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Report on the investigation of

the fire on the main vehicle deck of

Commodore Clipperwhile on passage to Portsmouth

16 June 2010

LESS SERIOUS MARINE CASUALTY REPORT NO 24/2011 NOVEMBER 2011

Pursuant to Regulation 6 of Chapter XI -1 of the International Convention for the Safety of Life at Sea (SOLAS) and the Code of the International Standards and Practices for a Safety Investigation into a Marine Casualty (Casualty Investigation Code) (Resolution MSC.255 (84)), the MAIB has investigated this accident with the co-operation and assistance of the Bahamas Maritime Authority. Their contribution to this investigation is acknowledged and greatly appreciated.

Extract from The United Kingdom Merchant Shipping (Accident Reporting and Investigation)

Regulations 2005 – Regulation 5:

“The sole objective of the investigation of an accident under the Merchant Shipping (Accident Reporting and Investigation) Regulations 2005 shall be the prevention of future accidents through the ascertainment of its causes and circumstances. It shall not be the purpose of an investigation to determine liability nor, except so far as is necessary to achieve its objective, to apportion blame.”

NOTE

This report is not written with litigation in mind and, pursuant to Regulation 13(9) of the Merchant Shipping (Accident Reporting and Investigation) Regulations 2005, shall be inadmissible in any judicial proceedings whose purpose, or one of whose purposes is to attribute or apportion liability or blame.

© Crown copyright, 2011You may re-use this document/publication (not including departmental or agency logos) free of charge in any format or medium. You must re-use it accurately and not in a misleading context. The material must be acknowledged as Crown copyright and you must give the title of the source publication. Where we have identified any third party copyright material you will need to obtain permission from the copyright holders concerned.

All MAIB publications can be found on our website: www.maib.gov.uk

For all enquiries:Email: maib@dft.gsi.gov.ukTelephone: +44 (0) 23 8039 5500Fax: +44 (0) 23 8023 2459

M A R I N E A C C I D E N T I N V E S T I G A T I O N B R A N C H

Marine Accident Investigation BranchMountbatten House

Grosvenor SquareSouthampton

SO15 2JU

The Bahamas Maritime Authority120 Old Broad StreetLondonEC2N 1AR

CONTENTS PageGLOSSARYOFABBREVIATIONSANDACRONYMS

SYNOPSIS 1

SECTION1-FACTUALINFORMATION 3

1.1 ParticularsofCommodore Clipperandaccident 31.2 Background 41.3 Eventsleadinguptothefire 4

1.3.1 CargooperationsinJersey 41.3.2 DeparturefromJerseyandreturnpassage 4

1.4 Fire 41.4.1 Earlyfiredevelopment 41.4.2 Initialresponse 61.4.3 Confirmation 61.4.4 Generalemergencystations 81.4.5 Musterstations 81.4.6 Containment 101.4.7 Firstassessment 121.4.8 EnteringtheSolent 131.4.9 Deterioratingcondition 131.4.10Lossofpowertomachinery 14

1.5 Initialemergencyresponse 161.5.1 Commandandcontrol 161.5.2 Specialistfire-fightingsupport 161.5.3 Firstre-entrytothemainvehicledeck 171.5.4 Preparationsforenteringharbour 181.5.5 Secondre-entrytothemainvehicledeck 191.5.6 PlannedentrytoPortsmouthHarbour 201.5.7 Sternramphydraulics 201.5.8 Helicoptertransfer 211.5.9 Delay 221.5.10EntryintoPortsmouthHarbour 22

1.6 EmergencyresponseonceCommodore Clipperwasalongside 241.6.1 Pedestrianaccess 241.6.2 Passengerevacuation 241.6.3 Assessment 25

1.7 Fire-fightingtactics 261.7.1 Visibility 261.7.2 Escalation 261.7.3 Cargohandling 291.7.4 Statutorypowersofintervention 30

1.8 Fireextinctionandpassengerdisembarkation 311.8.1 Accesstotheseatofthefire 311.8.2 MCAresponse 311.8.3 Removalofthelastburningtrailers 32

1.9 Keypersonnel 331.9.1 Crew 331.9.2 Companystaff 341.9.3 Training 34

1.10 Damagetostructureandsystems 341.10.1 Structuraldamage 341.10.2Steeringgear 351.10.3Firedetectionsystem 351.10.4Electricaldistributionsystems 361.10.5Fire-fightingandwatersprayingsystems 361.10.6Ro-rohydraulicsystems 37

1.11 Stability 371.11.1 Approvedstabilitybook 371.11.2 Damagestabilityinformation 371.11.3 Approvedonboardloadingcomputer 381.11.4 Loadingconditionfor15-16June2010 381.11.5 Effectofdrenchingwateronstability 381.11.6 Requirementsforpreventionoffire-fightingwateraccumulatingin ro-rospaces 40

1.12 Technicalinvestigation 401.12.1 Examinationofthefirescene 401.12.2Refrigeratedtrailersystem 431.12.3Electricalexamination 481.12.4Reefercables 501.12.5Reactiontofiretests 51

1.13 Portinformation 531.13.1 Portsmouthharbourauthorities 531.13.2PortsmouthInternationalPort 551.13.3Portinfrastructure 55

1.14 Commandandcontrolofemergencies 551.15 Othersimilaraccidents 561.16 OngoingdevelopmentworkattheIMO 57

1.16.1 Watersprayingsystems 571.16.2 Structuralfireprotection 571.16.3 Stability 571.16.4 SOLASamendments2008and2009 58

SECTION2-ANALYSIS 59

2.1 Aim 592.2 Causeofthefire 59

2.2.1 Reefercableassembly 592.2.2 Refrigeratedtrailerequipment 602.2.3 Electricalprotection 602.2.4 Trailerignition 61

2.3 Initialresponseandfireescalation 612.3.1 Crewresponsetothefirealarm 612.3.2 Effectivenessofthevehicledeckwaterdrenchingsystem 622.3.3 Abilityofcrewtofightthefireatsea 632.3.4 Containment 63

2.4 Firedamagetoship’ssystems 642.4.1 Consequencesoffiredamagetosystems 642.4.2 Effectivenessofregulations 65

2.5 Stabilityissues 652.5.1 Deckdrainblockages 652.5.2 Marginofstability 662.5.3 Requirementsfordamagestabilityinformation 67

2.6 Useofspecialisedprofessionalfirefighters 682.6.1 Informationgatheringandassessment 682.6.2 Roleofthemaster 692.6.3 ConstraintsontheuseofMIRG 702.6.4 Specialisedplanning 70

2.7 Entrytoharbour 712.7.1 Pilotagerequirements 712.7.2 Planningandco-ordination 72

2.8 Passengerdisembarkation 722.8.1 Designfactorsandtheeffectofregulations 722.8.2 Portinfrastructure 732.8.3 Balanceofrisktothepassengers 73

2.9 Fire-fightingtactics 742.9.1 Accesstotheseatofthefire 742.9.2 Cargohandling 75

2.10 Managementoftheemergencyresponse 762.10.1 Responsibility 762.10.2 Communicationandco-ordination 762.10.3 TheroleoftheSOSREP 782.10.4 Jurisdiction 782.10.5 Understandingspecialisedvesseltypes 792.10.6 Effectiveuseofavailableassets 802.10.7 Sharedstrategicplan 80

2.11 Widerrisks 812.11.1 Vulnerabilityofvehicledecks 812.11.2 Flammabilityofroadcargoes 812.11.3 Abilityofexistingmeasurestocontrolfiresinvehicledecks 81

2.12 Fatigue 82

SECTION3-CONCLUSIONS 83

3.1 Safetyissuesdirectlycontributingtotheaccidentwhichhaveresulted inrecommendations 833.2 Othersafetyissuesidentifiedduringtheinvestigationalsoleadingto recommendations 833.3 Safetyissuesidentifiedduringtheinvestigationwhichhavebeenaddressed orhavenotresultedinrecommendations 84

SECTION4-ACTIONTAkEN 87

4.1 MAIBactions 874.2 Actionstakenbyotherorganisations 87

SECTION5-RECOMMENDATIONS 90

FIGURES

Figure1 - SequenceofimagesrecordedbyCCTVcamerano.7from0237BST

Figure2 - LayoutofCCTVcamerasonthemainvehicledeck

Figure3 - Schematicdiagramoftheinitialsmokedetectoractivationandalarm silencingsequence

Figure4 - GeneralarrangementofCommodore Clipperandlocationofthefire

Figure5 - Cloudofsteamfromtheuppervehicledeckasboundarycoolingwas started

Figure6 - Heatdamagetotheuppervehicledeck

Figure7 - AnnotatedchartofEasternApproachestotheSolent

Figure8 - Accessplatformatdeck4abovethemainvehicledeck

Figure9 - Cargostowagediagram

Figure10 - ChartwithinsetshowingtheberthsavailableatPIP

Figure11 - Viewofthemainvehicledeckafterthesternrampwasopened

Figure12 - PartiallyburntdebrisontrailerFS61

Figure13 - Stevedorewearingbreathingapparatusinordertoremovetrailersfrom thesmoke-filledvehicledeck

Figure14 - TrailerCRF461continuingtoburnafterbeingremovedfromthemain vehicledeck

Figure15 - Blockedvehicledeckdrains

Figure16 - CharredanddelaminatedtyresontrailerGC13-1

Figure17 - TrailerCRF439

Figure18 - TrailerCRF461

Figure19 - TrailerCRF459

Figure20 - Insulatedcurtain-sidematerial

Figure21 - Dieselgenerator,refrigerationcompressorandfueltank

Figure22 - Electricalcontrolandpowerdistributionboxes

Figure23 - Externalpowersupplysocket

Figure24 - DamagedexternalpowersupplyconnectionontrailerCRF459

Figure25 - Reeferpowersupplycable

Figure26 - X-rayoftheexternalpowersupplyconnectionontrailerCRF459

Figure27 - Examinationofthereeferpowersupplyplugattachedtotrailer CRF459

Figure28 - StarToppluginstructionleaflet

Figure29 - OtherStarTopplugconnectionsassembledonboardCommodore Clipper

Figure30 - IgnitionoftheStarTopplugaftersustainedinternalheating

Figure31 - Ignitionofthecurtain-sidematerial

Figure32 - DivisionofStatutoryandCompetentHarbourAuthorityareasof jurisdiction

Figure33 - Linesofcommunicationduringtheresponsetotheincident

ANNEXES

AnnexA - Classificationsociety’sreportofthedamagecausedbythefire

AnnexB - IMOResolutionA.123(V)

AnnexC - Reportoftheexaminationoftheelectricalcomponents

AnnexD - Reportsonthereactiontofiretesting

AnnexE - MAIBSafetyBulletin3/2010

AnnexF - MAIBflyertoro-rovesseloperatorsandtheportsindustry

GLOSSARYOFABBREVIATIONSANDACRONYMSABB AseaBrownBoveri

ALP AerialLadderPlatform

ARCC AeronauticalRescueCo-ordinationCentre

BA BreathingApparatus

BMA BahamasMaritimeAuthority

BST BritishSummerTime

CCTV ClosedCircuitTelevision

CGLO CoastguardLiaisonOfficer

CHA CompetentHarbourAuthority

CMS CondorMarineServices

CPSO CounterPollutionandSalvageOfficer

DAO DutyAreaOfficer

DNV DetNorskeVeritas

DOD DutyOperationsDirector

DPA DesignatedPersonAshore

DQHM DutyQueen’sHarbourMaster

ECR EngineControlRoom

EEBD EmergencyEscapeBreathingDevice

FLM FireLiaisonManager

HFRS HampshireFireandRescueService

HMCG HerMajesty’sCoastguard

Hz Hertz

IDC InsulationDisplacementConnector

IEC InternationalElectrotechnicalCommission

IMO [The]InternationalMaritimeOrganization

IP IngressProtection[rating]

ISM InternationalSafetyManagement[Code]

kW kilowatt

MCA MaritimeandCoastguardAgency

MIRG MarineIncidentResponseGroup

MOD MinistryofDefence

MOU MemorandaofUnderstanding

MSC MaritimeSafetyCommittee

OOW OfficeroftheWatch

OSB OuterSpitBuoy

PEC PilotageExemptionCertificate

PIP PortsmouthInternationalPort

PMSC PortMarineSafetyCode

QHM Queen’sHarbourMaster

RAF RoyalAirForce

SAR SearchandRescue

SHA StatutoryHarbourAuthority

SLF IMOSub-CommitteeonStabilityandLoadLinesandFishingVesselsSafety

SOLAS InternationalConventiononSafetyofLifeatSea

SOLFIRE SolentandSouthamptonWaterMarineEmergencyPlan

SOSREP SecretaryofState’sRepresentative

STCW InternationalConventiononStandardsofTraining,CertificationandWatchkeepingforSeafarers

VCG VerticalCentreofGravity

VDR VoyageDataRecorder

VHF VeryHighFrequency

Times: Alltimesusedinthisreportarelocal(UTC+1)unlessotherwisestated.Timingstakenfromautomatedshipandcoastguardsystemsareallcorrectedtomatchvoyagedatarecordertime

1

SYNOPSISAt0242(BST)on16June2010,afirewasdetectedonthemainvehicledeckoftheBahamasregisteredro-roferryCommodore Clipper. ThevesselwasonpassagefromJerseytoPortsmouthandthevehicledeckwasloadedwithmanyfreighttrailers.Thecrewidentifiedthatanunaccompaniedrefrigeratedtrailerunit,poweredfromtheship’selectricalsupply,hadcaughtfire.

Thecrewcontainedthefireusingthevehicledeckwaterdrenchingsystemandboundarycoolingfromabove,butwerenotabletoextinguishit.Firedamagetounprotectedcablesandpipeworkinthemainvehicledeckcausedextensivedisruptiontosystems,affectingthevessel’sabilitytomanoeuvreandcontainthefire.Fire-fightingeffortshadtobesuspendedascargodebrisblockedvehicledeckdrains,causingwaterfromthefire-fightingefforttoaccumulateandreducethevessel’sstability.

AlthoughCommodore ClipperwasclosetoPortsmouthharbour,berthingwassignificantlydelayedthroughineffectiveco-ordinationbetweenshoreagenciesandbecauseofequipmentdefects.Oncealongside,thehighdensityofcargoandconstraintsinthedesignofthevessellimitedaccesstobothfightthefireandtodisembarkthepassengers.Asaconsequence,freighttrailershadtobetowedoffthevesselbeforethefirecouldbeextinguished.Thelastofthe62passengersdisembarkedfromthevesselnearly20hoursafterthefirestarted.

Theinvestigationidentifiedthatthefirestartedduetooverheatinginanelectricalcablethatprovidedpowerfromtheshiptooneoftherefrigeratedtrailerunits.Thematerialsusedbothinthecurtain-sidesandthecargopackagingburntreadily.

Thevesselmanagersandportauthoritieshavetakenarangeofactionsduringtheinvestigationwhichshouldreducethelikelihoodofasimilaraccidentrecurring,andimprovetheirabilitytorespondtofutureemergencies.TheMaritimeandCoastguardAgency(MCA)hasundertakentoimplementanumberofrecommendationsresultingfromaninternalreviewofitsresponsetotheincident.

TheMAIBhasmaderecommendationstotheMCAandthePortMarineSafetyCode(PMSC)steeringgroupregardingtheresponseto,andmanagementofsimilarincidentsinthefuture.

TheChiefInspectoroftheMAIBhaswrittentotheSecretaryGeneraloftheInternationalMaritimeOrganization(IMO)requestingthatthisreportandthereportsoftheinvestigationsintothefiresonboardAl Salaam Boccacio 98,Und Adriyatik,Lisco GloriaandPearl of Scandinavia,arereviewedwiththeaimofidentifyingimprovementsthatcanbemadetothefireprotectionstandardsappliedtoro-ropassengervesselsconstructedbefore1July2010toenhancetheirsurvivabilityandsafereturntoportintheeventofavehicledeckfire.

TheBahamasMaritimeAuthority(BMA)hasagreedtomakeasubmissiontotheInternationalMaritimeOrganizationonprovidingimprovedstabilityinformationtomastersofvesselsandtoworkwiththeMCAonajointsubmissionregardingpedestrianaccesstoro-roferries.

TheMAIBissuedasafetybulletininJuly2010identifyingtheriskofpowersupplycablestorefrigeratedtrailersoverheating,andhaspublishedaflyertoraiseawarenessofthesafetyissuesintheferryandportmanagementsectorsoftheindustry.

2

Com

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Clip

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SECTION1-FACTUALINFORMATION1.1 PARTICULARSOFCommodore ClipperANDACCIDENT

SHIPPARTICULARS

Flag Bahamas

Classificationsociety DetNorskeVeritas(DNV)

IMOnumber 9201750

Type Ro-ropassenger

Registeredowner CondorLimited

Manager(s) CondorMarineServices

Construction Steel

Lengthoverall 129.14m

Registeredlength 118.7m

Grosstonnage 14000

Minimumsafemanning 13

Authorisedcargo Notapplicable

VOYAGEPARTICULARS

Portofdeparture StHelier,Jersey

Portofarrival Portsmouth,UK

Typeofvoyage Shortinternationalvoyage

Cargoinformation Carsandroadfreighttrailers

Manning 39crew

MARINECASUALTYINFORMATION

Dateandtime 16June2010,0242

Typeofmarinecasualtyorincident LessSeriousMarineCasualty

Locationofincident 50o18.87N,001o29.76W

Placeonboard Deck3,specialcategoryspace

Injuries/fatalities None

Damage/environmentalimpact Materialdamagetothevessel

Shipoperation Onpassage

Voyagesegment Midwater

External&internalenvironment Dark,goodweatherconditions

Personsonboard 62passengersand39crew

4

1.2 BACkGROUND

Commodore ClipperprovidedapassengerandvehiclefreightservicelinkingSt.PeterPort,GuernseyandSt.Helier,JerseyintheChannelIslandswithPortsmouth.Oneroundtripofallthreeportswascompletedineach24-hourperiodfromMondaytoSaturday.Atthetimeoftheaccident,Commodore Clipperwasontheovernightleg,fromSt.HeliertoPortsmouth.Thevesselwascertifiedtocarry500passengers,but62wereonboardatthetime.Thevehicledeckswerealmostfulltocapacity,mainlywithunaccompaniedroadfreighttrailers.

1.3 EVENTSLEADINGUPTOTHEFIRE

1.3.1 CargooperationsinJersey

On15June2010, Commodore ClippersailedfromSt.PeterPortat1747andarrivedatSt.Helierat1940.ThemainseasonforexportingJerseyRoyalpotatoeswasreachingitsend;24ofthe77trailersthatwereloadedonboardwererefrigeratedunits,carryingpre-packagedpotatoesfordeliverystraighttosupermarkets.Thereweretoomanyrefrigeratedtrailerstoallowthemalltobeloadedontheuppervehicledeck(deck5),whichwasintheopenairandwouldhaveallowedtheirdiesel-poweredfridgeunitstoberun.Consequently,thoserefrigeratedtrailersthatcouldbepoweredfromtheship’selectricalsystemwereloadedontothemainvehicledeck(deck3).Thesetrailerswereconnectedtopowersocketsondeck3bystaffworkingforthehaulagecompany,usingcablesprovidedonboardCommodore Clipper.

1.3.2 DeparturefromJerseyandreturnpassage

CargooperationsandshipstabilitycalculationswerecompletedandCommodore ClipperdepartedfromSt.Helierat2145.Theweatherwasfair,theshipmadegoodprogresstoPortsmouthandwasabletoreducetoamoreeconomicalspeed.Crewconductedfireandsecuritychecksoftheaccommodationthroughthenighthours.TheOfficeroftheWatch(OOW)andlookoutmaintainedaperiodiccheckonthevehicledecksfromthebridge,bymonitoringtheclosedcircuittelevision(CCTV)andfiredetectionsystems.

Masters,deckofficersandmanagershadidentifiedthatthevessel’srepetitivedailyscheduledidnotprovidebridgewatchkeeperswiththebestopportunitiestorestiftraditionalwatchhandovertimeswerekept.Accordingly,thetwosecondofficershandedoverthebridgewatchat0230.Navigationaltrafficwaslightandtherewerenoindicationsofanyproblemsonboard.Atabout0240,theoff-goingsecondofficermadehiswayfromthebridgetothemessroom.Hedidnotnoticeanythinguntowardorsmellanysmokeashepassedthroughtheaccommodation.

1.4 FIRE

1.4.1 Earlyfiredevelopment

At0237,thepicturerecordedbyCCTVcamera7ontheportsideofthemainvehicledeckstartedtogethazy(Figure1).Thevehicledecklightingbegantoappearmorediffusedandthepicturegraduallyfadedgrey.Shortlyafterwardsamachinerycontrolalarmshowedanearthfaultatthebus-tiebreakerlinkingthetwopartsofthemain400Velectricaldistributionsystem.Thethirdengineer,ondutyintheenginecontrolroom,alsoheardthenoiseofthebreakeropening.Twominuteslater,at0241,theimagerecordedonCCTVcamera6,atthecentrelineofthemainvehicledeck(Figure2),begantodarken.

5

Figure1

SequenceofimagesrecordedbyCCTVcamerano.7from0237BST(CCTVtimingsareinUTC)

Figure2

LayoutofCCTVcamerasonthemainvehicledeck

Cam

era7

Cam

era6

6

1.4.2 Initialresponse

Theship’sfiredetectionsystemhadcontrolstationsonboththebridgeandintheenginecontrolroom(ECR).Thesystemhadnoparticularhistoryofspurious,nuisancealarms,andcompanyproceduresallowedeithertheOOWordutyengineertorespondtoanalarmandco-ordinatetheinitialresponse.Thealarmactivatedinbothlocationsat0242:36,indicatingthatsensorD24ontheportsideatthemidshipssectionofthevehicledeckhaddetectedsmoke.SensorsoneithersideofD24activatedwithinthenext30seconds(Figure3).ThethirdengineerhadgonetotheauxiliaryengineroomandhereturnedtotheECRtoinvestigatethealarm.Hesilencedthealarmandcontactedthesecondofficeronthebridgebytelephone,toreportthealarm.At0243,thesecondofficerinstructedthelookouttotakeaportableveryhighfrequency(VHF)radioandgoandcheckthemainvehicledecktoconfirmiftherewasafire.

Thethirdengineerhadnotsmelledanysmokeandsuspectedthatthealarmmightbeduetoafaultycomponentinthedetectionsystem.Aftercallingthebridge,hetelephonedtheelectricalfitterandaskedhimtoinvestigateiftherewasafaultwiththefiredetectionsystem.Thethirdengineercontinuedtosilencethealarmafurthersixtimesduringthenextthreeminutesbeforeresettingthesystemat0245:42.

Afterthefiredetectionsystemhadbeenreset,thesensorsreactivatedandthefirealarmsoundedagain.Thesecondofficersilencedthealarmonthebridgeat0246:20andresetthesystemfromhiscontrolstationimmediatelyafterwards.Bythetimethefiredetectionsystemhadreactivated,10differentsensorsontheportsideofthemainvehicledeck,rangingfromtheoriginallocationmidships,allthewayafttothesternramp,haddetectedsmoke.

1.4.3 Confirmation

Thelookoutknewthattheportableradiothathewasassignedwasnotreliable,andwasconcernedthathemightbecomeinjuredortrappednearthefireandnotbeabletosummonhelp.Afterleavingthebridge,ratherthangostraighttothemainvehicledeckhewenttothepassengerrestaurantondeck7andmetthetwonightstewards.Theycouldsmellsmokeinthearea,andthelookoutreturnedtothebridgeat0248.Meanwhile,thesecondofficerwastalkingtothethirdengineerintheECRusingthebridgetelephone.Itwaspossibletodetermine,fromlisteningtothesecondofficer’ssideoftheconversationonthevoyagedatarecorder(VDR),thatthetwoofficershadconcludedthatthelikelycauseofthefirealarmwasaproblemwiththedetectionsystem.Thethirdengineersubsequentlytelephonedthechiefengineertoreportthattherewasaproblemwiththefiredetectionsystemandthatitcouldnotbereset.

Thefiredetectionsystemceasedtofunctionat0249:12;6minutesand54secondsafterthefirstalarm.Duringthisperiod,16sensorsdetectedsmoke,activatingacombinedtotalof81times.Thesystemhadbeensilenced11timesandreset7timesbythecombinedinputsfromthebridgeandECRcontrolstations.

Thelookoutreportedtothesecondofficerthathehadsmelledsmokeintheaccommodationarea,butthathehadonlybeenasfarastherestaurant.Thesecondofficertoldhimtogotothemainvehicledeck;thelookoutleftthebridgeatabout0250.Overthenext7minutes,thesecondofficerreceived8distortedandunreadablecallsonhisportableVHFradio,allofwhichhethoughtwerelikelytohavebeenfromthelookout.

Throughoutthisperiod,theelectricalfitterhadbeenattemptingtogainaccesstothemainvehicledecktocheckthefiredetectionsensors.Hewasbeatenbackbysmoke,andwenttotheECRinstead.Theelectricalfitterreportedthesmoketothethirdengineer,andthetwomenisolatedtheelectricalpowersuppliestotherefrigeratedtrailerunitsonthemainvehicledeck.Thethirdengineeralsostartedanauxiliarygeneratortotaketheelectricalloadfromtheshaftgenerator.

7

Figure3

Schem

aticdiagram

oftheinitialsmokedetectoractivationandalarmsilencingsequence

8

RecordingsfromalltheCCTVcamerasonthemainvehicledeckshowedincreasinglyheavysmoke;visibilitywaslostby0254.ThesecondofficerreportedthathelookedattheCCTVpicturesofthemainvehicledeck,butdidnotseeanyindicationofafire.Machineryalarmrecordsindicatedthattheventilationfansonboththemainanduppervehicledeckswerestoppedatabout0255.However,thesystemhadanin-builtdelayof5minutesbetweenthefansstoppingandthemachineryalarmbeingactivated.Consequently,thevehicledeckfanswouldhavestoppedatabout0250andthiswascloselyfollowedbyasecondearthfaultbeingrecordedatthebus-tiebreaker.Thedampersontheventilationinletswerearrangedtoshutautomaticallybutpre-datedtherequirementfortheirpositiontobeindicatedremotely.

Atabout0258,themachinerycontrolsystemrecorded‘fail’ alarmsonbothsteeringgearno.1(port)andsteeringgearno.2(starboard).Therewasnoapparentfaultwiththesteering;themachineryrecordsshowedthatthealarmswereacceptedshortlyafterwardsandtheydidnotrecur.

1.4.4 Generalemergencystations

Thechiefengineerhadbeenasleepinhiscabinondeck9whenthethirdengineerreportedtheactivationofthefiredetectionsystemandhisconclusionthatitwasafalsealarm.Thechiefengineerdecidedtogototheclosestfiredetectionsystemcontrolstationonthebridgetotryandfindoutwhatwaswrong.Hesmelledsmokeassoonasheopenedhiscabindoor,andwentstraighttothebridge.Thesecondofficeronwatchreportedthatmanyfiredetectionsensorsonthemainvehicledeckhadbeenactivated,butthathewasnotsurewhy.Thechiefengineerconcludedthemostlikelyreasonwasthattherewasafire,ratherthanafaultwiththefiredetectionsystem.At0259:20,thelookoutcalledthesecondofficerbytelephoneandconfirmedthattherewasafireonthemainvehicledeck.Thechiefengineeractivatedthecrewalertsignalat0301andthen,concernedthatthesituationwasseriousanddevelopingrapidly,activatedthegeneralemergencysignalimmediatelyafterwards.Atthesametime,thesecondofficertelephonedthemasterandchiefofficerintheircabinsandtoldthemtherewasafireonthemainvehicledeck.

Thechiefengineerturnedtheswitchonthebridgetoensurethatthevehicledeckventilationfanshadbeenshutdown.Hethenstartedthevehicledeckdrenchingsystem1insection4,theimmediatelocationofthefire(Figure4).Atabout0306,mainvehicledeckwaterleakagealarmsweretriggered,indicatingthatwaterfromthedrenchershadstartedtodrainoverboardfromthecompartment.

1.4.5 Musterstations

Themasterandchiefofficerarrivedonthebridgesoonafterthealarmwassounded,andwerebriefedbythechiefengineer.Themastermadeanannouncementonthepublicaddresssystemforallthepassengerstomusterattheassemblystations,andthefirescreendoorswereshut.Thechiefengineeractivatedthedrenchersinsection6inadditiontosection4andleftthebridgetogotohismusterpointatthesafetystationondeck3.Thechiefofficerwenttohismusterpointatthesafetystationondeck9.

Hotelstaffcheckedeachcabininturnanddirectedthepassengerstotheassemblystationsateithertherestaurantondeck7orthebarondeck8,wheretheywereissuedwithlifejackets.

Crewinemergencyteam1musteredatthesafetystationondeck9andbegantoputonfire-fightingsuitsandbreathingapparatus(BA).Smokefromthemainvehicledeckhadgatheredinthecentralstairwell,andcrewinemergencyteam2,whowere

1 AnapprovedmanuallyoperatedfixedpressurewatersprayingsystemwasfittedinthemainvehicledeckasrequiredbySOLASChapterII-2,Regulation20andresolutionA.123(V).Thiswasknownonboardasthevehicledeckdrenchingsystem.

9

Bluestairs

Greenstairs

‘AO’class

deckboundary

Heataffectedarea

Fire

Smoke

Smoke

Bluestairs

Greenstairs

Drenchersection6

Drenchersection4

Mainvehicledeck

Uppervehicledeck

Figure4

GeneralarrangementofC

omm

odor

e C

lippe

randlocationofthefire

10

assignedtomusteratthesafetystationondeck3,wereunabletogetthrough.Theymusteredatthefirelockerondeck7andsubsequentlyjoinedupwithemergencyteam1.Thechiefengineer,realisingthatno-oneelsewascomingtojoinhim,leftthesafetystationondeck3andwenttotheECRtocheckonthemainmachineryandconfirmthatelectricalpowertotherefrigeratedtrailerunitshadbeenturnedoff.

Thelookouthadusedanemergencyescapebreathingdevice(EEBD)toenterthevehicledeckfromboththestarboardforwardandcentrelineaccessdoorsinordertoconfirmthelocationofthefire.Aftertelephoningthesecondofficer,hereturnedtothebridgeandreportedtothemasterthatoneoftheunaccompaniedtrailers,ontheportsideataboutthemidshipsposition,wasonfire.

At0307,Commodore Clipper’smastercalledSolentCoastguard2onVHFchannel16.HistransmissionwasmixedwithotherradiotrafficandSolentCoastguardaskedhimtocallagainonVHFchannel67.Whenthemastermadecontact,hereportedthattheshiphadafireonboardandthatthecrewwereinvestigating.Nodistressorurgencymessageprefixeswereused.Twominuteslater,SolentCoastguardcalledbackrequestingthenumberofpeopleonboardandotherinformationabouttheincident.ThesecondofficerprovidedthesedetailsandaskedfortheemergencyservicestomeettheshiponitsarrivalinPortsmouth.At0313,thecoastguardactivateditssearchandrescue(SAR)plansandmadepreparationstonotifytheMarineIncidentResponseGroup(MIRG)incasefirefightersfromHampshireFireandRescueService(HFRS)neededtobesentouttoCommodore Clipper.

Allthepassengershadnowmusteredineithertherestaurantondeck7orthebarondeck8.Astairwell,knownonboardasthe“greenstairs”,ledallthewayupfromthestarboardforwardcornerofthemainvehicledeck(deck3)totherestaurant.Smokefromthevehicledeckhaddriftedupthegreenstairsandhadbeguntomaketheatmosphereintherestaurantunpleasant.Thecrewdecidedtodirectthepassengerswhowereintherestauranttomovetothebarviaadoorontotheupperdeckandsomeexternalstairs.Allthepassengerswereaccountedforandmusteredtogetherinthebar.Althoughnotallthecrewwereabletoreachtheirdesignatedmusterpoints,theywereaccountedforquicklyandnoinjurieswerereported.

CondorMarineServices’(CMS)DesignatedPersonAshore(DPA)wastravellingonboardasapassenger.Hewenttothebridgetoofferhissupporttothemaster.Themasterhadactivatedcompanyemergencyplansandacall-outsystemtoinformkeyshorestaffwasinitiated.Someshorestaffgatheredinthecompany’sofficetoprovidesupportfromashore,whileothersbegantravellingtoPortsmouthtomeettheshiponarrival.TheDPAmaintainedcommunicationswiththeofficethroughouttheincident.

1.4.6 Containment

Thechiefengineerknewthattheventilationinletdampersclosedautomatically,andherequestedthatthebridgeteamsendsomeonetoclosethemanualexhaustdampersattheaftendofthemainvehicledeck.Theoff-watchsecondofficerandadeckcadetwenttothesternviatheuppervehicledeckand,takingEEBDsetsasaprecaution,closedthedampers.

Thechiefofficerledcrewfromemergencyteams1and2totheforwardpartoftheuppervehicledecktoprovideboundarycoolingabovethefire.Theystartedtorigtwofirehosesat0319,andcouldseethatthedeckwasveryhotandstartingtobuckle.Theinitialflowofwaterfromthehoseswasdescribedasbeing“steaminghot”andmadethemetalnozzlesuncomfortablyhottohold.CCTVcamerasondeck5recordedaverylargecloudofsteambeinggeneratedat0324aswaterwassprayedontothedeckareaimmediatelyabovethefire(Figure5).

2HerMajesty’sCoastguard’s(HMCG)SolentMaritimeRescueCo-ordinationCentre,referredtobyitsshorttitle,SolentCoastguard

11

Cloudofsteamfromtheuppervehicledeckasboundarycoolingwasstarted(CCTVtimingsareinUTC)

Figure5

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ThesecondofficeronthebridgecalledSolentCoastguardat0327toupdatethemonthesituation.Healsorequestedthatafire-fightingteambesentouttoCommodore Clipperbyhelicopter.Thecoastguardofficerconfirmedthisrequestandagreedtomakethenecessaryarrangements.

Afterabout30minutesofdrenchingandboundarycooling,thechiefandthirdengineersmeasuredthetemperatureoftheuppervehicledeckusingaportableinfra-redthermometer.Theyrecordedaveragedecktemperaturesabovethefireof180oC,andnotedthatthesteelplatinghadbuckledandthepaintcoatinghadgone.Theheatdidnotcauseanyofthecarsparkedintheimmediateareaabovethefiretoignite(Figure6).

1.4.7 Firstassessment

Commodore Clipper hadcontinuedonitsnormalcoursethroughouttheperiodsincethefirehadbeendiscovered,butthemasterhadincreasedtofullservicespeedwhenhearrivedonthebridge.Consequently,by0335thevesselwasabout12nauticalmilestothesouthoftheIsleofWight.

SolentCoastguardofficershadpagedtheMCA’sFireLiaisonManager(FLM)andDutyAreaOfficer(DAO),andby0336bothhadtelephonedthecoastguardstationandbeenbriefedonthesituation.TheFLM,afireandrescueserviceofficeronsecondmenttotheMCAtoco-ordinateMIRGactivity,askedthecoastguardwatchmanagertoconfirmifCommodore Clipper’smasterhadspecificallyaskedforaMIRGteamtobesenttotheship.Adifferentcoastguardofficerhadcommunicatedwiththeship,andthewatchmanagercouldnotconfirmifthemasterhadspecificallyrequestedassistancefromtheMIRG,orjustdiscussedtheoptionsavailable.At0339,theFLMaskedSolentCoastguardtoobtainmoredetailsaboutthefirefromCommodore Clipperand,particularly,toconfirmifthemasterwantedaMIRGteamtobesenttotheship.SolentCoastguardinterpretedthecommunicationsfromtheshiptomeanthattheMIRGwasnotrequiredimmediately,butshouldbeaskedtostandbyincaseitwassubsequentlyneeded.

Figure6

Heatdamagetotheuppervehicledeck

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Afewsecondslater,justbefore0340,Commodore Clipper’smastercalledSolentCoastguardreportingthathethoughtthedrenchersystemandboundarycoolingwerehavingagoodeffectandthatthefiremighthavebeenextinguished.ThemasteragreedwiththecoastguardthataMIRGteamwasnotrequired,butrequestedthatHFRSmeettheshiponceitwasalongsideinPortsmouth.Themastergaveanestimatedtimeofarrivalof0600,confirmedthattheshipwascarryingnohazardouscargo,andthattheburningtrailerhadbeenidentifiedasoneoftheunaccompaniedrefrigeratedtrailerunits.

1.4.8 EnteringtheSolent

By0340,theamountofsmokeescapingfromthemainvehicledeckhadreducedsignificantly,andcrewreportedthattheuppervehicledeckfeltcomfortablywarmastheycheckeditstemperaturewiththebacksoftheirbarehands.At0344,theFLMandDAOhadatelephoneconferencecallwiththecoastguardwatchmanagertoreviewthesituation,anditwasconcludedthattheincidentcouldbedealtwithbyHFRSoncetheshipwasalongside.Themastercalledwithanotherupdateat0352;no-onehadbeenintothemainvehicledecktoconfirmthestateofthefire,buthewasconfidentthefirewasundercontrolandpossiblyextinguished.Immediatelyafterwards,SolentCoastguardcalledtheportcontrolofficeoftheQueen’sHarbourMaster(QHM)Portsmouth.ThecoastguardbriefedtheQHMportcontrolsupervisoronthesituationand,havingconsideredtherisktothedockyardport,thesupervisoragreedtoallowCommodore Clippertoentertheharbour.ResponsibilityforPortsmouthharbourisdividedbetweenQHMandPortsmouthContinentalFerryPort3(PIP).QHMhasstatutoryresponsibilitiesforprotectingthedockyardportandsocontrolstrafficenteringtheharbour.QHMinformedPIPaboutthefireat0356.

By0400,thesituationonCommodore Clipperappearedtobeundercontrolandthemasterallowedthepassengerstoreturntotheircabinsiftheywished.Hotelstaffbeganpreparingbreakfastandthefiresafetydoorswerereset.

1.4.9 Deterioratingcondition

Commodore ClippercontinuedonitsnormalpassagethroughtheSolenttowardsPortsmouthuntilabout0443,whenthemasternoticedthatthevesselwasdevelopingalisttoport,whichreachedanangleofabout5o.Themasterandbridgeteamlookedoutfromthebridgewingstocheckthatwaterwasflowingfromthevehicledeckdrains.Somewatercouldbeseenflowingoverboardfromthedrains,butatamuchslowerratethanwhenthedrencherswerefirststarted.Thebridgeteamconcludedthatdebrisfromthefirewaspartiallyblockingthevehicledeckdrainsand,becauseofconcernabouttheadverseimpactanaccumulationofwateronthevehicledeckcouldhaveonthevessel’sstability,thedecisionwastakentoturnoffthedrenchersystem.Withthedrenchersturnedoff,Commodore Clippergraduallyreturnedupright,andthecrewbeganacycleofactivatingthedrenchingsystemuntilthelistreached2-3oandthenstoppingwhilethelistreduced.Eachtimedrenchingwasstopped,crewontheuppervehicledecknotedthatthetemperatureofthedeckbegantoincrease.

Atabout0445analarmsounded,indicatingthatsomeofthesteeringpumpshadfailed.Oneminutelater,theportruddermovedoverto20ºtostarboardandtheshipbegantoturn.ThemastertookwayofftheshipandreportedtheproblemtoSolentCoastguardwhilethechiefengineerwenttothesteeringgearcompartmentandcentredtheportrudderusinglocalhydrauliccontrols.Thechiefengineerattemptedtoreconnecttheportcontrolsystem,buttheportrudderwasdrivenbackovertostarboard.Theportcontrolsystemwasdisconnectedandtheportrudderwasleftcentralised.Thestarboardruddercontinuedtorespondtosteeringcommandsand,at0503,Commodore Clippercontinuedonpassage.QHMPortsmouthhadoverheardthereporttothecoastguardandofferedtosenditsdutytugtoassist.

3 PortsmouthCommercialPort,alsoknownasPortsmouthContinentalFerryPort,wasrenamedinJanuary2011toPortsmouthInternationalPort(PIP).

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Themasterwasconcernedthatsteeragewasnowreducedandthatthefiremightleadtocontrolofthestarboardrudderbeinglost.HecalledQHMPortsmouthandagreedthathewouldonlyattempttoentertheharbourwithtugassistance.Thestandbytug,SD Bustler,wasalertedandtoldtomeetCommodore ClipperinthevicinityoftheOuterSpitBuoy(OSB)(Figure7).

Figure7

AnnotatedchartofEasternApproachestotheSolent

ReproducedfromAdmiraltyChartBA2037bypermissionoftheControllerofHMSOandtheUKHydrographicOffice

SaintHelen’sRoadAnchorage

OuterSpitBuoy

Portsmouth

PortsmouthHarbour

IsleofWight

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By0523ithadbeenreportedthatmoresmokewasenteringtheaccommodationfromthegreenstairsandtheliftshaft.Allthesectionsofthedrenchersystemwereactivatedandthechiefofficerleftthebridgetoclosethefirescreendoorsandassesstheamountofsmokeintheaccommodation.Furtherearthfaultswererecordedonthemachineryalarmsystem,andthechiefengineerreturnedtothebridgetodiscusstheproblemswiththesteeringgearcontrols.

1.4.10Lossofpowertomachinery

Commodore ClipperwasstillonpassageandexpectingtoarriveinPortsmouthatbetween0630and0640.Atthisstageofthevoyage,theusualprocedurewastostartandtestbothbowthrusters.Afaulthadoccurredwithoneofthebowthrusterstarterswitchesonthebridgeafewdaysbeforetheaccident.Thecrewhadbeenunabletorepairtheswitchandhadre-arrangedthestartingcircuitsothatthebowthrustercouldbestartedfromthebowthrustercompartment.Thechiefofficerhadbynowreturnedtothebridgeandreportedthatthegreenstairs,theaccessroutetothebowthrustercompartment,wereheavilysmoke-logged.At0546,thechiefengineerandchiefofficercollectedBAsetsandusedthesetoenterthebowthrustercompartment.

Withallthedrenchersectionsactivated,thevessel’slistincreasedmorequickly.At0552,theDPAnotedthatthelisthadreached6ºandthedrencherswerestopped.Themastercommentedthathewasnolongerwillingtoattempttoentertheharbour,andcalledQHMbytelephonetodiscusswherehecouldanchorintheSolent.AfewminuteslateritwasagreedthatCommodore ClipperwouldanchorinStHelen’sRoad(Figure7)eastoftheIsleofWight.

TheQHMdutyofficer(DQHM)hadbeeninformedaboutthefireandcametotheharbourcontrolofficetomonitortheincident.HewasconcernedthatCommodore Clipper’sconditionwasdeterioratingmorequicklythanhadbeenanticipated.HecalledSolentCoastguardat0600toinformthemthatthemasterwasnolongerwillingtoentertheharbourandthatthevesselwasgoingtoanchor.DQHMaskedSolentCoastguardiftheMIRGwasstandingby,andifitshouldbesentouttothevesseltoassesstheextentofthefire.SolentCoastguardagreedthattheywoulddiscusstheoptionsfordeployingtheMIRGwiththeFLM.

OnboardCommodore Clipper,thechiefengineerhadbeenunabletostartthebowthrustersandhadgonetochecktheforwardmooringequipmentwhichwaspoweredfromthesamepartoftheelectricaldistributionnetwork.Nopowerwasavailabletoeitherthebowthrustersortheforwardmooringequipment,soalthoughtheanchorcouldbeletgo,itcouldnotberecovered.Consequently,themasteradvisedQHMthathenolongerwantedtogotoanchor.Commodore ClipperwasnowinthevicinityofOSB,andSD Bustler,thedutytug,wasstandingbytoassistifnecessary.

ThechiefengineerreturnedtothebridgeanddiscussedthesituationwiththemasterandDPA.ThemastercalledSolentCoastguardbyradio,andat0618updatedthemofCommodore Clipper’sdeterioratingcondition.Heaskedfora‘fire advisor’tobesentouttothevesselbyhelicopterasaccessbypilotladderwasontothemainvehicledeck,andthereforenotusableduetothefire.Thecoastguardofficeraskedthemastertoconfirmthathewantedtorequestafireadvisor.Themasterreplied,‘yes, I think so’.

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1.5 INITIALEMERGENCYRESPONSE

1.5.1 Commandandcontrol

SolentCoastguardwasresponsibleforco-ordinatingtheSARresponse,butcommandoftheemergencyonboardCommodore Clipperremainedwiththemaster.WhileherequiredpermissionfromQHMPortsmouthtoentertheharbour,andpermissionfromPIPtoberth,itwasforthemastertorequestfromSolentCoastguardwhatassistancehefeltherequired.TheSecretaryofState’sRepresentative(SOSREP)hadnotyetbeeninformedabouttheincident,andthestatutorypowersofintervention,exercisedbyhim,hadnotbeeninvoked.

Co-ordinationofemergencieswithintheSolentandsurroundingareasrequirestheco-operationofanumberofdifferentagencies,includingtheemergencyservices,localgovernmentandportauthorities.AsystemknownasSOLFIREhasbeendevelopedtoprovideaninfrastructureforthecommand,controlandcommunicationsneededtomanageemergencies.Intheearlystagesoftheincident,SolentCoastguarddidnotconsiderthefireonCommodore ClippertobeseriousenoughtowarrantactivatingSOLFIREprocedures.

SolentCoastguardhadinformedtheHFRScontrolcentreaboutthefireonboardCommodore Clipper,andarrangedforHFRSunitstomeetthevesselatPIP.HFRSunitsbegantoassembleatPIPfrom0450,andfireofficersmetwithCMS’soperationsdirectorandtechnicalsuperintendentstostudytheship’splansanddiscusshowtoattackthefire.

1.5.2 Specialistfire-fightingsupport

TheMIRGisapartnershipbetweentheMCAandthe15coastalfireandrescueservices4,anditsfunctionistodealwithfires,chemicalreleaseandindustrialaccidentsatsea.TheMIRGdoesnothaveauthoritytounilaterallydeploytovesselsindistress;itisthereforenecessaryforthemasterofavesseltospecificallyaskforMIRGassistance.

SolentCoastguardcalledtheFLMat0621,updatedhimonthedeterioratingsituationonCommodore Clipper,andinformedhimthatthemasterhadasked‘for a fire crew’. TheFLMaskedtobeputincommunicationwiththemaster,andaradiotelephonecallwasarranged.ThemastergavetheFLMasummaryofwhathadbeendone,butwasunabletoconfirmifthefirewasstillburning.Themasterreportedthatcrewcouldre-enterthemainvehicledecktodeterminetheextentofthefire,andtheFLMadvisedthemasterthatitwouldtake60-90minutesbeforeaMIRGteamcouldbemustered.

BoththemasterandFLMinterpretedthesubsequentdiscussiondifferently:themasterrelayedtotheDPAthattheFLMdidnotwanttodeploytheMIRGuntiltheextentofthefirewasknown,andtheFLMthoughttheopposite;thatthemasterdidnotwanttheMIRGtodeployuntilthecrewhaddeterminedtheextentofthefire.TheconversationwasconcludedwithbothmenagreeingthatthedecisiontoactivatetheMIRGshouldbedeferreduntilafterthecrewhadre-enteredthemainvehicledecktoassessthefire.

Immediatelyaftertheconversationwiththemaster,theFLMstartedmakingpreparationstoassembleanddeployaMIRGteamincasetheywererequired.HeaskedSolentCoastguardtoidentifythenearesthelicopterthatwascapableofcarryingsixfirefightersandtheirequipmenttoCommodore Clipper.Thecoastguard

4 ThefollowingFireandRescueServicescontributetotheMIRG:Cornwall,Guernsey,Hampshire,Jersey,Kent,EastSussex,Suffolk,Lincolnshire,Humberside,HighlandsandIslands,Strathclyde,LothianandBorders,Northumberland,NorthWales,andMidandWestWales.

17

helicopterstationedatLee-on-the-Solentwasnotlargeenoughtolifttheteaminonego,andSolentCoastguardaskedtheAeronauticalRescueCo-ordinationCentre(ARCC)atKinlosstoidentifyamoresuitablehelicopter.ASeaKinghelicopterfromRoyalAirForce(RAF)Wattisham,49minutesflyingtimeawayinSuffolk,wasputonstandby.

DQHMhadlistenedtotheconversationbetweentheFLMandCommodore Clipper’smasterandtelephonedSolentCoastguardtoreportthatheintendedtodeclareSOLFIREinhisareaofresponsibility(East).SOLFIREEast,categoryB,wasformallydeclaredbyQHMat0635.QHMexpectedthatpersonnelfromtheotherorganisationsrespondingtotheincidentwouldautomaticallycometoQHM’scontrolcentreaspartoftheSOLFIREplanstoco-ordinateactivities.SolentCoastguarddiscussedtheimplicationsofthe‘B’categorisationandcheckedtheSOLFIREprocedures.CategoryBwasintendedformoderatescaleincidents,anddidnotrequirepersonnelfromdifferentagenciestoco-locateattheleadauthority’s(QHM)controlcentre,unlesstheywerespecificallyasked.Accordingly,thecoastguard,FLMandHFRSremainedintheirownseparatelocations.

1.5.3 Firstre-entrytothemainvehicledeck

Thechiefofficerandoff-watchsecondofficerdressedinfirefighters’suitsandBA,andbegantore-enter5themainvehicledeckatabout0640.Theyusedanaccesstrunkontheportsideofthevesselthatwasslightlyaftofthefire.Thetrunkledfromtheuppervehicledeckallthewaydowntothestabiliserroomandhadadoorandsmallhalflandingatdeck4,slightlybelowtheleveloftheroofsofthefreighttrailers(Figure8).

5Re-enter/re-entry:usedinthiscontexttodescribetheactivityofenteringacompartmentinwhichafireis,orwas,burning.UsuallyinvolvesteamsofpersonnelwearingBA.

Figure8

Accessplatformatdeck4abovethemainvehicledeck

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Findingthestabiliserroomsmoke-logged,butundamagedbyfire,thetwoofficersopenedthedoorontothelandingatdeck4level.Supportedbythesecondofficerandconnectedbyalife-line,thechiefofficerclimbedontotheroofoftheclosestfreighttrailerandcrawledforward.Hecouldseeabout1mthroughthesmokeandwasabletomoveforwardsapproximately5-7m,totheendofthetrailer.Therewasnotmuchheatandnosignofglowingorflickeringlightthatwouldindicatethattherewereflamesnearby.Decidingnottojumpontotheneighbouringtrailerandgetcloser,thechiefofficerreturnedtothelanding;heandthesecondofficerleftthemainvehicledeck.At0655theytoldthechiefengineer,whowaswaitingnearby,whattheyhadfound.

Theseniorofficersgatheredonthebridgeshortlyafter0700toreviewthesituation.Despitethechiefofficernotseeinganyflames,therewasaconsiderableamountofpersistentsmokeandhecouldnotconfirmifthefirewasout,orifitwasstillburning.Thechiefandsecondofficersstartedplanningasecondre-entry,thistimefromthegreenstairsattheforwardendofthemainvehicledeckonthestarboardside.

1.5.4 Preparationsforenteringharbour

TheDPAandmastercheckedthestabilitycalculationsthatwerecompletedwhenCommodore ClippersailedfromJersey.Theysatisfiedthemselvesthatthevesselhadasubstantialmarginofstabilityandcouldtoleratesomedrencherwateraccumulatingonthemainvehicledeckwithoutbecomingunstable.Therewasnowayofcalculating,eitheronboardorinCMS’sofficeashore,whattheactualreductiontotheship’sstabilitywas,orthemaximumamountofwaterthatcouldbeallowedtoaccumulateonthevehicledeckbeforethevessel’sstabilityreducedtoadangerouslevel.CMSdidnotemployanemergencyresponseservicetoassistwithstabilityanddamageassessments,andtherewasnoregulatoryrequirementforthecompanytohavesucharrangementsinplace.

DQHMwasgrowingmoreconcernedthatCommodore Clippermightloseallpowerandrequireasecondtugtoconducta‘coldmove’6tobringthevesselintoharbour.ColdmovesofwarshipsandRoyalFleetAuxiliaryvesselswithinthenavaldockyardarecommonplace.TheyareroutinelyconductedbyanAdmiraltypilotwhocontrolsthetugsand,undertheQueen’sRegulationsfortheRoyalNavy,takesresponsibilityforthemovefromthecaptainofthevessel.At0642,DQHMdecidedtomakepreparationstodespatchasecondtugandembarkanAdmiraltypilotonCommodore Clipper.DQHM’sintentionwasthatthepilotwould:fulfiltheroleofforwardcontrolofficer(inaccordancewiththeSOLFIREplan),supportthemaster,provideassurancethattheconditionofthevesselwouldnotposeunduerisktothenavaldockyardand,takecontrolofthetugsifrequired.

HFRShadagreedtotheFLM’srequesttoputthelocalMIRGteamonstandby,andat0705theFLMreportedthatallthearrangementswereinplaceshouldtheMIRGberequired.CoastguardofficerswouldnormallyinformtheMCA’sdutyCounterPollutionandSalvageOfficer(CPSO)aboutapotentiallyseriousincidentassoonastheycould.TheyrealisedthattheyhadoverlookedthisandbriefedthedutyCPSOat0711.ThedutyCPSO’srolewastomonitortheincidentinordertoanticipateandreacttorisksofpollution,requirementsforsalvageassistanceorother,widersupport.TheCPSO’srolewasalsotobrieftheSOSREP,discussingifhisinvolvementwasmerited,identifyingifoneoftheMCA’sspeciallytrainedMarineCasualtyOfficersneededtobedeployedtothevessel,orifstatutoryintervention

6 ‘coldmove’–tomanoeuvreavesselwithouttheuseofitspropulsionsystem(s).

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neededtobeconsidered.However,theCPSOwascontentwiththewaytheincidentwasbeingmanagedandrequirednofurtherinterventionatthatstage,andsodidnotnotifytheSOSREPoftheongoingincident.

Commodore Clipper’smasterheldaPilotageExemptionCertificate(PEC)forPortsmouthharbourandhewouldnotnormallyhaverequiredtheassistanceofeitheranAdmiraltypilotforthetransitthroughthenavalbase,oracommercialpilottoberthatPIP.Theusualmeansofembarkingapilot(throughadoorinthehullplatingthatledontothemainvehicledeck)couldnotbeemployedbecausethecompartmentwasseverelysmoke-logged.Asanalternative,apilotcouldeitherbehoistedonboardusingCommodore Clipper’sfastrescueboat,orwincheddownfromahelicopter.QHMconsideredthatthequickestoptionwastotransfertheAdmiraltypilotbycoastguardhelicopter;at0718DQHMaskedSolentCoastguardifthiscouldbearranged.Thecoastguardofficerswereintheprocessofhandingovertotheoncomingwatch,butagreedtoaskthehelicoptercrew.Inthemeantime,theAdmiraltypilotstartedtravellingtothecoastguardhelicopterbaseatLee-on-the-Solent.

1.5.5 Secondre-entrytothemainvehicledeck

Ataround0720,theoff-watchsecondofficerreportedtoCommodore Clipper’smasterthatmorehotspotsweredevelopingontheuppervehicledeckattheforwardendoftheramp.Itwasalsoreportedthatmoresmokewascomingintotheaccommodationfromthegreenstairwell.

A4-manteamwasassembledanddressedinfire-fightingsuitsandBA,andthesecondre-entrytothemainvehicledeckbeganat0735.Theteamenteredfromthegreenstairsattheforwardendofthemainvehicledeck,ontheoppositesidefromthefire.Connectedbylife-lines,butwithouthosesorfireextinguishers,theteammadeitswaythroughthedenselypackedcargobycrawlingunderthetrailers.Theteamreportedthattheycouldnotfeeltoomuchheatatdecklevel,butthatvisibilitywaslimitedandprogresswasextremelyslow.LargenumbersofJerseyRoyalpotatoeshadspilledfromthefire-damagedtrailers;movingthroughthis,thetrailerlashingchains,andotherdebrisfromthefirewasfoundtobeverydifficult.

TrailerCRF459andtheoneimmediatelyaheadinthesamelane,trailerCRF461,werebothseentobeonfire(Figure9).Thecurtain-sidesonthetrailerswereburning,withtheplasticcurtainmaterialdescribedasdrippingdown,givingtheappearanceoflotsofcandleflamesandleadingtomultipleseatsoffire.Thechiefofficerwasabletoliftpartofthecurtainononeofthetrailers,andsawthatthepackagingmaterialsandplasticcratescontainingtheJerseyRoyalpotatoeswerealsoonfire.Therewaslittleevidencethatwaterfromthevehicledeckdrenchershadpenetratedinsidethetrailerorofhavingmucheffectonthefires.Theteamwithdrewandreportedtheirfindingstothemasterat0755.

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1.5.6 PlannedentrytoPortsmouthHarbour

PIP’scrisisteamhadbeenalertedabouttheincidentat0710,andacceptingthatthevesselwouldneedtoberth,begantomaketheirpreparationsforsupportingCommodore Clipperonarrivalintheport.ThePIPcrisisteamsetupintheport’sconferenceroom,closetotheferryberths.

DQHMandotherkeyQHMstaffhadrelocatedtotheirmajoroperationsroom,anticipatingthatpersonnelfromotheragencieswouldstartarrivingtoco-ordinatetheresponsetotheincident.At0736,DQHMcalledSolentCoastguardtoaskforanupdateandwastoldthatthecoastguardwatchofficerwasalreadyinconversationwithQHM’sportcontroloffice.DQHMaskedthatallcommunicationsnowbedirectedthroughQHM’soperationsroom,whichshouldnowbethecommandcentrefortheSOLFIREresponse.TheDAO,FLMandseniorofficersfromHFRShadgonetoSolentCoastguard’scontrolroom,andasSOLFIREBproceduresdidnotrequirethemtorelocate,theyallremainedthere.CMSstaffandotherHFRSofficersstayedinCMS’sofficesinPIP.

Thesecondtug,SD ReliablebeganstandingbyCommodore Clipperat0812.ItwasanticipatedthatoncetheAdmiraltypilothadbeenwinchedonboardbythecoastguardhelicopter,Commodore ClipperwouldreachOSBatbetween0830and0845andentertheharbourshortlythereafter.

1.5.7 Sternramphydraulics

Thechiefengineer,awarethatothersystemshadbeendamagedbythefire,wenttotheengineroomtocheckandtestthehydraulicsystemthatoperatedthesternrampunlockingandloweringmechanism.At0838,hereportedtothemasterthat

Figure9

Cargostowagediagram

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thesystemcouldnotbestarted.Withnootherwaytolowerthesternramponcealongside,thechiefengineerassistedbythesecondandthirdengineers,andtheelectricalfittersetaboutresolvingtheproblem.

Suspectingthatfirehaddamagedelectricalcontrolcircuits,thechiefengineerdirectedtheteamtoconductacompletecheckofthesystem.Theyfoundthat,coincidentaltothefire,anisolatingswitchthatprovidedelectricalpowertothehydraulicpackhadfailed.Theswitchwasreplaced,butthesystemstillwouldnotrun,sotheteamcheckedallthecontrolcircuits.Firedamagetocablesconnectingemergencystopbuttonsonthevehicledeckhadcauseda‘stop’signaltobegenerated,whichpreventedthesystemfromrunning.Theemergencystopcircuitwasisolatedandthechiefengineerbrieflystartedthehydraulicpacktocheckitwouldrun.

1.5.8 Helicoptertransfer

TheAdmiraltypilotwastransferredbypilotboattoGosportandwascollectedbyoneofthecoastguardofficersfromtheoff-goingwatch.TheyarrivedattheLee-on-the-SolentcoastguardhelicopterbasetofindthatthehelicoptercrewwerenotexpectingthemandhadnoknowledgeoftheneedtoflytheAdmiraltypilotouttoCommodore Clipper.ThecoastguardofficercalledSolentCoastguardat0801totrytoobtaintheproperhelicoptertaskinginstructions.

By0815,thechiefhelicopterpilotwasconcernedthathisaircraftmightnothavethecapabilitytoremainwithintheoperatingrulesfornormalpassengertransfersintheprevailingwindconditions.TheaircraftcouldachievethetaskifSARruleswereapplied,butcoastguardofficerswouldneedtodeclarethattransferringtheAdmiraltypilotwasaSARtask.

AcommercialpilotfromPIPwentouttoCommodore Clipperbypilotboattoassist,andarrivedonsceneat0825.Ataboutthesametime,DQHMandSolentCoastguardwerediscussingtheproblemsofflyingtheAdmiraltypilotinthecoastguardhelicopter.DQHMnotedthatCommodore Clipper’sconditionwasdeteriorating,andthatitwascriticaltogettheAdmiraltypilotonboardsothatthevesselcouldbebroughtalongsideassoonaspossible.

InordertoprovideapotentialmeansofembarkingthecommercialpilotontoCommodore Clipper,thesecondofficerbegantopreparetherescueboatsothatitcouldbeloweredatshortnotice.Thechiefengineeralsopreparedwatercoolingattachmentsfortheoutboardenginesothatitcouldbestartedandwarmedthroughbeforebeingputintothesea.TheplanwastolowertherescueboatsothatthecommercialpilotcouldclimbontoitfromthepilotboatandthenbehoistedonboardCommodore Clipper.

Thehelicopterwasformallytaskedat0827withinstructionstoflywiththeAdmiraltypilottoHaylingIsland,embarkaCoastguardLiaisonOfficer(CGLO)andthenflytoCommodore ClipperandwinchboththeAdmiraltypilotandCGLOonboard.ThisplanshouldhavehadtheAdmiraltypilotonboardbyabout0850.TheplanwasrelayedtoCommodore Clipperandthemasterdecidedthatitwasnotworthexposingthecommercialpilottothepotentialriskofbeinghoistedupintherescueboat,particularlyasQHMhadsaidthatanAdmiralty,ratherthanacommercial,pilotwasrequired.

At0845,thewatchmanagerfromtheoncomingshiftatSolentCoastguardupdatedARCCKinlossonthelatestsituation.ThewatchhadalsorecentlychangedatARCCKinlossandbothofficersagreedthat,withhindsight,itwouldhavebeenprudenttohaverepositionedthelargerhelicopterfromRAFWattisham(R125)toLee-on-the-SolentandembarkedtheMIRGteamtoassessthesituation.ItwasacceptedthatthiswindowofopportunityhadnowclosedandthepriorityshouldnowbetogetCommodore Clipperalongsidewithoutfurtherdelay.

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Throughoutthisperiod,thecoastguardhelicopterbasedatLee-on-the-Solent(R104)hadbeenundergoingitspre-flightchecksandanintermittentproblemwithitsrotorbrakehadbeenfound.At0850,thepilotinformedSolentCoastguardthattheaircraftwasunserviceableandthatcrewweretryingtorepairtheproblem.Immediatelyafterwards,SolentCoastguardrequestedARCCKinlosstoscrambleR125fromRAFWattisham.ARCCKinlossalsoofferedR106,ahelicoptersimilartoR104,basedatPortlandinDorset.ThisofferwasinitiallydeclinedbySolentCoastguardasR106didnothavethecapacitytoliftawholeMIRGteaminonego.

1.5.9 Delay

Commodore Clipper’smastercalledSolentCoastguardat0905toupdatethemonthestateofthevesselandtheurgentneedfortheAdmiraltypilottobeembarked.HeconfirmedthatthefirewascontainedandthateventhoughaMIRGteamwasnowassemblingattheLee-on-the-Solenthelicopterbase,theirassistancewasnotrequired.

At0916,ARCCKinlossreportedthatR125hadtakenoffandwasexpectedtoarriveonsceneat1000.SolentCoastguardthenrequestedthatR106bescrambledfromPortlandtotransfertheAdmiraltypilotandCGLO:thisrequestwasmadesome25minutesafterR104hadbeenreportedasbeingunserviceableandR106hadbeenofferedasareplacement.

By0930,R106wasonitswaytoLee-on-the-Solent,withanestimatedtimeofarrivalof0952.R104wasbeingrepairedandwouldnotbeavailableforatleastanhour.SolentCoastguardinstructedthecrewofR106toembarktheAdmiraltypilotonCommodore Clipperimmediately,beforegoingtoHaylingIslandtocollecttheCGLO.

TheDAOaskedQHMifaMIRGteamshouldassesstheconditionofCommodore Clipperbeforethevesselenteredtheharbour.QHMreportedthatthetidalstreamthroughtheentrancetoPortsmouthHarbourwasnowbuildingand,by1045,wouldbetoogreatforthetugstomanoeuvreanunpoweredvesselthroughtheentrancewithanacceptablemarginofsafety.ItwasagreedthatdeployingaMIRGteamatthisstagewouldcausefurtherdelaysandthatsecuringCommodore Clipperalongsideshouldremainthetoppriority.

1.5.10EntryintoPortsmouthHarbour

R106landedatLee-on-the-Solentat0951andcollectedtheAdmiraltypilot.HewaswinchedontoCommodore Clipperat0956.Immediatelyafterboarding,hecalledQHMandwasgivenpermissionforCommodore Clippertoentertheharbour.ThehelicopterdepartedtocollecttheCGLO,whowaswinchedonboardCommodore Clipper at1015.

ThemasterandAdmiraltypilotagreedtosecurethetug,SD Bustler,tothebowofCommodore Clipper.Thelinewastobekeptslack,butbereadyforimmediateuseifCommodore Clipperwasaffectedbyfurthersteeringcontrolproblems.SD ReliablewasinstructedtomaintainstationonCommodore Clipper’squarter.TheAdmiraltypilotaskedQHMtoconfirmwithPIPwherethevesselshouldberth.

Commodore ClippernormallyusedBerth5,themostnortherlyofthelinkspanberthsavailableatPIP(Figure10).Whileadequatefornormalservice,thisberthwasregardedasbeingthemostchallengingtouse,andPIPofferedBerth4asanalternative.ThemasterhadassessedthatBerth2wastheeasiestforhimtouse;itallowedhimtotakeadvantageoftherelativelyshelteredbasintoturnthevesselthrough180oandprovidedenoughspaceforthetugstobeabletoworkeffectively.

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Figure10

ChartwithinsetshowingtheberthsavailableatPIP

ReproducedfromAdmiraltyChartBA2631bypermissionoftheControllerofHMSOandtheUKHydrographicOffice

Berth5

Berth4

Berth2

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ThemasterconnedCommodore ClipperthroughoutthetransitofPortsmouthharbour.DiscussionaboutwhichberthshouldbeusedcontinuedbetweenSolentCoastguard,QHMandPIP.ItwasagreedthatBerth2couldbeused,butQHMwasconcernedthatthevesselcouldbeunstableandthatthe180oturnmightleadtoariskofcapsize.Consequently,itwasrecommendedthatCommodore Clipperberthbowontothelinkspan(ship’sheadeast).Asthevesselonlyhadasternrampandwouldnothavebeenabletodisembarkthepassengersorcargo,themaster,supportedbyCMSmanagersandDPA,electedtoturnherandberthsternto(ship’sheadwest).

Themastercommencedtheturnat1037andCommodore Clipperwassecuredalongsideat1055.UnitsfromHFRShadbeentoldtoexpectthevesseltouseeitherBerths4or5andtheyhurriedtorelocatetoBerth2.

1.6 EMERGENCYRESPONSEONCECommodore ClipperwASALONGSIDE

1.6.1 Pedestrianaccess

ThedesignofCommodore Clippermeantthattheonlyaccessroutefromthevesseltoshorewasviathemainvehicledeck(deck3)andthroughthesterndoor.Innormalservicethisworkedwell;themajorityofpassengersdrovetheirvehiclesonboard,andanyfootpassengerswerebroughtonbyminibus.Therelativelyfewfootpassengersthatwerecarried,andthesignificantchallengespresentedbythelargetidalrangesintheChannelIslandports,meantthataseparatepedestrianaccesswasnotrequiredandwouldhavebeendifficulttoarrange.Therewasnoregulationthatrequiredthevesseltohaveaprotectedroutetoapositiononboardwhereasecondaccesspointorgangwaycouldberigged.

CMSandPIPstaffhadidentifiedthatitwouldnotbepossibletogainaccesstothevesseloverthesternramp,andagreedtouseagangwaythathadbeenconstructedtoservevisitingcruiseships.Thegangwaywasliftedbycraneandrestedonguardrailsontheuppervehicledeck(deck5).HFRSofficers,CMSstaffandthePIPharbourmasterwereabletoboardCommodore Clipperatabout1130.

ThegangwayarrangementwasnotconsideredsatisfactoryforfurtheruseandpermissionwasgivenforPIPstafftocutawaytheship’sguardrailsothattheupperendofthegangwaycouldberestedonthedeck.Thegangwayandtemporaryguardrailsweresecuredat1145.MAIBinspectorsboardedthevesselat1200andfoundthatwhilethegangwayitselfwasadequate,thehighdensityoffreightvehiclesontheuppervehicledeckmadeitdifficultnotonlytogetoffthegangway,butalsotomoveacrossthedeckinordertoaccesstheaccommodation.

1.6.2 Passengerevacuation

ThepassengershadallbeenmusteredagaininpreparationforenteringPortsmouthharbour.Somediscomfortfromsmokewasreported,butallthedomesticandgalleyservicesremainedavailableandpassengerswereprovidedwithfoodandrefreshments.

CMS,PIP,HFRSandSolentCoastguardallrecognisedthatitwouldbeprudenttodisembarkthepassengersassoonaspossible,particularlyastherisingtidemeantthatthegangwaywouldsoonbecometoosteeptouse.Membersoftheemergencyservicesandmarinepersonnelwhohadboardedthevesselhaddonesowithoutsustaininganyinjuries,butfoundmovingacrosstheuppervehicledeckdifficult.Thedistancesbetweenfreightvehicleswere,inplaces,aslittleas150mm,andatbest450mm.Inmanycasesitwasnotpossibletowalkbetweenvehiclesandtheonlyroutewastocrawlundertrailerswheretheyweresupportedbytrestles.Freightvehicleswerelashedtothedeckwithchains,causingtriphazards.Obstructionsfromship’sfittings,cargoandtrailerspresentedmanyadditionalhazardsandahighdegreeofawarenesswasrequiredtoavoidinjurywhenmovingacrossthedeck.

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MAIBinspectorslaterfoundaroutethroughthetrailersontheuppervehicledeckthatcouldhavebeenmoreacceptableforable-bodiedpassengerstouseiftheywerecarefullysupervisedandescorted.Aslightlywidergapexistedbetweenthetrailersandthecentre-linecasing.Itmighthavebeenpossibletohavefollowedthisgapaft,thencrossthemooringdecktothestarboardsideofthevesselandwalkforwardtothegangwayposition.

BoththelifeboatandtheMarineEvacuationSystemontheport(outboard)sidewereavailableforuseifthesituationdeterioratedsuddenly.Thereisariskofpersonalinjurywhenusingtheseemergencysystemsonanyvessel,anditwasagreedbetweenCMSseniorstaff,thePIPharbourmaster,HFRSofficersandtheCGLOonCommodore Clipperthatthepassengerswouldbeatleastriskiftheyremainedonboarduntilthefirewasconfirmedashavingbeenextinguished,andthendisembarkedoncetherewasaclearroutetowalkthroughthemainvehicledeck.

1.6.3 Assessment

HFRSofficersconcludedthatthebestmeansofattackingthefirewastoopenthesternrampandallowthesmoketoclearbeforefirefightersenteredthecompartment.Thepossibilityofthefiredevelopingduetotheincreasedventilationwasacknowledged,andhosesweresetupatthesterntoprovideawatercurtaintocontainthefire.HFRSmanagersrecognisedthatitwouldtakeasignificantamountoftimeandresourcestodealwiththeincident.Theycalledforamobilecommandcentre,BAservicingworkshopandcateringunittocometoPIPtosupportthefire-fightingeffort.At1219,theCGLOinformedSolentCoastguardthatHFRSbelievedthatitwouldbeaprotractedincident.

Commodore Clipper’ssternrampwasopened,usingcontrolsontheuppervehicledeck,byabout1mshortlyafter1230andthenslowlyopenedtoitsfullextentoverthenextfewminutes(Figure11).Theredidnotappeartobesignificantamountsofsmokeinthemainvehicledeckandnoflamescouldbeseenfromthelinkspan.Itwasagreedthatasmuchcargoaspossibleshouldberemovedfromthemainvehicledecktoimproveaccesstowherethefirehadstarted.

Figure11

Viewofthemainvehicledeckafterthesternrampwasopened

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Asthesternrampopened,itwasnotedthatitdidnotmakecontactwiththelinkspanoverthefullareathatwasneededtospreadtheloadproperly.ThePIPharbourmasterwasconcernedthatthesternrampandlinkspanmightbedamaged,orworse,thatinthisstatethestructuresmightnotwithstandtheloadfromthevehiclesascargowasdischarged.Atabout1300,thesternrampwaslifted,thegangwayremovedandCommodore Clippermovedastern.Thevesselwasre-positioned,thesterndoorre-opened,andfrom1315onwardsitwaspossibleforsometradecarsandatrailercontaininghandbaggagetodisembark.

Thelevelofsmokeintheafterpartofthemainvehicledeckwastolerableinitiallyandcrewwereabletobeginunlashingthefreighttrailersnearestthestern.TheCCTVsysteminPIPrecordedthefirstthreeroadfreighttrailersbeingremovedfrom1320to1325.Theamountofsmokeincreasedsignificantlyaspersonnelmovedfurtherintothemainvehicledeckandoperationstoremovefreightwerestopped.

1.7 FIRE-FIGHTINGTACTICS

1.7.1 Visibility

Firefightersriggedhosesandledthemintothemainvehicledecktowardstheforwardendoftheship.Visibilitywasseverelyreducedassmokelevelsincreasedclosertotheseatofthefire.This,combinedwiththedifficultyofmovingbetweentrailersandthebuildupofdebrisonthedeckfromspilledcargo,madeitextremelyslowandhazardousforthefirefighterstogetclosetothefire.

Thevehicledeckdrenchingsystemwasveryeffectiveatreducingthelevelsofsmoke,butreducedvisibilityfurtherwhileitwasoperating.Itwasfoundthatdrenchingforabout20minutesandthenturningthedrenchingsystemoff,gaveaperiodofabout15minutesofimprovedvisibilitybeforethesmokebuiltupagain.Thistacticwasusedmanytimesduringthenextfewhours,andeachtimethefirefighterswithdrewfromthevehicledeckbeforethedrencherswerestarted.ThiswasreportedtoSolentCoastguard,butthewithdrawaloffirefighterswasinterpretedasbeingduetothemhavingbeenbeatenbackbythefire,ratherthanaspartofaplannedstrategy.

Firedamagetopowercablesandventilationfansinthemainvehicledeckpreventedanyofthevessel’sventilationsystemsfrombeingusedtoclearthesmoke.Theaccessdoorstothegreenstairsontheuppervehicledeckwereopenedandanoff-dutychiefengineerfromCMS,whohadcometohelphiscolleagues,donnedaBAsetandwentdownthegreenstairsandopenedupthedoorontothemainvehicledeck.Thewindwasblowingfromthestern,andstartedtoforcesmokeupthegreenstairsandintotheuppervehicledeck.Theforward,semi-enclosed,partoftheuppervehicledeckbecamesmoke-logged,butvisibilityinthemainvehicledeckbegantoimprove.

1.7.2 Escalation

Openingupthesterndoorandthegreenstairsallowedmoreairtogettothefireanditstartedtoburnmoreintensely.Duringtheperiodfrom1330to1430,thetemperatureoftheuppervehicledeckgraduallyincreasedandmoresmokewasproduced.Thevehicledeckdrenchingsystemwasturnedonagain,andtopreventanyfurtherstabilityproblems,Commodore Clipperwastrimmedbythesternsothatallthedrencherwatercouldflowoutoftheopensterndoor.Somewaterhadaccumulatedononesideofthemainvehicledeckandfromabout1400to1415,andagainfrom1445to1500,theheelingsystemwasoperatedtomakethevessellistfromsidetosidetohelpdraintheremainingwater.Boomswereriggedaroundthevesseltocontainthesmallamountofoilresiduesthatdrainedoverboard.The

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combinedeffectofusingtheheelingsysteminthiswayandseeingwaterflowingaboutinsidethemainvehicledeckgavetheappearanceofthevesselbeingunstableandpotentiallyinastateofloll.

MCACoastguardandsurveyingstaffwereobservingthevesselfromthelinkspan.Theyhadnotbeenbriefedonthefire-fightingtactics,theuseofthedrenchers,orheelingsystemandtheybecameincreasinglyconcernedaboutthestabilityofthevesselandsafetyofthepassengers.Commodore Clipperhadmovedabout2masterntomakepropercontactwiththelinkspan,butbuildingsontheberthnowobstructedthecruisepassengergangwayandpreventeditfrombeingputbackinposition.Substantialfittingsontheuppervehicledeckofthevesselwouldhavehadtobecutawayinordertore-positionthegangway;asithadbeendecidednottodisembarkthepassengersimmediately,itwasnotreplaced.HFRShadriggedaladderfurtheraftfromthegangwayposition,andat1500anAerialLadderPlatform(ALP)wassetuponthelinkspantoliftpersonnelandequipmentonandoffthesternofthevessel.

At1510,MCArepresentativesrequestedCMSstafftoarrangeforthepassengerstobedisembarkedusingthelifesavingapparatus.Thiswasdeclined.SolentCoastguardtelephonedQHMat1515withasimilarrequest.Thecontentofthecallwaslogged,anditwasnotedthatseniorMCAstaffwerekeenforQHMtoputpressureonCMStodisembarkthepassengers.QHMrelayedthecontentofthemessagetothePIPcrisisteam.

Smokefromthemainvehicledeckhadalsopenetratedthebluestairwell,whichledupfromthecentrelinecasingonthemainvehicledecktotheaccommodation.Makingare-entryontothemainvehicledeckfromthispositionhadseveraladvantages:theentrypointwasclosertothefire;and,firefighterscouldfollowthecentrelinecasing,whichnotonlygavethemawell-definedroute,butalsoshieldedthemfromthefire.HFRSfirefighterscouldonlymakeare-entryfromthispositionifthesmokecouldbecleared,andtheoff-dutychiefengineerincreasedthespeedoftheengineroomventilationfansandheldopenthedoorsfromtheengineroomintothebluestairwelltoallowtheexcessairtoescapeandforcethesmokeout.ThismethodhadbeensuccessfullydevelopedduringanearliertrainingexerciseconductedwithHFRS.

Withthesmokeremoved,firefighterswereabletomakere-entriesontothemainvehicledeckfromthebluestairwell.Debrisfromfire-damagedtrailerswasmovedtoimproveaccess,butseveralnewfiresdevelopedaspartiallycombustedmaterialwasexposedtotheair.Itwasobservedthatthemainseatofthefirehadspreadtotwomoretrailers,CR439andFS61inlane1ontheportsideofthemainvehicledeck(Figure9).ThefirehadspreadtotrailersGC13-1andFS61,asburningcargofellfromtheneighbouringtrailers.ApartiallyburntpotatocratewasfoundstucktothesideoftrailerFS61(Figure12).Theconstructionofthetrailersandtheirproximitytooneanotherpreventedthefirefightersfrombeingabletoreachallthefiresthatwereburninginsideandaroundthetrailers.

HFRSusedtheALPtoloadmoreequipmentandfirefightersontothevessel.Thefirewasattackedfromboththesternandthebluestairwelluntilshortlyafter1600,whenvisibilitybecameunacceptablylowandthedrencherswererestarted.

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PartiallyburntdebrisontrailerFS61

Figure12

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1.7.3 Cargohandling

WhenthefirewasfirsttackledviathesterndoorithadbeenpossibleforcrewtounlashthetrailersnearthesternwithoutanyneedforthemtowearBA.Similarly,thesmokelevelswerelowenoughforthestevedorestooperatethetrailer-handlingtractors(knowngenericallyastugmasters)inthenormalway.

By1630,thedrenchershaddampeddownthefiresandvisibilityhadimproved.Themainvehicledeckwasstillsmoke-loggedfurtherforward,anditwasnolongerpossibletounlashandremovethecargowithoutwearingBA.HFRSofficerswereuneasywiththeprincipleofallowingthecrewtoenterthemainvehicledeckwhilethefirewasburning.However,theyrecognisedthatthecrewwereneededtounlashthetrailersandthatthecrewallhadbasicfire-fightingtrainingandwerecompetenttoworkinBA.Commodore Clipperhadonly26cylindersfortheBAsetsonboard,theseweresoonusedupandthevesselhadnomeanstorechargethem.Thevessel’sBAsetswerecompatiblewiththoseusedbyHFRS,anditwasagreedthatcrewcouldborrowchargedcylindersfromHFRStofittotheirBAsetsandworkinpartnershipwiththefirefighterstoprogresstheremovalofthecargo.

Thestevedoreshadnoexperienceofworkinginsmoke-filledenvironmentsorwearingBA,andwerenotabletogetfarenoughintothemainvehicledecktoreachtheremainingcargo.Thefirehad,bynow,beenburningforabout14hoursandCMS’soperationsdirectorwasincreasinglyconcernedthatthetyresonthetrailerscouldhavebeendamaged,resultinginthetrailersbecomingunstableandcausingthesupportingtrestlestocollapse.CMSbeganmakingarrangementstocontractaheavyvehiclerecoverycompanytobringequipmentthatcouldbesetuponthelinkspanandthenbeconnectedtoeachtrailerinturntodragthemoutofthevessel.

Thefirewasstillcontainedbythecombinationofthedrenchersandattacksfromthefirefighters,butitcouldnotbecompletelyextinguishedwithoutremovingthetrailersfromthevehicledeck.HFRSofficersconsideredusingafirefighterwithaheavygoodsvehiclelicencetooperateatugmaster.However,tugmastersarehighlyspecialisedvehicles,withrotatingdrivingpositionstooperateinthereversemode,anditwasconsideredunlikelythatanyonewithoutpriorexperiencewouldbeabletooperateonesatisfactorily.

Oneofthestevedoreshadpreviouslytriedscubadivingwhileonholiday,andatabout1700hevolunteeredtoputonBAandcontinueusinghistugmastertoremovethecargo(Figure13).HFRSofficerswereextremelyconcernedabouthimworkinginthisway,butprogressinfightingthefirewaslimited.

FirefightersgavethestevedorebasictraininginhowtowearBA,andseveralfirefighterswerepositionedtomonitorhissafetyandassisthimifrequired.CrewenteredthevehicledeckusingBAand,withfirefighterscontainingthefire,startedtounlashthetrailers.Oncethetrailerswereunlashedandanyrefrigeratedunitsunpluggedfromtheelectricalsockets,crewclearedtheareaandthestevedoredrovethetugmasterintothemainvehicledeck.

Visibilityfromthecabofthetugmasterwaspoor,andreducedtozerointhethickestsmoke.Duetothelimitedspaceinthecab,theBAsethadtobeputtoonesideratherthanwornconventionally,andthelengthofthehosebetweenthecylinderandthefacemaskfurtherlimitedthestevedore’smovement.Thestevedoreusedhisknowledgeofthevesselandthemotionofthetugmasterasthetyresbumpedoverthelashingsecuringpointsinthedecktomanoeuvreintothecorrectpositionandattachtoeachtrailer.

Thestevedorereportedthatheremoved11trailersinthismannerandused7BAcylinders.Eachtrailertookbetween10and15minutestoremove,comparedwithabout5-6minutesinnormalcircumstances.

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1.7.4 Statutorypowersofintervention

At1710,theDAObriefedtheMCA’sDutyOperationsDirector(DOD)onprogresswithfightingthefire,andinformedhimthatthepassengerswerestillonboard.MCAstaffhadformedtheviewthatCommodore ClipperwaspotentiallyunstableandthatHFRSwerehavinglittlesuccessinfightingthefire.TheyconsideredthatthereasonforkeepingthepassengersonboardmightbeduetoCMSwantingtoavoidunfavourablemediacoverageofpassengersbeingevacuatedfromCommodore Clipperinalifeboat.

TheDODdirectedthattheDAOandCPSOshouldreviewhowthepowersofinterventionexercisedbytheSOSREPundertheMarineSafetyAct7mightbeappliedtoinfluencehowtheincidentwasbeingmanaged.From1730onwards,theCPSOandDutySOSREPstartedconsideringhowpowersofinterventionundertheMarineSafetyActmightbeusedtocompelCMSandHFRStoevacuatethepassengersfromCommodore Clipper.Atthesametime,theDAObeganpreparingplanswithSolentCoastguardtousehelicoptersR104andR106towinchpassengersoffthevessel.

By1800,theCPSOanddutySOSREPhadconcludedthatpowersofinterventionshouldnotbeusedasHFRSwasnowtheleadagencyfordealingwiththeemergencyandwouldnotintentionallyallowthepassengerstobeleftonboardatgreaterrisk.TheDODtelephonedSolentCoastguardtohavehisdissatisfactionandobjectionstothedelayinevacuatingthepassengersrecorded.

7MarineSafetyAct2003,Chapter16,Schedule1,‘NewSchedule3AtotheMerchantShippingAct1995–SafetyDirections’

Figure13

Stevedorewearingbreathingapparatusinordertoremovetrailersfromthesmoke-filledvehicledeck

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At1810,theCPSOrelayedhisconclusionstotheCGLOonboardCommodore Clipper,notingthattheincidentwasunderthecontrolofHFRS,themasterofthevesselandQHM,allofwhomwerereportedtobesatisfiedthatthepassengersweresafe.TheroleofPIPwasnotacknowledged.TheCPSOalsodiscussedthesituationwithCMS’sOperationsDirector,whoexplainedthefire-fightingstrategyandtheconsiderationgiventothebalanceofriskofevacuatingthepassengersagainstleavingthemonboard.ThelogkeptbystaffinCMS’sofficerecordedtheOperationsDirector’sviewat1839,thattheCPSOwascontentwiththecurrentplan.

ThedutySOSREPcontactedtheSOSREPtoadvisethattheDODhadrequestedtheuseofstatutorypowersofinterventiontobeconsideredinordertocompelthepassengerstobeevacuated,butthattheCPSOconsideredthatthepassengersweresafeandwouldbeputatgreaterriskiftheywereevacuatedbyemergencymeans.TheSOSREPaskedthedutySOSREPtoconfirmthiswiththeportauthoritiesandarrangedforoneofhisindependenttechnicaladvisorstoassessthesituation.At1915,theSOSREPtelephonedtheDODdirectlytoupdatehimanddiscussthesituationfurther.

1.8 FIREEXTINCTIONANDPASSENGERDISEMBARkATION

1.8.1 Accesstotheseatofthefire

Cargoremovalcontinuedandthefirstburningtrailer,CRF459,wasremovedfromCommodore Clipperat1855,10hoursafterthevesselhadmooredalongside.Cargowasstillalightinsidethetrailerandfirefighterscontinuedtodousetheflamesforanother10minutesafterthetrailerhadbeenremovedfromthevehicledeck.HFRSbeganaplannedwatchchangeoverat1900,fire-fightingandcargoremovalcontinuedwhilepersonnelconductedtheirhandovers.Fire-damagedtrailersCR439andFS61wereremovedat1910and1927respectively.

Asmoretrailersanddebriswereremoved,additionalfiresstartedandtwoteams,eachcomprisingfourfirefighters,continuedworkingonthemainvehicledeck.Asystemofcommunicationhadbeensetuptowarnthefirefighterswhenthetugmasterwasmovinginthevehicledeck,sothattheycouldkeepwellclear.However,atabout1930,twofirefighterswerefollowingahosetowardsthefire,whentheysawthetugmasteroperating.Theyretracedtheirstepsandwaiteduntiltheysawnomoremovement.Astheyfollowedthehosebacktowardsthefire,theyheardrushingwaterandfoundthatthehosehadbeencutbythemovementofthetugmasterandtrailer.Whiletheyweretryingtopassamessageforthewatertobeshutoff,theysawthelightsofthetugmasterreturningandhadtomovequicklyunderneighbouringtrailerstoavoidcollision.Thenear-misswasreportedandcargoremovalandfire-fightingwasthensuspendedwhiletheremaininghandoverswerecompletedandtheoncomingincidentcommandermadeafullassessmentofthesituation.

1.8.2 MCAresponse

TheMCAsurveyorstationedonthelinkspanissuedaprohibitionnoticetotheCMS’sOperationsDirectorat1945,requiringthat‘all operational activities (excluding those necessary for the immediate safety of the ship, safety of life, or the prevention of pollution of navigable waters)’ ceasedimmediately.

By2015theSOSREP’sindependentadvisorhadreportedbacktotheCPSO,statingthathewassatisfiedthatCommodore Clipperwasinnoimmediatedangerfromlossofstabilityandthatthefirewasbeingtackledappropriately.

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1.8.3 Removalofthelastburningtrailers

TrailerCRF461wasremovedat2015,stillburningstrongly(Figure14).Itwasbroughtupthelinkspanandparked,wherethefirewasextinguished.Thelasttraileraffectedbyfire,GC13-1,wasremovedatabout2100.

TrailerCRF461continuingtoburnafterbeingremovedfromthemainvehicledeck

Figure14

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From2100to2130firefightersextinguishedthelastremainingfiresinthemainvehicledeck.ParamedicsboardedCommodore Clipperviathemainvehicledeckatabout2125,totreatonepassengerwhowassufferingfromtheeffectsofapre-existingmedicalcondition.Debriswasremovedfromaroutethathadbeencleareddownthestarboardsideofthemainvehicledeckandpassengerswereassistedoffthevesselandontoawaitingcoachat2155.AllthepassengershadleftCommodore Clipperby2230,nearly20hoursafterthefirstindicationsofthefirestarting.

1.9 kEYPERSONNEL

1.9.1 Crew

ThemasterofCommodore Clipperwasaged52,hadspenthiswholecareeratseaandthelast25yearsworkingonferries.Hehadspent17yearsonthePortsmouth-ChannelIslandroutes,thelast8ofwhichhehadservedasmasterwithanunlimitedmaster’scertificateofcompetency(STCW8II/2).HestartedworkingonCommodore ClipperinApril2010,havingtransferredfromanothervesseloperatedbyCMS.Thiswasaroutinepracticeinthecompanytobringafreshperspective,bothtoseniorofficers’workingpracticesandtheoperationofthevessels.Likemostoftheotherofficers,themasterworkedacycleof2weeksworkand2weeksleave.HehadalsobeenthroughaprogrammeofunderstudyandhandoverwiththeexistingmasterofCommodore Clipperbeforetakingcommandhimself.ThemasterhadpreviouslyspentseveralyearsworkingasthechiefofficeronCommodore Clipperwhenthevesselwasfirstbuilt,andwasveryfamiliarwithitslayoutandoperation.

Thechiefengineerwasaged53andhadavariedcareeratseaandashorebeforejoiningCMSin1988.Heheldanunlimited(steamandmotor)STCWIII/2certificateofcompetencyandhadworkedonmanyofthedifferentvesselsinCMS’sfleetandalsoashoreasasuperintendentforthecompany.HereturnedtoseatobecomethechiefengineerofCommodore Clipperwhenitwasfirstbuilt,andhadworkedonboardthevesseleversince.

Thechiefofficerwasaged39,heldanunlimitedmaster’scertificateofcompetency(STCWII/2)andnormallyworkedforanothercompanyasamasteronitsro-rovessels.Hehadprovidedshort-termseasonalcoverforCMSduringhisnormalleaveperiodsseveraltimesoverthelast2years.Onthisoccasion,hejoinedthevesselthedaybeforetheaccident.HehadpreviouslycompletedCMS’sinductionandfamiliarisationtrainingonCommodore Clipper.

Thesecondofficerwhowasonwatchatthetimeoftheaccidentwasaged25,andkeptwatchesfrom0230-1030and1830-2230.Hecompletedhiscadetshipin2006,heldanSTCWII/1certificateofcompetencyandhadsinceworkedasathirdofficeronabulkcarrierandseveralcontainerships.HejoinedCMSon26May2010,andbeforestartinghisdutieshadspent3daysonboardcompletingfamiliarisationtrainingandunderstudyingamoreexperiencedsecondofficer.HewasduetoleaveCommodore Clipperonthedayoftheaccidenttobegin2weeksleave.

Thethirdengineerwasalsonewtotherank,havingpreviouslyworkedfor25yearsatseaasafitter.HehadworkedonboardCommodore Clipperfor3½yearsasafitter,andhadveryrecentlybeenpromotedaftergaininganSTCWIII/1certificatethatenabledhimtoworkasanofficerinchargeofanengineeringwatch.Heworkedadifferentpatternof12weeksonboardfollowedby6weeksleave,andworkedfrommidnightto0500and1200to1900.

AlltheofficersheldtheappropriateendorsementsfromtheBahamasMaritimeAuthority(BMA).Themaster,chiefengineerandchiefofficerallheldadditionalqualificationsinadvancedfire-fighting.Theregulartradingpatternandworkschedulesforallthekeycrewmembersinvolvedintheaccidentprovidedthemwithadequaterestperiods.

8 InternationalConventiononStandardsofTraining,CertificationandWatchkeepingforSeafarers,knownbytheshorttitle‘STCW’

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1.9.2 Companystaff

TheDPAhadworkedasamasteronCMSvesselsformanyyearsbeforemovingashore.Hemaintainedhismaster’squalificationandpilotageexemptioncertificates,notonlyasameansofassessingtheperformanceofstaff,butalsotoprovideemergencycoverintheeventofsicknessorotherstaffabsence.

Theoperationsdirectorwasalsoamastermariner,withexperienceonavarietyofvesseltypes.Healsomaintainedhisqualificationsandsailedoncompanyvesselsregularlytoassesstheeffectivenessofoperationsandcrewperformance.

1.9.3 Training

CMStookaveryproactiveapproachtotraining,andhadconductedanumberofmajorevacuationexerciseswiththeemergencyservicesoverpreviousyears.TheseexerciseshadincludedthedeploymentofMIRGteamsbyhelicoptertovesselsoperatedbyCMS.SeniorCMSstaffhadbuiltupagoodrelationshipwithanumberoffireofficersinthecourseoftheseexercises,andthiswasreportedbybothCMSandHFRStobebeneficialduringtheincident.

Crewfamiliarisation,asrequiredbytheInternationalSafetyManagement(ISM)Code9,followedadetailedsyllabusthatincludedtheresponsetovesselemergencies.Thesecondofficerwhowasonwatchwhenthefirestartedhadrecentlycompletedthistrainingandhadsuccessfullypassedthecompulsoryoralexaminationwiththemaster.

RecordsoftheemergencydrillsconductedonCommodore Clippershowedthattheresponsetovehicledeckfireshadbeenpractisedmostrecentlyon21Februaryand3May2010.Intheshortperiodthatthesecondofficerhadbeenonboard,threefiredrillshadbeenconducted:inthegalley,bow-thrustercompartmentandforecastlestore.Itwasreportedthatfiredrillswerenormallyinitiatedbythemastertellingoneofthedutyofficersthatafirehadbeendiscoveredinacertainlocation.Whilethefiredetectionsystemwasincludedinthefamiliarisationtrainingsystemsyllabus,itwasnotnormallyusedindrillsandwouldusuallyonlybeactivatedwhenitwasbeingtested.

1.10 DAMAGETOSTRUCTUREANDSYSTEMS

Thedamagerecordedbytheclassificationsociety’ssurveyafterthefire,issummarisedbelow.ThecompletereportisreproducedatAnnexA.

1.10.1 Structuraldamage

ThemainvehicledeckofCommodore ClipperwasdefinedasaspecialcategoryspaceinaccordancewithSOLAS10ChapterII-2,Regulation3.46.Thefollowingstructuraldamagewasrecorded:

• Theuppervehicledeck(deck5)deckplatingwasfoundbuckled,fromframe74toframe86,ontheportside,outboardfromtheinternalramp.

• Thesupportingstructurefortheuppervehicledeck(deck5)(i.ethemainvehicledeck-head)wasdamagedontheportside,outboardfromtheinternalrampwith:

• multiplelongitudinalstiffenersbuckledbetweenframes71and89;

• thewebandlowerflangeofframe77buckled.

9 InternationalSafetyManagementCode(ISM)Code,ResolutionA.741(18)asamended10 InternationalConventionfortheSafetyofLifeatSea(SOLAS)consolidatededition2009

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Thedeckboundarybetweenthemainanduppervehicledeckswassteelandwasto‘A0’standardinaccordancewiththeprovisionsofSOLASChapterII-2Regulation20.5.Consequently,ithadnothermalinsulationproperties.

1.10.2Steeringgear

Theportandstarboardrudderswereseparatelydrivenbytheirownrotaryvanetypehydraulicunits.Thepowerpackforeachrotaryvaneunitwasfittedwithtwopumps,eachfittedwithitsownsolenoidvalves,whichcouldbeoperatedlocally,tocontrolmovementoftherudder.

Separatesteeringcontrolcableswererunthroughtheportandstarboardsidesofthemainvehicledeck,mountedincabletraysinthedeck-headstructure.Thesteeringsystemonthebridgeconsistedofawheelthatcontrolledbothrudders,andtwoseparatejoysticktillersthatprovidedsecondary,independent,controlofeachrudder.Therudderscouldalsobecontrolledlocallyfromthesteeringgearcompartment.Allfoursteeringpumpscouldbestartedandstoppedeitherfromthebridgeorfromthesteeringgearcompartment.

Defectswerefoundthataffectedallfoursteeringpumpsandbothcontrolsystemsduetodamagetothe48coresteeringcontrolcablethatwasroutedthroughthedeck-headontheportsideofthemainvehicledeck.Incommonwiththeothercablespassingthroughthemainvehicledeck,ithadtheappropriatefireretardantpropertiesthatwererequiredbytheclassificationsociety’srules.Thecableswerenotrequiredtohaveanyotherprotectionfromfire.

Thefollowingpowerandcontrolfaultswerefoundontheportsteeringgear:

• No.1pumpforcedtherudderhardtostarboard,whenoperatinginremotecontrol.

• No.2pumpautomaticallystartedandcouldnotbestoppedbythecontrolsystem.Thepumpwasunabletoprovideanydirectionalcontroloftherudder,eitherinremoteorlocalmodes.

Powerandcontrolfaultsfoundonthestarboardsteeringgear:

• No.3pumpwas‘hunting’(oscillatingeithersideofthedesiredposition)whenintheremotecontrolmode.

• No.4pumpautomaticallystartedandcouldnotbestoppedbythecontrolsystem.Thepumpwasunabletoprovideanydirectionalcontroloftherudder,eitherinremoteorlocalmodes.

1.10.3Firedetectionsystem

Inadditiontothesmokedetectionsensorsimmediatelyabovethefirebeingdamagedbyheatandflame,damagetocablesthatwereroutedthroughthemainvehicledeckmadethefollowingloopsofthefiredetectionsysteminoperative:

• Mainvehicledeck(deck3)

• Steeringgearcompartment

• Enginecontrolroom

• Bowthrustercompartment.

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Lineisolators,thatwereintendedtoprotecttherestofthesystemifonepartwasdamaged,werefoundtohavebeenincorrectlyfitted.Thefiredetectionsystemcablesinthemainvehicledeckwereinstalledclosetomainpowercablesand,astheinsulationdegradedinthefire,thesystemwasexposedtohighvoltages.Withnoprotectionfromthelineisolators,highvoltagespassedthroughthesystemandburntoutasectionofthemotherboardinthecontrolunitonthebridge.

1.10.4Electricaldistributionsystems

Themainelectricalpowerdistributioncabletrayrunningthroughthedeck-headstructureontheportsideofthemainvehicledeckwasdamagedbetweenframes74and77.Thisledtothefollowingdisruptiontoelectricalsystems:

• Bothpowersuppliestotheforwardswitchboarddamagedandinoperable.

• Powersuppliestobothforwardandafterbowthrustersdamagedandinoperable.

• Powersuppliestotheanchoringandmooringequipmentdamagedandinoperable.

• Theinternalramp(mainvehicledecktouppervehicledeck),controlandindicationcircuitsdamagedandinoperable.

• Powersuppliestobothnavigationsternlampsandthecontrolcircuitsindicatinglampfailureweredamagedandinoperable.

• Powersuppliesandcontrolcircuitstomainvehicledeckventilationfansdamagedandinoperable.

• CCTV,publicaddresssystemandlightingcircuitsdamagedandinoperable.

• Inaddition,anumberofdistributionboxesandsocketsprovidingpowertorefrigeratedtrailersonthemainvehicledeckweredamagedbywaterusedinthefire-fightingoperation.

1.10.5Fire-fightingandwatersprayingsystems

Commodore Clipperwasfittedwithanapproved,manuallyoperated,fixedpressurewatersprayingsysteminthemainvehicledeckasrequiredbySOLASChapterII-2,Regulation20.6andResolutionA.123(V)(AnnexB).Thesystemwasdividedintolongitudinalandlateralsections,eachcoveringadiscreteareaofthemainvehicledeck,andwaterwasprovidedfroma360m3/hourcapacitypump.Thesystemcouldbeoperatedremotelyfromthebridge,orlocallyfromthe‘drenching room’justoffthebluestairsondeck4.Thechiefengineerwasawarethatthevalvesneededtobeopenedinthecorrectsequencetoensurethatthepumpprimedcorrectlyanddidnottrip.Hecontrolledtheoperationofthesystemthroughouttheincident.

Theintensityofthefirecausedthefiremaindistributionpipeworkrunningthroughthemainvehicledeck-headtobucklebetweenframes74and77.Thedistributionpipeworkforthewatersprayingsystemwasalsofoundtobebuckledinthesamelocation.Thewatersprayingsystemwastestedafterthefire,beforerepairswerestarted,andwasfoundtoworksatisfactorily,withwatercomingfromallthedrencherheadsandnoleaksinthedamagedareabeingevident.Itwasconfirmedthatroutinetestsofthesystemweredonewiththedrencherheadsremovedtoensurethatdebriswasflushedthroughandnotlefttoaccumulateandcauseblockages.

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1.10.6Ro-rohydraulicsystems

Anumberofhydraulicpipeswereroutedthroughthedeck-headstructureofthemainvehicledeck.Pipesandcouplingsealsimmediatelyabovethefirewerefoundtohavebeenaffectedbyhightemperatures,butthepipeworkhadremainedintact.

1.11 STABILITY

1.11.1 Approvedstabilitybook

Commodore Clipper’sstabilitybookwasapprovedbyDetNorskeVeritas(DNV)on20December1999,andincludedthefollowingwarningregardingthedrainageofvehicledecks:

The Master’s attention is drawn to dangers of flooding. The Master must be aware of the adverse effect that water trapped on the Vehicle Decks has on stability, for example when the drenching system is in operation. Therefore, it must be ensured that the drainage deck drains on the Vehicle Decks are always clear of obstructions, rubbish, etc, and free at all times for operation. [sic]

1.11.2 Damagestabilityinformation

Anassessmentsimulatingthevessel’sabilitytoretainanadequatemarginofstabilitywithspecifiedtypesofdamagetothehullwasapprovedbyDNVascomplyingwiththerequirementsofIMOResolutionA.265(VIII)11.Theserequirementsstipulatedthatmaximumpermissibleverticalcentreofgravity(VCG)datashouldbeavailabletothevessel’smaster,alongwith“all other data and aids which might be necessary to maintain the required stability after damage”.ThisdatawasincorporatedintothestabilitybookintablesanddiagramsthatillustratedthecombinedmaximumVCGvaluesforbothintactanddamagedhullscenarios.CrewcouldcheckthattheycompliedwiththestabilityrequirementsbycalculatingtheVCGforthevessel’sconditionandmakingsurethatitdidnotexceedthemaximumVCGvaluesstatedinthestabilitybook.ThisfacilitymeantthatCommodore Clipper didnotneedtohaveaspecificdamagecontrolmanual.

ThestabilitybookstatedthatthemaximumVCGvalueshadbeenderivedfromthemostpessimisticdamagecases.Itdidnotdescribetheassumptionsthatthesecaseshadbeenbasedon.Consequently,itwasnotclearifthemaximumVCGvaluesincludedtheeffectofaccumulatedwaterfromfire-fightingattemptsbeingentrainedonthemainvehicledeck.Thestabilitybookoutlineddetailsoftherequirementtobeabletosurviveanaccumulationofwaterinthedamagedpartofapassengerro-rospacethatwasagreedatthe1995SOLASConference12.However,thisrequirementwasdependentonthesizeofavessel’sresidualfreeboardafterdamagehadoccurred.InCommodore Clipper’scase,theresidualfreeboardinthespecifieddamagescenariowasgreaterthanthelimitingvalueof2m.Therefore,therewasnoneedforthevesseltobeabletowithstandanyaccumulationofwateronthemainvehicledeck.Thiswasnotexplainedinthestabilitybook,beyondthegeneralwarningthatdrewthemaster’sattentiontothedangersofflooding(reproducedinparagraph1.11.1).

11 Adoptedon20November1973,Agendaitem10,RegulationofSubdivisionandStabilityofPassengerShipsasanEquivalenttoPartBofChapterIIoftheInternationalConventionfortheSafetyofLifeatSea,1960(1960SOLASConferenceRecommend6,SOLASChII-1PartB)

12SOLAS/CONF.3-ResolutionsoftheConferenceofContractingGovernmentstotheInternationalConventionfortheSafetyofLifeatSea,1974-(November1995)-Resolution14-Regionalagreementsonspecificstabilityrequirementsforro-ropassengerships-(Adoptedon29November1995)

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1.11.3 Approvedonboardloadingcomputer

Thevesselhadastabilityandlongitudinalstrengthsoftwareprogram,knownbytheproprietarynameCPC,installedonboard.ThisprogramhadalsobeenapprovedbyDNV,andthevesselwasgiventheclassnotation“Loading Computer System approved and certified for calculation and control of loading conditions with respect to Longitudinal Strength, Intact Stability and Damage Stability”.AlthoughthemaximumpermissibleVCGdatafordamagestabilitywasincorporatedintheprogram,theversionofthesoftwarethatwasonboardCommodore Clipperdidnothavethecapabilitytoassesstheeffectofdamagedorfloodedcompartments.

1.11.4 Loadingconditionfor15-16June2010

Thevessel’sloadingconditionondeparturefromJerseyon15June2010wascalculatedbyship’sstaffusingtheCPCsoftware.Followingtheaccident,theMAIBidentifiedanumberofminorinconsistenciesbetweenthedataenteredintotheCPCsoftwareandthatcontainedinthevessel’slogbook.Boththecalculatedandcorrectedloadingconditions,however,mettherequiredintactstabilitycriteriawithhealthymargins.

1.11.5 Effectofdrenchingwateronstability

Commodore Clipperlistedtoanangleofabout5°duringtheattemptstocontrolthefireusingthemainvehicledeckdrenchingsystem.Astheangleincreased,drenchingwastemporarilysuspendedtoallowthewatertodrainawaythroughthepartiallyblockeddeckdrainsandreducethelist(Figure15).Thisreactionwasduetoconcernsregardingthedetrimentaleffectofthiswateronstability;nocalculationswereconductedeitherbyship’sstafforthecompanyashoreduringtheincidenttoverifytheextentoftheproblem.

TheMAIBhasconductedasimplified13stabilityanalysissimulatingthepresenceofvariousamountsofwaterondeck3;theactualquantitiesofwaterwereunknownduetotheuncertaintyregardingtheextentofdeckdrainblockageatanygiventime.Forthepurposeofthesecalculations,theonlyinterruptiontothewater’sfreesurface14wasassumedtobeprovidedbythevessel’sinternalstructure.Inreality,thefreesurfacewouldalsohavebeendisturbedbyvariousminoritemssuchasthetrailerwheelsandtrestles.

Theanalysisconfirmedthatallbutverylargeamountsofwaterondeckwouldhavehadaballastingeffectonstability(duetodeck3beingaround1mbelowtheoverallloadingconditionVCG).However,withthevesseluprightandwaterassumedtobecoveringtheentiresurfaceofdeck3,thelargefreesurfacemomentwouldhavedangerouslydegradedstability,causingbothanegativerightinglever(GZ)curveandtransversemetacentricheight(GM).

TheMAIBalsomodelledotherfloodingscenariosinordertodeterminehowmuchwateronthemainvehicledeckwouldhavebeenrequiredtocausethe5°list.Giventhatmostofthedrenchingeffortwasconcentratedontheportsideandthevesselwasobservedtolisttoport,theeffectofhypotheticalaccumulationsofwateronthissideoftheuprightvessel’sdeckwereanalysed.Theworstcasewasfoundtobewithwatertoauniformdepthofabout5cm,whichresultedinaminorfailureofoneofthestabilitycriteria.Marginallyincreasingthisdepthofwateracrosstheporthalfofthedeckwasfoundtoslightlyimprovestability15,withtherelevantcriterianowbeingmet.

13Calculationswerebasedonsmallangleassumptionsandadynamicmodelwasnotconstructed.14 Freesurfaceinthiscontextreferstoanunconstrainedliquidsurfacewhichisfreetomovetransverselyasavesselheelstooneside.Thismovementresultsintheliquid’scentreofgravityalsotransferringtowardsthedirectionofheel,whichthereforecounterstherightingmomentattemptingtobringthevesselbackupright,andthusreducestheoverallstability.

15 Anincreaseinthedepthofthewaterfrom5cmto10cm,althoughdoublingtheweightofwater(whichwouldbesignificant,giventhelargesurfacearea),wouldresultinonlyaminorincreaseofthewaterVCGfrom8.625mto8.65m(whichisbelowtheoverallVCG).

39

Thefinalpartoftheanalysisexploredtheeffectofvariousamountsofwaterondecktransferringintowedgesontheportoutboardsideofdeck3asthevessellistedto5°.AlthoughtheseassumedwedgesresultedinaslightincreaseinVCG,theeffectivebreadthofwaterasitformedintoawedgeshapedecreased,whichreducedthefreesurfacemoment.Thisresultedinthevesselmeetingthestabilitycriteriafully.Itwascalculatedthatbetween10and20cmofstandingwateronthe

Deckdraincoverwithpotatoesremoved

Figure15

Deckdrainblockedbypotatoes

40

vessel’sportside,transferringtoformanequivalentwedgeofwaterweighing150tonnes,wouldhavecauseda5°list.Theintactstabilitycriteriacouldhavestillbeenmetwiththevessellistingtoanglesgreaterthan5°listandwithlargerweightsofwater.Adamagedstabilitymodel,withgreatercapabilitythaneithertheinformationheldonboardCommodore ClipperorthesimplifiedanalysisconductedbytheMAIB(basedonthesameinformation),wouldberequiredtocalculatethemaximumangleoflistthatcouldhavebeenreachedsafely.

1.11.6 Requirementsforpreventionoffire-fightingwateraccumulatinginro-rospaces

SOLASregulationII-2/20.6.1.416highlightsthepotentialseriouslossofstabilitythatcouldarisefromtheaccumulationoflargequantitiesofwaterondeckduringtheoperationofawater-sprayingfire-extinguishingsystem.RegulationII-2/20.6.1.4.1.1requiresthatdeckdrainsshouldbefittedtospacesabovethebulkheaddeck17onpassengershipstoensurethatsuchwaterisrapidlydischargeddirectlyoverboard.RegulationII-2/20.6.1.4.1.2statesthatforcargoships,wheretherequirementsforclearingsuchwatercannotbemet,theadverseeffectuponstabilityoftheaddedweightandfreesurfaceofwatershallbetakenintoaccountasdeemednecessarybytheAuthorityinitsapprovalofthestabilityinformation.Suchinformationshallbeincludedinthestabilityinformationsuppliedtothemasterasrequired.

InJune2009,IMOcircularMSC.1/Circ.132018providedguidelinesforSOLASregulationII-2/20.6.1.5regardingtherequirementforeffectivemeasurestoensurefloatingdebrisdoesnotblockdrainsinspaceswherefixedwater-basedfire-extinguishingsystemsareprovided;thisSOLASregulationcameintoeffecton1January2010forshipsconstructedonorafterthatdate,withexistingshipstocomplybythefirstsurveythereafter.Thecircularrecommendedthataneasilyremovablescreenorgratingshouldbeinstalledovereachdrain,raisedabovethedeckorinstalledatanangletopreventlargeobjectsfromblockingthedrain.

Alargemeshbox,thatcouldbefittedoverexistingdrainsandmettherequirementsofMSC.1/Circ.1320,hadbeentrialledonCommodore Clipper.Thetrialwasconsideredacceptablebuttheprototypehadbeenremovedtoprovideapatternfortheremaindertobefabricatedingoodtimetomeettherequireddeadline.

1.12 TECHNICALINVESTIGATION

1.12.1 Examinationofthefirescene

Oncethetrailersandcargodebriswereremovedfromthemainvehicledeck,therewasnoevidenceofaseatoffireinthevessel’sstructureormajoritemsofequipment.Thefreighttrailersandtheircargoesprovidedthevastmajorityoftheavailablecombustiblematerial.

Mostofthefire-damagedtrailers,apartfromGC13-1,wererefrigeratedunits,andallwereinspectedastheywereremovedfromCommodore Clipper.TrailersFS61andGC13-1werehard-sided,andgenerallyonlyhadexternalstructuraldamagewhereburningcargofromneighbouringcurtain-sidedtrailershadfallenontothem.Burningdebrisonthedeckhadcharredthetyresontheright-handsideofGC13-119,causingthemtodelaminateinplaces(Figure16).

16 SOLASamendments2008and2009,ResolutionMSC.256(84)17 Bulkheaddeckistheuppermostdecktowhichthetransversewatertightbulkheadsarecarried(whichforCommodoreClipper,isthemainvehicledeck)

18GuidelinesfortheDrainageofFire-FightingWaterfromClosedVehicleandRo-roSpacesandSpecialCategorySpacesofPassengerandCargoShips,11June2009

19 Alldamagetotrailersisdescribedinrelationtothetrailer’snormalroad-goingorientation.UnaccompaniedtrailerswerereversedontoCommodore Clipper,sotherearofthetrailerwouldhavebeenpointingtowardsthebowofthevesselandthetowingendpointingtothestern.

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TrailerCR439hadcurtain-sides,buttheonlyfiredamagewastothecargoareaattherearontheleft-handside.Thecurtainhadbeenburntawayoverthelasthalfofthetrailer,andtheouteredgesoftheexposedcargoofpre-packagedpotatoeshadbeeninvolvedinthefire(Figure17).

Thecurtain-sideontrailerCRF461hadbeenburntawayoverthefronttwo-thirdsonboththeleftandright-handsides(Figures14and18).Thefrontendofthetrailerwasfire-damaged,buttherearparthadnotbeeninvolvedinthefire.

TrailerCRF459hadthemostextensivedamage,withtheentirecurtainontheright-handsidehavingbeenburntaway(Figure19).Therewasextensivedamagetothecargointhecentralsectionontheright-handside,immediatelyabovetheelectricalpowerdistributioncircuits.Thecompositealuminium/glassreinforcedplasticroofhadalsobeendestroyedinthisarea,withremnantsofmoltenandsolidifiedaluminiumattheperiphery.Theleft-handsidewaslessdamaged,butthecurtainhaddetachedatthetopovertherearthree-quartersofthetrailer.Somecargoontheupperlevelshadalsobeeninvolvedinthefire,buttheamountofdamagereducedconsiderablylowerdown.

CharredanddelaminatedtyresontrailerGC13-1

Figure16

Heatdamagetotyre

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TrailerCRF439

Figure17

TrailerCRF461

Figure18

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1.12.2Refrigeratedtrailersystem

TrailersCRF459andCRF461weresimilartriple-deckedunits,designedtocarryfreshproduce,chilledtobetween5ºand8oC.Whenfull,eachtrailerwascapableofcarryingabout18-20tonnesofpackagedpotatoes.Thecurtain-sidesweremadefromtwoouterlayersoftoughplasticwhichenclosedacentrallayerofflexibleinsulatingmaterial.Thecurtain-sideshungjustbelowthesidesoftheload-bedandweresecuredinplacewithwebbingstraps(Figure20).

TherefrigerationsystemwasmanufacturedbyFrigoblocktomeetahighcustomerspecificationforperformanceandreliability.Itconsistedofasmalldiesel-electricgeneratorunitwhichprovidedpowertoaseparate,electricallydrivenrefrigerationcompressor.Bothunitsweremountedattheforwardendofthetrailerontheleft-handside.Beneaththeseunits,mountedunderneaththeload-bedwasanaluminiumfueltank(Figure21).TheeconomicbenefitsofpurchasingfuelintheChannelIslandsmeantthatalltherefrigeratedunitscarriedonthislegoftheroutewerelikelytohavebeenfulloffuel,andCRF459andCRF461eachcarriedapproximately200litresofdiesel.Fourchillerunits,mountedonthedividingdecks,circulatedairthroughoutthecargospacetomaintaintherequiredtemperature.Therefrigerationsystemswerecheckedona6-monthmaintenancecycle,andCRF459waslastservicedon13May2010.

TrailerCRF459

Figure19

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Figure20

Insulatedcurtain-sidematerialFigure21

Dieselgenerator,refrigerationcompressorandfueltank

Refrigerationcompressor

Diesel/electricgenerator

200Lfueltank

45

Threeelectricalcontrolandpowerdistributioncabinets,manufacturedtomeetIP67ingressprotectionstandards20,weremountedontheright-handsideofthechassisbeneaththeload-bedoftrailerCRF459(Figure22).Thecabinetthatwasfurthestforwardhousedtheincomingpowersupplybreaker,distributioncircuitandachangeoverswitchthatallowedthefridgeunittobepoweredbythetrailer’sowngeneratororanexternalsupply.Thechangeoverswitchwasfoundintheexternalpowersupplyposition.Thenextcabinetalong,housedthecompressormotorstartingcircuits.Thethirdcabinethousedthecontrolcircuitsandcontactorsforthechillerfanmotors.Aseparatecabinetfurtherforwardcontainedatemperaturedataloggingunit.

Thesocketforanexternalpowersupplywasmountedtotheundersideoftheload-bedtotherearofthethreecabinets(Figure23).Thesocketwasconnectedtoaphasechangingdevice,whichautomaticallysensedthephaserotationofthepowersupplyandcorrectedittosuitthecorrectrotationofthecompressormotor.

Alltheelectricalcomponentsinthetrailer’srefrigerationsystemhadbeenselectedsothattheycouldfunctionsatisfactorilyonawiderangeofinputpower.Thesystemcouldoperateoninputvoltagesintherangeof200Vto690VAC,atfrequenciesofbetween25Hzand87Hzwithoutcausingoverheatingofwindingsorchatteringofcontactors.

20 IngressprotectionstandardsasdefinedintheInternationalElectrotechnicalCommission(IEC)standard‘Degrees of protection provided by enclosures’ IEC60529

Figure22

Electricalcontrolandpowerdistributionboxes

Temperaturecontrolcircuitsandchillermotorstarters

Compressormotorstartingcircuits

Incomingpowersupplybreakerandchangeovercircuit

UndamagedunitsontrailerCRF461

DamagedunitsontrailerCRF459

46

TheexternalpowersupplysocketontrailerCRF459wasfoundtohavedetachedfromtheundersideoftheload-bed,andhadindicationsofinternaloverheating,ratherthanexternalcharringfromfire(Figure24).Insulationmaterialswhichwerefittedintotheload-bed,andthelowerflangeofthesteelbeamformingtheouteredgeoftheload-bedintheareawherethesocketwasfitted,werealsodamagedbyheat.ItwaspossibletodeterminethatpartoftheplugfittingfromCommodore Clipper’spowersupplywasstillattached.Theremainderoftheplughadbeenconsumedbyfire,andthepartsofthecableterminalsthatwereleftwereheavilycharred.Thecablewasnolongerattached.

Crewwhohadbeeninvolvedintheunlashingandremovaloftrailerswereabletoconfirmthattheyhadunpluggedallthevessel’spowersupplycablesfromrefrigeratedtrailers,apartfromonethatwastoobadlydamaged.Althoughtheycouldnotconfirmwhichtrailerthiswas,theywerecertainthatthiswastheonlyonethatwaspulledoutbythetugmasterwherethecablehadnotbeenremoved.

Onepowercable,whichhadconsistedoftwostandard20mlengthspluggedtogether,wasfoundlyinginastraightlineleadingfromsocketNo.9onabankofpowersupplysocketsclosetoframe101,toapositioninlane2atframe201(Figure25).Theconnectingendsofthetwostandardcableswerefoundpulledapartatframe86.Theplugandsocketssharedacommonpatternofdamagethatwaslikelytohavebeensustainedduringthefire-fightingandcargoremovaloperation,indicatingthattheyhadbeenconnectedduringtheaccident.Theendofthecablethatwouldhavebeenconnectedtothetrailerwastheonlyonewithoutaplug,andthebarewireswereexposed.Anothersetofpowersupplysocketswasclosertothetrailersinvolvedinthefire,andthesecouldhavebeenusedtoavoidtheneedtouseanextensionlead.

Figure23

Externalpowersupplysocket

47

Figure24

DamagedexternalpowersupplyconnectionontrailerCRF459

Figure25

Reeferpowersupplycable

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1.12.3Electricalexamination

Powersupplysystem

ThepowersupplysystemfortherefrigeratedtrailerswasfedfromCommodore Clipper’sswitchboardthroughadistributionnetworkvia250Aandthen125Abreakers.Thesystemusedthreephasesandanearth:therewerenotransformersorneutralpointsinthesystem.Althoughtheclassificationsocietyrequiredthepowersupplysocketsonthemainvehicledecktohaveaminimumingressprotection(IP)ratingof55,thishadbeenoverlooked,andthevessel’splugsandsocketsallhadthelesserIP44rating.

Powertothesupplybreakerfeedingsocketno.9atframe101hadbeenisolatedatthemainswitchboard,andafterthefirethesupplybreakerwasfoundinthe‘on’position.Thebreakerwasa‘System pro M’manufacturedbyAseaBrownBoveri(ABB)andratedat32A.Ithada‘K-characteristic’,whichwasdescribedbythemanufacturerasmakingitsuitableforcableandapplianceprotection.Accordingly,ithadelectromagneticanddelayedthermaltripstotakeaccountofhighmotorstartingloadsandgiveprotectionagainstlongertermoverloadcurrents.Whentestedbyanelectricalcontractor,thebreakertrippedafterafewsecondsatafaultcurrentof84A;insubsequentteststhebreakertrippedat77Aandthenat70A21.Thiswasinaccordancewiththemanufacturer’sspecification,andtheprogressivereductionwasduetothebuildupofheatinthethermaltrippingmechanismaseachtestwasdone.

Trailerelectricaldistributionboxes

AlltheelectricaldistributionboxesontrailerCRF459wereseverelydamagedbyfire.Thepowersupplybreakeronthetrailerwasinthe‘off’position,butasthiswasalsofittedwithathermaltrippingdevice,heatduringthefirewouldhavecausedittotripifithadnotalreadydonesoforotherreasons.Thecompressormotorcircuitwasfittedwithphaseimbalanceandwindingoverheatingdetection.Thecompressormotorwindingswerefoundtohavethecorrectresistance,themotorandcompressorwerefreetoturn,andtherewasnothingelsetoindicateacurrentoverloadhadoccurredinthetrailer’srefrigerationsystem.

Theelectricaldistributioncircuitswerecutawayfromthetrailerandexaminedinmoredetailbyaspecialistcontractor.Allthecomponentsshowedevidenceofexternaldamagefromhavingbeeninvolvedinafire.Therewasnoevidenceofarcingorwires‘beading’fromcurrentoverload,andalltheterminationsweretightandwellmade.

Powersupplyplugandsocketconnections

ThepowersupplycableplugandsocketwereremovedfromCRF459andx-rayedtodeterminetheconditionoftheterminals.Thex-rayshowedseveralglobulesofmetalaroundtheareaofoneoftheplugterminalswheretheship’spowersupplycablewasconnected(Figure26).Theplugwasidentifiedasa‘StarTop’type,manufacturedbyMennekes.

Theplugandsocketwereseparated;therewasnodamagetoeitherthemaleorfemaleconnectors.Screwedcableterminationsinthetrailersocketpartwereallwellmade,nonewereloose,andtherewerenosignsofarcingoroverload.Charredmaterialaroundtheterminationsoftheplugpartwasremovedtoexposetheterminals.Theterminalswereoftheinsulationdisplacementconnector(IDC)type.Thesecutthroughthecableinsulationsecuringtheconductorinpositionandareintendedtosaveassemblytimebyavoidingtheneedtostripwiresortightenterminalscrews.

21Otherrefrigeratedtrailerpowersupplysocketsonthemainvehicledeckwerefittedwithfusesratedat35A,insteadofbreakers.Afusewastestedforcomparison;itdidnotblowatthemaximumtestloadof100A.

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Oneoftheterminalshadpartiallymeltedandtheseveralwirestrandscouldbeseenweldedontotheremainsoftheterminal(Figure27).Theterminalmaterialwasreportedbythemanufacturerstohaveameltingpointofbetween900and925oC.Itwaspossibletodetermine,fromtheorientationoftheterminationsandcomparisonwithanundamagedplug,thatthemeltedterminalwasthebrownphase.

Figure26

X-rayoftheexternalpowersupplyconnectionontrailerCRF459

DebrisfrompartiallymeltedIDCterminal

Figure27

ExaminationofthereeferpowersupplyplugattachedtotrailerCRF459

Partiallymeltedbrownphaseterminal

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ThebareendedreefercableremovedfromthemainvehicledeckofCommodore Clipperwasexaminedfurther,andcharacteristicbeadswerefoundattheendofseveralstrandsofwirefromthebrownphase.

Theexaminationconcludedthattheterminationofthebrownphasehadbecomelooseinsidetheplug,leadingtoincreasedresistanceinthatphase,heatingandarcing.Inthesecircumstances,thefaultcurrentwouldhavebeenlimitedtotheloadcurrentofaround25Aandtheship’ssupplybreakerwouldnothavetripped.

ThecompletereportoftheelectricalexaminationisatAnnexC.

1.12.4Reefercables

Thecablesprovidingship’spowertotherefrigeratedtrailers,knownonboardasreefercables,hadpreviouslybeenmanufacturedashore.Responsibilityformakingupnewreefercableswaspassedtothecrewfrom1May2006withtheship’selectricianandelectricalfitterdoingthiswork.Thecreworderedcableandconnectorsdirectlyfromcommercialsuppliers,anditemsfromseveraldifferentmanufacturerswereinuse.InApril2009,thefirstbatchofStarTopplugswasordered.ThesewerethefirsttypeofconnectorswithIDCterminalsthathadbeenusedonboard.AsecondbatchwasorderedinMay2010.

TheStarTopplugsweresuitableforupto440Vand32AandwereIP44rated.ThecablecoresusedonCommodore ClipperwerethemaximumsizethattheStarTopIDCterminalscouldaccommodate.Eachplugwassuppliedwithasmallinstructionleaflet(Figure28)thatwassecuredtotheterminalsinsideeachplugassemblyandindicatedthatinsulationshouldnotberemovedfromtheconductors.Instead,eachcoreofthecableshouldbeinsertedintotheplugandthecappusheddownbyhandorleveredintoplaceusingascrewdriver.ThisforcedthecablecoreintotheIDCandcuttheinsulation,securingtheconductortotheterminal.Inpractice,aconsiderableamountofforcewasrequiredtoachievethissuccessfullywhenusingthemaximumcablesize.

Figure28

StarToppluginstructionleaflet

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ThethreeotherexamplesofreefercablesfoundonboardCommodore Clipper,thatwerefittedwithStarTopplugs,wereexamined(Figure29).Ineachcase,theinsulationhadbeenremovedfromtheendsofthecablecoresbeforetheyhadbeeninsertedintotheIDC.Itisnormalpracticetoremoveinsulationforatraditionalscrewterminal,butwhenusinganIDC,theinsulationisrequiredtosupportthestrandsoftheconductorandsecuretheminposition.Intheundamagedexamples,thestrandsoftheconductorswerefoundtobedisplacedandatriskofnotmakingadequatecontactwiththeterminal.Thiswouldhavebeenexacerbatedifthecableglandbecamelooseandthehandlingloadsweretransferredtotheterminals.

Thevessel’splannedmaintenancesystemrequiredallthereefercablestobeinspectedannually.ThiswastimedtooccuratthebeginningofthepotatoseasoninMay.Theconditionofacablewasotherwisecheckedonlyifitwasfoundtobedefectiveinservice.Systemstoidentifyeachreefercablehadpreviouslybeentried,butwereconsideredunsuccessful,andtherewasnomeansofmonitoringtheservicehistoryofanindividualcable.

1.12.5Reactiontofiretests

TheStarTopplug,curtain-sidematerial,webbingsecuringstrapsandplasticpotatocratesweresubjectedtoaseriesoftests,conductedbyspecialistcontractors,toexaminetheirreactiontofire.ThefullreportsofthesetestsareatAnnexD.

Figure29

OtherStarTopplugconnectionsassembledonboardCommodore Clipper

Displacedconductorstrands

Exposedconductorstrands

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TheStarTopplugwasmanufacturedtomeettheEN60309-2standard,whichrequiredtheplugtopassa‘glowwiretest’.Thistestisdesignedtoshowthattheplugmaterialthatsurroundstheterminalswillnotignitewhenputincontactwithaglowinghotwire.Consequently,thewhitematerialaroundtheterminalswasapolyamidereinforcedwithglassfibre(PA6GF20FR22).Theremainingredmaterialofthebodywaspolyamide6.

Inthereefercableapplication,theplugwasconductingaround25Aat400V,equivalentto8kW(atanassumedpowerfactorof0.8).Asoneoftheterminalshadmelted,itwasknownthattemperaturesinsidetheplughadbeeninexcessof900oC.Aplatinumcoilwasconstructedsothatitcouldbeinsertedinsideoneofthefemaleconnectorsontheplug.Currentandvoltagewasselectedsothatwhenpowerwasappliedtothecoil,itwasabletoreachasimilartemperature.

Afterapproximately10minutesofsustainedheating,thewhiteplasticmaterialaroundtheterminalsignited.Oneandahalfminuteslater,flameshadspreadupwardsandstartedtoaffecttheredplasticcap(Figure30).

TheStarTopplughadbeenarrangedunderneathaverticalsectionofcurtain-sidematerialtore-producethearrangementoftrailerCRF459.Inthetests,itwasnotpossibletocontrivetheflametospreadfromthecapoftheStarTopplugtothewebbingstrap.However,asectionofwebbingstrapwasheldabovetheflamingpluganditignitedreadily.Thecurtain-sidematerialalsoignitedreadily(Figure31).

22Halogen-freeandphosphorus-freeflameproofedinjectionmouldinggradewithfree-flowproperties,goodelectricalpropertiesandlowsmokedensity;resistanttoglowwiretestto960°C.

Figure30

IgnitionoftheStarTopplugaftersustainedinternalheating

Aluminiumtapeusedtosecuretheheatingelementinplace

Heatingelementterminalblock

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Thewebbingstrap,curtain-sideandpotatotraymaterialsweresubjectedtomorecontrolledteststodeterminethecriticalheatfluxrequiredtoignitethematerial,theheatreleaserateonceburningandsmokegenerationproperties.

Itwasfoundthatthecriticalheatfluxrequiredtoignitethecurtain-sidematerialwassolowthatfurtherspecialisedtestswouldhavebeenneededtoestimatetheactualvalue.Thematerialthenburntreadilydevelopingtemperaturesapproaching700oC.Thewebbingstrapignitedatanestimatedcriticalheatfluxofbetween7.3and12.6kW/m2andwhenburning,generatedtemperaturesinexcessof800oC.Thepotatocratesrequiredamoresustainedperiodofheating,butatarelativelylowestimatedcriticalheatfluxofbetween3.4and11.4kW/m2,beforeigniting.Oncealight,temperaturesofover900oCwereachieved.

1.13 PORTINFORMATION

1.13.1 Portsmouthharbourauthorities

ThecontrolofPortsmouthharbourisdividedbetweenmilitaryandcivilauthorities.QHMistheregulatoryauthorityforthepartsoftheharbourdefinedbythedockyardportlimit,derivingthatauthorityfromtheDockyardPortAct,1865.QHMhasastatutoryresponsibilitytotheSecretaryofStateforDefencefortheprotectionofthedockyardport.Hisorders,regardingentrytotheharbour,prevail.Thecommercialferryportwasopenedinthemid1970s,thefacilityisownedbyPortsmouthCityCouncilwhoserepresentativesactastheCompetentHarbourAuthority(CHA)underthe1987PilotageAct.Thegeographicareasthattheseresponsibilitiesapplytoarealsodifferent(Figure32).

Figure31

Ignitionofthecurtain-sidematerial

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TheeffectofthisarrangementisthatacommercialvesselenteringPortsmouthharbourmusthavepermissionfromQHMtoenterandtransitthroughthedockyardport,andpermissionfromPIPtoenterandberthatthecommercialport.Pilotagefunctionsareseparated,withtheCHAresponsibleforallactsofpilotageoncommercialvessels.AlltheAdmiraltypilotswerecivilianMODemployeeswithcommercialmaster’scertificatesofcompetency.TheywerenotauthorisedtoconductactsofpilotageoncommercialvesselstoPIPberths,butregularlycontrolledthemovementofcommercialvesselsenteringthedockyardportformaintenancework.

20 21

Portsmouth Competent Harbour Authority

AREA OF JURISDICTION

CHAPTER THREE

PILOT BOAT RECOGNITIONAND BOARDING POINTS

1. There will not be a pilot boat permanently on station.

2. a) The boarding points for vessels to the South and East of the Isleof Wight are

i) For vessels of an overall length greater than 150 metres, thePilot will board in the Pilot boarding area,1 mile to theWest of the NAB Tower.

ii) For vessels of an overall length not greater than 150 metresthe Pilot will board in the Pilot boarding area in the vicinityof the St Helens Buoy.

b) For vessels approaching from the Western Solent the boardingpoint for Portsmouth Pilots is approximately 0.75 nauticalmiles NW of the North Sturbridge Buoy.

3. In adverse weather these points may be altered and up to dateinformation can be obtained from ‘Portsmouth Pilots’ on VHFChannel 11.

4. Direct communication may be made with the pilot boat on VHFChannel 12 or 9 when on station.

CHAPTER FOUR

FACILITIES TO BE PROVIDED FOR PILOTS

1. The Master of a vessel having accepted the service of an authorisedpilot is required to facilitate his boarding and disembarkation andto comply with the Solas Chapter V (Pilot Transfer arrangements)Regulation 23 and associated annex 2.

2. The Master of a vessel who has accepted the services of anauthorised pilot is required to declare its draught, length and beam,and to provide him with other information relating to the ship orits cargo as he requires and is necessary to enable the pilot to carryout his duties.

14382 Dues Rates & Charges 2011.qxd:CC-49 7/2/11 15:42 Page 20

Figure32

DivisionofStatutoryandCom

petentHarbourAuthorityareasofjurisdiction

CourtesyofPortsmouthInternationalPort

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Commodore Clipper’smasterheldaPECforthecommercialport.Thisqualificationincludedthecontroloftugstoaidmanoeuvringandberthing.WhilePIPcanprovideberthingtugs,thedockyardporthasfarmorecapablevesselswhichcanbemadeavailabletoassistcommercialvesselsatshortnotice.However,AdmiraltypilotshavefargreaterexperienceofconductingcoldmovesthanatypicalPECholderwouldhave.

1.13.2PortsmouthInternationalPort

TheprincipaltypesofvesseltradingatPIPwerero-ropassengerandfreightferriesandrefrigeratedcargovessels,buttheporthaddiversifiedmorerecentlyandanincreasingnumberofsmallcruiseshipswerecalling.

TheportcompliedwiththePortMarineSafetyCode(PMSC)andmaintainedasafetymanagementsystem.Acargofireinaferryalongsidehadnotbeenincludedintheriskregister,andnospecificcontrolmeasures(beyondastandardemergencyresponse)hadbeenidentified.Noformalconsiderationhadbeengiventowhichoftheberthsmightbemostsuitablefordealingwithavesselthatwasarrivingintheportandneededemergencyassistance.Whileportstaffhadpractisedemergencydrills,noneoftheseincludedrespondingtoafireofthisscaleinthevehicledeckofaferry.

1.13.3Portinfrastructure

Apartfromthelinkspansforvehicletraffic,PIPhadagangwaythathadbeenprocuredtoservecruisevessels,andathree-tieredaccesstowerthathadbeendesignedtosuitadifferentcompany’svessels.Thethree-tieredtowerwasabespokedesign,withveryshortgangwaysateachofitsthreelevels,whichmadeitdifficulttouseforanythingotherthanitsintendedpurpose.Thecruiseshipgangwaywas8mlongand,withself-levellingsteps,suitableforpassengerstouseatanglesofupto45ofromthehorizontal.TheheightofCommodore Clipper’sweatherdeckabovethejettymeantthatthislimitationwouldhavebeenexceededasthetidebegantoflood.

Stevedoringserviceswerecontractedtoaseparatecompany.Theirrole,andthecapabilitythattheycouldprovide,hadnotbeenrecognisedintheport’semergencyplans.

1.14 COMMANDANDCONTROLOFEMERGENCIES

TheMCAconductedaninternalreviewofthecoastguard’sresponsetotheincidentonboardCommodore Clipper.Itconsideredthefollowingareas:

• Co-ordinationoftheincident,including:

• Jurisdiction

• TaskingofMIRG

• Roleofrescuehelicopters

• DeploymentoftheCGLO

• CommandandcontrolwithintheMCA’sdutyofficersystem

• PrinciplesandapplicationofSOLFIRE.

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Thereviewconcludedthatthejurisdictionandresponsibilityforco-ordinatingSARinharboursandinlandwaterswasunclear,leadingtoconfusionandconflict.ThiswascompoundedbynotsendingaliaisonofficertoQHM’scontrolcentrewhenSOLFIREprocedureswereinitiated.ThereviewfoundthattheavailabilityanduseofMIRGhadnotbeenadequatelyexplainedtothemasterofCommodore Clipper,despitealltheappropriateresourcesbeingavailable.DeploymentoftheCGLOwasnotinaccordancewithcoastguardprocedures,andtherewasuncertaintyamongMCAstaffaboutwhetherstatutorypowersofinterventioncouldbeused.

TheMCA’sreviewmadeanumberofhighlevelrecommendationstoseniormanagers,including:

• ProductionofdefinitiveinstructionsonthejurisdictionandlegalresponsibilitiesrelatingtotheconductofmaritimeSAR.

• Reviewofallexistinglocalarrangements(suchasSOLFIRE)nationwidetoensurethattheymeetnationalpolicyandareconsistentwithcoastguardoperatinginstructions.

• Incorporationofthelessonslearnedfromtheincidentinnewoperationaldoctrinealreadybeingdeveloped,withparticularreferenceto:

• Effectiveinformationgatheringtechniques

• Unambiguouscommunicationwithvesselsindistressandotheragencies

• Developingcoherentactionplanstomanageemergencies.

1.15 OTHERSIMILARACCIDENTS

Atotalof38casesinvolvingfiresonvehicledecksofro-roferrieshavebeenreportedtotheMAIBfrom1995to2010.Analysisofthesecasesdeterminedthatthemostfrequentcausesoffireswere:

• Elevenelectricalfiresspecificallyrecordedashavingoccurredonrefrigerationtrailers

• Elevenelectricalfiresonothervehicles

• Sevenfiresinvehiclecabs.

Duringthisinvestigation,areportwasreceivedofareefercablethatwasbeingdisconnectedinSt.Helier,beinghottothetouch.FivedaysafterthefireonCommodore Clipper,aferryonanIrishSearoutereportedanoverheatingtransformerinthepowersupplysystemforrefrigeratedtrailerscarriedondeck.

ThemostsignificantlossoflifeinaferryaccidentinrecentyearsoccurredontheAl Salam Boccaccio 98on3February2006.Theaccidentoccurredwhenafirebrokeoutonthecardeck.Deckdrainsbecameblockedandacombinationofwaterfromthefire-fightingeffortsbeingentrainedonthecardeckandcounterballastingledtothevesselcapsizing.Ofthe1418whowereonboard,1031peoplewereeitherreportedmissingorconfirmeddead.

On6February2008thero-rofreightvesselUnd Adriyatiksufferedafirethatstartedinafreighttrailer.Crewwereunabletoactivatethevehicledeckdrenchingsystem,andthefirespreadrapidlytoallthecargospaceswithin20minutes.Fireblockedtheroutetothelifeboats,andthe9passengersand22crewwereforcedtoclimbdownfromtheaccommodationusingfirehosesandropes.Theymanagedtomaketheirwaytotheforecastleand,asthefireapproached,abandonedthevesseltotheoneremainingsix-manliferaft.Theywereallrecovered.Thefirecontinuedtoburnforthenext2days,andthevesselwasatotalconstructiveloss.

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Duringthenightof8/9October2010,amajorfirewasreportedonthevehicledeckofthero-ropassengerferryLisco Gloria.ThevesselwasonpassagefromKieltoKlaipeda,with236peopleonboard.Thefiredevelopedveryrapidlyandeveryoneonboardabandonedthevessellessthananhourafterthefirewasfirstreported.Thefirecontinuedtoburnoverthenextfewdaysbeforeitwasextinguished,andthevesselwasdeclaredtobeatotalconstructiveloss.Theinvestigationintothisaccidentwasstillongoingatthetimeofpublication.

On17November2010,afirestartedonthevehicledeckofthero-ropassengerferryPearl of Scandinavia whileitwasonpassagefromOslotoCopenhagen.Thefirewasextinguishedafter2hoursthroughacombinationofthevehicledeckdrenchingsystemandmanualfire-fightingbyboththecrewandshore-basedfirefighters,whowereflownouttothevessel.Thedamageresultedinthevesselbeingoutofservicefor6days.Theinvestigationconcludedthatthefirebeganinthebatteriesofanelectricallypoweredcar.Thebatterieswerebeingrechargedfromtheship’spowersupplyatthetime.

1.16 ONGOINGDEVELOPMENTwORkATTHEIMO

1.16.1watersprayingsystems

ResolutionA.123(V),Recommendation on fixed fire extinguishing systems for special category spaces,waspublishedinOctober1967.Sincethen,ithasbeenrecognisedthatthefire-loadingofdenselypackedvehiclesandtheircargoesissignificant,andthatatraditionalwaterdrenchingsystemmaynotbeabletoextinguishsuchafire23.The2009consolidatededitionofSOLASnowreferstosuchsystemsaswatersprayingsystems,inrecognitionthattheymaynolongerbeabletoextinguishthefireasimpliedbythetitleofA.123(V)(AnnexB).

NewapprovalcriteriawerepublishedinMSC.Circ1272inJune2008foraperformancebasedapproachtofixedfire-fightingsystemsforvehicle,ro-roandspecialcategoryspaces.Thecriteriaallowforautomaticandmanuallyoperatedsystemsthatarecapableoffiresuppressionandcontrol.Alternativesystemshavebeendeveloped,andatleastonewatermistsystemhasbeentypeapproved.However,thereisnorequirementtobeabletoextinguishafireinallcircumstances,andthenewcriteriaonlyapplytovesselsconstructedafter2008.

1.16.2Structuralfireprotection

SOLASChapterII-2,Regulation20.5allowsaspecialcategoryspacetohaveanA-0classboundary,whereanopendeckspaceisontheotherside.ThiswasthecaseonCommodore Clipper,andthedeckseparatingthemainanduppervehicledeckswasasteelstructurewithnoheatinsulationproperties.Theregulationdoesnottakeintoaccountthepurposeoftheopendeckortheriskofheattransfertovehiclesthatmightbethere.

TheproblemofheattransferbetweensuchcompartmentswasrecognisedbytheFireProtectionsub-committeeinApril2007,buttheissuewasoutsidethescopeofworkatthetimeandwasnotprogressed.TheChineseadministrationsubsequentlyrequestedthattheissuebereviewed,andamendmentstoSOLASwereapprovedatMSC88inDecember2010.Theseincreasethefireprotectionrequiredbetweenvehicle,ro-roandadjacentspaces,butonlyapplytopassengervesselscarryingnotmorethan36passengers,anddonotincludespecialcategoryspaces.

1.16.3Stability

InFebruary2007,documentSLF50/4/7wassubmittedbyChinatotheIMOSub-CommitteeonStabilityandLoadLinesandFishingVesselsSafety(SLF)proposingrevisionstotheIntactStabilityCoderegardingtheeffectsonstabilityof

23MCAresearchproject,‘Assessment of the fire behaviour of cargo loaded on Ro-ro vehicle decks in relation to the design standards for fire suppression systems’,conductedbyBREFireandSecurity,November2006.

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wateraccumulatingonthero-rodeckofpassengerships.Thedocumentproposedthatsuchvesselsshouldbeprovidedwithinformationonthepotentialadverseeffectsonstabilityofwateraccumulatingonaro-rodeck,inparticularwhenundertakingfire-fightingactions.Thiswastobeintheformofacurveofwateraccumulationheightagainstheelingangle.TheSLFSub-Committeeconsideredthisproposal,butdecidedtotakenofurtheraction,asSOLASregulationII-2/20.6.1.4alreadyrequireddeckdrainstoensuretherapiddischargeofaccumulatedwaterondeck.

1.16.4SOLASamendments2008and2009

Additionstothe2009consolidatededitionofSOLAS,thathadnotenteredforce,werepublishedseparatelyinthebooklet‘SOLASamendments2008and2009’.Thisintroducesnewrequirementsfor:the‘SafeReturntoPort’concept;meansofembarkation;andprotectionofvehicle,ro-roandspecialcategoryspacesinnewlybuiltships.

SafeReturntoPort

ResolutionMSC.216(82)Annex3includesnewrequirementsforpassengervesselswithalengthofmorethan120mandthreeormoremainverticalsectionsthatarebuiltafter1July2010.Regulations21,22and23wereaddedtoSOLASChapterII-2,respectivelydescribingtherequirementsfor:

• Casualtythreshold,SafeReturntoPort,andsafeareas

• Designcriteriaforsystemstoremainoperationalafterafirecasualty

• Safetycentresonpassengerships.

Collectively,theseregulationsrequirethatthevesselcanwithstandaspecifiedamountofdamageandcontinuetofunctionwithanadequatemarginofsafetysothatitcanreturntoport.

Meansofembarkation/disembarkation

ResolutionMSC.256(84)includestheadditionofRegulation3-9toChapterII-1whichrequiresthatshipsconstructedafter1January2010haveaMeans of embarkation and disembarkation.Thisisrequiredforuseinportsandport-relatedoperations,andmustbeinstalled,maintainedandinspectedinaccordancewithguidelinespublishedinMSC.1/Circ.1331.

Protectionofvehicle,ro-roandspecialcategoryspaces

AdditionstoChapterII-2Regulation20,regardingtheprotectionofvehicle,ro-roandspecialcategoryspacesarealsodescribedinResolutionMSC.256(84).Theserefertoimprovedarrangementsfordrainingwaterfromdecks.

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SECTION2-ANALYSIS2.1 AIM

Thepurposeoftheanalysisistodeterminethecontributorycausesandcircumstancesoftheaccidentasabasisformakingrecommendationstopreventsimilaraccidentsoccurringinthefuture.

2.2 CAUSEOFTHEFIRE

ThefirstindicationsofsmokewererecordedontheCCTVsystemat0237.Giventhatneitherofthesecondofficerssmelledanysmokeintheaccommodationbeforeoraftertheirhandover,itisunlikelythatthefirestartedmuchbeforethistime.Themainvehicledeckwasalargecompartment,anditisnotsurprisingthatthefiredidnotproduceenoughsmoketoactivatethedetectionsystemuntil0242.

2.2.1 Reefercableassembly

ThefirestartedduetosustainedoverheatinginthereefercableplugthatwasconnectedtotrailerCRF459.Thiswasduetoahighresistancefaultinthebrownphase,wheretheconductorsinthecablecoremadecontactwiththeIDCterminalinsidetheplug.ItislikelythatthisfaulthadexistedsinceCommodore ClipperdepartedfromJerseythepreviousevening.Heatbuiltupinsidetheplugassemblyduringthefollowing7hours,untilitwassufficienttomeltthecablecoreandpartoftheterminalmaterial.Thisindicatesthatatemperatureofatleast900oCwasachievedinsidetheplugassembly.ThefaultwasalmostcertainlycausedbythecableconductorsmakingapoorelectricalcontactwiththeIDCterminalinsidetheplug.

Poorelectricalcontactsresultinahighresistancetocurrentflow,whichleadstolocaloverheatingandarcingasintermittentcontactismade,orcurrentsjumpacrosssmallairgapsbetweenthecableconductorstrandsandtheterminal.Inthelatterstages,astheplugbegantoburnandtheinsulationbrokedown,electricalcurrentswouldhavearcedbetweenthephases,anditislikelythatthiswasrelatedtotheearthfaultthatcausedthebus-tiebreakertotrip.

Tworeefercables,withacombinedlengthof40mhadbeenconnectedtogethertopowertrailerCRF459.Somevoltagedropwouldhaveoccurredacrossthislength,andthecurrentthatwasdrawnwouldhaveincreasedaccordingly.Thiswouldhaveaddedtotheheatingeffectacrossalltheconnections.Otherreefercablepowerpoints,closertothetrailer,wereavailableandcouldhavebeenusedinsteadofanextensioncable.Theextenttowhichthisexacerbatedtheoverheatingcannotbedetermined,butitwaspoorpractice,andtheuseofextensioncablesshouldbeavoided.

ThreeotherplugsofthesametypeasthatinvolvedinthefirewerefoundonCommodore Clipper;nonehadbeenassembledinaccordancewiththemanufacturer’sinstructions.TheinsulationoneachcablecorehadbeenremovedbeforeputtingthecablecoreintotheIDCterminal.Examinationoftheexposedconductingstrandsontheundamagedplugsshowedthatseveralhadbeendistorted.Withouttheinsulation,thestrandsofwirewerenotheldinplacesecurely,andtherewaslittletopreventindividualstrandsfromsplayingapartandmakingonlypartialcontactwiththeterminal.Whiletherewerenosignsofoverheatinginanyofthethreeundamagedplugs,itwasevidentthattheconductorstrandswerenotmakingpropercontactwiththeIDCterminal.GiventhatthreeoutofthefourStarTopplugsthatwereonboardCommodore Clipperwerefoundtobeassembledincorrectly,itisreasonabletoconcludethatthefourth,theonethatwasinvolvedinthefire,wasputtogetherinthesameway.

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TheinstructionsprovidedwiththeStarTopplugswereprintedonasmallleafletthatwasattachedtotheplugterminalssothatitwouldbefoundduringassembly.Thepictorialinstructionsreferringtothepreparationofcablescouldbeinterpretedincorrectly,andtherewasariskthattheleafletcouldbediscarded.Thesignificanceofnotstrippingthecablesandpotentialeffectsofremovingtheinsulationwerenotadequatelyemphasised.

Reefercablesoperateinaveryharshenvironmentanditwasevident,fromexaminingtheotherStarTopconnections,thattwohadloosecable-glandnuts.ThiswouldhaveallowedanystrainonthecabletobetransferredtotheindividualcablecoresatthepointwheretheyconnectedtotheIDCterminal,makingthemmorelikelytobecomeloose.Thecable-glandnutontheplugconnectedtotrailerCRF459wasconsumedbyfire,butitispossiblethatitwasalsoloose.Ifso,thiswouldhaveexacerbatedtheassemblyerrorandcontributedtodevelopingahighresistancefaultattheIDCterminal.

Theannualinspectionofthereefercablesprovidedsomeassurancethattheywereinanadequateconditionatthebeginningofthepotatoseason.However,themaintenancesystemdidnottakesufficientaccountofthewearandteareachcablereceivedinregularuse.

2.2.2 Refrigeratedtrailerequipment

TherewasnoevidenceofelectricalfaultsontrailerCRF459’srefrigerationsystem.TheequipmenthadawideoperatingrangeandwasextremelyunlikelytobeadverselyaffectedbyanyvoltageandfrequencyfluctuationsinCommodore Clipper’spowersupply.Thewindingsofthecompressormotorwerefoundtobeingoodorder,andtherewerenootherindicationsofmechanicalorelectricaloverload.

2.2.3 Electricalprotection

Theoverheatingwasduetohighresistanceinasinglephase,andtheonlyelectricalsymptomwouldhavebeenaslightlyhighercurrentbeingdrawnbythebrownphase,whencomparedwiththeothertwophases.Althoughtheelectricalprotectionsystemontherefrigeratedtrailerwascapableofdetectingthistypeoffaultonthetrailer,theship’ssupplybreakerwasnot.Consequently,thesupplycontinuedandasthetrailerrefrigerationsystemfunctionedcorrectly,nofaultswereapparentandneitherbreakertripped.

Itislikelythatthehighresistancefaulthadexistedsincethereefercablewasconnectedtothetrailer,butittookseveralhourstodeterioratetothepointwherearcingandthehightemperatureswereachieved.Oncearcinghadbegun,theconductorstrandswouldhavemeltedfairlyquickly,anopencircuitfaultwouldhaveoccurred,andthetrailer’sbreakerwouldhavetripped.However,bythistimesufficientheathadbeengeneratedtoignitethesurroundingmaterials.

TheStarTopplugwasconstructedtotheappropriateIECstandard,butthisonlyrequiredthematerialsurroundingtheterminalstowithstandaglowinghotwirewithoutigniting.Thematerialwasnotintendedtobeabletowithstandtheheatgeneratedbyaresistancefault,particularlywhenitwassustainedoverseveralhours,andtestsshowedthatitcouldbeignitedbyahighinternaltemperature.Theremainderoftheplugcasinghadnofireresistantpropertiesanditburntreadily.

ThereeferpowersupplyconnectionsonthemainvehicledeckandreefercablefittingsallhadanIP44rating,ratherthantheminimumIP55ratingthatwasrequiredbytheclassificationsociety.Thisshortfallhadbeenoverlookedduringthesurveyprocess.Whilethehighresistancefaultintheplugwasunrelatedtoingressprotection,connectorsprovidedbyMennekeswithahigherIPratingweremorerobustlyconstructedanddidnotuseIDCterminals.Itisthereforeconsideredless

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likelythatahighresistancefaultwoulddevelopinaconnectorwithahigherIPratingand,ifonedid,morelikelythattheconnectorwouldbeabletocontainthefaultwithoutigniting.

2.2.4 Trailerignition

Therewasnorequirementforthematerialsusedintheconstructionofroadtrailerstohaveanyfireresistantproperties,andtestsshowedthatthecurtain-sideandwebbingstrapswererelativelyeasytoignite.Theplugwasmounteddirectlyundertheload-bedoftrailerCRF459,andtheheatfromtheresistancefaultwouldhavetransferredstraightontothecurtain-sidematerialorawebbingstrapifonewasnearby.Insulationmaterialintheload-bedabovetheplugandsocketwasseverelydamagedbyheat.ThiswasincontrasttotrailerCRF461,whichwasofsimilarconstructionandhadalsobeeninvolvedinthefire,buthadnodamagetotheinsulationintheload-bed.Flamefromtheburningplugcasingwouldhaveignitedeitherofthematerialsafterbeingincontactforafewseconds.

Ideally,reeferpowersocketsshouldbemountedawayfromthecurtain-sideorothercombustiblematerialssothat,ifoneshouldoverheat,thechanceofthisresultinginafireisminimised.However,powersocketsalsoneedtobeaccessible,andthislimitstheoptionsformountingthemwellclearofflammablematerials.Giventhevulnerability,itisofutmostimportancethatownersandoperatorsrecognisethisrisk,andtakestepstoensurethattrailerpowersupplyfittingsandconnectionsarefitfortaskandappropriatelymaintainedatalltimes.

2.3 INITIALRESPONSEANDFIREESCALATION

2.3.1 Crewresponsetothefirealarm

Thesecondofficeronthebridgemadethecorrectresponseinsendingthelookouttoinvestigatethefirstfirealarm.Hethenallowedhimselftobepersuadedbythethirdengineerthatthealarmwasduetoafault,andheconcentratedontryingtosilencethealarmratherthanchallengethethirdengineer’sanalysis.Thethirdengineerhadnotsmelledanysmokeandbecauseabreakertrippedataboutthesametime,hemadealinkbetweenthealarmandthebreaker,interpretingthembothasbeingduetoanelectricalfaultonthemainvehicledeck.Whilethiswascorrect(thefirewasduetoanelectricalfault),hedidnotconsiderthecauseoftheproblemanyfurther,otherthantocalltheelectricalfittertoinvestigate.Intheabsenceofanyothercorroboratinginformation,hedidnotassociatetheelectricalfaultwithafire.

Commodore Clipperdidnothaveaparticularhistoryofspurious,nuisancefirealarms,butthesecondofficerhadexperiencedthisproblembeforeonothervessels.Boththesecondofficerandthethirdengineerpreferredtobelievethatafaultyalarmwasmorelikelythanafire.Theyreinforcedeachother’sfalsebeliefintheirsubsequentconversationsandcollectiveactions,thatresultedinthemsilencingandresettingthesystematotalof18timesinlessthan7minutes.Althoughbothofficershadabasicunderstandingofthefiredetectionsystemfromtheirfamiliarisationtraining,thesystemwasnotroutinelyusedaspartofthefiredrills,andthealarmwasnormallyactivatedonlyduringmaintenanceortesting.

Thesecondofficer’sandthethirdengineer’smistakenopinionscouldhavebeenchangedbyeitherareportfromthelookoutorbythesecondofficerlookingattheCCTVpictureofthemainvehicledeck.However,thelookoutinitiallyonlywentasfarastherestaurant,anddespitetheCCTVrecordingsshowingthebuildupofsmokeinthemainvehicledeckthesecondofficerdidnotreportseeinganyindicationoftherebeingafire.Theinterpretationofthefiredetectionsystembeingfaultywasconfirmedinbothofficers’mindswhenitstoppedworkingat0249,only7minutesafterfirstactivating.

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Thelookouthadsmelledsmokeintherestaurant,butwhenhereturnedtothebridge,thesecondofficerwasinconversationwiththethirdengineer,andhewaitedbeforemakinghisreportratherthaninterrupt.Thelookout’sreportstartedtochallengethesecondofficer’sperceptionoftheproblem,butlackedurgency,andasthelookouthadnotactuallyseenafire,thiswasnotenoughtopersuadethesecondofficertostartalertingtherestofthecrew.Therewasnootherinformationthatcouldmakethesecondofficerchangehismindaboutwhatwashappening,andhewasalsofrustratedthatthelookouthadnotgonetothevehicledeckinthefirstinstance.Hesentthelookoutawayagaintocheckiftherewasafire,anddecidedtotakenofurtheractionuntilhehadadefinitereport.Thelookout’sfaultyradiomeantthatconfirmationwasfurtherdelayed.

Thedelayinverifyingthattherewasafireonthemainvehicledeckhadallowedthefiretoescalate,andbythetimethechiefengineerlefthiscabintherewasastrongsmellofsmokeintheaccommodation.Althoughsmokelatercausedproblemstotheemergencyteamsanddiscomforttothepassengers,itdidmakeitimmediatelyobvioustothechiefengineerwhythefirealarmhadbeenactivated.Whenhearrivedonthebridge,itwasalsocleartohimthatnoactionshadbeentakentocontrolorextinguishthefire,andhereactedimmediately.Thematerialsinvolvedburntreadily,andtemperatureswouldhaveincreasedrapidly.Machineryalarmsindicatedthatdamagetoelectricalcablesbeganwithinthefirstfewminutesofthefireandwellbeforethedrenchersystemwasstarted.Thefirealsohadtimetobecomewellestablishedinsidethetrailer,whereitwasshelteredfromthedrencherwater.

Giventhepotentialforrapidfiredevelopmentonvehicle,ro-roandspecialcategorydecks,itisessentialthatcrewreactpositivelyatthefirstindicationsofafireandinitiatetheproperemergencyresponse.Detectionsystemsmustbereliableandincorporatedintotrainingdrillssothatcrewcanbecomeconfidentwiththesystemandtrusttheinformationthatisprovided.Whileobtainingconfirmationofthelocationandextentofafirefromaneye-witnessisimportant,itmustbeunderstoodthatthisinformationcouldcomeatahighcost.Firstlyitcouldtaketimetoobtainand,secondly,itmaywellputtheeye-witnessatrisk.Thelookoutenteredapotentiallydangerous,smoke-loggedcompartmentwithafaultyradioandanEEBD;equipmentthatisdesignedsolelyforemergencyescapeandisnotsuitableforinvestigatingfires.

Activationofasmokedetector,unexplainedelectricalfaults,andasmellofsmokehighintheaccommodationshouldbeenoughinformationtopersuadedutyofficersthatemergencyresponseplansshouldbeactivated.

2.3.2 Effectivenessofthevehicledeckwaterdrenchingsystem

Itisevidentfromthisaccident,andfromthelanguageusedinsuccessivedocumentspublishedbytheIMO,thatawaterdrenchingsysteminavehicledeckshouldnotbereliedupontoextinguishafire.ResolutionA123,publishedin1967,describesafireextinguishingsystem,butthe2009consolidatededitionofSOLASmerelyrequiresawatersprayingsystem.TheimplicationthatitmaynotputoutafireiscontradictedbythecontinuedreferencetotheperformancestandarddescribedinResolutionA123.Yet,eveninthemostrecentperformancestandardforequivalentsystemsdescribedinMSC.Circ1272,thereisstillnorequirementtoactuallyextinguishthefire.

Technically,itisextremelydemandingforatraditionalwaterdrenchingsystemtoextinguishafireonadenselypackedvehicledeck.Vehiclesaredesignedtoresistwateringress,butare,bycomparisonwiththematerialsallowedintheconstructionofpassengervessels,extremelyflammable.ACO2systemmightbemoreeffective,butcouldputpassengersatgreaterriskand,understandably,isnotconsidered

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appropriateforspecialcategoryspaces.However,improvedmethodsthatmeettheperformancestandardsdescribedinMSC.Circ1272,shouldbeencouragedonexistingvesselsinservice.

2.3.3 Abilityofcrewtofightthefireatsea

CrewenteredthemainvehicledeckonthreeseparateoccasionsbeforeCommodore ClipperberthedatPIP,andHFRSteamssubsequentlyenteredthecompartmentmanytimes.Thecrewdidnotattempttofightthefirebecauseofacombinationofthreefactors:firstly,theyexpectedthedrencherstoextinguishtheflames;secondly,theyknewverywellthatmovingaroundthemainvehicledeckwashardenoughwithoutattemptingtohandlechargedhosesaswell;andlastly,theyexpectedprofessionalfirefightersfromashoretoputthefireoutmoreeffectivelythantheycouldoncethevesselwasalongside.

FirefightersfromHFRSfounditextremelydifficulttoworkinthemainvehicledeckandcouldnotdirecttheirhosesontoalltheseatsoffire.Consequently,nomatterhowhardtheytried,firescontinuedtoburn,shelteredbythevehiclestructuresandcargo.

TheconclusionfromboththecrewandHFRS’sexperienceisthatitisimpracticaltoexpectawell-developedfire,thatislocateddeepinafullyloadedspecialcategoryspace,tobeextinguishedbytraditionalmanualtechniques.ThiscouldnotbeachievedevenafterCommodore Clipperwasalongside,andisthereforeevenlesslikelywhilesuchavesselisatsea.

2.3.4 Containment

Thisaccidentdemonstratesthatitisunlikelythatevenamoderatefireinaspecialcategoryspacewillbeextinguishedwhilethevesselisatsea.Itisthereforeessentialthatthefirecanbecontainedsuchthateitheranorderlyevacuationcanbeconducted,orthevesselcancontinuetoaportofrefuge.ThisistheaimoftheSafeReturntoPortamendmentstoSOLAS.However,theseapplyonlytovesselsbuiltafter2010thataregreaterthan120minlength,orhavemorethanthreeverticalzones;themajorityofro-ropassengerferriescurrentlytradingwillnotbebuilttothesestandards.

ThedeckboundarybetweenthemainanduppervehicledecksonCommodore ClippermettherequirementsoftheexistingregulationsandwastoA0standard.Thisofferednothermalinsulation,andheatfromthefirewasveryquicklytransferredtothedeckabove.Wereitnotfortheactivationofthedrenchersandtheboundarycoolingappliedbythecrew,itishighlylikelythattheheatwouldhaveignitedthetyresofthecarsonthedeckaboveandthefirewouldhavedevelopedonbothdecks.

ThecurrentSOLASregulationsconsidervehicle,specialcategoryandro-rodeckstogetherasagroup,andonlyrequirethermalinsulationattheirouterboundaries.Whilethisisunderstandableintheory,inpracticeafirecanonlybecontainedwithinasinglecompartmentinsidethisenvelopebyusingfixedsystemsandboundarycooling.Iftheseshouldfail,thereissomuchfuelavailablefromthevehiclesbeingcarried,thatafirewouldgrowquicklytosuchanextentthatabandonmentbecomestheonlypossiblecourseofaction.ThiswasevidentfromtheoutcomeofthevehicledeckfiresinboththeUnd AdriyatikandLisco Gloriacases.

Whilethecomplexitiesofretro-fittingthermalinsulationinbetweenspecialcategoryspacesandvehicledecksontheweatherdeckareobvious,thiswouldbealogicalmethodoflimitingtherateoffirespread.

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2.4 FIREDAMAGETOSHIP’SSYSTEMS

2.4.1 Consequencesoffiredamagetosystems

Steeringcontrolsystem

ThedamagetoCommodore Clipper’ssteeringcontrolcableaffectedbothsteeringsystems,eventhoughonlytheportcablewasdamaged.Thedamagecausedtheportruddertobedrivenovertoalargeangle,andcontrolofthestarboardrudderbecameunstableincertainconditions.Itisextremelydifficulttopredicttheeffectofsuchdamageonmodernmicroprocessor-controlledequipment,andthereisnoobligationintheregulationstodoso.Whilecrewshouldbeabletoreverttoemergencycontrolmethodsifthereissufficienttimetorespond,itwouldbeextremelydifficulttopreventacollisionorgroundingifaruddersuddenlymovedtoalargeanglewhenavesselwasinconfinedwaters.Therequirementtoseparatethecableswithinthecompartmentassumesthatthesystemshavesimilarelectronicseparation.However,thismaynotnecessarilybethecase,andthisaccidentdemonstratesthatitispossibletosatisfythewordingoftheregulationwithoutachievingitsintent.

Firedetectionsystem

Itisexpectedthatfiredetectionsensorsintheimmediatevicinityofafirearelikelytobeburntout.Systemsarethereforedesignedsothatthedamagetoindividualsensorshasminimaleffectonthesystemasawhole.ThedetectionsysteminCommodore Clipperhadbeenincorrectlyinstalled,probablyatbuild,withisolatingdevicesinthewrongpositions.Thisallowedhighvoltagesfromotherdamagedcablestoenterthefiredetectionnetwork,overloadthecontrolcircuits,andshutdownthewholesystem.

Theconsequencesofthefiredetectionsystemfailingsoearlyduringtheincidentweresignificant.Firstly,itreinforcedthedutyofficers’perceptionthattherewasatechnicalfault,ratherthanafire,andsecondlyitdeniedthecrewanymoreinformationabouttheextentanddevelopmentofthefire.Thistypeofequipmentinstallationerrorwouldhavebeendifficulttodetectinserviceandcanonlybeavoidedbycarefulqualitycontrolduringbuild.Evenso,itisimpracticaltoexpectashiptobebuiltwithoutanydefects;pre-plannedemergencyresponsesmustthereforebedesignedsothattheyareresilienttotheeffectsofequipmentfailure.Inthisaccident,failureofthefiredetectionsystemmeantthatasystemofpatrolswasrequiredtodetectanyfurtherspreadofthefire.

Firemainanddrencherpipework

Boththefiremaindistributionpipeworkandthedrencherpipeworkweredamagedbytheheatgeneratedbythefire.Itwasfortunatethatoncethesystemswereactivated,theflowofwaterthroughthepipeswassufficienttopreventfurtherheatdamage.Itisimportanttonote,however,thatthiswaterflowwasinterruptedmanytimeswhenthedrencherswereturnedofftohelpmaintainthevessel’sstabilityandwiththeintermittentneedforboundarycooling.

Itispossiblethatifthefirehadbeenmoreintenseintheearlystages,ortheflowofwaterturnedoffforlongerperiods,thepipeworkcouldhavebeenruptured.Theresultingleakswouldhavedisruptedeffortstofightandcontainthefire,potentiallyleadingtogreaterdamage.

Powersupplies

Damagetothepowersupplycablesbegansoonafterthefirebeganandledtothelossofvehicledeckventilation,theforwardmooringequipmentandbowthrusters.Whilethiscertainlylimitedtheoptionsavailabletothemasterandreducedthe

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vessel’sabilitytoberthwithouttugassistance,itdidnotundulyaffecttheconditionofthevessel.Removingtheoptionofgoingtoanchor(exceptinanextremeemergencywhentheanchorcouldhavebeenjettisoned)wasarguablyapositiveinfluence,asitputtheemphasisfirmlyongettingCommodore Clipperalongside.Itwouldhavebeenfarmoredifficulttofightthefireanddrainwaterfromthemainvehicledeckwiththevesselatanchor,andtheinevitabledelaywouldonlyhaveledtothesituationdeterioratingfurther.

Farmoresignificantwasthedamagetothero-rohydrauliccontrolcircuits.Wereitnotforthechiefengineerandhisteam’sskillandtenacityinrepairingthetwoseparatefaults,itwouldhavebeenextremelyhardtoopenthesterndoor.Thiswouldhave:severelyhamperedthefire-fightingefforts;preventedtheremovalofcargo;and,asthesterndoorwasalsothepedestrianaccessroute,obligedthepassengerstouseother,morehazardousexitroutes.

2.4.2 Effectivenessofregulations

Itisinevitablethatvehicledeckstakeupthemajorityofthespaceinaro-roferryandthatcablesandpipeworkaresubsequentlyroutedthroughthesespacesbecauseotherroutesareinaccessible.Theregulationsallowthispractice,withtheprovisothatcablesforcriticalsystems,suchassteeringgearcontrols,areduplicatedandseparatedasfaraspossible.Thereisnorequirementforthesecablestobeprotectedfromfireorheatdamage,beyondcableinsulationbeingmadeofafireretardantmaterial.Thispropertyisoflimitedvalueifcablesareexposedtoawell-developedfire.

Similarly,thereisnorequirementtoprotectpipeworkfromheatdamage,andsothesystemsthatareessentialtohelpcontainthefirearealsoatriskfromit.Hydraulicpipework,necessarytooperatemoveabledecks,rampsanddoorscanbedamaged,and,ifbreached,willnotonlydenytheuseofthisequipment,butalsoaddtotheintensityofthefire.

Theeffectofthedesignisthatanyoftheship’ssystemsthatneedtoberoutedalonganymajorpartofthelengthofaro-roferryarelikelytopassthroughavehiclecarryingcompartment.Wherethisoccurs,theprotectionfromfirethatisrequiredbytheregulationsisminimalanddamagemustbeexpected.

Manyoftheseissuesareaddressedfornewbuildpassengervesselsofmorethan120mbyMSC.216(82)Annex3whichcontainstherequirementforthemtomakea‘SafeReturntoPort’.Applyingtheseprovisionsretrospectivelytoexistingvesselsmightbedisproportionatelyburdensomeontheindustry;thebenefitsandpracticalitiesofthisoptionshouldbecarefullyconsideredbythememberstatesoftheIMO.However,untilsuchtimeasinternationalregulationsarechanged,itremainstheresponsibilityforownersandoperatorstoidentifythecriticalsystemandfireprotectionvulnerabilitiesintheirvessels,asrequiredbytheISMCode,andtakeappropriatemitigatingactions.

2.5 STABILITYISSUES

Thepotentiallossofstabilityduetotheaccumulationoffire-fightingwateronro-ropassengershipsisofseriousconcern.ThiswasmostevidentinthemassivelossoflifeduringtheaccidentonAl Salam Boccaccio 98, whenthevesselcapsizedduringattemptstocontrolafireonavehicledeck.

2.5.1 Deckdrainblockages

ThemainvehicledeckwaterdrenchingsystemonCommodore Clipperwasusedconstantlytocontainthefireuntilthevesselbegantolist.ThemasterandDPAthoughtthatthiswasprobablyduetothemainvehicledeckdrainsbecomingpartiallyblockedandwateraccumulating.Asthelistincreasedto5°theydecided

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tousethewaterdrenchingsystemintermittently,allowingmoretimeforthewatertodrainawayandthelisttoreduce.Themasterwasmindfulofthewarninginthevessel’sstabilitybookhighlightingthepotentialdangerfromthissituation,andmadealogicaldecisiontosafeguardthevessel’sstability.However,cessationofdrenchingallowedthefiretointensify.Hadthecrewbeenabletousethedrenchingsystemcontinuously,itislikelythatthefiredamagetothevesselanditscargowouldhavebeenreduced.

Thecauseoftheblockagewassubsequentlyconfirmedasbeingduetothepotatoesescapingfromsomeofthetrailers,afterbeingdislodgedbytheactionofthefireanddrenching.Theloosepotatoeswouldhavefloatedinthewaterondeck,buteffectivelypluggedthecircularholesinthedraincoversasthewaterattemptedtoflowaway(Figure15).Althoughthestabilitybookhighlightedthegeneralriskofblockages,therewasnothingthatthecrewcouldhavedonetoclearthedrainsduringtheincident;accesstothecoverswouldhavebeenhinderedbothbythetrailersandthefireitself.

Itisevidentthatthedesignofthedrains,althoughintendedtopreventblockages,wasineffectiveinallowingthewatertoclear.TheintroductionofSOLASRegulationII-2/20.6.1.5in2010,combinedwiththeguidanceofferedintheIMOcircularMSC.1/Circ.1320regardingeffectivemeasurestoensurefloatingdebrisdoesnotblocksuchdrains,shouldhelptoreducetheriskofsimilarblockagesinthefuture.

2.5.2 Marginofstability

ThedecisiontostopdrenchingwasbasedonCommodore Clipper’sincreasinglist,buttheinformationthatwasavailabletoconductanyfurtheranalysiswaslimitedanddifficulttouse.Consequently,neitherthecrewnorcompanystaffashorewereabletomakeanobjectiveassessmentoftheremainingmarginofstabilityorthemaximumpermissibleangleoflist.

DespiteboththestabilitybookandthestabilitycomputeronboardcontainingmaximumpermissibleVCGdatafordamagestability,thedataandexplanatoryinformationwerelimitedbythefollowingfactors:

• NoinformationwasavailabletoexplainhowthemaximumVCGdatahadbeenderived,inparticularwhetheritincludedthescenarioofaccumulatedfire-fightingwateronthemainvehicledeck.

• Informationwasnotreadilyavailableoneithertheeffectsonstabilityofwateraccumulatingondeck3,orofthearrangementofthespaceitself.Thisinformationwasvitalincalculatingthevolumeandfreesurfaceofanyaccumulatedwaterondeck.

• Althoughthestabilitybookcontaineddetailsofthe1995SOLASConferencerequirementforthepermissiblevolumeofseawateronthero-rodeckfollowingdamage,therewasnoanalysisoftheeffectthiswouldhaveonCommodore Clipper.

• DespiteitsapprovalbyDNVasappropriateforthecalculationofdamagestability,thevessel’sloadingsoftwaredidnotincorporateadamagestabilitymodulethatallowedtheeffectofdamagedorfloodedcompartments,suchasthemainvehicledeck,tobeassessed.

ThestabilityanalysisconductedbytheMAIBwasbasedonthesameinformationthatwasavailabletothecrew.Itwastimeconsuming,requiredreferencetoship’sdrawingsforthecalculationofgeometricdetailsandanumberofassumptionshadtobemadeinordertoquantifytheunknownfactors.Itwouldbeimpracticaltoconductsuchanassessmentinanemergencysituation.

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Althoughtheverticalpositionofthemainvehicledeck,around1mbelowthevessel’soverallVCG,meantthatallbutlargequantitiesofwaterondeckwouldhavehadaballastingeffectonthevessel,thepotentialfreesurfacewasofgreaterconcern.Withevenasmalldepthofwatercoveringtheentiremainvehicledeckarea,thelargeeffectivefreesurfacemomentwouldhavedegradedthevessel’sstabilitymarginssufficientlytointroducearealriskofcapsize.However,theeffectoffreesurfacewouldhavebeenreducedifwaterhadonlycoveredpartofthedeck.Forexample,inahypotheticalscenarioofwateraccumulatingonlyonthevessel’sportside,thestabilitycriteriawouldhavebeenmet,exceptwithverysmallquantitiesofwater.Stabilitywouldevenhaveimprovedasthewaterdepthincreased.Asthevessellisted,anywaterondeckwouldhavetransferredtoformawedge,reducingthefreesurfaceeffect.However,unlesslongitudinalsub-divisioncanbeintroduced,thisaccumulationofwaterhasthepotentialtocreateastateofloll.Therefore,theneedtoensurethewaterisdrainedawayquicklymustremainahighpriority.

IntheanalysisconductedbytheMAIB,itwasestimatedthatawedgeofabout150tonnesofwaterwouldhavegenerateda5°list,andthatthevesselwouldhavecompliedwiththerequiredintactstabilitycriteriainthiscondition.Theanalysisfurthersuggestedthatthesecriteriawouldstillhavebeenmetwithevenlargerwedgesofwaterthatproducedanglesoflistgreaterthan5°.Itwasnotpossible,withintheconstraintsofthedataandanalysismethods,todeterminewhatthemaximumpermissibleangleoflistwouldhavebeen.Amoredetaileddamagestabilitymodeloraseriesofhypotheticaldamagecaseexampleswouldhavebeenneededtoprovidethisinformation.

Therefore,althoughthedecisiontostopdrenchingwhenthevesselstartedtolistwasunderstandable,hadappropriatetoolsandsupportinginformationbeenavailabletoallowthevessel’sstabilitytobequicklyandaccuratelyassessed,itislikelythatthedrenchingcouldhavebeencontinuedforlonger.Withouttheabilitytodeterminewhateffecttheaccumulationofwaterwashavingonstability,theriskofcontinuingtousethedrenchingsystemwasunknown.Achievingtheoptimumbalancebetweentryingtocontrolthefireandmaintainingadequatestability,wasimpossiblegiventhetimeandthequalityoftheinformationthatwasavailableduringtheincident.

2.5.3 Requirementsfordamagestabilityinformation

AlthoughIMOResolutionA.265(VIII)requiredthatthevessel’smasterbeprovidedwithallnecessaryinformationtoensurethatadequatestabilitywasmaintainedfollowingdamage,therearedifferencesofopinionregardingtheamountofinformationthatshouldbeavailable.TheproposalssubmittedindocumentSLF50/4/7totheIMOinFebruary2007,wentsomewaytoresolvingthis.However,theywerenottakenforwardbytheIMOasitwasconsideredthattherequirementforadequatedeckdrainsaddressedtherisk.SOLASRegulationII-2/20.6.1.4.1.2requiresthatfurtherstabilityinformation,regardingtheaccumulationoffire-fightingwaterondeck,isprovidedtothemastersofcargoships.However,thisappliesonlywheretherequirementsforremovingsuchwatercannotbemet.

AlthoughtherecentrequirementandguidanceprovidedinMSC.1/Circ.1320andSOLASshouldreducetheriskofdebrisblockingvehicledeckdrainsduringwater-basedfire-fightingoperations,itisunlikelythatthesecanpreventwaterfromaccumulatinginallcircumstances.Thereforethereisstillaneedformoredamagestabilitytools,andinformationtobeavailabletomasterssothattheycanmanagetheeffectsofaccumulatedfire-fightingwaterondeck.

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2.6 USEOFSPECIALISEDPROFESSIONALFIREFIGHTERS

2.6.1 Informationgatheringandassessment

Inanyemergencysituation,thereisanaturaldesiretowanttofindoutasmuchdetailaspossibleaboutwhatishappening.Therightinformationiscriticaltoenableeffectivedecisionmakingandfortheoptimumresponsetobeprovided.However,thereisapointwherethedelay,effortandriskincurredfromgatheringinformationoutweighsthebenefitgained.Thepointatwhichthisoccurswillnaturallyvarydependingontheperspectiveofthedifferentorganisationsandindividualsthatareinvolved,buttheoverallbalanceshouldbeconsidered.Difficultiesinachievingthisbalancewereevidentthroughouttheincident,butweremostacuteduringtheearlystages,whenCommodore Clipperhadnotyetenteredharbour.

ThereweretworequestsfromCommodore Clipperforspecialisedfirefighterstobeflownouttothevessel;SolentCoastguardbegandrawingupMIRGtaskingplanssoonaftertheywerefirstalertedat0313.Thefirstrequestfromthevesselwasmadeat0327,shortlyafterboundarycoolinghadbeenstarted,whenthefire’sseveritybecameevidenttothecrew.However,therequestwasretractedbythemastersoonafterwardsbecausetheinformationthatwasavailabletohimsuggestedthatthefiremighthavebeenextinguished.Thiswasnotthecase,andsubsequentinvestigationshowedthatthedrencherswereunlikelytohavebeenabletoputoutafirethatwascapableofgeneratingsuchhightemperatures.Professionalfirefighterswerefarbetterqualifiedtointerprettheinformationavailableatthetimeand,hadtheybeenabletoboardCommodore Clipper,wouldalmostcertainlyhavedeterminedthatthefirehadnotbeenextinguished.

Thesecondrequestforspecialisedfire-fightingassistancecameat0618,aftertheextentofdamagetothevessel’ssystemsbecameclear.ThemisunderstandingbetweenthemasterandtheFLMledtothecrewmakingtwore-entriestothefire.Theymadenoattempttofightthefire;thepurposewassolelytogainmoredetailedinformationtofeedbacktotheemergencyservicesashore.Bothre-entriesexposedcrewtosomeriskandthebenefitgainedwasmarginal.Theysimplyconfirmedthatthefirewasstillburning;aconclusionthatcouldhavebeendrawnfromtheheatandsmokethatwasstillcomingfromthemainvehicledeck.

Theinformationthatthecrewdidobtainwaspassedbacktofirefightersviathemasterandcoastguardofficers.Inevitably,theamountofdetailandrelevanceoftheinformationwasdilutedthroughthischainofcommunication,sotheriskultimatelyoutweighedthebenefit.Similarly,thetwore-entriesstartedataround0630andtookabout1.5hoursintotal.Thefirecontinuedtoburnthroughout,andthetimecouldhavebeenbetterusedingettingthevesseltoasuitableberth,wherethefirecouldbetackledmoreeffectively.

DeployingprofessionalfirefighterstoCommodore Clipperofferedtwopotentialbenefits;themostsignificantbeingthatHFRScouldhavegainedfirst-handknowledgeofthenatureandextentofthefire.Thiswouldhavebeenrelayedbacktoseniorfireofficersashoreusingtheterminologyandformatthattheywerefamiliarwith.Thesecondpotentialbenefitwasthatfirefighterscouldhavestartedtounderstandtheconstraintsonfire-fightingimposedbythevessel’sdesign,andassessthebestwaytofightthefire.

Inthisaccident,theheatandsmokethatwerepresentshouldhavesignifiedthatthefirewasstillburning.Thevalueoftheinformationgainedbythecrewfromtheirre-entriestothemainvehicledeckwasfaroutweighedbythedelaycausedandtheriskthattheywereexposedto.Ifahighlevelofdetailedinformationabouttheextentofafireisconsideredtobeabsolutelynecessary,thenitwouldbebetterforaspecialistfirefightertogatherit.Firefightersarebestplacedtounderstandwhatinformationisneeded,reportthefindingsandmakeanassessmentonthemosteffectivewaytotacklethefire.

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2.6.2 Roleofthemaster

ThemasterdidnotuseanydistressorurgencyprefixesinhisfirstradiocontactwithSolentCoastguard,andhisreportwastransferredtoaworkingradiochannel.This,andthetoneofthesubsequentconversation,gavetheimpressionthattheincidentwasrelativelyminor.Theimpressionpersisted,andwasreinforcedsoonafterwhenthemasterreportedthatthefirewaspossiblyout.Laterreportsdescribedthedeterioratingsituation,butneverpromptedSolentCoastguardtoconsiderthatitwarranteda“Mayday”or“PanPan”designation,ortoinstigateSOLFIREprocedures.Itisunderstandablewhycrewmaynotwanttooverstateanemergencyonboardtheirvessel.Thisdoes,however,carrytheriskthatitmaythenbecomedifficulttosubsequentlychangetheemergencyservices’perceptionoftheseverityofthesituation,andofthehelpthatisthereforeneeded.Theconsequence,asinthiscase,isthatthemostappropriatelevelofresponsemaynotbeprovided.

SolentCoastguardwasthesearchandrescueco-ordinatingauthorityandthestatutorypowersofinterventionexercisedbySOSREPhadnotbeenused.TheFireServicesActdoesnotapplytovesselsatseaandHFRShadnojurisdictionuntilCommodore Clipperwasalongside.Consequently,Commodore Clipper’smasterremainedincommandofdealingwiththeemergency,andtorequestanyassistancethathefelttobeappropriatewasathisdiscretion.Whilethispositionmightseemclearinisolation,inpracticeitwascomplicatedbytheneedtoobtainQHM’spermissiontoenterPortsmouthharbour.Similarly,whencommunicatingwiththeemergencyservicesitisnaturaltodefertotheirjudgmentandtocomplywiththeirrequests.

Intheearlystagesoftheincident,themaster’sintentionwastoberthasnormalandrequestHFRStodealwiththefireonarrivalatPIP.Thiswasalogicalplan;themasterwasveryexperiencedinnormalferryoperationsandknewthecrewwereunlikelytobeabletoenterthemainvehicledeckandfightthefiresuccessfully,becausethetrailerswereparkedsoclosetogether.Hisreportatabout0340,thatthedrenchersmighthaveextinguishedthefire,wasreasonableinthecircumstances;adetailedstudyofSOLASandtherelevantcirculars,orpracticalknowledgeofseriousvehiclefireswouldhavebeenneededinordertoappreciatethatvehicledeckdrenchersarenolongerconsideredtobecapableofextinguishingsuchfires.

DoubtwascastontheplantoenterPortsmouthharbouratabout0500,whenCommodore Clipper’slistbecameapparentandcontrolofitssteeringequipmentdeteriorated.Theriskofthevesselcapsizing,orbeingincollisionincreasedconsiderably,andinthosecircumstancesitwasnotdesirablefromeitherthevessel’sortheport’sperspectiveforCommodore Clippertoenterconfinedwaters.However,thecrew’seffortsandthetugprovidedbyQHMhadmitigatedtheserisksbyabout0630,andthemaster’soriginalplanbecameaviableoptionagain.

Furtherdeteriorationinthevessel’sconditionwaspossibleandSolentCoastguardandQHMmadefurthercontingencies.SolentCoastguardfocusedonassessingtheconditionofthefireandQHMonnavigationalsafety.Bothwereprudentprecautions,buteachplacedadditionalburdensanddelaysonthemaster.ThemasterheldtheappropriatePEC,butQHM’srequirementforanAdmiraltypilotwasanimplicitconditionongrantingpermissiontoenterPortsmouthharbour.Similarly,themasterfeltobligedtoprovidemoredetailedinformationabouttheextentofthefire.

Withtugsonstation,amasterwhowasanexperiencedPECholder,andafirethatwasburningbutcontained,Commodore ClippercouldhaveenteredPortsmouthHarbourfrom0630onwardsandbeenalongsidesoonafter0700.However,themaster(andtheDPA,whowasonthebridgethroughout)wereheavilyinfluencedbytheshoreauthoritiesandwerereticentinchallengingtheirrequirements.

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2.6.3 ConstraintsontheuseofMIRG

TheMIRGdoesnothaveauthoritytounilaterallydeploytovesselsindistressandmustobtainthemaster’spermissiontodoso.TheFLMneededtocheckthatthispermissionhadbeengivenandaskedSolentCoastguardofficerstoconfirmthatCommodore ClipperhadrequestedMIRGassistance.TheFLMwasexpectingthecoastguardofficerstosimplyconfirmorotherwisethatarequesthadbeenmade.However,itwasclearfromthecoastguard’sresponse,thattheyinterpretedthisrequestforconfirmationasachallengeratherthantheassurancethatwasintended.Thisledtothecoastguardofficers,andultimatelytheFLM,tocommunicatewiththemastertocheckiftheMIRGwasrequired.Themasteralsointerpretedthischeckasmoreofachallengethanaconfirmation,andcommittedhiscrewtoenterthefireinanattempttogaintheinformationthathethoughtwasneeded.

Intheevent,theconfusionoverwhetherarequesthadbeenmade,andsubsequentmisinterpretationoftheconversationbetweentheFLMandthemaster,ledtotheMIRGnotbeingdeployed.RequestsfromvesselsforMIRGassistancemustbeaccuratelyrecordedand,whereclarificationisrequired,itshouldbemadeveryclearthatthisissimplytoconfirm,ratherthantochallengetherequest.

IfaMIRGteamhadbeenactivated,therewouldstillhavebeenseveralobstaclestoovercomebeforetheycouldhavemadeapositivecontribution.Inordertobecredible,aMIRGteamislikelytoconsistofatleastsixfirefightersallcarryingtheassociatedmarinesafetyandfire-fightingequipment.Theteamtakestimetoassembleandisasubstantialloadtotransferbyhelicopter.Itisconsideredtobepreferableforthewholeteamtobetransferredinonehelicoptermovement;evenifithadbeenserviceable,R104wasthoughttobetoosmalltoachievethistask.ThehelicopterfromRAFWattisham(R125)wassufficientlylarge,butwouldhavetakenatleastanhourtoreachLee-on-the-SolentbeforetheMIRGteamcouldembark.

IftheMIRGteamhadbeenactivatedimmediatelyaftertherequestat0618,itisunlikelythattheycouldhavebeenonboardmuchbefore0830.Onceonboard,theywouldhavehadtomaketheirpreparationsbeforeassessingthefire.Itisestimatedthattheywouldnothavebeenabletoprovideadetailedreportontheconditionofthefireuntilabout0930.ItislikelythatalargerMIRGteamwouldhavebeenneededonboardbeforetheywouldhaveconsideredenteringthemainvehicledeck.

WhileaMIRGteamcouldhaveprovidedadetailedassessmentofthefireonCommodore Clipper,thiswouldhavetakenseveralhourstoachieve.Inordertoavoidunnecessarydelay,ifdeploymentofaMIRGteamisthoughttobebeneficial,itmustbestartedattheearliestopportunity.EvenifaMIRGteamhadbeendeployed,itislikelythattheywouldhavereachedthesameconclusion:thatthemosteffectivewayoffightingthefirewastobringthevesselalongsideaberth.

2.6.4 Specialisedplanning

SeniorfireofficerswereawarethatCommodore Clipper’svehicledeckdrencherswereunlikelytoextinguishthefireandthatalargenumberoffirefighterswouldbeneededtodealwithwhattheyexpectedtobeaprotractedincident.Conversely,thecrew,companymanagersandcoastguardofficersfeltthatoncethevesselwasalongside,firefighterswouldextinguishthefirerelativelyquicklyandtheincidentwouldsoonbeover.Thesedifferentexpectationsdemonstratethatthereisaclearbenefittoseekingspecialisedfire-fightingadviceearlyoninanincidenttoinfluencehowthemarinephaseoftheemergencyismanaged.ActivatingSOLFIREproceduresearlyduringtheincidentwouldhaveprovidedthemeanstoachievethis.

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2.7 ENTRYTOHARBOUR

2.7.1 Pilotagerequirements

QHMstaffwereconfrontedwithtwoconflictingproblems:satisfyingthemselvesthatCommodore Clipperdidnotposeanunacceptablerisktothemilitaryport,butatthesametimebeingawarethatthevessel’sconditionwoulddeteriorate(andtheriskwouldincrease)whiletheydidso.

Thedutytugwassenttoassistthevesselincasefurthersteeringproblemswereencountered.Asthesituationdeteriorated,sendingthesecondtugwasaprudentprecautionasCommodore Clippercouldstillbebroughtintotheharbourevenifitlostallpower.ItwasQHM’sstandardproceduretohaveanAdmiraltypilottooverseevesselmovementsinsuchcircumstances,andthereforeitwaslogicaltodosointhiscase.Equally,transfersofpersonnelbymilitaryhelicopteraremorecommonforwarshipsandMODvesselsandQHMwouldnotnecessarilyappreciatethepotentiallimitationsofthecoastguardhelicopter’soperatingrules.Itisthereforeunderstandable,whenthebackgroundtothedecisionisconsidered,thatQHMthoughtthatembarkinganAdmiraltypilotbyhelicopterofferedadditionalassurancewithoutimposingasignificantdelay.

ThecrewofR104hadnotbeenbriefedaboutthesituationonCommodore ClipperorformallytaskedtoembarktheAdmiraltypilot.Theydidnotappreciatethesignificanceofthetaskandwereconcernedthattheyshouldnotbreachtheiroperatingrules.GiventhepotentialconsequencesofanyfurtherdelaytogettingCommodore Clipperalongside,itoughttohavebeenreasonabletoconductthetaskunderSARrules,aswasdonelater.SolentCoastguarddidnotmakethisdeclaration,andinsteadsoughttocircumventtheproblembyembarkingaCGLOaswell.Itwasunfortunatethat,aftertheconfusionwasresolved,R104wasfoundtobeunserviceable.However,ifthesignificanceofembarkingtheAdmiraltypilothadbeenrecognisedproperly,R106couldhavebeentaskedimmediatelyandtheadditional25minutewaitthatfollowedcouldhavebeenavoided.

ProblemswithembarkingtheAdmiraltypilotbyhelicopterledtoa2hourdelay,fromabout0800to1000.PIPattemptedtoassistbysendingacommercialpilotouttoCommodore Clipperbyboat.Hecouldhavebeenbroughtonboardusingtherescueboat,butastheimpressionwasgiventhatonlyanAdmiraltypilotcouldbeusedandthathewouldbeembarkedatanymoment,themastersawnobenefitinexposingthecommercialpilottothepotentialriskofbeinghoistedupintherescueboat.QHMandPIPhadnotdiscussedpilotage,butiftheycouldhaveagreedthatacommercialpilotwasacceptable,hecouldhavebeenonboardbyabout0830.

ItwasanunderstandablereactionforQHMstafftowantanAdmiraltypilotonboardCommodore Clipper togivethemfirsthandassurancethatitwassafeforthevesseltoentertheharbourandtoprovideexpertassistanceincasethepropulsionfailedandacoldmovewasrequired.However,inpracticetheAdmiraltypilotcouldonlyachievealimitedamountandtheconsequencesofthedelayinhimgettingonboardoutweighedthebenefitofhimbeingthere.TheAdmiraltypilotwasnotauthorisedtopilotacommercialvesseltoaPIPberthandthemasterwasalreadyqualifiedbyhisPECtotransitthroughtheharbourandcontrolthetugs.ThemasterconductedtheactofpilotagewhenCommodore ClipperdideventuallyenterPortsmouthharbourand,whilethepresenceoftheAdmiraltypilotwaswelcomed,itwasnotnecessary.

Thedelaycausedbytheconfusionandtechnicaldifficultiesinembarkingapilotledtofurtherfiredamageandneedlessrisk.Atthefirstsignofdelay,theneedtoembarkapilotshouldhavebeenre-evaluatedandalternativesolutionsconsidered.Therewereatleastthreeotheroptionsavailable,including:embarkthecommercialpilot;allowthemastertocontinueusinghisPEC,orconductremotepilotagefromaboat.ThedelayalsopromptedreneweddebateoverwhethertodeployaMIRGteamtoCommodore Clipper.Thetidalwindowforanunpoweredvesseltosafely

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enterPortsmouthharbourwasclosing,andthedelaythatwouldhavebeenincurredbyeitheraMIRGdeploymentorwaitingforthenexttidalwindowwouldhavebeensubstantial.

2.7.2 Planningandco-ordination

Delaystoberthingallstemmedfromtheneedtochecktheconditionofthefireandmitigatepotentialnavigationalrisks.Itwasclearthatthevesselwouldattempttoenterportatsomepointanditwaswidelyassumedthatitwouldgotoitsusualberth.

Astheconditionofthevesseldeteriorated,themasterpreferredtouseoneofthemoreaccessibleberths,ideallyBerth2.Hewasalsowellawarethathewouldneedtoturnthevesselthrough180oinordertolowerthesternrampontothelinkspanandprovidethenecessaryaccesstoshore.However,despitethetimeavailable,thisphasewasnotdiscussedinmuchdetailuntilafter1000,whenCommodore Clipperhadstartedtheentrytotheharbour.

BothCMSandPIPstaffhadexpectedCommodore ClippertouseeitherBerth4or5andHFRShadsetupitsequipmentaccordingly.QHMstaffhadthoughtittooriskytoturnthevessel,andsuggestedthatitberthedbowsontothelinkspan.Themaster’sdecisiontoturnthevesselanduseBerth2wasentirelylogical,andwasagreedwithPIP,butbecauseithadnotbeendiscussedwithalltheotherorganisationsinvolved,HFRShadsetupinthewrongplaceandinsufficientconsiderationhadbeengiventohowthismightaffectaccessorpassengerevacuation.

Thelackofplanningandco-ordinationmeantthatfirefightershadtorelocatefromoneberthtoanother,anditdeniedthemtheopportunitytomakebestuseoftheport’sinfrastructure.Properdiscussion,betweenPIP,CMS,HFRSandCommodore Clipper’smaster,andappropriatepreparationswereneeded;itmighthavebeenpossibletouseadifferentberth,evenifitwasonlytemporarily,toprovidebetteroptionsforaccesstothevessel.

2.8 PASSENGERDISEMBARkATION

2.8.1 Designfactorsandtheeffectofregulations

Allvesselsarerequiredtohaveameansofaccesstoshore.Inro-roferries,thiscanbeviathevehicleramp,providedthereisabarriertoseparatepedestriansfromvehicletraffic.Commodore Clippertradedtoportswherethetidalrangesarelarge,andintheorderof10-13m.Fewfootpassengerswerecarriedandtherewasnocommercialneed,orregulatoryrequirementtomakethesubstantialinvestmentthatwouldhavebeenneededtoprovideaseparatefootpassengeraccessthatwouldworkatallstatesoftide.Consequently,thishadnotbeenconsideredasadesignoroperationalfactor.

SOLASrequiresthataprotectedmeansofaccessisprovidedfromassemblyareastolifesavingappliances,butthereisnosimilarrequirementtoprovideaprotectedroutetoashoreaccesspoint.Asmostoftheavailableweatherdeckwastakenupbycargo,therewereveryfewplaceswhereagangwaycouldbesecured.Thedesignofthevesselalsomeantthataccessroutesfromtheaccommodationareastoagangwaywereobstructed,toavaryingextent,byvehicles.On16June,thedensityofvehiclesontheupperdeckprecludedpassengersfromusingthegangwayduringtheshorttimethatitwasinplace.Ifthevesselhadarrivedearlierontherisingtideandthebestroutesthroughthevehiclesbeenresearched,itmighthavebeenpossible,undercarefulsupervision,todisembarktheable-bodiedpassengerswithanacceptabledegreeofrisk.

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Anotherpossibleoptionmighthavebeentousetheforwardmooringdeckanditisconceivablethat,atanappropriateberth,agangwaycouldhavebeensecuredthere.Assumingthattheroutepasttherelativelywell-spacedpassengercarsattheforwardendoftheuppervehicledeckhadbeenkeptclearofsmoke24,passengerscouldhavebeenescorteddownthegreenstairstotheuppervehicledeck,ontotheforwardmooringdeckandashore.Howeverthiswasnotpossibleasthepartoftheberththatwasadjacenttotheforwardmooringdeckwasaraisedplatformanditwouldnothavebeenpossibletoputagangwaythere.

SOLASregulationsareintendedtoprovideaprotectedroutetolifesavingappliancesinanemergency.Theneedforasimilarpedestrianaccessroutetoshoreshouldbeconsidered.

2.8.2 Portinfrastructure

ItwasfortuitousthatPIPhadagangwaythatwascapableofreachingCommodore Clipper’sweatherdeck,acraneandthepersonnelavailabletoliftitintoplace.WhilethelayoutofBerth2limitedwherethegangwaycouldbepositioned,therewereplaceswherethegangway,HFRS’sladderandALPcouldbesetup.TheseprovidedalternativemeansofaccesstoCommodore Clipper whichmightnothavebeenpossibletoarrangeatothertypesofberth,particularlythosewheremooringdolphinsareused.

PIPhadnotcarriedoutastructuredassessmentofhowassistancemightbeprovidedtoadistressedvesselinitsport,andwasfortunatethatithadresourcesavailabletosupportthevesselandtheemergencyservices.Allportoperatorsshouldconsiderhowtheirinfrastructureandresourcescouldbeusedinanemergency,particularlytosupportthevesselsthatcallregularly.Astructuredassessmentmightconcludethat:

• aberththatismostsuitedtosupportingavesselindistressisidentified;

• alistofstaffwithspecialisedskillswhocanbecalledtoadviseandassist,iscompiled;

• alistofsub-contractorswhocanprovidespecialisedequipmentorservicesiskept

• or,thataportisunsuitedtosupportinganythingmorethanaminorincident.

Whatevertheoutcomeoftheassessment,theconclusionsshouldbereadilyavailabletoinformandadvisemanagersandtheemergencyservicesonthemosteffectiveactionintheeventoffutureincidents.

2.8.3 Balanceofrisktothepassengers

Itisafundamentalprinciplethatpeopleshouldbeevacuatedawayfromthesceneofanemergencysothatfewerareputatriskofinjury.However,itisdifficulttojustifyputtingthisprincipleintopracticewhentherisksassociatedwiththeevacuationareconsideredtobegreaterthanthosefacedatthescene.ThiswasthecaseonCommodore Clipperwherethecargodensity,limitationsofthevessel’sdesignandthelayoutoftheberthcombinedwiththepotentialrisksfromusingthevessel’slifesavingappliances.Theconsensusthatthepassengersweresaferremainingonboardwaslogicalandwasborneoutduringtheincident.However,itwasanundesirablesituationimposedbyshortcomingsinthedesignofthevesselanditsequipment,allofwhichwereallowedbySOLASregulations.

24WhenCommodore Clipperfirstberthedalongside,theforwardendoftheuppervehicledeckwasfreeofsmoke.Smokeaccumulatedinthisarealaterwhenthegreenstairwellwasopeneduptohelpsmokeexhaustfromthemainvehicledeck.

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Ifitisacceptedthatafireinaspecialcategoryspacemightnotbeextinguishedwhilethevesselisatsea,thenameansofdisembarkingpassengersandcrewwithaminimumriskofinjuryshouldbeprovidedoncethevesselhasberthed.Althoughlifeboatsandmarineevacuationsystemscanbeusedwhenavesselisalongside,inprincipleitshouldbesafertoallowpassengerstowalk(orbeassisted)ashoreviaagangway.

The2008and2009amendmentstoSOLASaddressthisissueandtheadditionofRegulation3.9toChapterII-1requiresthatameansofembarkationanddisembarkationforuseinportisprovided.However,thisonlyappliestovesselsconstructedafter1January2010,andthereisnorequirementfortheretobeaprotectedroutefromtheassemblystationtothepointofdisembarkation.Onexistingro-ropassengerferrieswherethisregulationdoesnotapply,itwouldbegoodpracticeforoperatorstoconsiderhowtheymightdisembarkpedestriansundertherequirementsoftheInternationalSafetyManagement25Codetoestablishemergencyoperatingprocedures.

2.9 FIRE-FIGHTINGTACTICS

2.9.1 Accesstotheseatofthefire

Allferryoperatorsneedtocarrythemaximumamountofcargointheirvesselstomakevoyageseconomicallysuccessful,andtherearenoregulationsthatspecifyaminimumdistancebetweeneachvehicle.Inpractice,accessroutesbetweenvehiclesareonlymaintainedwherecrewhavetoreachequipment,orwherepassengersneedtogetoutoftheircars.Theissuebecomesmostacutewithunaccompaniedfreighttrailersthatareloadedbystevedoresandlasheddownbythecrew.Crewareexpectedtobeabletomoveunderthetrailerload-bedsandthroughnarrowergapsthanwouldbeexpectedofpassengers.ThedistancebetweentrailersonthemainvehicledeckofCommodore Clipperwasgenerallyintheorderof150-450mmandinsomecases,adjacenttrailerswerenearlytouching.Thisdensityoftrailersencourageshigherratesoffiregrowthandreducestheeffectivenessoffixeddrenchersystemsandportablefire-fightingequipment.

Crewandfirefighterssawwaterfromthedrenchersystembouncingofftheroofsofthetrailersandrunningdowntheirsides,whilethecargocontinuedtoburninside,sheltered,yetventilatedthroughthedamagedcurtain-sides.MovingaroundthemainvehicledeckwasverydifficultinnormalcircumstancesandbecamefarworsewhenwearingBA.Similarly,man-handlingachargedfirehoseinbetweentrailerstodirectwaterontofiressetdeepinsidetrailerswasalsoextremelychallenging.Allthiswasmadeharderbythelowvisibility,cargodebrisandchainlashings.

Effectiveaccesscouldonlybegainedfromthesternramp,andventilationwasneededtomaintainadequatevisibility.HFRSofficersacceptedthatthiswouldincreasetheintensityofthefireand,althoughtheyattemptedtomitigatethis,theywereunabletopreventitcompletely.Ifthismethodofattackingthefireistobeused,itmustbeexpectedthatthefirewillintensifybeforeitisbroughtundercontrol.Thepotentialrisktoanypassengersonboardwillincreaseduringthisperiodanditwouldbepreferabletoevacuateallnon-essentialpersonnelbeforeattackingthefireinthisway.

Balancingtheprioritiesofevacuatingpassengersandcreatingaccesstofightthefirerequiresathoroughunderstandingoftheconstraintsofthevessel’slayoutandthetimeneededtoextinguishafireofthistype.

25ISMCode,2010edition,section8,emergencypreparedness

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2.9.2 Cargohandling

Itwasevidentfromtheattemptsofbothcrewandfirefightersthatthemosteffectivewaytoattackthefirewastoremovesomefreighttrailersandimproveaccess.Thisrequiredspecialisedskillsandequipmentandcouldonlybeachievedwithco-operationbetweenHFRS,thecrewandthestevedores.ThecrewsoonusedupthelimitedsupplyofchargedBAcylinderskeptonCommodore Clipper.Therewasnomeanstorechargethemonboardand,iftherehadbeen,itwouldprobablyhavebeentimeconsumingandriskedfillingthecylinderswithsmoke-contaminatedair.ItwasgoodfortunethattheBAsetsonthevesselwerecompatiblewiththoseusedbyHFRS,andtheexperiencegainedfrompreviousjointexercisesallowedagreementtobereachedforthecrewtouseHFRS’cylinders.

Theoperationtoremovecargowassuspendedwhenthesmokebecametoothickforthestevedorestocontinueworking.Morecargostillneededtoberemovedandthealternativesolutionsofusingfirefighterstooperateatugmasterorutilisingheavyrecoverycontractorsbothhadsignificantlimitations.Therateofprogresswitheitheroptionwouldhavebeenslower,andbothbroughtadditionalrisksofinjuryanddamage.

HFRS,PIPandCMShadnotbeenconfrontedwithasimilarproblembefore,andtherewasnocontingencyplantofallbackon.Itispossiblethat,withsomeofthecargoremoved,firefighterscouldhavehadabetterchanceofputtingouttheremainingfires,butprogresswouldhavebeenveryslowanddifficult.

ThestevedoresworkingatPIPhadnoformalroleinrespondingtoemergenciesintheportandhadnotrainingforworkinginsmoke-filledenvironments.ThatoneofthemshouldvolunteertoworkinBA,whenhisonlypriorexperiencewasaholidayscuba-dive,wasextremelycommendable.Theriskofhimbecomingtrappedorinjuredasaresultofhisunfamiliaritywiththeequipmentwasclear,butthepotentialbenefits,ifhecoulddotheworksafely,weresubstantial.

ThestevedorewhousedBAtocontinueoperatinghistugmasterwasmonitoredverycarefully.Astep-by-stepprocedurewasagreedthatshouldhavemeantthattherewerenocreworfirefightersinthemainvehicledeckwhenthetugmasterentered.Thisrequiredclosesupervision,constantcommunicationandcarefulco-ordination.Itwasextremelyfortunatethatwhenthisbrokedownlateron,thetwofirefighterswhofoundthemselvesinthepathoftheapproachingtugmasterwereabletoescape.

Ultimately,theabilitytoremovetheunaccompaniedtrailerswasoneofthekeyfactorsindealingwiththefiresuccessfully,butitwastimeconsuming,labourintensiveandrequiredacombinationofspecialisedskillsandequipment.Threetrailerswerestillalightwhentheywereremoved,despitemanyhoursofdrenchingandotherfire-fightingefforts.Haditnotbeenpossibletoremovethetrailers,thefire-fightingtacticswouldhaveneededtobeverydifferentandprobablyfocusedoncontainmentuntilthefireburntitselfout.Farmorematerialwouldhavebeeninvolved,includingthevehicletyresandthedieselfuelcarriedbytherefrigeratedtrailers.Thedamagewouldhavebeensignificantlygreaterand,inevitably,thepassengerswouldhavehadtobeevacuatedbylifeboatandviathemarineevacuationsystem.

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2.10 MANAGEMENTOFTHEEMERGENCYRESPONSE

2.10.1Responsibility

Nosinglepersonororganisationhadresponsibilityforthewholeincident.Responsibilitieswerebroadlydividedasfollows:

• MasterofCommodore Clipper–safetyofthepassengers,crewandthevessel;preventionofpollution

• CMS–supportingthemasterandmanagingthecommercialmattersassociatedwiththeincident

• SolentCoastguard–co-ordinationofmaritimesearchandrescue

• MCA–maritimesearchandrescue,MIRG,salvageandcounter-pollutionresponseco-ordinatingwiththeSOSREPandstatutoryportstateinspectionofthevessel

• HFRS–MIRGandfire-fightingoncethevesselwasalongside

• QHM–instigatoroftheSOLFIREresponse,safety,andregulatoryauthorityofthemilitaryport

• PIP–SHAfortheirberthsandCHAforthewiderPortsmouthharbourarea.

Allsharedacommonaim,buteachhadadifferentperspectiveonhowthisshouldbeachievedandwhattherelativeprioritieswere.Therewereconflictingrisksthatneededtobebalanced,andeachorganisationreliedontheothersforadviceandresources.Itwasevident,fromthediscussionsduringtheincident,thatasharedstrategywasneveragreedbetweenallthepartiesandthatacommonunderstandingoftheprioritieswasnotreacheduntilverylateon.Thescopeofthedecisionsthatneededtobemadewasapparentindiscussionaboutthefollowingsubjects:

• WhetherCommodore ClippershouldenterPortsmouthharbourorgotoanchor

• Theextentofthefire,andwhethertheMIRGteamshouldbedeployed

• Whattheeffectofthefirewasonthevessel’scondition

• Whatwerethemostappropriatefire-fightingtacticsoncethevesselwasalongside;and

• Whenandhowthepassengersshouldbeevacuated.

WhiletheseissueshavebeenrecognisedbytheMCAinitsinternalreviewoftheincident,theyarerelevanttoallorganisationsthatcouldfindthemselvesinvolvedinasimilaremergency.

2.10.2Communicationandco-ordination

Thekeytomanagingallthephasesoftheincidentefficientlywascommunicationandco-ordinationbetweenalltheorganisations.ThisisexactlywhattheSOLFIREprocedureswereintendedtosupport,butbecausetherequirementtosendrepresentativestoacommoncontrolcentrewasinterpreteddifferently,thepotentialbenefitswerenotrealised.

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Instead,localcontrolcentresproliferated:onboardCommodore Clipper;SolentCoastguard;HFRS,CMScompanyoffice,CMSofficeatPIP,PIPemergencyteamandsoon(Figure33).Maintainingeffectivecommunicationsandacommonsenseofpurposeinthatenvironmentwasalmostimpossible.Thiswasmostevidentduringthemiddlephaseoftheincident,from0630whenCommodore Clipperwasattemptingtoentertheharbour,to1230whenshore-basedfire-fightingoperationsbeganinearnest.Significantamountsoftimewerelostatacriticalpointbecausenoneoftheorganisationscouldadaptquicklyenoughtothechangingcircumstancesontheirown.Allthecontrolcentreswereinterdependent,andthelinesofcommunicationwerenotgoodenoughtoenablethemtofunctioncollectively.

SolentCG

SeniorC

Gofficers

FLM/

MIRG

HantsFRS

Con

dors

hore

managersand

HFR

Sofficers

PIP

QHM

Figure33

Linesofcom

municationduringtheresponsetotheincident

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Inanyincidentwheremultipleagenciesneedtoco-operate,itisessentialthattheycanshareacentralfocustocommunicateandco-ordinatetheiractivities.If,asinthiscase,anincidentappearstobeminorattheoutsetandthereisdoubtastowhethersucheffortandinfrastructurearewarranted,itisfareasiertoscalebackanorganisationthantobuildoneinahurry,andtheworstcaseshouldbeplannedfor.

2.10.3TheroleoftheSOSREP

TheroleoftheSOSREPhasbeendesignedtoprovideafocusformanagingmarineemergencies.Inthiscase,theCPSOwasinformedseveralhoursaftertheincidentbegan,andthendidnottakeanactivepartuntillateronintheafternoon.TheSOSREPwasnotawareoftheincidentanddidnotbecomeinvolveduntilmuchlater.HehadlittleopportunitytounderstandthesituationordirecttheCPSOandhisownstaff.

AlthoughstatutorypowersofinterventionwerenotrequiredandtheSOSREP’srolewaslimitedinthisincident,indifferentcircumstancestherewereseveralpotentialareaswherehisexpertiseandstatutorypowerscouldhavebeenbeneficial.Thesemighthaveincluded:

• Advisingthatlocalcontingencyplans(suchasSOLFIRE)beactivatedorenhanced

• Obtaininga‘portofrefuge’

• Obligingthemastertoacceptatow

• Obligingthemastertoacceptamarinecasualtyofficertoassesstheconditionofthevessel

• Requiringevacuationofpassengersandnon-essentialcrew/staff.

Foranyofthesemeasurestobeeffective,itisessentialthattheSOSREPisproperlybriefedviathecoastguardandCPSOreportingchain.

2.10.4Jurisdiction

Theproblemofco-ordinationwascompoundedbyissuesofjurisdiction.Portsmouthharbour’soperationiscomplicatedbytheco-existenceofthemilitaryandcommercialports,butthemajorissuesapplytomostportareas.

ThemasterremainedincommandofhisvesselthroughoutandSolentCoastguardwas,bylegislation,theco-ordinatingauthorityformaritimesearchandrescue.NeithersearchnorrescuewasrequiredanditsrolewaslargelytofacilitatetransferoftheAdmiraltypilotforQHMandtomakearrangementswithHFRS.However,SolentCoastguardalsohadaresponsibilitytoitsparentorganisation,theMCA,toinformpotentialcounter-pollution,salvageandportstateinspectionresponses.

TransferofresponsibilitywascomplicatedwhenQHMinstigatedSOLFIREprocedures.ThesestatedthatresponsibilityforcontroloftheincidentshouldpassfromSolentCoastguardtoQHM.Whilethismightbepossibleatapracticallevel,therewasneitherthemechanismnorintentiontotransferalltheMCA’sresponsibilitiestoaharbourauthority.TherewasnoformalhandoverofresponsibilityandthelimitofQHM’scontrolwasnotdiscussedordefined.

Similarly,PIPhadjurisdictionasCHAforthewholeareaandSHAfortheirberths,butdidnothaveanactiveroleuntilrelativelylateintheincident.TherewasnorecordindicatingthatPIPhadagreedtoCommodore Clipperberthinginitsport,and

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thevessel’sarrivalcouldbeinterpretedasa‘faitaccompli’.PIP’slimitedinvolvementinplanningandmanagingtheearlyphasesoftheincidentrestrictedtheopportunityforthemtoinfluencepilotageormakebestuseoftheport’sinfrastructure.

TheMCA’ssearchandrescuefunctionwasdischargedwhenCommodore ClipperberthedatPIPandtheFireServicesActapplied,makingHFRStheleademergencyservice.Counter-pollution,salvageandportstateresponsibilitiesremained,however,andastheincidentwasstillessentiallyamarineemergency,theMCAclearlyhadanongoinginterest.ThiswastestedduringtheafternoonasMCApersonnelbecameincreasinglyconcernedaboutthesafetyofthepassengers.

ThedutyCPSOhadnotbeentoldabouttheincidentuntilseveralhoursafterithadstarted,andneitherhenortheportstatecontrolsurveyorhadbeeninvolvedindiscussionsaboutthefire-fightingtacticsandpassengerevacuation.Bothhadimportantresponsibilities,butbecausetheydidnothaveafullappreciationofwhatwashappeningtheyinterpretedevents,suchastheuseoftheheelingsystemtohelpdrainwaterfromthevehicledeck,incorrectly.

ItwasapparentthatMCAstaffdidnotfullyappreciatehowtheextentoftheirjurisdictionorthepowersoftherelevantlegislationshouldbeimplementedinthiscase.

Itwasfortunatethatthedisagreementoverthedisembarkationofthepassengerswasdefused;itwasanunnecessarydistractiontothosewhowereattemptingtofightthefire.Itismoreconcerninghowever,toconsiderwhatmighthappeninagenuinedispute,wherethewideraimsofSOSREPdifferfromlocalobjectives.ItisessentialthattheMCAworkswithSOSREP,thefireandrescueauthoritiesandtheportsindustrytodevelopacommonunderstandingofhowcontrolofamarineemergencyismanagedasavesselindistressapproachesthecoast,entersportandberths.

2.10.5Understandingspecialisedvesseltypes

Thisaccidentdemonstratesthatdealingwithafireonaro-roferryrequirescarefulthoughtandco-ordinationduetothespecificneedsandlimitationsofthevessel’sdesign.Thebestexampleofthiswastheimportanceofaccesstothemainvehicledeck–forembarkingthepilot,fightingthefireanddisembarkingthepassengers.UnderstandingthelayoutandoperationofCommodore Clipperwasvitalinfightingthefireeffectivelyandsafeguardingthepassengers.Forexample,QHM’sadvicenottoturnCommodore Clipperofftheberth,waswellintended.However,thiswouldhavehinderedattemptstofightthefire.

Inordertoenablecoastguardofficerstoprovidethebestresponse,theMCAshouldworkwithvesseloperatorsandtheportsindustrytoidentifythekeyfactorstoconsiderwhendealingwiththeprincipaltypesofspecialisedvessel.Thisshouldresultinproducingguidance,availabletoalltheorganisationslikelytobeinvolvedinanemergency,whichshouldincludeareassuchas:

• Mainriskfactorsandhighpriorityissuesassociatedwiththevesseltype

- eg.vehicledeckdrenchingsystemsareunlikelytoextinguishafireandmayreducearo-rovessel’sstability

• Themainlimitationsandrequirementsofthevesseltype

- eg.firefighterswillhavegreatdifficultyfightingafireonavehicledeckdenselypackedwithhigh-sidedvehiclesandtrailers

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• Thetypeandextentofinformationthatneedstobegainedfromthevesselindistressinordertoinformdecisions

- eg.aremanoeuvrabilityandstabilityatriskordegradedasaresultofthefire?

• Therangeofpotentialoptionsthatshouldbeconsidered

- eg.taketimetoassessthevesselatsea,orbringitalongsideassoonaspossibletolimitfurtherdamage

• Thefactorsthatshouldbeconsideredinreachingadecision

- eg.availabilityofberthswithacompatiblelinkspanand/orpassengeraccessfacilities

• Specialisedskillsandequipmentthatmightberequired

- eg.cargohandlingequipment

Thisguidanceshouldbereadilyavailableandtestedroutinelyinexercisestoensurethatitremainsrelevantandisofvaluewhenitisneeded.

2.10.6Effectiveuseofavailableassets

AMIRGteamwasavailableandcouldhavebeendeployedtoCommodore Clipper.Ifateamhadbeenonboard,theycouldhaveprovidedvaluableinformationtotheircounterpartsashorethatmighthaveimprovedtheoverallresponsetotheincident.However,thisinformationwouldhavetakentimetogatherand,ifthisoptionwastobeusedwithoutimposingunduedelay,itshouldhavebeendoneassoonaspossible.Inthiscase,themostappropriatetimetodeploytheMIRGwouldhavebeenafterthefirstrequestfromCommodore Clipperat0327.

CoastguardhelicoptersareprovidedtoconductSARoperations.EmbarkingtheAdmiraltypilotfelloutsidethestrictdefinitionofSARyet,ifitisacceptedthathispresencewasessential,ithadadirectinfluenceonthesafetyofCommodore Clipperandeveryoneonboard.CoastguardofficersmusthavetheabilitytoidentifywhenitisappropriateforSARassetstobeusedoutsidetheirnormaldefinitionsofemployment,andalsohavetheconfidencetoauthorisesuchactivity.

2.10.7Sharedstrategicplan

Withseveralorganisationsinvolved,acommonstrategyfordealingwithanincidentisfundamentaltoprovidingandco-ordinatingthemosteffectiveresponse.AlthoughalltheorganisationsinvolvedinassistingCommodore Clipperhadthesameultimateaimandwereequallywellintentioned,therewaslittlesharedplanningandnocombinedstrategy.Itwasinevitablethat,whileindividualcomponentpartsworkedwell,theoverallresponsewasdisjointedanddelayedwhileorganisationssoughttokeeppacewiththeincident.

Themosteffectivewayofdevelopingacommonstrategywouldhavebeenforthedifferentorganisationstoco-locateatasharedcontrolcentre.ThiswaswhatQHMhadintendedbyinstigatingSOLFIREprocedures.Itisessentialthatallorganisationscontributetotheselocalproceduresinordertorealisethebenefitofsharedplanningandcontrol.

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2.11 wIDERRISkS

2.11.1 Vulnerabilityofvehicledecks

Withro-rodecksandspecialcategoryspacestakingupsuchalargeproportionofatypicalferry,emergenciesintheseareaswillhaveasignificantimpactonthevesselasawhole.Thisisexacerbatedbythelackofanystructuralfireprotectionbetweenspecialcategoryspacesandweatherdeckswherevehiclesarestowed,andcompoundedbythelimitedeffectivenessoffixedwaterspraysystems.Withoutpromptandeffectiveboundarycooling,amoderatefirecanspreadrapidlythroughoutitsowndeckandintoadjacentvehiclestowageareas.

Intheory,thepassengerandcrewareasareprotectedby“A60”26boundaries,butsomuchflammablematerialisavailableinavehiclefirethatitcangrowtoanextentwhereitwillovercomeanA60ratedmaterial.ThiswasevidentinboththeUnd AdriyatikandLisco Gloriacases,wherethefiresgrewsorapidlythatallthoseonboardwereforcedtoabandonship.Incontrast,thefiresonCommodore Clipper andPearl of Scandinaviawereonlycontainedbythevehicledeckdrenchersandmanualfire-fightingmethods.Withoutthese,andtheskillofthecrewinusingthemreliably,itisalmostcertainthatthefireswouldhavespreadandthreatenedpassengerandcrewareas.

Aswellasposingafirerisktotherestofthevessel,thespecialcategoryspaceonCommodore Clipperwasacriticalcompartmentformanyotherfunctions.Access(inseveralforms),integrityofship’ssystemsandstabilitywereallcompromised,andthevesselbecameincreasinglyvulnerableduetowhatwasonlyamoderatefireinasinglecompartment.

2.11.2Flammabilityofroadcargoes

Therearenorequirementstolimittheflammabilityofthematerialsusedintheconstructionofroadtrailersthatarecarriedonships.TheconstructivetotallossesofUnd AdriyatikandLisco Gloriaclearlyillustratetheeffectsofafireinvolvingmanyburningvehicles.Testsconductedinthisinvestigationindicatethatthecurtain-sideandcargopackagingmaterialswereeasilyignitableandreleasedsignificantamountsofthermalenergy.Yetthesewereinnocuousvehiclesandcargoes,typicalofmanyanddifficulttojustifydescribingasbeing‘hazardous’.

Measurestolimittheflammabilityofroadtrailersthatarecarriedonshipsshouldbeconsidered.Thiswouldnotonlybenefitmarinetraffic,butalsoreducetherisktoroadtransport,particularlywheretrailerspassthroughmajortunnelsorarestoredinotherenclosedstructures.

2.11.3Abilityofexistingmeasurestocontrolfiresinvehicledecks

The38casesinvolvingfiresonvehicledecksofro-roferriesreportedtotheMAIBinthe15-yearperiodfrom1995to2010indicatethepotentialfutureriskposedbyfiresinspecialcategoryspaces.However,existingfixedsystemsandstructuralfireprotectiononro-rovesselsmaynotbeabletocontainorextinguishafire.Promptcrewinterventionisrequiredjusttocontainthefire,andifafullcargoisbeingcarriedthereislittlechanceofthecrewbeingabletoextinguishanythingmorethanasmallfirewhilethevesselisatsea.

Existingmeasurestocontrolfiresinvehicledecksarenotcapableofdealingwithawell-developedvehicleandcargofire.ThecurrenteffortsthatareunderwayattheIMO,toimprovethefiresafetyofro-roferries,shouldbesupported.However,itmustberememberedthatmostofthesemeasuresapplyonlytonewvessels.

26InaccordancewiththeprovisionsofSOLASChapter11-2Regulation20.5

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Retrospectiveactiontocontroltheriskonexistingvessels,shouldbeconsideredmorewidelyasthelikelihoodofelectricalfaultscanoftenincreasewitholderequipment.

Thisreport,alongwiththereportsintothefiresonboardthero-rovesselsLisco GloriaandPearl of Scandinavia,shouldbereviewedbytheIMOsub-committeeonFlagStateImplementationasabasisforstimulatingacomprehensivereview,theaimofwhichistheimprovementinfireprotectionmeasuresonro-rovesselsconstructedpriorto1July2010toenhancetheirsurvivabilityandsafereturntoport.

2.12 FATIGUE

Thereisnoevidencethatanyofthecrewweresufferingfromfatigueand,therefore,itisnotconsideredacontributingfactortothisaccident.

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SECTION3-CONCLUSIONS3.1 SAFETYISSUESDIRECTLYCONTRIBUTINGTOTHEACCIDENTwHICH

HAVERESULTEDINRECOMMENDATIONS

1. TheelectricalprotectiondevicesfittedtoCommodore Clipper’sreeferpowersupplysystemmettheclassificationsociety’srequirementsandwerefunctioningcorrectly.However,theywerenotcapableofdetectingthefaultinthereefercablethatwasconnectedtotrailerCRF459.[2.2.3]

2. Highcargodensityanddebrisseverelyrestrictedtheabilityofcrewandfirefighterstomoveinsidethemainvehicledeck,andlimitedtheirabilitytofightthefire.[2.3.3]

3. Duetothehighcargodensity,thebestrouteforfirefighterstoattackthefirewasthroughthesternramp.Thisventilatedthefire,increasingitsintensity.Itwouldhavebeenpreferabletoevacuatenon-essentialpersonnelbeforeattackingthefireinthisway.[2.9.1]

3.2 OTHERSAFETYISSUESIDENTIFIEDDURINGTHEINVESTIGATIONALSOLEADINGTORECOMMENDATIONS

1. Therewerenoappropriatetoolsandsupportinginformationavailabletoassesstheeffectoftheentrainedwateronthemainvehicledeckonthevessel’sstability.Consequently,theonlyremainingoptionwastoceasedrenchingwhilethelistreduced.[2.5.2]

2. Despitetheintroductionofpracticalmeasurestoreducethelikelihoodofdeckdrainsbeingblocked,itisimpossibletocompletelypreventwaterfromfire-fightingeffortsfrombeingentrainedonvehicledecks.Theneedforadequatestabilitytoolsandinformationtobeavailabletomastersremains.[2.5.3]

3. Thevalueoftheinformationgainedbythecrewfromtheirre-entriestothefirewasoutweighedbythedelaycausedandtheriskthattheywereexposedto.Ifsuchdetailedinformationabouttheextentofafireisrequired,itisbestgatheredbyaspecialistfirefighterwhounderstandswhatisneededandhowtoreportthefindings.[2.6.1]

4. ConstraintsonthedeploymentofaMIRGteammeanthatapositiverequestmustbereceivedbeforeonecanbeactivated.Thereisalsoasignificantleadtimefromwhentheyarerequested,towhentheycanbegintoachievepositiveresults.Ifateamistobedeployed,therequestmustbeunambiguousandtheteamshouldbeactivatedattheearliestopportunity.[2.6.3]

5. Thelackofplanningandco-ordinationoverwhichberthCommodore Clippershoulduseledtofurtherdelay,asfirefightershadtorelocatefromoneberthtoanother,anddeniedanyopportunitytomakebestuseoftheport’sinfrastructure.[2.7.2]

6. ThedesignofCommodore Clippermeantthattherewasnoeffectiveshoreaccesspointforpassengersotherthanviathemainvehicledeckandsternramp.Thismettherequirementsoftheregulations.[2.8.1]

7. WhilePIPhadtheresourcestooffersupporttoCommodore Clipperandtheemergencyservices,thishadnotbeenpreviouslyconsidered.Itwasgoodfortunethatitwasavailable.Allportsshouldconductastructuredassessmentofhowtheirinfrastructureandresourcesmightbeusedtobesteffectintheeventofasimilaremergency,particularlytosupportvesselsthatcallregularly.[2.8.2]

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8. Thedecisionnottodisembarkthepassengersuntilafterthefirehadbeenextinguishedwaslogicalandbasedonthebalanceofrisk.However,thisdecisionwasdictatedbyshortcomingsinthevessel’sdesignandtheassociatedregulations.Itwouldbegoodpracticeforallferryoperatorstoconsiderhowtheymightdisembarkpedestriansinsimilarcircumstances,undertherequirementsintheISMCodetoestablishemergencyoperatingprocedures.[2.8.3]

9. TheabilitytoremovethecargofromCommodore Clipperwasakeyfactorindealingwiththeincidentsuccessfully,butitwastimeconsuming,labourintensiveandrequiredacombinationofspecialisedskillsandequipment.[2.9.2]

10. ItisessentialthattheMCAworkswithSOSREP,thefireandrescueauthoritiesandtheportsindustrytodevelopacommonunderstandingofhowcontrolofamarineemergencyismanagedasavesselindistressapproachesthecoast,entersportandberths.[2.10.2]

11. Inordertoenablecoastguardofficerstoprovidethebestresponse,theMCAshouldworkwithvesseloperatorsandtheportsindustrytoproduceguidancethatidentifiesthekeyfactorsthatshouldbeconsideredwhendealingwiththemaintypesofspecialisedvessels.[2.10.3]

3.3 SAFETYISSUESIDENTIFIEDDURINGTHEINVESTIGATIONwHICHHAVEBEENADDRESSEDORHAVENOTRESULTEDINRECOMMENDATIONS

1. Thefirestartedduetosustainedoverheating,causedbyanassemblyerrorinthereefercableplugthatwasconnectedtotrailerCRF459.[2.2.1]

2. TherewasnoevidenceofanyelectricalfaultsontrailerCRF459’srefrigerationequipmentandnosignofelectricalormechanicaloverload.[2.2.2]

3. ThereeferpowersupplyconnectionsonthemainvehicledeckweretoIP44ratingratherthantheIP55ratingthatwasrequiredbytheclassificationsociety.Whilethehighresistancefaultintheplugwasunrelatedtoingressprotection,connectorswithahigherIPratingaremorerobustlyconstructedandlesslikelytodevelop,andignitefromasimilarhighresistancefault.[2.2.3]

4. Therewasnorequirementforanyofthematerialsusedintheconstructionofroadtrailerstohaveanyfireresistantproperties.Thematerialsthatwereusedinthecurtain-sideandcargopackagingmaterialsintrailerCRF459were,bycomparisonwithothermaterialsusedinpassengervessels,easytoigniteandburntreadily.[2.2.4]

5. Althoughboththesecondofficeronthebridgeandthethirdengineerrespondedtothefirealarmveryquickly,bothinitiallyinterpreteditasbeingduetoatechnicalfault,delayingtheresponsetothefire.Giventhepotentialforrapidfiredevelopmentonvehicledecks,itisessentialthatcrewreactpositivelytofirealarmsandinitiatetheproperemergencyresponse.[2.3.1]

6. Thereisnorequirementintheregulationsforavehicledeckwaterdrenchingsystemtobeabletoextinguishafire,anditwouldbetechnicallydemandingtoachievethiswherevehiclesarecarriedinhighdensities.Vehiclesaredesignedtoresistwateringressbutare,bycomparisonwithothermaterialsusedintheconstructionofpassengervessels,extremelyflammable.[2.3.2]

7. Atsea,itwouldbeimpracticalforacrewtomanuallyextinguishawell-developedfirethatislocateddeepinafullyloadedro-rovehicledeck.[2.3.3]

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8. Thedeckboundarybetweenthemainanduppervehicledeckhadnothermalinsulation.Withouttheboundarycoolingthatwasappliedbythecrew,itislikelythatheatwouldhaveignitedthetyresofthecarsparkedontheuppervehicledeck,allowingthefiretodevelopdramatically.[2.3.4]

9. Firedamagetocablesandpipeworkrunningthroughthemainvehicledeckcausedseveralimportantsystemstomalfunctionandthreatenedthevessel’sabilitytocontainthefireandreturntoport.[2.4.1]

10.Regulationsrequirethatonlyminimalprotectionisgiventosystemsthatpassthroughspecialcategoryspaces.Intheeventofafire,damagetothesesystemsmustbeexpected.[2.4.2]

11.Earlycommunicationfromthemastercreatedtheimpressionthattheincidentwasrelativelyminor,anddidnotgeneratethelevelofresponsefromtheemergencyservicesandshoreauthoritiesthatwaslaterfoundtobenecessarytodealwiththeincident.[2.6.2]

12.ActivationofSOLFIREproceduresearlyduringtheincidentwouldhaveprovidedthemeansforspecialistfire-fightingadvicetobesoughtandusedtoinfluencethemosteffectivewayofmanagingthemarinephaseoftheemergency.[2.6.4]

13.ThedelaycausedbytheconfusionandtechnicaldifficultiesinembarkingtheAdmiraltypilotledtofurtherfiredamageandavoidablerisk.Atthefirstsignofdelay,theneedtoembarktheAdmiraltypilotshouldhavebeenre-evaluatedandalternativesolutionsconsidered.[2.7.1]

14.Inanyincidentwheremultipleagenciesneedtoco-operate,itisessentialthattheycanshareacentralfocustocommunicateandco-ordinatetheiractivities.ThisiswhattheSOLFIREprocedureswereintendedtosupport,butbecausetherequirementtosendrepresentativestoacommoncontrolcentrewasinterpreteddifferently,thepotentialbenefitswerenotrealised.[2.10.1]

15.TheroleoftheSOSREPprovidesanaturalfocusforthemanagementofmarineemergencies.Forthistobeeffective,itisessentialthattheSOSREPisproperlybriefedviathecoastguardandCPSOreportingchain.[2.10.3]

16.CoastguardofficersmusthavetheabilitytoidentifywhenitisappropriateforSARassetstobeusedoutsidetheirnormaldefinitionsofemployment,andalsohavetheconfidencetoauthorisesuchactivity.[2.10.6]

17.Therewaslittleevidenceofsharedplanningbetweenalloftheorganisationsinvolved,andnocombinedstrategyformanagingtheincident.ThisispreciselywhatSOLFIREproceduresweremeanttoavoidanditisessentialthatallorganisationscontributetotheseinitiativesinordertorealisethevalueofsharedplanningandcontrol.[2.10.6]

18.ThemainvehicledeckonboardCommodoreClipperwascriticaltomanyofthevessel’sfunctions.Access,integrityofship’ssystems,andstabilitywereallcompromised,andthevesselbecameincreasinglyvulnerableduetoamoderatelysizedfireinasinglecompartment.[2.11.1]

19.Measurestolimittheflammabilityofroadtrailersthatarecarriedonshipsshouldbeconsidered.Thiswouldnotonlybenefitmarinetraffic,butalsoreducetherisktoroadtransport,particularlywheretrailerspassthroughmajortunnelsorarestoredinotherenclosedstructures.[2.11.2]

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20.Existingmeasurestocontrolfiresinvehicledecksarenotcapableofdealingwithawell-developedvehicleandcargofire.ThecurrenteffortsthatareunderwayattheIMOtoimprovethefiresafetyofro-roferriesshouldbesupported.However,itmustberememberedthatmostofthesemeasuresapplyonlytonewvessels.Retrospectiveaction,tocontroltheriskonexistingvessels,shouldbeconsideredmorewidelyasthelikelihoodofelectricalfaultscanoftenincreasewitholderequipment.[2.11.3]

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SECTION4-ACTIONTAkEN4.1 MAIBACTIONS

InJuly2010,theMAIBissuedaSafetyBulletin(AnnexE)highlightingthepotentialriskthatpowersupplycablesfittedtorefrigeratedtrailerscarriedonshipscouldoverheat.Thesafetybulletinrecommendedthatoperatorsshould:

• Takeimmediateactiontoensurethatallpowersupplycablesandfittingsprovidedforrefrigeratedtrailerunitsareingoodconditionandthatelectricalprotectiondeviceswillactivateatanappropriatelevel.

• UntilsuchtimeastheexactcausesofthefireonCommodore Clipperhavebeenestablished,makeadditionalchecksofrefrigeratedtrailerspoweredbyships’electricalsystemstoprovideearlywarningofanyoverheating.

TheChiefInspectoroftheMAIBhaswrittentotheSecretaryGeneraloftheIMOtorequestthattheIMOsub-committeeonFlagStateImplementation,indischargingitsobligationtoreviewthecontentsofthisreport,carefullyconsidersthesafetyissuesidentified,togetherwiththosecontainedinthemarineaccidentreportssubmittedbyTurkey,GermanyandDenmarkonthefireswhichoccurredon,respectively,thero-rovesselsUnd Adriyatik,Lisco GloriaandPearl of Scandinavia.Indoingso,considerationshouldbegiventoidentifyingimprovementsthatcanbemadetothefireprotectionstandardsappliedtoro-ropassengervesselsconstructedbefore1July2010tofacilitateenhancementoftheirsurvivabilityandsafereturntoportintheeventofavehicledeckfire.

Inaddition,theMAIBhasalsopublishedaflyer(AnnexF),forwidedisseminationtotheindustry,describingthemainsafetyissuesforferryandportoperators.

TheMAIBhasalsobroughtthiscasetotheattentionoftherelevantsectionsoftheDepartmentforTransportresponsibleforfreightvehicleconstructionstandards.

4.2 ACTIONSTAkENBYOTHERORGANISATIONS

Mennekes,themanufacturersoftheStarTopconnectorhas:

• RevisedtheinstructionleafletprovidedwithStarTopconnectorstoclarifythatinsulationshouldnotberemovedbeforeinsertingcablesintoIDCterminals.

CondorMarineServiceshas:

• Arrangedforvehiclesaffectedbythefiretobeindependentlyassessedimmediatelyaftertheaccident.Affectedvehicleswerecleanedand,wherenecessary,tyreswerereplaced.

• SatisfiedtheconditionsoftheprohibitionnoticeservedbytheMCA.

• Completeditsowninvestigationintotheaccident,andasaresulthastakenthefollowingactions:

– RemovedallStarTopconnectorsfromCommodore Clipperandallothervesselsinitsfleet,andprohibitedfutureuseofIDCtypeterminalconnectors.

– Re-introducedasystemtouniquelyidentifyeachreeferpowersupplycableandplannedmaintenancetoassesstheconditionofeachcable.

– Installedimprovedprotectiondevicesintherefrigeratedpowersupplysystemthatcandetectphaseimbalanceandprovideresidualcurrentdetection.

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– InstalledIP56ratedconnectionsintherefrigeratedpowersupplysystem.

– Revisedthecompany’sinstructionstomastersanditssafetymanagementsystemtoemphasisethemaster’sauthorityinemergencysituationsandtheconductofsearchandrescueoperations.

– Rectifiedinstallationerrorsinthefiredetectionsystem.

– Modifiedtheconductoffiredrillsonallcompanyvesselstoincludetheuseofthefiredetectionsystem.

– FitteddeckdraincoversinaccordancewiththeIMOcircularMSC.1/Circ.1320onallcompanyvessels.

– Conductedtable-topexerciseswiththeportauthoritiesandFireandRescueServicesinJerseyandGuernseytodiscusshowasimilarincidentmightbedealtwithintheChannelIslands.

– Removedthebuiltindelayinthefiredetectionsystem(suchthatallfirealarmsinitiallysoundedonlyonthebridgeandECRifsilencedwithin30s)sothatallalarms(butnotsystemfaultalerts)immediatelysoundthroughoutcrewaccommodation,thusalertingallcrewtoapotentialproblem.

– OrganisedinconjunctionwithHFRSafurtherjointexercisewithHFRS,Jersey,andGuernseyMIRGteamsthatwasheldonboardCommodore Clipperon11October2011toreinforcethelessonslearnedduringtheincidenton16June2010.

– CommissionedthedevelopmentofanenhancedintactanddamagestabilitycomputersystemforCommodore ClipperandCommodore Goodwill,accessibletothecompany’scrisisteam.

Queen’sHarbourMasterPortsmouthhas:

• BegunareviewoftheSOLFIREemergencyresponseprocedures,togetherwiththeMCAandotherstakeholders.

• HostedamajorSOLFIREexerciseintheautumnof2010.

• RevieweditsrequirementsforpilotagewithPIPandagreedthatinfutureincidents,discussionswillbeheldwithPIPandSolentCoastguardtoidentifythemostappropriatemeansofprovidingpilotagesupporttovesselsindistress.

PortsmouthInternationalPorthas:

• BegunareviewoftheSOLFIREemergencyresponseprocedures,togetherwiththeMCAandotherstakeholders.

• Updateditsriskregistertoincludeavesselwithavehicledeckfireberthinginitsport.

• Updateditscontingencyplanstoreflectthelevelofsupportthattheportcanprovidetosupportvesselsthatrequireemergencyassistance.

DetNorskeVeritashas:

• Clarifiedtherequirementsinthesociety’srulesregardingtherequiredingressprotectionratingforelectricalequipmentinspecialcategoryspaces.

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HampshireFireandRescueServiceshas:

• Conductedaninternalreviewofthelessonslearnedfromfightingafireonboardaferrywithdenselypackedcargo,andhaspromulgatedtheselessonstootherfireserviceswhichcouldfacesimilarincidents.

TheMaritimeandCoastguardAgencyhas:

• Conductedaninternalreviewofthecoastguardresponseandthemanagementissuesassociatedwithrespondingtoavesselindistressasitentersharbourandberths.

• Undertakentoimplementthefollowingrecommendationsfromtheinternalreview:

– SAROperationsBranchshouldreviewallcurrenthighlevelMemorandaofUnderstanding(MOU),legislationandguidanceandproduceadefinitivedocumentwhichisclearandunambiguousregardingthejurisdictionalandlegislativeresponsibilitiesoftheMCA/HMCGfortheconductofSAR.ThisshouldinformtherewriteoftheSARUKFrameworkandbepassedtotheSARStrategicCommitteeforendorsement.

– SAROperationsBranchshoulddirectareviewofallexistingMOUsandLocalGuidancerelatingtoSARtoensurethatitiscompliantwithcurrentpolicy,guidanceandlegislationandtoremoveambiguityordoubtregardingprecedence.Suchplansshouldbeavailable,electronically,foraccessbyMCAdutyofficers.Inthiscase,theEastofEnglandRegionalDirectorshouldinitiateareviewoftheSOLFIREplantoensurethatitisconsistentwiththenormaloperatingrequirements,guidance,policiesandpracticesofHMCG.Inparticular,theroleoftheCGLO.

– NewHMCGoperationalprotocolsareunderdevelopment.TheOperationalManagementSystemshouldcontainguidance:

• RegardinginformationgatheringtechniquesusedtodevelopaclearawarenessofthesituationanddrawingonthedeploymentofliaisonofficersandSitrepsfromothercommandgroups.

• Onhowtopassunambiguousinformationtomasterstoassistthemintheirdecisionmaking.

• Onhowtodevelopacoherentplanofactionthatisnotinconflictwithexistingregulations.

– TheSOSREPdeputy/dutystructureshouldbereviewedtoremoveanyambiguityabouttheauthorityofindividuals.Thisshould:

• ProvidefortheformaldelegationofSOSREPauthorityandpowerstoanominateddeputyduringperiodswhenthenominalSOSREPisunavailable(e.gduringperiodsofleave,overseastravelorsicknessabsence).

• DistinguishbetweenadvicethatisbeingofferedbySOSREPduringevolutionandrequirementsthatresultfromtheexerciseofthepowersofintervention.

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SECTION5-RECOMMENDATIONSTheMaritimeandCoastguardAgencyisrecommendedto:

2011/140 Workwithitsstakeholderstoproduceindustryguidelinesformaritimeemergencyresponderstoconsiderwhenprovidingfire-fightingorotheremergencysupporttoshipsinUKwaters.Theguidelinesshouldinclude,interalia:

• Bestpracticecommandandcontrolprinciples

• Informationgatheringandliaisononscene

• Safetyofpassengersandcrew

• Shipspecificrisksandconsiderationswithparticularemphasisonissuesassociatedwithpassengerro-rovesselsandvesselscarryinghazardouscargoes

• Factorstobeconsideredindecidingwhethertobringavesselintoport/alongside

• Specialisedequipmentandotherresources.

ThePortMarineSafetyCodeSteeringGroupisrecommendedto:

2011/141 Provideadviceintheguidetogoodpracticeonportmarineoperationsregarding:

• Theneedforportstoidentifyandlistthecapabilitiesandlimitationsofthefacilitiestheycanoffertosupportvesselsrequiringemergencyassistanceoncetheyarealongside.

• Howsupportfromcargohandlingequipmentandotherportinfrastructuremightbeprovidedtotheprincipalvesseltypesthataretradinginaport,inordertoassistindealingwithanemergencyonboardavesselthatisalongside.

DetNorskeVeritasisrecommendedtomakeasubmissiontoIACStodevelopaunifiedrequirementto:

2011/142 Improvethestandardofelectricalfaultprotectiononsystemsdesignedtoprovideelectricalpowertoroadfreightunitsstoredonvehicledeck,specialcategoryandro-rospaces.Suchprotectionshouldinclude:

• Residualcurrentdetectiontoreducetheriskofelectricshock

• Shortcircuitandoverloaddetection

• Phaseimbalancedetection

91

TheBahamasMaritimeAuthorityisrecommendedto:

2011/143 MakeasubmissiontotheIMOtoconsiderarequirementforallexistingro-ropassengervesselstobefittedwith,orhavereadyaccessto,meansofdeterminingtheeffectofdamageorentrainedwaterfromfirefightingonthevessel’sstability.

2011/144 DevelopajointpaperwiththeMaritimeandCoastguardAgencyforsubmissiontotheIMOtoconsiderarequirementforallvessels,whoseprincipalmeansofaccessisviaasingleramptoavehicle,specialcategoryorro-rospace,toassesshowanalternativemeansofpedestrianaccesstoshorecouldbeprovidedinanemergency.

Safetyrecommendationsshallinnocasecreateapresumptionofblameorliability

Annex A

Classification society’s report of the damage caused by the fire

Rev. [1]

DET NORSKE VERITAS

SURVEY REPORT

DNV id. no.

21616

Job Id.

191416

Name of vessel

COMMODORE CLIPPER

Name of owner

Condor Limited

IMO no.

9201750

Station

Southampton

Place of survey

Portsmouth, UK

Survey started

2010-06-16

Survey completed

2010-07-02

Lead surveyor’s name

Survey team

If any person suffers loss or damage which is proved to have been caused by any negligent act or omission of Det Norske Veritas, then Det Norske Veritas shall pay compensation to such person for his proved direct loss or damage. However, the compensation shall not exceed an amount equal to ten times the fee charged for the service in question, provided that the maximum compensation shall never exceed USD 2 million. In this provision "Det Norske Veritas" shall mean the Foundation Det Norske Veritas as well as all its subsidiaries, directors, officers, employees, agents and any other acting on behalf of Det Norske Veritas.

DET NORSKE VERITAS AS, VERITASVEIEN 1, N-1322 HØVIK, NORWAY, TEL.INT.: +47 67 57 99 00, TELEFAX: +47 67 57 99 11

Form No.: 40.9 Issue: April 2005 Page 1 of 11

Survey, Following Main Vehicle Deck Fire

This is to confirm that the following has been carried out:

Surveys

Survey Code Survey Name Result

MISC.O Miscellaneous item occasional - Survey, following main vehicle deck fire Complete

Conditions and Memoranda – Given Due Date

CC 40 Before the due date, No.20 void starboard bilge valve, remote control is to be repaired or

renewed.

Finding(s):

[Bilge handling control and monitoring system (Bilge Remote Control valves)] No.20 void, starboard bilge valve, remote control valve was removed.

2010-10-02

CC 41 Before the due date, the starboard main engine, local telegraph is to be repaired.

Finding(s):

[Engine telegraph] Starboard main engine, local telegraph was found inoperable, due to an electrical fault.

2010-10-02

Name of vessel

COMMODORE CLIPPER

Name of owner

Condor Limited

DNV id. no.

21616

Job Id..

191416

DET NORSKE VERITAS AS, VERITASVEIEN 1, N-1322 HØVIK, NORWAY, TEL.INT.: +47 67 57 99 00, TELEFAX: +47 67 57 99 11

Form No.: 40.9 Issue: April 2005 Page 2 of 11

Survey Observations and Findings

Events

Fire was reported to have started at sea, in a freight trailer, on the port side of the main vehicle deck, at approx

03:00hrs on 2010-06-16.

The vessel came alongside Portsmouth Continental Ferry Port, No.2 Berth, the fire was reported extinguished by the

Fire Brigade and passengers disembarked at 23:00hrs on 2010-06-16.

Four trailers, in total, were found to be damaged by fire.

The vessel was attended by Bahama Maritime Authority and UK Marine Accident Investigation Branch, for the

purpose of incident investigation.

The vessel was also attended by the UK MCA, as port state control, who issued a "Prohibition Notice" with 10

deficiencies.

All deficiencies were dealt with before departure.

On completion of repairs and basin trials, the vessel was subjected to a sea trial.

All systems were found to be operating satisfactorily.

Fire damaged trailer

Fire damaged trailer

Fire damaged trailer

Fire damaged trailer

Vessel alongside, with the fire brigade in

attendance

Name of vessel

COMMODORE CLIPPER

Name of owner

Condor Limited

DNV id. no.

21616

Job Id..

191416

DET NORSKE VERITAS AS, VERITASVEIEN 1, N-1322 HØVIK, NORWAY, TEL.INT.: +47 67 57 99 00, TELEFAX: +47 67 57 99 11

Form No.: 40.9 Issue: April 2005 Page 3 of 11

Findings

Fire damage was found in the following locations:

Main Vehicle Deck (deck 3), port side, between frames 71 and 89.

- Longitudinal and transverse frames on deckhead buckled.

- Pipework buckled.

- Electrical cables and equipment burnt out.

Upper Vehice Deck (deck 5), port side, between frames 74 and 86.

- Deck buckled.

Fire / water damage was found to the following systems:

- Drencher system pipework, on deck 3.

- Fire main pipework, on deck 3.

- Fresh water pipework, on deck 3.

- Fire detection system, on deck3, steering gear and engine control room.

- Public address system, on deck 3.

- CCTV system, on deck 3.

- Steering gear, remote and local, control and feedback systems.

- Forward switchboard supply (including anchor hydraulics, car deck fans and bow thrusters).

- Main and emergency lighting, on deck 3.

- Reefer sockets, on deck 3.

- Internal ramp control and indication electrics.

After fire

Repaired: Fire damage was repaired, as necessary, as detailed in the following report.

Smoke affected zones were washed down with fresh water.

Name of vessel

COMMODORE CLIPPER

Name of owner

Condor Limited

DNV id. no.

21616

Job Id..

191416

DET NORSKE VERITAS AS, VERITASVEIEN 1, N-1322 HØVIK, NORWAY, TEL.INT.: +47 67 57 99 00, TELEFAX: +47 67 57 99 11

Form No.: 40.9 Issue: April 2005 Page 4 of 11

After repairs

Decks

Findings [Deck]

The Upper Vehicle Deck (deck 5) deck plating was found buckled, from frame 74 to frame 86, port side, outboard of

the internal ramp.

The following damage was found to the Upper Vehicle Deck (deck 5) supporting structure, port side, outboard of the

internal ramp:

- Between frames 71 and 74 - 3 longitudinals buckled.

- Between frames 74 and 77 - 6 longitudinals and 1 deep longitudinal buckled.

- Frame 77, web and lower flange buckled.

- Between frames 77 and 80 - 6 longitudinals and 1 deep longitudinal buckled.

- Between frames 80 and 83 - 6 longitudinals buckled.

- Between frames 83 and 86 - 4 longitudinals and 1 deep longitudinal buckled.

- Between frames 83 and 86 - 1 deep longitudinal buckled, just forward of ramp.

- Between frames 86 and 89 - 2 longitudinals buckled.

Longitudinal buckled

Longitudinal buckled

Section of cropped deep frame

Upper Vehicle Deck buckled

Name of vessel

COMMODORE CLIPPER

Name of owner

Condor Limited

DNV id. no.

21616

Job Id..

191416

DET NORSKE VERITAS AS, VERITASVEIEN 1, N-1322 HØVIK, NORWAY, TEL.INT.: +47 67 57 99 00, TELEFAX: +47 67 57 99 11

Form No.: 40.9 Issue: April 2005 Page 5 of 11

Longitudinal buckled

Frame 77, web and lower flange buckled (buckled

longitudinal deep frame already removed)

Repaired: The following repairs were carried out, by Testbank Ship Repair:

- Upper Vehicle Deck plating was cropped and renewed, from frame 73 to frame 88, 6 metres wide.

- Longitudinal frames were cropped and renewed, from frame 74 to frame 88, as required.

- Deep frames and deep longitudinals were cropped and inserted, as necessary.

Welding procedures, welder qualifications, materials and consumables certificates were reviewed and found

in order.

AH 36 steel has been replaced with DH 36 or EH 36, due to availability.

12mm deck plating has been replaced with 14mm, due to availablity.

Ultrasonic thickness measurement and magnetic particle testing was carried out by DNV approved service

supplier, Ultramag, on a representative number of welds.

100% visual inspection was completed by the undersigned Surveyor.

No defects were noted.

Shell doors water leakage detection alarm system

Findings "Water on vehicle deck" alarms were noted damaged and inoperable.

Repaired: "Water on vehicle deck" alarms were repaired and satisfactorily function tested.

Anchoring arrangement

Findings [Anchor winch hydraulic power system]

Electrical power supply was noted lost to the forward hydraulics, for anchoring and mooring equipment.

Repaired: Damaged cables were cropped, spliced and enclosed in approved heat shrink closures.

Anchoring and mooring equipment was satisfactorily function tested.

Steering gear arrangement P

Name of vessel

COMMODORE CLIPPER

Name of owner

Condor Limited

DNV id. no.

21616

Job Id..

191416

DET NORSKE VERITAS AS, VERITASVEIEN 1, N-1322 HØVIK, NORWAY, TEL.INT.: +47 67 57 99 00, TELEFAX: +47 67 57 99 11

Form No.: 40.9 Issue: April 2005 Page 6 of 11

Findings The following power and control faults were found on the port steering gear:

- No.1 pump forced the rudder hard to starboard, in remote.

- No.2 pump auto-starting, unable to stop, no directional control, in remote or local.

The following power and control faults were found on the starboard steering gear:

- No.3 pump hunting, in remote.

- No.4 pump auto-starting, unable to stop, no directional control, in remote or local.

Repaired: The fire damaged 48 core steering control cable was cropped, a junction box was installed at each

end and the cable was renewed.

Steering power and control was fully function tested and found in order.

Manoeuvring thruster arrangement A

Findings Electrical power and control was noted lost to the aft bow thruster hydraulics.

Repaired: Damaged power supply cables to the forward swtichboard were cropped, spliced and enclosed in

approved heat shrink closures.

The aft bow thruster was satisfactorily function tested.

Manoeuvring thruster arrangement F

Findings Electrical power and control was noted lost to the forward bow thruster hydraulics.

Repaired: Damaged power supply cables to the forward swtichboard were cropped, spliced and enclosed in

approved heat shrink closures.

The forward bow thruster was satisfactorily function tested.

Main electric power distribution

Findings The following was noted on the electrical power distribution system:

-Main Vehicle Deck (deck3), port side main cable tray buckled and cable insulation destroyed, between frames 74

and 77.

- Forward switchboard, both power supplies fire damaged.

- Reefer socket, fuse boxes and breaker cabinets water damaged.

Name of vessel

COMMODORE CLIPPER

Name of owner

Condor Limited

DNV id. no.

21616

Job Id..

191416

DET NORSKE VERITAS AS, VERITASVEIEN 1, N-1322 HØVIK, NORWAY, TEL.INT.: +47 67 57 99 00, TELEFAX: +47 67 57 99 11

Form No.: 40.9 Issue: April 2005 Page 7 of 11

Fire damaged cable tray

Fire damaged cable tray

Repaired: Damaged cables were cropped, spliced and enclosed in approved heat shrink closures.

Reefer socket circuit breakers were renewed and fuse boxes were taken out of service.

Fresh water generation, storage and distribution system

Findings Main Vehicle Deck (deck3), port side domestic fresh water main buckled, between frames 74 and 77.

Repaired: The damaged section of pipework was renewed.

Bilge handling control and monitoring system (Bilge Remote Control valves)

Findings The port forward engine room bilge valve, remote control was noted inoperable.

Repaired: The remote control valve was renewed.

Electronic chart display and information systems (ECDIS)

Findings [Electronic chart display and information system (ECDIS) 1]

Software malfunctions were noted on the ECDIS.

Repaired: The ECDIS was repaired by the manufacturer's representative.

Navigation lights, shapes and signalling devices

Findings [Navigation lantern]

Both lamps and alarm indication for the stern light were found to be inoperable, after fire damage to the cabling.

Repaired: Damaged cables were renewed.

Both lamps and the alarm indiciation were satisfactorily function tested.

Public address system

Findings The following sections of the public address system were noted inoperable:

- Main Vehicle Deck (deck 3).

Repaired: Damaged cables and speakers were renewed.

The system was satisfactorily function tested.

Name of vessel

COMMODORE CLIPPER

Name of owner

Condor Limited

DNV id. no.

21616

Job Id..

191416

DET NORSKE VERITAS AS, VERITASVEIEN 1, N-1322 HØVIK, NORWAY, TEL.INT.: +47 67 57 99 00, TELEFAX: +47 67 57 99 11

Form No.: 40.9 Issue: April 2005 Page 8 of 11

Watch call alarm system

A Bridge Navigational Watch Alarm System was verified as fitted in accordance with MSC.128(75) and function

tested, satisfactorily.

Fire detection system

Findings The following sections of the fire detection system were found inoperable:

- Main Vehicle Deck (deck 3).

- Steering gear.

- Engine control room.

- Bow thruster room.

One section of the motherboard, in the control unit was also found burnt out.

Fire damaged, fire detector head

Repaired: Damaged cables and detector heads were renewed.

The motherboard was replaced in the control unit.

The system was satisfactorily function tested.

Fire water distribution arrangement

Findings Main Vehicle Deck (deck3), port side fire main buckled, between frames 74 and 77.

Repaired: Fire main pipework, within the fire area, was renewed.

The system was satisfactorily pressure tested and no leaks were noted.

Deep-fat cooking device foam fire extinguishing system

In the main galley, an approved deep fat fryer, foam fire extinguishing system was noted as fitted in accoredance with

SOLAS Ch.II-2, Reg.10, 6.4.

Vehicle, special category and ro-ro space water spraying fire extinguishing system

Name of vessel

COMMODORE CLIPPER

Name of owner

Condor Limited

DNV id. no.

21616

Job Id..

191416

DET NORSKE VERITAS AS, VERITASVEIEN 1, N-1322 HØVIK, NORWAY, TEL.INT.: +47 67 57 99 00, TELEFAX: +47 67 57 99 11

Form No.: 40.9 Issue: April 2005 Page 9 of 11

Findings Main Vehicle Deck (deck3), port side drencher main (zone 4) buckled, between frames 74 and 77.

Buckled drencher main aft of frame 77

Buckled drencher main aft of frame 77

Repaired: Drencher main pipework, within the fire area, was renewed.

The system was satisfactorily function tested and no leaks were noted.

Other safety arrangements

Findings Main Vehicle Deck (deck 3), CCTV was found fire damaged and inoperable.

Repaired: Damaged cables and cameras were renewed.

The system was satisfactorily function tested.

Ventilation systems for accommodation spaces

Main laundry dryer exhaust dampers and filters were fitted in accordance with the latest SOLAS amendments and

function tested, satisfactorily.

Ventilation systems for hazardous cargo spaces

Findings Electrical power supply was noted lost to all car deck fans.

Repaired: Damaged cables were renewed.

Fans were satisfactorily function tested.

Lighting arrangement

Findings Main Vehicle Deck (deck3), main and emergency lights were found fire damaged and inoperable.

Name of vessel

COMMODORE CLIPPER

Name of owner

Condor Limited

DNV id. no.

21616

Job Id..

191416

DET NORSKE VERITAS AS, VERITASVEIEN 1, N-1322 HØVIK, NORWAY, TEL.INT.: +47 67 57 99 00, TELEFAX: +47 67 57 99 11

Form No.: 40.9 Issue: April 2005 Page 10 of 11

Fire damaged light

Repaired: Damaged cables and lights were renewed.

Main and emergency lighting system were satisfactorily function tested.

Internal moveable ramp arrangement

As a precautionary measure, the following maintenance was completed:

- Flexible hydraulic hoses renewed.

- Hydraulic rams overhauled.

- Hinge pins and locking mechanisms overhauled.

- Sheaves renewed, as necessary.

- Main lifting wire renewed.

The internal ramp was recommissioned, by the manufacturer's representative and then overload tested in operation,

with 85 tonnes (10%+ in excess of the safe working load of 75 tonnes).

Internal ramp

Internal ramp hoses

Findings [Internal moveable ramp control and monitoring system]

The internal ramp (main vehicle deck to upper vehicle deck), control and indication electrics were found fire damaged

and inoperable.

Repaired: The control and indication electrics were renewed and the system was satisfactorily function tested.

Hydraulic pipework, outboard of the ramp, was found fire damaged.

Repaired: Hydraulic pipework was renewed, flushed and satisfactorily pressure tested.

Name of vessel

COMMODORE CLIPPER

Name of owner

Condor Limited

DNV id. no.

21616

Job Id..

191416

DET NORSKE VERITAS AS, VERITASVEIEN 1, N-1322 HØVIK, NORWAY, TEL.INT.: +47 67 57 99 00, TELEFAX: +47 67 57 99 11

Form No.: 40.9 Issue: April 2005 Page 11 of 11

Annex B

IMO Resolution A.123(V)

Annex C

Report of the examination of the electrical components

Page 1 of 26

Commercial-in-Confidence

Business Unit: Cobham Technical Services Engineering Consultancy Services

Report Title: Examination of Electrical Components from Fire on the Commodore Clipper

Author:

Client: Marine Accident Investigation Branch

Client Reference: MAIB10010

Report Number: 2010-0506

Project Number: 7F0625001

Report Version: Final Report

Document Control: Commercial-in-Confidence

Report Checked by: Approved by:

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PURPOSE OF DISTRIBUTION:

This document is distributed to Marine Accident Investigation Branch for the sole purpose of commercial and technical use. Rights to copy or distribute this document are only granted for the stated purpose. The document may not otherwise be used or distributed without the prior written permission of Cobham Technical Services.

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Summary

A fire occurred on 16 June 2010 on the Commodore Clipper while on passage from Jersey to Portsmouth. The crew identified that a refrigerated trailer unit, powered from the ship’s electrical supply, had caught fire.

Following an initial investigation by Marine Accident Investigation Branch (MAIB), Cobham Technical Services was asked to assist in the investigation. This assistance involved the examination of the electrical components relating to the refrigeration system on the trailer.

From the examination of the remains it has been concluded that the fire was initiated by arcing at an insulation displacement connector in the socket, on the ship’s supply cable, which connected to a fixed plug on the trailer. The arcing was caused by a high resistance connection in the socket.

A second socket of the same design, from the Commodore Clipper, was found to have been incorrectly terminated. The error was that the insulation had been stripped back at the end of the cable cores before they were inserted into the IDC terminal. This error could lead to a high resistance connection. It is considered that incorrect assembly of the termination is the most likely cause of the high resistance connection that led to the fire. However the possibility that excessive tension on the cable had partially pulled the conductors out of the IDC terminations cannot be ruled out.

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Contents

Page No.

1. Introduction 7

2. Background 7

3. Examination 7

3.1 On-site examination 7

3.2 Examination at Cobham 11

4. Discussion 24

5. Conclusions 25

Figures List

Page No.

Figure 1 Location of electrical units.......................................................................... 8

Figure 2 Layout of electrical units ............................................................................ 8

Figure 3 Supply socket............................................................................................ 9

Figure 4 Control box assembly, fire damaged ......................................................... 10

Figure 5 Control box assembly, undamaged ........................................................... 10

Figure 6 Trailer mounted intake plug ..................................................................... 11

Figure 7 X-ray of plug and socket .......................................................................... 12

Figure 8 Insulation displacement connectors .......................................................... 12

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Figure 9 Changeover switches ............................................................................... 13

Figure 10 Trailer MCB............................................................................................. 13

Figure 11 Fire damaged wiring................................................................................ 14

Figure 12 Terminal and spring contact..................................................................... 15

Figure 13 Contacts ................................................................................................. 15

Figure 14 Terminals in fixed plug ............................................................................ 16

Figure 15 Damaged and undamaged free socket...................................................... 16

Figure 16 Charred free socket ................................................................................. 17

Figure 17 Contact pins............................................................................................ 18

Figure 18 Free socket ............................................................................................. 18

Figure 19 Blue phase IDC ....................................................................................... 19

Figure 20 Brown phase IDC .................................................................................... 20

Figure 21 Conductor strands adhered to terminal ..................................................... 20

Figure 22 Conductor strands and copper globules .................................................... 21

Figure 23 Undamaged IDC connector ...................................................................... 21

Figure 24 Conductor strands in connector ................................................................ 22

Figure 25 Insulation removed before fitting ............................................................. 22

Figure 26 Correctly terminated core ........................................................................ 23

Figure 27 Cable cores ............................................................................................. 23

Figure 28 Copper globule........................................................................................ 24

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1. Introduction

At 0242 (BST) on 16 June 2010 while Commodore Clipper was on passage from Jersey to Portsmouth, a fire was detected on the main vehicle deck. The vehicle deck was loaded with unaccompanied freight trailers including a number of refrigerated, curtain-sided lorries containing potatoes in plastic trays. The crew identified that one of the refrigerated trailer units, powered from the ship’s electrical supply, had caught fire.

Following an initial investigation by Marine Accident Investigation Branch (MAIB), Cobham Technical Services was asked to assist in the investigation. This assistance comprised an examination of the electrical components relating to the refrigeration system on the trailer.

This report gives details of the examination of the electrical components.

2. Background

Cobham was provided with the following information concerning the incident.

The trailer’s 400 V, 3 phase refrigeration system can be powered from the tractor unit’s engine, from a diesel driven generator within the trailer or from an external power source. The electrical control units for the refrigeration system and the supply intake are mounted under the bed of the trailer at one side. The burn pattern and damage to the supporting cargo pallets indicated that the fire started below the trailer bed in the immediate vicinity of the electrical controls.

It is known that the trailer was supplied from the ship’s electrical 400 V, 50 Hz, 3 phase system via a 32 A circuit breaker, which had not operated. The trailer’s electrical system was also protected by a miniature circuit breaker (MCB).

There was no obvious evidence of “beading” or “fusing” of the burned out wiring in the refrigeration control system.

3. Examination

3.1 On-site examination

The trailer that had been directly involved in the fire, CRF459, and a similar unit with no fire damage to the electrical components, CRF461, had been stored at Portsmouth ferry terminal. These units were examined, on site, by Cobham on 16 July 2010.

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A general view of the location of the fire damage to the components under the bed of the trailer is shown in Fig. 1.

Figure 1 Location of electrical units

The layout of the electrical units on the damaged trailer was identical to that on the undamaged trailer, Fig. 2. All of the electrical controls were housed in plastic enclosures.

Figure 2 Layout of electrical units

Electrical intake

Phase change relay

Evaporator relays

Compressor relays

Changeover switch and MCB

Data Logger

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The on site examination did not reveal any obvious signs of arcing between the fire damaged electrical components or between the electrical equipment and the body of the trailer.

The plug and socket arrangement at the power intake to the trailer was badly melted and was heavily carbonised at the free socket end, Fig. 3. The free socket had been on the end of the cable from the ship’s power supply.

Figure 3 Supply socket

The damaged electrical units and some of the equivalent undamaged units from the second trailer were removed.

The items removed included:

1. Supply intake plug and socket from fire damaged unit, CRF459

2. Phase change relay from fire damaged unit

3. Assembly of three control boxes from fire damaged unit, Fig. 4

4. Assembly of three control boxes from undamaged unit, CRF461, Fig. 5

5. Supply intake plug from undamaged unit, Fig. 6

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Figure 4 Control box assembly, fire damaged

Figure 5 Control box assembly, undamaged

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Figure 6 Trailer mounted intake plug

The data logger unit from the fire damaged trailer was retained by MAIB.

Cobham was also provided with the flexible cable that had supplied the damaged trailer, a second complete lead and the plugs and sockets cut from a further two leads.

3.2 Examination at Cobham

The items collected by Cobham were examined on 4 August 2010 in the presence of representatives from BMA, Burgoynes, Geoffrey Hunt and Partners, Hawkins and MAIB.

Prior to the examination the MCB from the control assembly and the fire damaged intake plug and socket had been subjected to X-ray examination. It was not possible to determine the position of the contacts in the MCB from the X-ray examination. Prior to removing the MCB from the control box a continuity measurement across the poles indicated that the MCB could be in the ‘on’ position. After removal a continuity measurement showed the MCB to be in the ‘off’ position. Checking the wiring that had been disconnected from the MCB confirmed that all of the cables to the MCB were in contact, hence the erroneous ‘on’ indication.

The X-rays of the plug and socket revealed that the free socket had insulation displacement connectors, IDC, at the cable terminals whereas the fixed plug on the trailer had screw terminals, Fig. 7.

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Figure 7 X-ray of plug and socket

The X-ray also revealed what appeared to be globules of metal around one of the IDC connectors. Prior to examining the connector the other items recovered from the trailer were examined.

The cut-away picture extracted from the manufacturer’s catalogue shows the IDC connector arrangement, Fig. 8.

Figure 8 Insulation displacement connectors

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The changeover switch on the side of the control unit was found to be in the correct position for taking a mains supply from the ship, Fig. 9

Fire damaged Undamaged

Figure 9 Changeover switches

An examination of the MCB in the trailer control box showed that there was no evidence of arcing at its terminations and the condition of the MCB confirmed that the fire had not started at the MCB, Fig. 10.

Figure 10 Trailer MCB

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Examination of the phase change relay and the cable from the trailer mounted plug to the relay did not reveal any evidence of arcing or other features that would indicate that they were the cause of the fire.

The wiring and the remains of the contactors in the three linked control units was examined in detail for evidence of arcing between cables, at contacts or at terminations, Figs 11 to 13. The middle unit was the most severely damaged with the main compressor contactor housing having been completely destroyed. The insulation had been burned away from most of the interconnecting wiring and the cases of the remaining relays and contactors were charred.

No evidence of arcing or other features that could have been the cause of the fire were found.

Figure 11 Fire damaged wiring

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Figure 12 Terminal and spring contact

Figure 13 Contacts

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The free socket at the trailer end of the cable from the ship’s supply was a five-pin, 32 A, Mennekes ‘Startop’ socket. The trailer mounted plug and the socket were fused together by molten plastic. At the plug end the terminals were visible and did not show any evidence of arcing or severe overheating, Fig. 14. A large portion of the free socket had burned away, Fig. 15. The ends of one of the IDC connectors could be seen emerging from the charred plastic, Fig. 16.

Figure 14 Terminals in fixed plug

Figure 15 Damaged and undamaged free socket

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Figure 16 Charred free socket

The plug and socket were separated and the contact faces of the pins were examined. The corrosion and debris seen on the pins was light and probably partially due to the fire fighting activities, Fig. 17. There was no evidence of poor contacts between the plug and the socket and no arc damage at the ends of the pins to indicate that it may have been connected or disconnected ‘on-load’. From the condition of the socket it appeared that a grease may have been applied to the pins at some stage, Fig. 18.

End of IDC

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Figure 17 Contact pins

Figure 18 Free socket

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The carbonised plastic around the IDC terminals was carefully removed so that the condition of the five connectors could be examined. What appeared to be slight arcing damage was seen at the end of the Blue phase terminal, Fig. 19. Later examination showed this to be melted plastic.

Figure 19 Blue phase IDC

The brown phase terminal had severe arcing damage and the remains of some conductor strands were adhered to the back of the terminal, Figs 20 & 21.

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Figure 20 Brown phase IDC

Figure 21 Conductor strands adhered to terminal

A number of conductor strands and globules of copper were found in the carbonised debris, Fig 22.

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Figure 22 Conductor strands and copper globules

The remaining IDC showed no signs or arcing, Fig. 23

Figure 23 Undamaged IDC connector

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The other plugs and sockets recovered from the Commodore Clipper were examined. Most of these had screw terminals all of which were found to be tight with no evidence of overheating. One of the free sockets, recovered from the Commodore Clipper, was a ‘Startop’ socket with IDC terminals. On examination of this unit it was noted that the ends of some strands could be seen in the connector, Fig. 24. On dismantling the connector it was noted that the insulation appeared to have been stripped from the ends of the cable cores before the cable was inserted into the IDC, Fig. 25. Cobham remade one connection into the IDC without stripping the insulation, Fig. 26.

Figure 24 Conductor strands in connector

Figure 25 Insulation removed before fitting

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Figure 26 Correctly terminated core

It was also noted that the undamaged ‘Startop’ socket had a cable retaining gland marked with a minimum torque of 5 Nm.

The ends of the cable that had been fitted to the free socket were examined. The exposed conductors on two of the cores were the same length; the third core had some strands broken off shorter than the rest and on the fourth core all of the strands were shorter. The fourth core was the brown phase, Fig. 27. It was reported to Cobham that the cable had been pulled out of the connector during the fire fighting operation.

Figure 27 Cable cores

Close examination of the conductor strands of the brown core revealed several small globules of melted copper, Fig. 28.

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Figure 28 Copper globule

A simple test was carried out to compare the burning properties of the red and white plastics used in the free socket. A small sample of each material was held in a Bunsen flame for a short time and then removed from the flame. Both materials continued to burn for a short time and dropped globules of burning plastic. However the red material appeared to burn more readily and continued to burn longer after removal from the flame.

No further examinations were carried out.

4. Discussion

The only evidence of arcing or other damage that could have cause a fire in the electrical equipment was the arcing at the brown phase IDC termination in the free socket that had been connected to the ship’s cable. From the available evidence it is considered that this arcing would have ignited the plastic of the free socket. The resulting flames than ignited the curtain sides of the trailer and burning plastic from the curtains or the packaging of the trailer contents then set fire to the plastic electrical enclosures.

The arcing at the brown phase IDC would have been initiated by a high resistance connection. The heat generated by a high resistance connection would have degraded the surrounding insulation as well as oxidising the contact materials. The oxidisation of the contact would increase the contact resistance and hence increase the heating at the contact. This would have been an ongoing process until the condition of the contact deteriorated to the stage at which arcing occurred.

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Because the arcing was ‘in-line’ rather than between two different phases the arc current would have been limited to the load current. The circuit breaker in the ship’s supply circuit would not be expected to trip in these circumstances.

The plastic used in the construction of the socket would probably have been subject to a ‘glow wire’ test to demonstrate that it would not ignite if subjected to arcs and sparks. The energy available in a glow wire test and its duration is much less than that which would be present during in-line arcing. Thus it is not surprising that the plastic ignited.

The examination of the second ‘Startop’ socket recovered from the Commodore Clipper showed that it had been incorrectly assembled. The insulation had been removed from the ends of the cores before they were inserted into the insulation displacement connector. This would have removed some of the support from the conductor strands allowing then to splay out as they were inserted into the connector. This would have resulted in a poor quality connection that could further deteriorate when on load. An IDC termination is designed so that the blades of the termination push through the insulation and make firm contact with the conductor.

The cable is gripped in the body of the socket by a gland nut at the rear that is intended to be hand tightened. If this was not sufficiently tightened the pulling on the cable may cause the conductors to partially pull out of their IDC terminations.

During the examination it was found that the MCB at the trailer end of the circuit appeared to have operated. The MCB would have contained both a magnetic trip and a thermal overload trip. The thermal trip would have been a bimetallic element that would be expected to operate at somewhere between 150 and 200 °C. Thus it is most likely that the heat from the fire caused the MCB to trip rather than an electrical overload. Because no arcing damage was found on the wiring in the control boxes it is considered that the supply had been lost before the insulation on the wiring burned away.

5. Conclusions

From the examination of the remains of the components of the supply to the trailer refrigeration unit it is concluded that the fire was initiated by arcing at an IDC termination in the socket on the ship’s supply cable to the trailer. The arcing was caused by a high resistance connection in the socket.

A second socket of the same design, from the Commodore Clipper, was found to have been incorrectly terminated. The error was that the insulation had been stripped back at the end of the cable cores before they were inserted into the IDC terminal. This error could lead to a high resistance connection. It is considered that incorrect assembly of the termination is

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the most likely cause of the high resistance connection that led to the fire. However the possibility that excessive tension on the cable had partially pulled the conductors out of the IDC terminations cannot be ruled out.

Annex D

Reports on the reaction to fire testing

12 November 2010

Dear

Commodore Clipper fire investigation

Please find attached as appendix A to this letter a summary of the work undertaken to investigate a potential ignition scenario related to the fire incident on board the Commodore Clipper.

Yours sincerely

Appendix A Introduction Following a fire in June 2010 on a freight trailer on the main deck of the Commodore Clipper, the Marine accident Investigation Branch (MAIB) have commissioned BRE Global to undertake a test to simulate a potential ignition source to inform their investigation of the incident. Description of the project BRE Global at the request of the MAIB has undertaken a test to simulate a potential ignition source caused by a fault within the power supply to the 3 phase refrigeration system on the freight trailer. The test set up consisted of a hollow section representing the side rail of the trailer, a profile representing the frame to which the electrical socket was attached and a section of the curtain side material incorporating samples of the webbing straps used on the trailer. Figure 1 shows the location of the socket on an identical trailer to the one involved in the incident while Figure 2 shows the experimental set up.

Figure 1 Location of socket on freight trailer

Figure 2 Experimental set up A high temperature platinum alloy coil was placed inside one of the terminals in the 32 amp socket provided to BRE by the MAIB. The coil was heated using a variable voltage power supply with a maximum output of 100 Volts at a current of 10amps. The coil was placed in to the lowest (earth) terminal within the socket as shown in Figure 3.

Side curtain

Electrical socket

webbing Power supply

Figure 3 location of heated platinum coil Findings The coil was heated slowly until glowing red hot. Attempts to measure the temperature directly using a thermocouple probe were unsuccessful as the junction between the probe and the coil interrupted the circuit and cut the power to the coil. Spot readings were taken with a hand held infra red thermometer. The results indicated a temperature of 180°C in the area around the coil and up to 120°C on the white inner plastic of the socket. However, this was not an accurate measurement of the coil temperature. Subsequent testing in the laboratory has established that the coil temperature when glowing red hot is 980°C. After just a few minutes smoke could be seen from the socket and the white plastic inner core local to the heat source began to discolour and then to melt (Figure 4). At this stage the input to the coil was approximately 40Volts at 10Amps.

Coil placed within this terminal

Figure 4 Localised damage to inner plastic core Ten minutes into the test flames could be seen in the socket and the white plastic core began to melt away (Figure 5).

Figure 5 Initial flaming of plastic core

Approximately eleven and a half minutes into the test the flames had spread upwards to involve the red outer casing of the socket. Shortly afterwards the flame was extinguished. The damage to the outer casing is clearly visible in Figure 6.

Figure 6 Damage to socket from initial flaming The voltage was increased to 50V at 10 amps. Approximately 20 minutes from the start of the test smoke could be seen emanating from the rear of the socket. The material of the socket reignited and molten plastic was dripping onto the floor. The coil was moved into direct contact with the housing using tongs leading to immediate ignition of the material causing flash flaming sufficient to ignite any combustible material in the vicinity. During the test no ignition of the webbing or the curtain material took place. Once the flaming had died down a piece of webbing was placed into contact with the coil and ignited immediately. The flame spread up the webbing strap and ignited the side curtain material though this did not lead to extensive fire spread and the flames self-extinguished after a few minutes. Finally a direct flame source (gas burner) was applied to the webbing straps. This caused fire spread to the curtain material (Figure 7).

Figure 7 Ignition of curtain material following direct application of gas burner to webbing strap Conclusions BRE Global has undertaken a test to simulate an electrical short circuit within an electrical socket to investigate the feasibility of this being the initial source of ignition in the incident on board the Commodore Clipper. The heat source within the socket led to the development of flaming which could easily have ignited combustible materials such as the strapping webs used to secure the side curtain. The tests have shown that a sustained source of heat is required to achieve ignition of the plastic material used to form the housing for the socket. Both the socket and the strapping web produce burning droplets when flaming.

Annex E

MAIB Safety Bulletin 3/2010

MAIB SAFETY BULLETIN 3/2010

Vehicle deck fire on board the ro-ro passenger ferry Commodore Clipper

Bahamas Maritime Authority

20 Old Broad Street

London

EC2N 1AR

Marine Accident Investigation BranchMountbatten House

Grosvenor HouseSouthampton

SO15 2JU

MAIB SAFETY BULLETIN 3/2010

This document, containing safety lessons, has been produced for marine safety purposes only, on the basis of information available to date.

The Merchant Shipping (Accident Reporting and Investigation) Regulations 2005 provide for the Chief Inspector of Marine Accidents to make recommendations at any time during the course of an investigation if, in his opinion, it is necessary or desirable to do so.

Stephen MeyerChief Inspector of Marine Accidents

NOTE

This bulletin is not written with litigation in mind and, pursuant to Regulation 13(9) of the Merchant Shipping (Accident Reporting and Investigation) Regulations 2005, shall not be admissible in any judicial proceedings whose purpose, or one of whose purposes, is to apportion liability or blame.

As the flag state, the Bahamas Maritime Authority has agreed the content of this Bulletin.

This bulletin is also available on our website: www.maib.gov.ukPress Enquiries: 020 7944 6433/3387; Out of hours: 020 7944 4292

Public Enquiries: 0300 330 3000

BACKGROUND

At 0242 (BST) on 16 June 2010, while the ro-ro ferry Commodore Clipper was on passage from Jersey to Portsmouth, a fire was detected on the main vehicle deck. The vehicle deck was loaded with unaccompanied freight trailers and crew identified that a refrigerated trailer unit, powered from the ship’s electrical supply, had caught fire.

The vehicle deck was fully enclosed and smoke built up quickly. The crew contained the fire using the vehicle deck water drenching system and boundary cooling from above, but were not able to extinguish it.

The vessel came into port and the crew assisted the local fire and rescue service in attempts to fight the fire. Freight trailers were packed closely on the vehicle deck and firefighters found it extremely difficult to reach the seat of the fire. Trailers had to be towed off before the fire, which had by now burned for about 18 hours and spread to four trailers, was finally put out.

Firefighters preparing to attack the fire from the stern door

ANALYSISPreliminary findings of the subsequent accident investigation indicate that the fire was caused by an electrical fault involving the power supply from the ship and the trailer’s refrigeration control system. The resultant sustained overheating led to the curtain-side of the trailer igniting. Although the ship’s electrical breakers were found to be working correctly, they did not trip before the fire started.

MAIB has also received other reports of power supply cables to refrigerated trailers becoming very hot while in use.

RECOMMENDATIONS2010/118M Operators of vessels carrying refrigerated trailer units should:

• Take immediate action to ensure that all power supply cables and fittings provided for refrigerated trailer units are in good condition and that electrical protection devices will activate at an appropriate level.

• Until such time as the exact causes of this fire have been established, make additional checks of refrigerated trailers powered by ships’ electrical systems to provide early warning of any overheating.

Issued July 2010

Damage to one of the refrigerated trailers and its cargo of potatoes

Electrical power connection Damaged refrigeration control units

Annex F

MAIB flyer to ro-ro vessel operators and the ports industry

M A R I N E A C C I D E N T I N V E S T I G A T I O N B R A N C H

FLYER TO RO-RO VESSEL OPERATORS AND THE PORTS INDUSTRY

Commodore Clipper – Fire on the main vehicle deck due to an overheating reefer cable connection

During an overnight passage from Jersey to Portsmouth on 16 June 2010, a fire was detected on the main vehicle deck of the ro-ro passenger vessel Commodore Clipper. The officer of the watch and duty engineer initially thought the alarm was due to a fault with the fire detection system, and the vehicle deck water drenching system was not started until 20 minutes later.

The fire developed in an unaccompanied curtain-sided refrigerated trailer that was carrying a load of potatoes. The trailer roof shielded the flames from the drenchers and the fire continued to burn. The trailers were tightly stowed; crew had great difficulty gaining access to the fire and were unable to extinguish it.

Unprotected cables and pipework running above the fire were soon damaged in the high temperatures that were generated by the burning curtain-side and cargo packaging materials. The vessel lost power to forward mooring deck winches and bow thrusters, control of the rudders was disrupted and the port rudder suddenly moved hard to starboard. Loose cargo partially blocked the deck drains and drencher water caused Commodore Clipper to list. Drenching was stopped while water drained to prevent further risk to the vessel’s stability, but each time it was stopped, the fire grew in intensity.

Commodore Clipper

With tugs standing by, Commodore Clipper entered harbour and berthed alongside. The control circuits for the ro-ro hydraulics had been burnt out, but the engineers managed to bypass the system and were able to open the stern door. Few foot passengers were carried on the route and Commodore Clipper never used a gangway. Although the port was able to provide a gangway, it was difficult for personnel to move through the tightly stowed vehicles on the upper vehicle deck to get from the gangway into the accommodation. It was decided that it was safer to leave the 62 passengers on board rather than risk evacuating them by the gangway, lifeboat or marine evacuation system.

The local fire and rescue service (FRS) attempted to gain access to the seat of the fire, but struggled to get past the vehicles and make their way through the cargo debris. Firefighters, crew and stevedores worked together to contain the fire, unlash and remove undamaged trailers. As they got deeper into the main vehicle deck, the smoke became thicker and it was no longer possible to work without wearing breathing apparatus (BA). Firefighters could not reach all the seats of fire without the trailers being removed from the main vehicle deck. The vessel’s supply of spare BA cylinders had been used up and the stevedores had no previous experience of working in BA. There was a pause in fighting the fire while it was decided what to do next.

Commodore Clipper’s crew had previously trained with the local FRS on exercises and managers had developed a good relationship. Fortunately, their BA sets were compatible and the FRS agreed to lend the crew additional cylinders so that they could continue to unlash the trailers and guide the firefighters. As senior fire officers and company managers were considering how they could get the remaining trailers off the vessel, one of the stevedores volunteered to drive his tugmaster while wearing BA. The stevedore was familiarised with the equipment and a number of firefighters stood by to monitor his safety and assist him if necessary. He carried on towing the trailers off the vessel until he reached the five units that were on fire. Still alight, the trailers were towed off the vessel and finally extinguished. Once a route through the main vehicle deck had been cleared the passengers were escorted off, nearly 20 hours after the fire had first been detected.

Subsequent investigation found that the fire was due to one of the ship’s reefer cables being assembled incorrectly. The reefer cable plugs used ‘insulation displacement connectors’ (IDC) that are meant to speed up assembly by avoiding the need to strip insulation from cable ends. However, the insulation had been stripped away, and as the design relied on the insulation to help secure the cable in place, the connection became loose. This led to a local high-resistance fault and then arcing in one of the phases. The electrical protection in the vessel’s circuit breakers was not able to detect this fault and heat built up inside the plug until the plastic casing ignited. The socket on the trailer was mounted close to the load-bed where the curtain-side was secured. In tests, the material ignited readily and flames spread quickly.

Fortunately, no-one was hurt on Commodore Clipper and the accident is a good illustration of how a vehicle deck fire can affect many different aspects of the vessel’s operation. The total constructive losses of the ferries Und Adriyatik and Lisco Gloria show what can happen in similar circumstances if vehicle fires develop out of control.

The MAIB has also published a detailed report, 24/2011 about the accident which identifies all the safety issues raised by the case.

Safety Lessons

Ro-ro ferry operators

1. Check their vessels’ vehicle decks for critical and vulnerable systems, and take action as necessary to improve their resilience to fire damage.

2. Check all reefer trailer power cables regularly. Consider upgrading existing electrical protection to a system that can detect in-line phase faults and provides residual current detection.

3. React quickly and positively to early indications of fires on vehicle decks. Fires in densely packed vehicle spaces can grow very quickly and, once they are established, can be very difficult to put out.

4. Existing vehicle deck drenching systems may not be able to extinguish the fire; there is not always a requirement for structural fire protection between vehicle decks, heat can transfer through decks and spread the fire very quickly. Boundary cooling is essential.

5. Review emergency response plans and identify the most effective options for vessels that trade on regular routes to obtain assistance from external authorities.

Port operators

1. Consider which berths in the port are best suited to supporting a vessel that needs assistance to deal with an emergency incident. Identify and record the capabilities and limitations of berths.

2. Work with vessel operators to identify and record how passengers could be evacuated and cargo moved to assist the emergency services in responding to an incident involving a vessel in the port.

3. Identify and record how other aspects of the existing port infrastructure and resources could be used to best effect in supporting a vessel that is alongside and needs emergency assistance.

4. Liaise with local emergency services to ensure that they understand the capabilities or limitations of the port’s resources and infrastructure and what it is able to provide to help support vessels in distress.

This flyer and the MAIB’s investigation report are posted on our website:www.maib.gov.uk

For all other enquiries:

Marine Accident Investigation Branch Tel: 023 8039 5500Mountbatten House Fax: 023 8023 2459Grosvenor Square Email: maib@dft.gsi.gov.ukSouthamptonSO15 2JU

Marine Accident Investigation BranchNovember 2011

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