scandinavian shipyard / 2011 vessel fire whilst in dry dock incident investigation... ·...
TRANSCRIPT
2
Slide Agenda
1. Introduction2. Sequence of Events3. Investigation Analysis4. Recommendations5. Recommendations for the Industry.
3
Introduction
1. IntroductionHigh level major eventsConsequences
2. Sequence of Events3. Investigation Analysis4. Recommendations5. Recommendations for the industry
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High Level Major Events
• Vessel in Dry Dock
• Blasting in Forepeak tank revealed a missing seam weld
• Remedial work required hot work (not in original yard plan)
• Fire and smoke damage through 2 decks
• All crew admitted to local hospital: smoke inhalation
checks for unknown toxic gas
• Accommodation areas rebuilt: 5 days delay in yard
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Consequences
Actual PotentialHuman (P) C1 (P) C5Environment - -Assets (A) C3* (A) C5#
Final Classification: Major Asset DamagePotential Multiple Fatalities
* Severity 3 = above 50 KUSD but less than 500 KUSD# Severity 5 = above 5 MUSD
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Sequence of events
1. Introduction2. Sequence of Events
Location mapDetailed sequence
3. Investigation Analysis4. Recommendations5. Recommendations for the Industry.
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Investigation analysis
1. Introduction2. Sequence of Events3. Investigation Analysis
Analysis MethodologyRelevant DiagramsMain causes
4. Recommendations5. Recommendations for the Industry.
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Analysis Methodology
• Full TOPSET Incident Investigation
• Investigation Team of 2 x QHSE and VM
• Separate interviews of entire crew
• Supervised interviews of Yard Workers & Foremen
• Immediate Underlying Root Causes
• Reviewed by Ship Managers and Seismic Contractor
• Root Causes QHSE MS Weaknesses
• Report distributed across fleet(s)
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Fire In PPE Store Foam Ignited
Fire Watch departed area
Hot Work on-going
Foam scrapings not totally removed
Diagrams
Why? Why?
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Fire Watch departed
area
Left with Supervisor
F.W. Supervisor unable to contact
Welder’s Supervisor
No Radio’s & No mobile signal
Yard’s Commsprocedures not
adequate
No direct contact with Welder
F.W. did not think Hot Work was
continuing
No Activity for > 1 hour
Welder took a meal break @ 18:00
Resumed work in another part of Forepeak Tank
Other Hot Work not known about
Single PTW covered multiple
locations
Diagrams
Why? Why? Why? Why?
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Fire In PPE Store Foam Ignited
Fire Watch departed area
Hot Work on-going
Foam scrapings not totally removed
Diagrams
Why? Why?
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Hot Work on-going
Seal Reference Hole
Pilot/Locator hole drilled through
Bulkhead
Verification of location of plate
seam
Working opposite sides of a Bulkhead
To see how much combustibles had
to be removed
Repair Seam from Tank-side
Previously only tack-welded
Only became visible after shot-
blastingPreviously treated
with concrete wash
Diagrams
Why? Why? Why? Why?
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Fire In PPE Store Foam Ignited
Fire Watch departed area
Hot Work on-going
Foam scrapings not totally removed
Diagrams
Why? Why?
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Foam scrapings not totally removed
Hot Work checklist not
followed
No Hot Work checklist was
completed
Hot Work PTW not fully
completed
Yard’s own procedures not
followed
Previous lessons learned were not
remembered
Yard HSE Plan template not
updated
Diagrams
Why? Why? Why? Why?
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Diagrams
Casualties with Smoke inhalation
Automatic Fire Alarm too late
Not Optimal setting for
unmanned Bridge
Settings not reviewed before
Yard stay
Unmanned BridgeNo Policy for 24hr
Manned Bridge whilst in Yard
Smoke Hood not properly used
Use not regularly drilled
Their use was not part of new-hire
Induction
Why? Why? Why?
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Findings
• Inadequate Hot Work Procedures
o Did not address multiple HW tasks within same tank
o Ineffective communication methods/tools
o Carpenters did not clear combustibles as per procedure
• Inadequate sub-contractor communication
• Sub-Optimal Fire Alarm configuration during Yard stay
o Ship-wide alarm sounded too late (Pre-Alarm not heard)
• Use of smoke Hoods unfamiliar to some of crew
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Other Observations
• Test residual main water pressure from yard
• Ensure Fire Plans are posted on gang-way
• Mobile phones useless under MSL, in metal! Use UHF
• 2 of 4 smoke hoods used were not activated
• Investigators - Download event logs immediately!
o FiFo buffer of Fire Alarm no longer held history far enough back
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Recommendations
1. Introduction2. Sequence of Events3. Investigation Analysis4. Recommendations
1. Immediate actions taken2. Recommendations
5. Recommendations for the Industry.
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Immediate actions taken
• Crew tested at Hospital for possible inhalation of toxins
• All clear and back at work the next morning (Hotel-based)
• 24 hour Bridge watch
• Accommodation rebuild
• Air Quality measured before crew returned to ship
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Recommendations
• Familiarisation of Fire Alarm settings by OOW
• Familiarisation of Smoke Hoods with more realistic Drills
• 24 hour Bridge watch during all future yard stays
• Pre-Yard, 2-way presentations of recent “lessons learned”
• Hot Work Permit process more rigorous (by task, not area)
• Audit Yard’s contractor management wrt communication
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Recommendations
1. Introduction2. Sequence of Events3. Investigation Analysis4. Recommendations5. Recommendations for the Industry.
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Recommendations for the Industry
• Your Yard HSE Plans to include reference to:
o Yard’s contractor communications (our sub-contractor management!)
o HWP should be issued by task, not by area, and be risk-assessed
o Use UHF Radios – do not rely on mobile phones
o Optimise Fire Alarm settings before entering yard (e.g. pre-alarm)
o Residual water pressure for fire hoses
• Consider retaining 24 hr Bridge Watch during any Yard.
• More regular drills involving the use of smoke-hoods.