 19 November.The search was continued until last light on 21 November, but none of the other three crewwere found.
The report recommends safety actions toimprove the ISM documentation carried onships to include clear instructions for alloperations in enclosed spaces and guidance onthe conditions under which work in enclosedspaces should be undertaken. Recommendedsafety actions are also directed to the DampierPort Authority with regard to an emergencyresponse plan.
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Sources ofInformationOfficers and crew of Nego Kim
Western Australia Police Service, Dampier
Disaster Victim Identification Team, WesternAustralia Police Service
Dampier Port Authority
Hammersley Iron Limited
Woodside Energy Limited
Mermaid Sound Port and Marine Services
Master ‘Lady Valisia’
Chugoku Marine Paints (S) Pte Ltd
Nippon Kaiji Kyokai
AusSAR - Australian Maritime Safety Authority
Defence Science and Technology Organisation
The Coroner, Port Hedland
Western Australian Forensic Science Laboratory
ReferencesDeHaan, J.D. Kirk’s Fire Investigation, 4thEdition, Prentice Hall, 1997
Dampier Port Authority, Marine Safety Plan,March 2001
Feasibility Study, Dampier Port Authority, PortControl Facility, August 2001
International Safety Guide for Oil Tankers andTerminals, 4th Edition, International Chamberof Shipping 1996
AcknowledgmentCover photo and fig.1 supplied by WestAustralian Newspapers Limited
2
Certain reproductions of chart sections in thispublication are reproduced by permission of TheAustralian Hydrographic Service.
© Commonwealth of Australia 12 May 2000. Allrights reserved.
Other than for the purposes of copying thispublication for public use, the chart informationfrom the chart sections may not be extracted,translated, or reduced to any electronic medium ormachine readable form for incorporation into aderived product, in whole or part, without the priorwritten consent of the Australian HydrographicService.
Narrative
Nego KimAt the time of the incident Nego Kim was aHong Kong flag geared bulk carrier owned bySaratoga Shipping Ltd and under themanagement of Wallem Shipmanagement Ltd,Hong Kong. The ship, which was classed byNippon Kaiji Kyokai (NK), was built inHakodate in Japan in 1985 and was originallynamed Mashu. Subsequent names were Teresa O(1988) and Maersk Cypress (1990) before it wasnamed Nego Kim in 1993.
The vessel has a length overall of 167.2 m, abeam of 26 m, a depth of 13.30 m and asummer deadweight of 26591 tonnes at adraught of 9.543 m. The ship was constructedwith five holds served by four 30.48 tonne deckcranes and was also assigned a timber loadline.The ship is powered by a single B & W6L50MCE slow speed diesel engine delivering5074kW to a single fixed pitch propeller.
The bridge, engine room and accommodationare all situated aft of frame 34. Forward, thecollision bulkhead is at frame 201, while theafter bulkhead of the raised forecastle is at
frame 193. Water ballast can be carried in nos 2and 4 port and starboard side/bottom tanks andnos 1, 3 and 5 port and starboard combinedside/bottom/double bottom tanks. Ballast canalso be carried in topside ballast tanks (TBT)nos 1-5 port and starboard.
No.1 TBT extends 21.56 m from the collisionbulkhead aft to the bulkhead between nos 1 and2 holds, at frame 173. The tank is 21.56 m inlength and is of a triangular cross section havinga maximum depth 3.2 m at the after end and 1.9 m at the forward end. No.1 TBT has acapacity of 197.2 m3. Frame spacing within thetank and hold is 0.77 m. Access to the tank is bytwo manholes. The forward manhole, betweenframes 197 and 198, is within the forecastlespace. The after manhole is positioned betweenframes 177 and 178.
The ship’s complement consisted of twentythree; the master, mate, second and third mates,chief and three engineers, an electrician, abosun, four engine room ratings, six deckratings, a cook, steward and a deck cadet. Allwere nationals of the Peoples Republic of China.
The incidentAt about 0200 on 17 November 2001, Nego Kimarrived off the port of Dampier with a little over17 000 tonnes of scrap steel on board. The
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No. 1 Port, topside ballast tank
Fr 201Fr 193Fr 173
No. 1 Port, topsideballast tank
FIGURE 3:Layout of Nego Kim (forward)
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FIGURE 4:Portion of chart Aus 57 showing anchored position of Nego Kim in relation to Dampier Port Control.
Anchored position ofNego Kim 340º(T)
20°25’S
20°30’S
20°35’S
20°40’S
116°40’N116°35’N 116°45’N
Dampier Port Control
ACT
NSW
NT
Qld
WA
SA
Vic
Tas
NT
NSW
ACT
Location ofincident
WARNINGNot to be used for navigaion
vessel was on a time charter, to load partcargoes of scrap steel at the ports of Fremantle,Adelaide and Dampier, for discharge inIndonesia and Singapore. On its arrival, themaster made several attempts to contactDampier Port Control for instructions, unawarethat the control tower had ceased 24-houroperation. However, his calls were overheard bythe operator in the control centre ofHammersley Iron. The operator told the masterthat he was not Dampier Port Control. Theoperator advised the master that the anchoragepositions were no longer designated by numberand the outer anchorage north-west of the Seabuoy was all now referred to as the ‘WesternAnchorage’. The master was told to contact hisagent for instructions.
The master did not have either the agent’s homeor mobile telephone number. He anchored NegoKim about one mile within the port limits, in aposition 340°(T) by 15.4 miles from Dampierport control tower, previously designated asanchorage A4, to await berthing instructions.The ship remained at anchor through Saturdayand Sunday.
Over the previous period of some months theship’s crew had been engaged in progressivelypainting the topside ballast tanks (TBT) usingtwo different types of paint in alternate tanks.No. 1 port TBT was to be cleaned and paintedin accordance with a work order generated fromthe ship’s planned maintenance system, raisedon 10 November. The two tank manholes wereopened up with work on the tank due to start on11 November. Preparation of the tank interiorincluded thorough washing with fresh water,removing rust, removing dirt and mud, removingoil and grease and generally preparing thesurfaces for painting.
On the morning of Sunday 18 November 2001,the crew performed some routine cleaning of theaccommodation. Later the deck crew was topaint the inside of no. 1 port TBT, using epoxypaint applied with an airless paint spray gun.The mate stated that he had instructed the bosunregarding the wearing of safety clothing, thatsmoking was prohibited and that respiratorsmust be worn inside the tank.
A little before 0800 the mate sampled no. 1 portTBT for oxygen content and found that thespace registered 21 percent oxygen. At 0800 heticked all the boxes on the company checklist,which formed both the checklist and a confinedspace entry permit. He signed, dated and notatedthe time of signing at the end of thechecklist/permit.
The mate stated that at 1300 he again measuredthe oxygen level in no.1 port TBT in preparationfor painting. The tank was ventilated by meansof an open ended, 19 mm, compressed air hoseled through the after manhole from a supply atthe forecastle space (with its discharge end at ornear the actual work site within the tank) and a300 mm diameter electric fan, which was riggedat an angle above the after manhole and set toblow air into the tank. Illumination of the insideof the tank was by a cargo light, consisting of a300 watt reflector bulb, a shade and a lightmetal grill to protect the bulb. The cargo lightwas suspended through the after manhole by alanyard held by one of the deck crew ormanually directed at the painting site when asecond man was in the tank. The paint reservoirand the pneumatic paint pump were positionedon the open deck aft of the after manhole nearto the mast house. The paint was mixed adjacentto the paint reservoir and the hose supplying thespray gun was led through the after manhole.
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Neither the electric fan nor the light were of anexplosion-proof 1 or intrinsically-safe2 design.Communication with the accommodation/bridgewas maintained through a portable VHF radio.The radio, also, was not of an intrinsically safedesign.
The deck ratings were reportedly dressed incotton overalls, wearing safety boots, gloves andsafety helmets. A rating in the tank, additionallyequipped with a mask over his mouth and noseand a visor, started spray painting. After aboutfive minutes it was found that the spray gun wasleaking, so the operation was suspended whilethe equipment was repaired.
At about 1430 the mate took another sample ofthe atmosphere in no. 1 port TBT. He made norecord of the test, but recalled that the readingwas 21 per cent oxygen. The deck crew resumedspray painting inside the tank. The entire deckcrew of eight men were involved in this task,either inside or outside, the tank.
The paint used was a two-part epoxy mix, towhich the appropriate thinner, supplied by thepaint manufacturer, was added. According to themate, the volume of thinner used was between30 and 50 percent of the total mixture.
At about 1545, the mate went to the bridge tostart his 1600 to 2000 anchor watch, leaving thebosun and deck fitter in charge at the site. Hepassed the hand-held VHF radio to the deckfitter before leaving for the bridge.
At 1600 the mate took over the anchor watch.The log book entry recorded the wind as beingfrom the west, force 6 (22-27 knots, 10.8-13.8 m/s),the atmospheric pressure as 1010 hPa and theair temperature on the bridge as 26°C.
At about 1640 a large explosion ripped throughno.1 topside ballast tank. The explosion blewthe tank apart, setting up the main deck by somethree metres and blew three men down thelength of the main deck killing them instantly.The explosion also blew four other men,apparently standing on the deck above the tank,over the side of the ship into the sea.
A spinning drum of burning thinners wasprojected aft along the main deck, while a firefuelled by burning paint and thinners erupted onthe deck near the aft end of the tank.Immediately after the explosion, other crewmembers rushed toward the port shoulder andquickly extinguished the fire using dry powderextinguishers and a fire hose.
After the fire was extinguished they found thatone man, who was still in the tank, remainedalive although he was severely burned. He wasassisted out of the tank through the rupturedmaindeck plating. Although initially able towalk a short distance with assistance, hecollapsed soon afterwards.
The crew on deck then continued the search forthe other crew members from the explosion site.When they realised that more men weremissing, they decided to launch the shipslifeboat to search the waters around the ship.Due to the sea conditions at the time, they hadconsiderable difficulty with the launching andeventually, with the arrival of externalassistance, this process was aborted. Theseactivities with the lifeboat, however, createdsome confusion for the aircrew in the firsthelicopter as they had been informed about‘people in the water’ and, upon the helicopter’sarrival, saw some of the ship’s crew in the boat.
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1 Explosion-proof (‘Flame-proof’)Electrical equipment is defined and certified as explosion-(flame-)proof when it is enclosed in a case which is capable of withstanding the explosion within it of a hydrocarbon gas/air mixture or other specified flammable gas mixture. It must also prevent the iginition of such a mixture outside the case either by spark or flame from the internal explosion or as a result of the temperature rise of the case following the internal explosion. The equipment must operate at such an external temperature that a surrounding flammable atmospherewill not be ignited.
2 Intrinsically safeAn electrical circuit or part of a circuit is intrinsically safe if any spark or thermal effect produced normally (ie, by breaking or closing the circuit) or accidently (e.g. by short circuit or earth fault) is incapable, under prescribed test conditions, of igniting a prescribed gas mixture.
The situation was eventually clarified and thesea search continued.
Emergency responseAt 1644:45 the master made the first call onchannel 11 VHF. He called ‘Port Control’ veryrapidly five times followed by a short silence ofthree seconds, then
‘Urgent – Urgent – Nego Kim calling – Nego
Kim calling’.
From the first ‘Port Control’ to the final ‘NegoKim calling’ eight seconds had elapsed. Themaster made a further four calls over a period of45 seconds, none of which were prefaced withthe urgency group PAN or MAYDAY and noneof which were answered by any shore station.
The master broadcast a further four messagesalternating between channel 16 and channel 11,calling ‘port control’ but not providing anyinformation on the nature of the call. At1646:13, 1 min 28 secs after the initial call,Hamersley Iron Control Centre answered themaster’s VHF call on channel 16.
The master responded in very rapid English:
‘Nego Kim master speaking now. Urgent –Urgent, I need your help – Urgent, I need yourhelp. The vessel- vessel exploded – exploded. Ineed the emergency, emergency, emergencyassistance.’
The Hamersley Iron Control Centre centreoperator asked the master to slow down andrepeat his message. The master slowed downinitially but then increased his speed:
‘Now – now – the crew working in no.1 hatch –now the reason don’t know – exploded –exploded. Some injury, high injury I understandmay be died. I need the emergency fire –helicopter – emergency assistance fire on ourship - exploded.’
The control centre operator immediatelyimplemented the measures prescribed inHamersley Iron procedures for ‘HelicopterRescue Support’ as they related to a marine
emergency. The operator called HelicoptersAustralia, the police and Hamersley IronEmergency Response officers. The dampierpilot boat had also picked up the call from NegoKim and responded at 1651. Dampier Policelogged their first notification as being at 1650.At 1655 the police put Karratha Hospital onstand-by. At 1658 the Australian Search andRescue organisation (AusSAR) was alerted andinformed that ‘local emergency services weredealing with the incident’. AusSAR issued an‘urgency’ (XXX) broadcast to all shippingrequesting a sharp lookout by all vessels in thearea.
While the helicopter was being readied, themaster frequently used the VHF to call theHamersley Iron operator on channel 16, alsomaking some contact with the pilot service onVHF channel 11.
At 1710, the master of a dynamic positioningsupport vessel employed in the area, CSOVenturer, alerted the Dampier Port Authorityduty officer to the emergency, on the emergencytelephone number. He called the Dampier PortAuthority Chief Executive Officer, who wentstraight to the Port Authority building. This callwas followed at 1713 by a call from a Dampierport pilot and at 1714 by the Port HedlandHarbour Master ensuring the Dampier PortAuthority were aware of the situation.
At 1712:31, helicopter VH-HRZ withemergency staff on board lifted off from thehelipad at Hamersley Iron.
At 1716:59, the master requested the assistanceof a boat, reporting that people were in thewater and confirming that the fire had beenextinguished. This message was received, onVHF channel 11, by the pilot boat which wasalready on its way to the scene.
At 1719, the police telephoned WoodsideEnergy Limited (WEL) gate house, which actedas a communications centre, and notified themof the explosion. Suitably trained WELpersonnel embarked on the pilot boat Burrup
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Pilot for Nego Kim at about 1800, with traumakits and resuscitation equipment.
With the information that there were people inthe water, the Western Australia Policeimmediately initiated a search by small surfacecraft.
The situation facing the police was that of avessel 15 miles from Dampier, freshening windsto about 30 knots with seas/swell reported as 5 to 6 m at the ship, and nightfall approaching.The distance from the port meant that surfacecraft would take about an hour to reach the ship.Sunset was at 1832 and civil twilight at 1856.
At 1726:29, Bristow Helicopters informed theHamersley Iron operator that a large helicopterwith winching capacity could be ready in onehour. A further helicopter was available to helpin either evacuating crew from the ship orsearching. However, preparing that aircraftwould also take an hour. Neither of thehelicopters available was equipped to undertakethe type of operations required during the hoursof darkness.
Helicopter HRZ landed on board at 1728:11and, at 1732:33, confirmed that there were threedead on board and one ‘not looking good’. Afteran initial assessment its engine was stopped toallow the critically injured seaman to be placedaboard the helicopter. The helicopter departedthe vessel, at about 1756, for Karratha Hospital.
By 1823 the helicopter had delivered the injuredcrewman and refuelled. The helicopter returnedto search the area. Another helicopter, fromCSO Apache, joined the search, but the aerialsearch was suspended at about 1910, as it wasgrowing too dark.
At 1940, with three Dampier Port Authoritystaff on duty in the Port Authority offices, theDampier port control tower was offered to theDampier police as the search and rescue (SAR)communications/co-ordination centre. As thepolice SAR coordination centre had been
established for some hours, and relocationwould have taken both time and resources, theoffer was declined.
There was some confusion or misunderstandingover the issue of SAR datum buoys. The police,coordinating the search, had discussed the issueof SAR datum buoys with AusSAR at 1740 and,at 1755 shortly after it had left, the VolunteerCoastguard Shark-Cat Shirley Holland turnedback to collect the buoys. These buoys, however,were stored at the State Emergency Servicesdepot at Karratha and were not immediatelyavailable. They were not finally provided to thepolice until 2133.
Initially, the police search had to rely on smalllaunches. The pilot boat was already on the wayand arrived in the area at about 1825 to start thesearch. At about 1800 the second launch, ShirleyHolland, again left Dampier, without the datumbuoys, and was on site at about 1900. Thesevessels were joined by a further small launch. At2000, the offshore support vessel Lady Valisia,on charter to Mermaid Sound Port Servicesjoined the search, her master assuming the roleof on-scene commander.
The effectiveness of the three small launcheswas limited by the rough conditions and theywere eventually released from the search,returning to port between 2030 and 2100. LadyValisia continued searching and, during thenight, was joined by Mermaid Reunion (aharbour work launch), and the offshore supportvessels Pacific Maple and Pacific Commander.
Throughout the early stages of the SARoperation, the police had been in frequentcontact with AusSAR. At 0142 on 19 NovemberDampier police formally requested AusSAR tocoordinate an air search of a 12 mile square areaaround Nego Kim.
At daybreak on 19 November, the surface searchcontinued. AusSAR coordinated an air searchusing 2 fixed wing aircraft and 6 helicopters at
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the request, and under the general direction of,the Western Australia Police.
At 1323 on 19 November, a fixed wing aircraftreported seeing ‘something orange’ in the water.Pacific Commander was directed to the positionwhere a body was recovered. PacificCommander then resumed the search. At 1800the search for the remaining three bodies wassuspended overnight and the recovered body ofthe crew member was returned to Dampier.
The search, including a search of the coastlineby boat and on shore, was continued until 1600on 21 November, but with no result.
The surviving deck crewman, an AB, who hadbeen assisted out of the tank after the explosion,was transferred to Karratha Hospital and latertransferred to the special burns unit in RoyalPerth Hospital in a critical condition. Hesubsequently died of his injuries on 4 December, having not regained consciousness.
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FIGURE 5:Area of explosion shown from boat deck
FIGURE 6:Top of ballast tank viewed from hatch cover
FIGURE 7:Interior of port topside ballast tank after the explosion
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Comment andanalysis
EvidenceInterviews were conducted with the master andthe relevant officers and crew of Nego Kim.Interviews were also conducted with the officersof Dampier Port Authority, WA Police, Dampier,Hamersley Iron Limited and the Master of LadyValisia. The ATSB also appointed aninvestigator with extensive skills in transportmedicine, under the provisions of regulation6(c) of the Navigation (Marine Casualty)Regulations. The medical investigator attendedat the post-mortem examination of the fivebodies.
Other information was provided by WEL andDampier Port Authority by letter, telephone andelectronic mail.
The ATSB engaged the Defence Science andTechnology Organisation (DSTO) to analyse thelikely sequence of events which had occurredwithin no. 1 port TBT and to determine, withthe limited amount of factual data available,possible air/vapour ratios within the tank. Thecalculations by DSTO referred to in thisanalysis are based on information supplied inthe paint’s material safety data sheet. Thisinformation provides for an application rate of1.5 lt/min (4 m2/min) with a maximum wet filmthickness of 0.373 mm and for the addition ofup to 5 per cent of solvent (thinner), the upperlimit for normal painting conditions. The DSTOcalculations however, were also carried out forvarious mixture ratios of added thinner up to thevalue of 30 per cent, the proportion that wasused as stated by the mate. In addition, DSTOinvestigated the likely effects of exposure byhumans to various levels of toxic vapours fromconstituents in the paint mix.
Information and Material Safety Data Sheets(MSDS) were supplied by the paintmanufacturer and taken from Internet sites.
FIGURE 8:Upper deck of Nego Kim - over port topside ballast tank (shown shaded)
Four seamen probably working in this area with one or moreadjacent to the after manhole
Approximate position of paint mixing and paint reservoir.Three seaman probably working in this area.
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The post mortem examination reports on thefive recovered bodies were supplied by theCoroner, Port Hedland, together with toxicologyreports requested by the ATSB. While the actualcause of death in each case is a matter for theCoroner to determine, the five men died as aconsequence of the explosion in no.1 port TBT.It may be surmised that the three seamen whowere not found also died as a consequence ofthe explosion.
The post mortem examination would suggestthat the three seamen who were killed on thedeck of Nego Kim were standing aft of frame175 over no.2 topside tank. The crewman whosebody was recovered from the water hadprobably been standing between frame 175 andframe 190, over no.1 TBT. The other missingseamen were also probably standing over thearea of deck that had violently ruptured.
The explosion and the deaths of the eight crewoccurred as a result of a failure of the safetysystem on board to prevent an unsafe condition(an explosive atmosphere) coming into contactwith a hazard (a source of ignition).
Previous painting activityExtensive painting of the topside tanks hadtaken place over the preceding months. In atleast half the tanks completed, the same paint aswas in use on 18 November had been used. Themethod of application had been the same. Therehad been no adverse outcome on thoseoccasions and it would appear that only a matterof chance had prevented this incident fromoccurring earlier.
It is possible that on previous occasions theatmosphere in the tank did not reach the lowerexplosive level (LEL), or there was no source ofignition, or both. The forward manhole of bothno. 1 TBTs was within the enclosed focsle-head.The tank was not uniform in shape, having avery restricted forward area with deep framingand small manholes. The combination of the
location of the manhole within the focsle spaceand the restricted nature of the forward area ofthe tank may have reduced the number ofoptions for ventilating the tank.
Evidence provided by the mate indicates thatsubstantial amounts of extra thinners were usedon this occasion, adding to the already volatileconstituents of the paint.
Regardless of whether the painting of no.1 portTBT created conditions different from theconditions in painting the other topside tanks, anumber of unsafe conditions had been presentduring the painting of all the tanks.
The explosionAn explosion is a very rapid oxidation with theevolution of considerable heat, accompanied bya disruptive effect (the result of pressure andconfinement).3 The oxidation takes place at thesurface of the fuel source. The ambient airtemperature, recorded in the logbook shortlybefore the explosion was 26° C. The weatherconditions recorded in the log were consistentwith those at Karratha Automatic WeatherStation, where the wind direction was recordedas being 270° (T) at 21 knots, the temperature28.8°C and the relative humidity 63 per cent.
With the sun on the deck and the ship’s side,however, the temperature within the tank wouldhave been significantly greater. When investi-gators measured the temperature in no.1starboard TBT some days later, under similarambient conditions, an internal temperature of38°C was recorded. It is probable that thetemperature in no.1 port TBT at the time of theincident was at least 38°C.
The explosion probably originated within thetank, rather than as a result of an initialexplosion on deck spreading to the tank. Thecrew were mixing paint and adding thinner onthe open deck above the after end of the tank.However, as discussed later, there was no
3 Turner, C.F., and McCreery, J.W. The Chemistry of Fire and Hazardous Materials, Allyn & Bacon, Boston, 1981, p.92. As quoted in Kirks Fire Investigation, p 286.
evidence to indicate that the mixing of the paintwas the initiating event. Although an alternativepoint of ignition cannot be discounted withabsolute certainty the probability is that theexplosion originated within no. 1 port TBT.
The tank formed an enclosed space of 197.2 m3,within which an explosive atmosphere couldform. The close framing (0.770 m) and webmembers within the tank provided pockets inwhich gases that are heavier than air couldaccumulate and concentrate.
Following the explosion, all the internal surfacesof the tank were covered by a fine, grey powder,the products of combustion.
The fuel sourceNo.1 port TBT was used as a water ballast tankonly. There was no evidence that anything otherthan water had been carried in the tank.Inspection of the tank by investigators foundvery little mud or ballast residue, which wasconsistent with the work order covering theplanned maintenance of the tank. A smallquantity of water in the tank was probably theresult of firefighting immediately after theexplosion.
No.1 hold was partially loaded with 2000 tonnesof scrap metal. Examination of the cargo in thehold found no source of possible fuel. Giventhat the explosion occurred within the ballasttank, the possibility that any fumes from thecargo would have entered no. 1 port TBT was soremote as to be discounted.
The crew were using an epoxy-based paint andusing thinner to allow the paint to be applied byan airless spray gun. The two parts of the paint,the epoxy base and the hardener are mixed infixed proportions and additional thinner appliedto aid application. The hazardous chemicalconstituents of the paint are shown in the tablebelow.
The vapour densities of the chemicals involvedwere all heavier than air. In theory the fumeswould have sunk to the bottom of the tank.There would have been some disturbance of the
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FIGURE 9:Port shoulder after the explosion
Compound 4 Flammability Limit Flash Vapour Auto-ignitionper cent by volume Point (°C) Density temperature
in air (Air = 1) (°C)
Toluene 1.1 – 7.1 4 3.14 480Xylene 1.1 – 7.0 27 3.7 527N-butanol 1.7 – 9.8 29 2.6 345Isobutanol 1.7 – 10.9 28 2.6 415
4 International Chemical Safety Cards data. Note the values of the critical properties of the chemicals vary marginally from authority to authority.
fumes through the injection of compressed airthrough the open ended compressed air hoseand from the fan above the aft manhole. Alsoany crew member moving within the tank,particularly in the lower levels would havedisturbed the vapours and there would havebeen some convective mixing due to the temper-atures at the time. The proportion of vapour toair that constitutes the flammable range is small.The temperature within the tank was above theflash point of at least three of the compounds,but did not approach their auto-ignition temper-atures.
Although the fumes were heavier than air,experiments by the DSTO suggested that thevapours would form an homogeneous mixwithin the tank, which would persist over time.
As part of the work requested by the Bureau,DSTO was asked to determine whether the paintand paint thinner were the probable explosivemedium. The DSTO analysis found that, withoutany ventilation and using 5 per cent thinner, theconcentration of solvent within the tankatmosphere would have reached the LEL (1 per cent) in about 42 minutes. Under thesame conditions, using thinner at 30 per cent,the tank atmosphere would have reached avolatile concentration of about 1.4 per cent intwenty minutes. Painting in no. 1 port TBT tankhad been under way for about two hours and tenminutes before the explosion occurred.
In the absence of any other credible fuel sourcethe Inspector concludes that fumes from thepaint and thinners formed an explosive mixture.Given that the vapour densities of thecombustible elements were all heavier than airand considering the effect of the wind on deck,the ignition point was most probably within thetank. Theoretically it was in the bottom half ofthe tank, though the DSTO findings indicatedthat this was not necessarily the case.
Tank ventilationTank ventilation was provided from two sources,the compressed air hose led through the aftermanhole (with its open end at or near the actual
work site at the after end of the tank) and theelectric fan supplying air through the aftermanhole.
DSTO calculated that the volume of air suppliedby the 19 mm compressed airline was about2.27 m3/min.
A ship’s fan similar to that used on 18 November and in use the next day was riggedat an angle above the manhole. This fan was a300mm, 400W electric fan of Chinesemanufacture and had, on the data plate, a statedair delivery rate of 61 m3/min. The DSTO reportnotes that electric fans of this wattage usuallyrate in the range 30-60 m3/min. The reportcomments that a rating of 61 m3/min isoptimistic and it is more likely to be less than 30 m3/min.
The report calculated that, had the fan deliveredair at the rate of 61 m3/min, the atmosphereinside the tank would not have reached the LEL.With the addition of 5 per cent thinner, themaximum suggested by the paint manufacturer,the concentration of volatile elements wouldhave remained below 0.06 per cent. By adding30 per cent thinner, a maximum concentrationof 0.2 per cent would have been reached.
However, the electric fan was directed at thetank at an angle, severely reducing the flow ofair into the tank. At an airflow rate of 40 m3/min, the tank atmosphere produced bypaint mixed with 5 per cent thinner would bemaintained at or marginally below 10 per centof the LEL of toluene.
The fan was set to supply air (blow into) thetank rather than exhaust the atmosphere fromwithin the tank as recommended in the paintmanufacturer’s instructions. When using asupply fan, a trunking should be used to deliverthe supply air to the bottom of the space ratherthan just to the upper area. Not only was the fanset to supply air to the tank without a trunking,but it was set at an angle to the manhole thusrendering a calculation of the volume of airsupplied to the tank highly problematic.
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15
The probability is that the actual airflow rateinto the tank was far less than 40 m3/min andthe concentration of volatile thinner added wassignificantly higher than 5 per cent, themaximum volume recommended. The evidenceis that, with these combined factors, anexplosive atmosphere accumulated within the 2 hours and 10 minutes which elapsed from1430, when painting was resumed, to the time ofthe explosion.
Source of ignition Examination of the scene was unable to identifythe source of ignition with any certainty.However five potential sources were present atthe scene:
• the electrically driven fan;
• the portable light;
• the hand-held VHF radio;
• cigarettes/lighters/matches;
• an impact from a metallic item dropped intothe tank.
The paint manufacturer’s MSDS specified thatan explosion-proof exhaust ventilation fanshould be used. The electrically drivenventilation fan in use was neither explosion-proof nor intrinsically safe. However it wasexternal to the tank and, given the vapourdensities involved, it is unlikely that a flame waspropagated from outside the tank. The
significant breeze blowing across the deck alsosuggests that it would be unlikely that gas in theexplosive range would have accumulated in thevicinity of fan.
The cargo light assembly was suspended withinthe tank. It consisted of a shade, approximately350 mm in diameter, a screw fitting housing a300 watt incandescent reflector bulb and a lightsteel mesh which protected the bulb. Theelectrical cable, plugged into a socket in themast housing, was passed down through theafter manhole. The weight of the assembly wastaken by a lanyard which also passed throughthe manhole. The lanyard was held by a crewmember positioned above the manhole, to beraised and lowered as required by the personspray painting within the tank.
The light assembly would have been relativelyhot, with the main heat source being the bulbitself. The maximum temperature wouldprobably have been around 200°C. The bulbtemperature would not have been sufficient toraise the vapours to the auto-ignitiontemperature of any of the constituentcompounds.
There are at least three possible ways in whichthe light bulb may have initiated the explosionby producing a spark:
• the deterioration of the cement holding theglass globe, particularly with a globe at thelimit of its life, could allow vapour to comeinto contact with the incandescent filament;
• poor connection between the screw cap andthe lamp holder fitting, particularly in anatmosphere prone to corrosion which canlead to high resistance or sparking;
• had the light been dropped and the bulbshattered, the incandescent filament wouldhave momentarily provided such an ignitionsource.
It is not known at what height the light wassuspended in the tank at the time of theexplosion. However, given that the wholeinterior of the tank was being painted and that
FIGURE 10:Similar fan rigged on 21 November
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the shade was blown out of the tank by theexplosion, the light was probably, but notnecessarily, at the upper level of the tank. It isalso possible, given the time of the incident, thatthe crew were withdrawing the equipment fromthe tank in preparation for completing the day’swork as usual at about 1700. Just prior to thetime of the explosion, it was probablysuspended directly below the manhole.
The VHF hand-held radio in use was not intrin-sically safe. As with the fan, however, given themovement of air across the deck and the limitedlevel of vapour on deck, it is unlikely that, ifused outside the tank, the radio would haveinitiated the explosion. If used inside the tank,however, it could have been the source ofignition. No evidence of the radio was foundinside the tank. When the mate left the vicinityof no. 1 port TBT at about 1530, he handed theVHF radio to the deck fitter. The probability isthat the radio was not used inside the tank andone of the crew lost overboard had the radiowith him; possibly the deck fitter, whose bodywas not recovered.
Direct ignition from a lit cigarette, match orlighter is also a possibility. The mate stated thathe gave strict orders that the crew were not tosmoke. Investigators did recover a number ofcigarettes and cigarette fragments, from themain deck at the scene of the explosion. Itappeared that none of the cigarettes recovered,however, had been lit.
The possibility of a falling object cannot bediscounted. Metal tools striking steel memberswithin the tank, or a non-ferrous tool embeddedwith grit, could have generated a spark.However, the only tools or items present in thetank after the explosion were a small pair ofpliers and a small tin can both found high(about 1.5 m below the deck, just behind frame175) in the tank. These were considered unlikelyto have generated such a spark as any impactenergy at this level would not be very great.
The most probable point of ignition was thelight assembly, either through a spark in theelectrical system, or by being dropped and thebulb breaking, introducing the very hotincandescent filament into a vapour concen-tration within the flammable range. The latter issupported by the discovery of the lightassembly’s protective mesh and the light socketat the bottom of the tank, directly below themanhole, while the light shade was recoveredfrom the deck. This indicates that the point ofignition was probably below the shade whichwas blown out of the tank, possibly through theafter manhole or through the ruptured deckplating.
FIGURE 11:Cargo light assembly
FIGURE 12:Burnt light shade recovered from deck
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Notwithstanding the source of ignition, therewere at least four unsafe conditions present atthe scene of the accident, any one of which,given the right circumstances could have beenthe source of ignition. Neither the fan, nor thelight, nor the radio, were intrinsically safe. Thecrew carried cigarettes on deck and the strongprobability is that they would also have carriedlighters or matches.
Material Safety Data Sheets(MSDS)The work order of 10 November 2001 coveringthe painting of no.1 port TBT, generated underthe planned maintenance system, containedinstructions on safety, handling chemicals andpainting. Chemicals were used in the cleaningprocess. These chemicals were kept in a mast-house and the ship carried MSDS givingguidance in their use and handling.
The work instruction document, under a sectionheaded ‘Handling Chemicals Safety’, stated:
6. Paints, Cleaning detergents, Acids, Alkalies.Lubricants, Toxic materials and anyunknown substances are to be treated asCHEMICALS.
The ship did not carry MSDS for the paints. Thepaint manufacturer confirmed that MSDS wereavailable for the base and hardener componentsof the paint. The paint manufacturer stated thatMSDS are provided with the first order but,where paint is ordered continuously, a MSDS isnot supplied unless specifically requested. Thepaint manufacturer did not issue a MSDS inrespect of the thinner.
In a memorandum to a superintendent of theship management company, written in August2001, the then mate requested instructions onthe application of both types of paint being usedin the maintenance programme. However, therequest was not specifically about safety issuesand the context seems to suggest that it wasmore concerned with the issue of application.
Mixing of the hardener with the paint base wasconducted by the boatswain on the basis of hisprevious experience and, according to the mate,on the basis of instructions on the paintcontainers. No instructions were provided inrespect of the addition of the thinner. The matestated that the thinner was applied to the mix ina proportion of about 30 per cent. Theinstructions provided to the Inspector by thepaint manufacturers contained specificreferences to the use of thinner.
2(e) Most paints do not require adjustment, butunder conditions of excessively high or lowtemperature a small amount of appropriatethinner may be added in order to easebrushing or to bring the paint to a sprayingconsistency. Do not exceed the amount ofthinner specified by the manufacturer.
The paint manufacturer’s instructions for mixingepoxy and tar-epoxy paints noted that poormixing may impair drying property and toensure a homogeneous mix, mixing should bedone by a pneumatic mixing machine or thelike.
Mixing on Nego Kim was done by hand and thedifficulty experienced in achieving ahomogeneous consistency could help explainthe excessive amount of thinner used. Anotherreason could have been the high ambienttemperature, which would accelerate thechemical reaction in the mix, in a 20 litre drum,to ‘go off’ (to start hardening) too quickly.
The DSTO analysis by chromatography/massspectrometry showed that the paint thinner wasmade up of the following volatile compounds:
Raw material Per cent
Xylenes 68.0Toluene 23.0Ketone 6.4Iso-propanol 2.6
The constituents of the thinner had the sameexplosive limits, flash point and auto-ignition
18
characteristics as the volatile componentsmaking up the base and hardener of the paint.
The manufacturer’s MSDS for the hardenerspecifies 5 per cent by volume as the maximumvolume of thinner that should be used. The crewwere using at least six times the recommendedlevel of volatile thinner.
The MSDS details the volatile constituents ofthe paint, the flash point and the explosionlimits. The sheets detailed the need to wearprotective goggles, a respiratory mask fororganic solvent gases, overalls, safety shoes andgloves and also the need to use an explosion-proof ventilation fan set to exhaust. It followsthat, if the fan was required to be explosion-proof, any other electrical equipment shouldalso be explosion proof or intrinsically safe.
It might be expected that an experienced mateand boatswain might be aware of the dangers ofpainting in an enclosed space and take sensibleprecautions based on that experience. However,the lack of appropriate MSDS for the paint andthinner must be regarded as an importantdeficiency in the safety system.
Neither the master, nor mate, nor the crewinvolved comprehended the potential danger ofusing epoxy-based paints in an enclosed space.
Crew exposure to fumesThe crew working with the paint would havebeen exposed to the paint and thinner fumes andto some degree could have suffered from theirinhalation or absorption through the skin.Samples of blood and brain tissue were takenfrom those killed by the explosion during theautopsies conducted at Perth on 5 December.Traces of xylene (<0.05 mg/kg to <0.2 mg kg)were detected in the brain tissue of the fourbodies and similar traces of toluene weredetected in three of the deceased. However,these levels are very low and well below anydanger limit. The level of toluene or xylene in
the blood suggests that the four men had onlycasual exposure to the paint fumes, consistentwith mixing the paint in the open air or beingadjacent to open tins of volatile substances.
The levels of absorption would suggest that theconcentrations of volatile compounds on theopen deck were minimal. Such concentrationswould tend to discount the possibility that theexplosion was initiated by a ‘flash over’ fromthe open deck.
The DSTO report provides comment on thehealth effects of the solvents in use, whichsupport standard tests on the subject. Humanexposure to high concentrations can contributeto chronic health effects as well as affectingphysical co-ordination and mental processes.
The results of the toxicology analyses however,showed that the levels of absorption were notconsistent with intoxication or impairment fromthe effects of the chemicals. Two of the bodiesshowed some alcohol content, one 0.025 per centin urine and the other 0.024 per cent in blood.These quantities are consistent with naturallyoccurring alcohol through putrefaction and donot indicate the consumption of alcohol.
Evidence provided by the mate indicated thatthe crew were dressed in overalls, safety boots,hard hats and gloves and that the person in thetank wore a respirator. However the evidenceprovided by the police Disaster VictimIdentification Team suggests that the seamaninside the tank, painting at the time of theexplosion was wearing only partial appropriateprotective clothing. He wore a full face visorwith a perspex window (similar to a weldersvisor), a fabric mask over his mouth and noseand cotton overalls, which offered no protectionagainst absorption of the paint chemicals byinhalation or absorption through the skin. Inaddition, an open-toed, backless, slip-on, plasticsandal was found inside the tank after theexplosion.
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In Australia, the maximum permissible exposureto the solvents used is based on 8 hour time-weighted average levels (TWA) and short termexposures limits of 0.5 hour (STEL)5.
In the following table, 100 parts per million(ppm) equates to 0.01 per cent of atmosphere.
Human Exposure Levels
Chemical TWA STEL
Xylene 80 ppm 150 ppm
Toluene 100 ppm 150 ppm
Methyl Isobutyl Ketone 50 ppm 75 ppm
Isopropyl Alcohol 400 ppm 500 ppm
The DSTO report notes that the human exposurelevels are significantly below the 10 per centLEL of 1000 ppm and comments that tomaintain solvent concentrations at a safe level inno.1 port TBT it would require a ventilation rateof 60m3/min combined with a slow painting rateof 0.7 m2/min. This calculation was based onthinner being added at 5 per cent.
Autopsy results from the AB who was in thetank, but who died 18 days later, showed noevidence of toluene or xylene and only showedevidence of drugs administered in hospital. Hisextended period under medication andventilation, however, would have expelled anyevidence of exposure to toxic effects from thepaint. It is not known whether this man was theonly crew member who was working inside thetank on 18 November.
Given the above information, it is apparent thatthe crew, particularly any inside the tank, werenot appropriately dressed. Conventional overallsand a simple facemask do not offer protectionfrom toxic vapours. Impermeable clothing and arespirator should be worn.
In hot weather, impermeable clothing and otherpersonal protection equipment used for work in
toxic atmospheres becomes oppressive if wornfor any length of time. Painting in an enclosedspace, with the ship at anchor in a tropical port,would invite crew involved to violate safetyprocedures for their own comfort.
Neither the issue of toxicology, nor the volatilityof the chemicals involved, were covered in anyinstructions carried on board Nego Kim.
The International SafetyManagement Code (ISM Code)The Safety Management Certificate on boardNego Kim was dated 15 May 1998 under theauthority of the Hong Kong SpecialAdministrative Region. This certificate wasissued by Nippon Kaiji Kyokai based onevidence that the ship had the necessaryprocedures and documents in place forshipboard operations to comply with therequirements of the ISM Code for a SafetyManagement System (SMS). The SMS had beenaudited on board in April 2000.
The Document of Compliance issued by theHong Kong Director of Marine to the shipmanagement company6 was dated 30 April1998. The Document of Compliance had beenperiodically verified each May since 1998.
The purpose of the Code is to provide aninternational standard for the safe managementand operation of ships and for the prevention ofpollution. The Code, as adopted by theInternational Maritime Organization inAssembly Resolution A.741 (18), provides, interalia:
• the objectives of the Code are to ensure safetyat sea, prevention of human injury or loss oflife, and avoidance of damage to theenvironment, in particular the marineenvironment, and property;
• safety-management objectives of the companyshould, inter-alia;
5 National Occupational Health and Safety Commission (NOHSC), Commonwealth of Australia Exposure Standards.6 The company means the owner of the ship or any other organization or person who assumes responsibility for the ship on behalf of
the shipowner. In this case Wallem Shipmanagement Ltd.
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- provide for safe practices in shipoperation and a safe workingenvironment;
- establish safeguards against allidentified risks; and
- continuously improve safetymanagement skills of personnel ashoreand aboard ships including preparing foremergencies related to safety andenvironmental protection;
• the safety management system should ensure;
- compliance with mandatory rules andregulations; and
- that applicable codes, guidelines andstandards recommended by theOrganization, Administrations, classifi-cation societies and maritimeorganizations are taken into account.
The ISM Code requires that the ‘company’should:
• establish a safety and environmentalprotection policy which describes how theobjectives will be achieved;
• ensure that the policy is implemented andmaintained at all levels of the organization,both shipboard and shore-based;
• establish procedures for the preparation ofplans and instructions for key shipboardoperations concerning the safety of the shipand the prevention of pollution;
• provide for the reporting of non-conformities,accidents and hazardous situations and thatthey should be analysed with the objective ofimproving safety and pollution prevention.
The on-board managementThe on-board documentation was in English,while some volumes had been translated intoChinese.
The on-board documentation includedinstructions relating to the ‘Enclosed SpaceEntry Permit and Checklist’ and associatedprocedures. These are contained in Chapter 7 of
the company Safety Manual. There are someminor inconsistencies between the instructionsand the checklist that are not material to thisincident. However, two specific requirementsare particularly relevant:
• 7.8.iv. of the Manual refers to item 5 on thechecklist and requires details of the ‘Resultsof atmosphere checks as applicable to type ofship and cargo’;
• item 16 asks ‘Is all equipment of theapproved type?’
There were no instructions for continuousworking in an enclosed space.
The mate completed the check for oxygen andticked the appropriate boxes on the checklist.The permit/checklist also required tests forhydrocarbons and toxic gases under certaincircumstances. The ship, not being a tanker andnot carrying coal, was viewed as being free ofthe risk of explosion. As no.1 port TBT had hadno cargo and had been entered for washing andcleaning over the preceding days, there was noreason to test it for hydrocarbons. The onlyhazard that could be anticipated before the startof painting was that of depleted oxygen withinthe tank’s atmosphere. The test for this wascarried out.
While the depletion of oxygen is one hazard, inthis case there were both the additional issues ofthe development of a potentially explosiveatmosphere and of toxic paint fumes. Thedangers of painting in an enclosed space werenot recognised by the master, mate, boatswain orthe ship’s crew, perhaps because ‘painting ship’is most often carried out on the open deck infresh air.
A major deficiency in the management of thepainting operation was the lack of properventilation. The ventilation was clearlyinadequate and showed a lack of understandingfor the need to maintain a safe, non-explosive,non-toxic atmosphere within the tank.
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The hazards inherent in the paint were detailedin the MSDS and the associated paintmanufacturer’s instructions. The absence ofthese documents on board meant that the crewshould have treated the paint as a chemicalunder the company’s own safety procedures.
Once the painting had started, no test forhydrocarbon levels was undertaken. Indeed, itcould not have been as there was no equipmentwith which to carry out such tests.
Item 16 of the checklist. ‘Is all equipment ofapproved type’ referred to the fan, lighting andradio equipment being of a type approved forworking in a potentially gaseous atmosphere.The box was ticked. However, the ship did notcarry explosion proof or intrinsically safe fans,radios or lights.
Following the explosion, on the instruction ofthe Hong Kong Marine Department, NipponKaiji Kyokai (as the issuing and auditing organi-sation) undertook an ‘Additional’ ISM audit ofNego Kim. The auditor concentrated on thedocumented procedures for enclosed space entryand painting. The auditor reviewed the joininginstructions for new ship’s crew and the trainingvideos carried on board. He also reviewed thecompany’s procedures and relevant records. Theauditor came to the conclusion that theprocedures for painting the ballast tanksinternally had been complied with to asubstantial degree and there were no non-conformities to note. The Inspector raised theissue of ‘approved equipment’ with the auditor.He explained that this was raised by him at thetime. The master and company representativeexplained the item was taken as ‘referring to oiltankers and other ships carrying dangerouscargoes’.
The auditor, however, did make a number ofobservations. The observations included arecommendation that the company shouldreview the specific issues of spray painting andwork in enclosed spaces while using spray paintequipment and chemicals. He also observed that
the maintenance and calibration records for thegas detector were ‘untraceable’.
Ship maintenance by painting is a major,fundamental and indispensable ship operation.The ISM Code has inter alia, the objective ofproviding for safe shipboard operations andpractices and for the identification of risks.There is a requirement for the procedures, plansand instructions for all key shipboard operationsto be documented and to be observed. In thisinstance, they were not.
The ship management companyThe ship managers provided the paint to theship for maintenance under the Nego Kim’splanned maintenance system. It was the shipmanagers that had ultimate oversight of theship’s maintenance programme and theknowledge of the equipment carried on the ship.The painting of ship structures is a routine and‘key shipboard operation’, for which (under theISM Code) the ‘company is required to establishprocedures for the preparations of plans andprocedures’.
In an e-mail of 10 August 2001 the then chiefofficer specifically asked for instructions onhow to apply the paints supplied.
The paint supplied and the thinner were highlyvolatile. The MSDS stated this and providedadvice on its mixing and application. However,as with the ship personnel, the ship managersdid not make the connection between routinepainting and the potential hazards associatedwith using such paint in an enclosed space.
The mate was charged with ensuring that theatmosphere within the tank was safe. He testedfor oxygen content before the work started, buthe did not check for a hazardous atmosphere. Itis likely that he did not connect the paint fumeswith a possible explosion. Even if he had,however, the investigators learned that the gasdetector had not been on board for some timehaving been landed in Singapore for repair. Theship managers were aware of this and were
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conscious of the fact that no gas analyser wascarried. In a message to the ship a superin-tendent instructed:
Regarding Explosimeter Pls raise Reqn forsupply of new unit. Meanwhile keep Multigasdetector away from sight as this is required onlywhile loading coal.
The meaning of this instruction is not clear.Neither is the view of the master and thecompany representative, mentioned above, thatsuch a meter ‘was required only for oil tankersand other vessels carrying dangerous cargoes’,consistent with this instruction relating to theloading of coal.
The significant point, however, is that there wasno equipment on board for testing for anexplosive atmosphere.
With regard to personal protective equipment,no recognition was made of the potentialtoxicity of the paint and the need forimpermeable clothing and a proper respirator toprotect the painter from the extremely toxicsubstances.
In short, the ship was not provided with theproper equipment with which to complete theoperation safely.
The SMS was deficient in providing proceduresto protect the crew as:
• the generation of fumes from epoxy paint isan identifiable risk;
• the requirement for effective ventilation is abasic safety measure; and
• the need for explosion-proof electricalequipment is essential.
Ship management company remedialactionsImmediately following the explosion WallemShipmanagement banned all spray painting inenclosed spaces and initiated its own investi-gation and analysis of the incident. As a result,in February 2002 the Company produced a newand detailed checklist, specifically for paintingin enclosed spaces and prohibiting spray
painting in enclosed spaces unless theCompany’s Safety and Insurance Departmentgave specific permission. In addition theCompany issued detailed precautions that had tobe followed, when painting in enclosed spaces,covering prevention of explosion and fire andthe risks associated with the toxic nature ofpaint fumes.
Port communicationsThe effectiveness of communications betweenNego Kim and Dampier Port is not an issue inthe events that lead up to the explosion in no.1TSBT. It is, however, an issue in the master’scall for help, the response to that call and thereasonable expectations of the masters andcrews of vessels using the port.
The port is a multi-user port with iron ore andgas exports being the main trade. There is also asignificant salt export trade and, in addition,some import and export trade through the publicwharf. The port is also a base for offshoresupport vessels.
Approximately 1700 trading vessels berth at theport of Dampier each year. The Dampier PortAuthority 2001 Annual Report notes that for2000-2001 the total tonnage of exports andimports was 81 452 840 metric tonnes;
‘The Authority has therefore re-established itselfas the largest port in terms of trade tonnage.’
Under the heading ‘Principal Activities’ nineactivities were identified including:
• operate port communications;
• provide emergency response planning.
The Dampier Port Authority (DPA) operates theport under the provisions of the WesternAustralian Port Authorities Act 1999, with twoof the functions being:
• facilitating trade within and throughout theport and planning for future growth anddevelopment;
• being responsible for safe and efficientoperation of the port.
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Under section 114 of the Port Authorities Act1999, a port authority ‘is to have, maintain andimplement a marine safety plan for its port.’ Theplan must be approved by the Minister. Such aplan had been drawn up by the DPA, but theMinister had declined to accept that plan. Theplan remained therefore as an unapproved draft.
Section 4.5 of the draft plan makes provision for‘Communications’. This brief section does notdeal with an emergency broadcast by a ship. Itprovides for a 24-hour mobile telephone contactfor serious accidents. This seems to bepredicated on some person with access to theprovisions of the plan being aware of thenumber. A visiting ship would not necessarilyhave access to the number before arrivingalongside unless it had been specificallyprovided.
In July 2001 a review was commissioned by theDPA to address the following:
• whether the functions of Port Control can bediscontinued;
• in the event that the functions were discon-tinued, would the Dampier Port Authority stillbe complying with its legal obligations underthe relevant legislation;
• if any of the current functions were viewed tobe essential, to document the reasons for thisview and to provide recommendations as tooptions for the Dampier Port Authority for thecarrying out of those functions consideredessential.
This review concluded, inter alia:
‘It is therefore recommended that Port Controlcan be abolished, and in so doing, the safety ofmarine operations within the Port would not becompromised in an unacceptable way.
However the Marine Safety Plan would need tobe addressed to ensure any residual risks aremanaged by formalising and strengtheningcommunications protocols between operatorswithin the Port.’
The investigation established that the mastertried to pass his arrival message through
‘Dampier Port Control’ and to seek direction onwhere to anchor his ship. His calls to ‘PortControl’ were eventually answered by theoperator at Hamersley Iron Control Centre. Theoperator explained that his station was notDampier Port Control, and the master shouldcontact the ship’s appointed agent by telephone.
As an immediate reaction to the explosion, themaster’s first instinct was to contact ‘PortControl’ for emergency help. When the Mastermade the initial call for help, starting at1644:45, he did not follow the recognisedformat of a MAYDAY or even a PAN message.The master, obviously under great stress, startedhis message eight seconds after the call buttonwas depressed. None of his subsequent callswere prefaced with the emergency or urgencyprefix.
The effectiveness of the response to theemergency call was due to the initiative of theHamersley Iron Control Centre operator. It wasalso fortuitous that the Hamersley Iron ControlCentre was manned on this Sunday afternoon.While the room is often operated on a 24-hourbasis, this is not necessarily the case on alloccasions.
Communication with the master of Nego Kimwas, and remained, difficult. It is not clearwhether he understood that Hamersley IronControl Centre operator was not port control.He seemed to have been reassured when, at1648:08, the Port Hedland Control operatorreplied to a series of radio calls and pleas forassistance, made while the Hamersley IronControl Centre operator was contacting thehelicopter and police.
It is understandable that a foreign master withonly basic English should not fully grasp thesituation of a port not having a control centre.Dampier is a major port. Indeed, as statedabove, the port with the largest tonnagethroughput in Australia. In the Inspector’sopinion it is hard to imagine a comparableranking, multi-user port within Australia, or
internationally, that would not have some formof 24-hour operations centre.
DPA submitted:
(This paragraph) ignores the fact that the majorusers in the Port, being HammersleyIron/Dampier Salt and Woodside, in fact operateon a 24 hours basis. Consequently thesecompanies have communication procedures andoperations centres commensurate with theiroperations. The companies operate under theirrespective State Agreement Acts. It is significantthat in excess of 99 per cent of vessel visits to thePort are on behalf of the three companiesoperating under their respective State AgreementActs. In other words less, than than 1 per cent ofvessels visiting the Port utilise the only common-user facility within the port, being DampierPublic Wharf.
The apparent assumption was that, with theclosure of the communications tower, trainedWEL communications staff at the WELgatehouse would monitor all channel 16emergency traffic on their VHF radio. However,the WEL staff understood their responsibility asbeing that of implementing appropriateoperational and communications procedures forthe safe shipping movements for the NorthwestShelf Project, particularly during arrival anddepartures at the Whithnell Bay terminal. Whiletheir role within the WEL Emergency ResponsePlan was understood, the staff were not aware oftheir role in a more general port emergency.This role had not been explained to them, norhad they been trained in it. Consequently thecalls made on Channel 16 by Nego Kim’s masterat 1644:45, and subsequent radio traffic betweenthe ship and Hamersley Operations Centre, wereonly monitored, and not recorded, at WEL.
The DPA Board’s decision to limit the operationof the Port Control Tower services to officehours was based on a comparison with otherports. The compared ports were either smaller,of much lower traffic volumes, or not in riskareas for tropical cyclones, or in areas wereother control towers were in close proximity.
In submission the DPA stated:
With respect, the ATSB is not aware of theextensive process and considerations that lead tothe decision by the board to effect changes inport communications. The DPA Board fullyconsidered the risks and ensured that safecommunication procedures were put in place aspart of an approved Transition Plan. These ‘new’procedures have been in place since September2001 and have significantly improved safety ofvessels moving in the Port. Given that 99 percent of vessels are visiting the port on behalf ofthese companies (including Dampier Salt) themost significant consideration by Directors wasthat the Port continued to operate safely.
In the Inspector’s opinion, in closing down theport control tower and removing its communi-cations function, the DPA did not makeadequate alternative provision for portcommunications, particularly in an emergency.The risks and countermeasures were notproperly considered. The alternative provisionswere not properly formulated or promulgated toother interested parties in the port community.
Response to the emergencyThe draft Marine Safety Plan, under 4.4‘Emergency Response’ states that ‘in light of thePort Authorities Act 1999 and the proposed newregulations the DPA will undertake a compre-hensive review and update of the Port’s ERP(Emergency Response Plan). Under 4.4.1‘Performance’ the draft plan states that:
‘the DPA will respond to and oversee allemergencies within its area of operations . . .’.Also ‘the DPA will provide independentcommand and control facilities to enableescalation and co-ordination of a response.’
The review of July 2001 did not expresslyconsider either this issue or an emergencyresponse to a ship. Indeed, it appears that therewas an unwritten understanding that WELwould deal with issues or emergencies affectingvessels using its facilities and Hammersley Ironwould likewise deal with vessels using itsfacilities. The question of an emergency
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affecting a vessel not on charter to either ofthese companies, or which was to berth at thepublic wharf, appears to have received noconsideration.
Following the closure of the Port Control Towerby Dampier Port Authority in September, theWestern Australian Minister for Planning andInfrastructure, whose portfolio includes respon-sibility for the administration of the WesternAustralian Port Authorities Act 1999, initiated areview of the Safety Management System at thePort.
A risk management consultant was subsequentlycommissioned to:
‘ . . . review (audit) the Dampier Port AuthorityMarine Safety Plan 2001 to ensure it provides anadequate and suitable safety management systemof policies, procedures and processes to addressthe hazards and risks identified, and include anassessment of whether closure of the Port ControlTower allows the Port of Dampier to provide asafe port.’
This review looked at broader issues than thoserelating to the response to emergency incidentslike that involving Nego Kim. In terms of thisreview, the deficiencies in safety related to:
• the lack of a recognised centre for communi-cations and co-ordination, wherever situated;
• the lack of a coherent, up-to-date emergencyplan; and
• the decision not to promulgate the plan tothose who would implement any such plan.
The port had no approved Marine Safety Plan.The draft Emergency Response Plan in place onthe 18 November had been drafted before thedraft Marine Safety Plan. Provisions made bythe draft Marine Safety Plan were inconsistentwith the draft Emergency Response Plan, whichwas predicated on the DPA control tower beingin operation. Organisations such as the police,hospital, the pilotage providers and staff fromthe port user bodies were not aware of the draft
Marine Safety Plan or the implications it had forthe Emergency Response Plan.
Search and rescue operationsAlthough responsible for ‘safe and efficientoperation of the port’, it was not the role of theDPA to manage the emergency response.
Under the policy of the State EmergencyManagement Advisory Committee (Police, Fire,State Government Department, etc), revised inDecember 1998, the Western Australia Policeare responsible for responding to reports ofsudden death and for search and rescue,including marine search and rescue.
The first notification that men had been lostoverboard was made at about 1717, some 30 minutes after the explosion. In the circum-stances this delay was inevitable. The master didnot know that men had been lost overboard untilthe remaining crew had extinguished the fireand a search of both no.1 TBT and no.1 holdhad been completed.
The Hamersley Iron Control Centre operatorexercised his initiative in responding to NegoKim. The police assumed the role as HazardManagement Coordinator. No time was lost indeploying the helicopter. The priority was to liftthe injured man to hospital. The period of about22 to 24 minutes between being alerted andlifting off at 1712:31, with three persons onboard, was as rapid as could reasonably beexpected, consistent with essential pre-flightsafety procedures. This helicopter was aMedivac response and not part of the search andrescue, as it was not known initially that anyonewas overboard from the ship.
After 1717, the nature of the emergencychanged from a medical evacuation to a searchfor people in the water. The officer in charge ofthe Dampier Police station continued as theHazard Management Coordinator. He wasqualified in marine search and rescue.
The Australian Search and Rescue Manual notesthat the initial stages of a search are often adhoc. A command structure needs to be createdand recognised. There is also an initial need togather relevant information, which initially canbe ambiguous or incomplete. Sea searches are‘dynamic’ in that any target is in a movingenvironment. Although there are SARprogrammes that are followed, these are basedon certain assumptions as well as tidal andweather information.
The search coordinator must define a searcharea that is searchable by the resources availableand in which the people may reasonably beexpected to be found. If the search resources aresurface based, such an area is of necessitysmaller than one where aviation resources areavailable. Other factors such as night and dayand the availability of appropriate resources arealso considerations in such a search operation.
In this case there was no aviation asset with anight search capability and hence any air searchwas limited to daylight hours. The initial phaseof the sea search was conducted by smallvessels, with a police officer aboard the vesselShirley Holland appointed as ‘on scenecommander’.
In particular, the capacity of any survivors in thewater to signal for assistance is an importantfeature of night search and rescue. In this case,it is almost certain that any survivor from theexplosion would not have been equipped withlights or flares. They would therefore be verydifficult to find in the dark. Until first light, asurface search would be more likely to succeedthan an air search.
There were some initial delays in aspects of theSAR operation on 18 November. Probably thatof most note was the delay in deploying theSAR datum buoys, which assist in determiningthe surface movement of the water. In areas ofstrong tides early deployment of SAR datumbuoys is essential so that their movementproperly matches the tidal cycle.
The deployment of the SAR datum buoys took41⁄4 hours between the notification that men werelost overboard and the delivery of SAR datumbuoys to the search coordination centre. Thebuoys were stored at the State EmergencyServices Depot in Karratha, about 20 km fromDampier. By the time the SAR datum buoyswere available to the search coordinators theweather had deteriorated to such an extent thatMermaid Reunion had to be diverted from thesearch to collect the buoys for deployment. Inthe event, because of the delay, the decision wasmade not to deploy the buoys until the tide wasat a similar state to that at the actual time of theexplosion. Advice from AusSAR is that this isproper practice to be able to assess the probablemovements of targets in the water.
The initial SAR effort was concentrated in theimmediate area of the ship itself. This initialsearching was conducted using small boats andhelicopters. But due to weather and darknessthese assets were soon replaced when the largerships arrived on the scene.
The police provided a continuing surface searchgrid for use in the SAR operation based on thebest information available, including meteoro-logical and tidal data. The search grid was about6 miles square and was updated and adjustedperiodically in accordance with the SAR plan.At first light the air search was commenced overa larger area.
The body recovered at 1325 on 19 October wasdetected by an aircraft and was about 1.5 milesoutside the surface grid, but within the aviationgrid. Given the adverse weather conditions andthe time lost in deploying the SAR datumbuoys, the fact that the body was found outsidethe surface search area is understandable. It alsoreflects that the air search area will often bebigger than the surface search area, since thelatter is more likely to be constrained by speedof assets and the width they can sweep. Thesearch grid was revised when this informationwas received and updated for the remainder ofthe search.
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There were also some delays in obtaining boatsfor the initial search and there were potentialassets that were not utilised. Primarily, this is afailure of the port to have an effectiveemergency response procedure and tocommunicate that procedure to key organi-sations and people within the port community.
The surface search involved five offshore supplyvessels. Lady Valisia was first on the scene andassumed the role of the ‘on scene coordinator’ atthe request of the police. Lady Valisia wasprogressively joined by Mermaid Reunion,
Pacific Commander, Pacific Commander, andPacifc Bloodhound. These ships searched until1900 on 19 November when Dampier Policenotified them that they were no longer required.The three smaller harbour launches weredeployed throughout the 19 to 21 November asrequired.
The air search involved 6 helicopters flying 15search sorties for in excess of 35 hours and twofixed wing planes flying five sorties for justunder 15 hours.
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ConclusionsThese conclusions identify the different factorscontributing to the incident and should not beread as apportioning blame or liability to anyparticular individual or organisation.
Based on the evidence available, the followingfactors are considered to have contributed to theincident:
1. The five dead, and three presumed dead,crew members died as a consequence of anexplosion following the ignition of anexplosive atmosphere within no.1 TBT tank.
2. The tank contained vapour concentrations,within the explosive range, of the volatilecompounds making up the epoxy paint andthinner being used to spray paint the tank.
3. Hand mixing the paint, together with highambient temperatures, probably contributedto the use of quantities of thinner far inexcess of the recommended maximum.
4. The ventilation of the tank was grosslyinadequate and allowed the creation of anexplosive atmosphere.
5. The electrical equipment in use was notintrinsically safe/explosion proof.
6. The ship management company did notrecognise the potential risks associated withthe use of epoxy (hydrocarbon based) paintand thinner in an enclosed space.
7. The ship management company did notensure that adequate instructions in theusage and dangers of the epoxy based paintwere provided to the ship and understood bythe crew.
8. The ship management company had notsupplied the ship with the equipment
required to complete the ‘key operationaltask’ of painting safely in that explosion-proof fans, radios and lights were notavailable to the crew, neither was a gasdetection meter.
9. There was no adequate perception of therisks involved in using epoxy paints in anenclosed space and those involved did notassociate danger with the painting of theinterior of the ballast tank.
10. There was no Material Safety Datainformation held on board relating to thehazardous nature of the paint and the propermethod of ventilation.
Additionally:
11. The most probable source of ignition wasthe momentary exposure of the light globefilament to the explosive atmosphere as aresult of the light falling within the tank andthe globe breaking. There were, however,other potential sources of ignition.
12. The ambient temperature within no.1 porttopside ballast tank was unsuitable forpainting with epoxy paint in an enclosedspace.
13. The ship management company did notrecognise the risks of prolonged exposure totoxic paint fumes and had not suppliedproper personal protective equipment andclothing.
14. The objectives of the International SafetyManagement Code were not met in thatprocedures did not provide a basis for:
• preventing injury and loss of life;
• establishing safeguards against allrecognised risks;
• establishing procedures for thepreparation of plans and instructions for
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the key shipboard operation of paintingthe ship’s internal structure.
The Inspector also notes that:
15. The initial prompt response to theemergency was due to the initiative of theoperator in Hamersley Iron Control Centreand the police activating their emergencyplan.
16. Dampier Port Authority’s draft MarineSafety Plan and the draft EmergencyResponse Plan, were not approved and weredeficient in that:
• the draft Emergency Response Plan didnot reflect organisational and proceduralchanges made as a result of closing thecommunications tower;
• the changes brought about by the closingof the communications tower were notsufficiently promulgated or understoodby key staff.
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FIGURE 13:Nego Kim: Events and causal factors chart 18 November 2001
Even
ts
Cond
ition
s
Inci
dent
In addition to the safety measures already taken,the Inspector recommends that:
1. ISM manuals should include clearinstructions for all operations in enclosedspaces, including the hazards of anyoperation and instructions regarding thewearing of appropriate clothing andprotective equipment.
2. ISM manuals should provide guidance on theconditions under which work in enclosedspaces should be undertaken.
3. The Port of Dampier draft EmergencyResponse Plan should be reviewed to removeambiguities and to ensure a consistent andappropriate approach to emergency situationswithin the port, including clear communi-cations.
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Recommendations
SubmissionsUnder sub-regulation 16(3) of the Navigation(Marine Casualty) Regulations, if a report, orpart of a report, relates to a person’s affairs to amaterial extent, the Inspector must, if it isreasonable to do so, give that person a copy ofthe report or the relevant part of the report.Sub-regulation 16(4) provides that such a personmay provide written comments or informationrelating to the report.
The final draft of the report, or relevant partsthereof, was sent to:
Wallem Shipmanagement
The Master. Nego Kim
The Mate, Nego Kim
Dampier Port Authority
Dampier Police
Hammersley Iron Limited
Class NK
Woodside Energy Limited
Transport W.A.
Australian Maritime Safety Authority
Where appropriate the text has been changed tocorrect the draft or reflect the submission.
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Nego KimIMO Number 8507535
Flag Hong Kong
Port of Registry Hong Kong
Classification Society Nippon Kaiji Kyokai ( NK)
Ship Type Geared Bulk Carrier
Builder Usuki Iron Works Ltd Saiki, Japan
Year Built 1985
Owners Saratoga Shipping Limited
Ship Managers Wallem Ship Management Ltd, Hong Kong
Gross Tonnage 15 832
Net Tonnage 8 990
Deadweight (summer) 26 591 tonnes
Summer draught 9.543 m
Length overall 167.2 m
Breadth 26 m
Moulded depth 13.30 m
Engine 1 x B & W 6L50MCE
Total power 6 090 BHP (5074 kW)
Crew 23 PRC nationals
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