ministry of infrastructure and transport directorate

MINISTRY OF INFRASTRUCTURE AND TRANSPORT

Directorate General for Rail and Marine Investigations

3^ Division – Marine Investigations

Fire on board of the ro-ro pax NORMAN ATLANTIC

28 December 2014

Final Report

Pag. 2

DIGIFEMA – 3^ Division Marine Investigations

M/V NORMAN ATLANTIC Final investigation report

Index ......................................................................................................................................

GLOSSARY ......................................................................................................................... 6

1. SUMMARY ................................................................................................................... 9

2. FACTUAL INFORMATION ............................................................................................ 11

2.1 Photo of the ship NORMAN ATLANTIC ................................................................... 11

2.2 Ship details ............................................................................................................... 11

2.2.1 Minimum Safe Manning ..................................................................................... 13

Grade/qualification ............................................................................................................. 13

2.3 Voyage details .......................................................................................................... 14

2.4 Information on the accident ...................................................................................... 15

2.5 Intervention by the competent authority and emergency measures ......................... 15

2.5.1 Intervention team members ............................................................................... 15

2.5.2 Actions taken ..................................................................................................... 16

2.5.3 Results achieved ............................................................................................... 16

3. THE EVENTS ............................................................................................................. 17

3.1 The emergency ........................................................................................................ 19

3.2 The situation of life saving appliances ...................................................................... 21

3.3 Rescue and evacuation operations .......................................................................... 22

3.4 The wreck removal ................................................................................................... 25

3.5 Investigations ........................................................................................................... 25

3.6 Unloading operations ............................................................................................... 26

4. ANALYSIS ..................................................................................................................... 28

4.1 Ship organization...................................................................................................... 28

4.1.1 Recruiting .......................................................................................................... 31

4.1.2 Minimum Safe manning - Crew organization ..................................................... 31

4.1.3 Working language on board ............................................................................... 33

4.1.5 Safety certificates and operational restrictions .................................................. 33

4.1.6 Loading and lashing operations ......................................................................... 34

4.1.7 Further procedures concerning the loading operations ...................................... 37

4.1.8 Watchkeeping on the navigation bridge ............................................................. 37

4.1.9 Working hours on board .................................................................................... 38

4.1.10 Procedures for passenger boarding ................................................................. 38

4.1.11 Organization on board according to the Charter Party Agreement .................. 39

4.2 Analysis of the emergency management and Muster list ......................................... 39

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4.2.1 The emergency phase ....................................................................................... 41

4.2.2 ECR situation and activation of the Drencher pump .......................................... 43

4.2.3 Analysis of the human factor and influence over the emergency management . 45

4.2.4 Other issues related to the emergency management ........................................ 46

4.3 VDR data extraction and analysis and problems encountered ................................. 47

4.3.1 Netwave software for viewing and converting data in NMEA ............................. 54

4.3.2 Sequence of events ........................................................................................... 64

4.3.3 Fire doors status ................................................................................................ 65

4.3.4 Data recorded by Kongsberg ............................................................................. 70

4.3.5 Situation of the Quick Closing Valves ................................................................ 81

4.3.6 The engine shutdown hypothesis ...................................................................... 85

4.3.7 Video surveillance system ................................................................................. 87

4.4 The situation of the rescue equipment ..................................................................... 92

4.4.1 Efficiency of lifeboats ......................................................................................... 93

4.4.2 Mini chute – critical aspects ............................................................................... 93

4.5 Fire propagation analysis ......................................................................................... 99

4.5.1 Origin of fire and analysis of the causes ............................................................ 99

4.5.2 Study of the fire evolution, in a truck, in absence of extinguishing attempts. ... 109

4.5.3 Analysis of the fire evolution and of the propagation from the first truck to the other vehicles. .................................................................................................................... 113

4.5.4 Analysis of the fire propagation through fds ..................................................... 122

4.5.5 Geometric modelling ........................................................................................ 123

4.5.6 Geometric modelling of the ship and trucks ..................................................... 124

4.5.7 Comparative test of the Drencher pump made on board of the sister ship ...... 131

4.5.8 Checking the Drencher system on deck 4 ....................................................... 132

4.6 Electric system and black-out ................................................................................. 134

4.6.1 General condition of the electric system on board ........................................... 134

4.6.2 Analysis of the electric black out and malfunctioning of the emergency generator.................................................................................................................................. 134

4.6.3 Description and placement of auxiliary (AG) and emergency generators (EG)................................................................................................................................... 136

4.6.4 Description of the mode of operation and automation of DG1, DG2, DG3 and of the emergency generator. ......................................................................................... 142

4.6.5 Hypothesis on the loss of power supply for the services and on the non-intervention of emergency devices. .......................................................................... 144

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4.6.6 Black out time sequence .................................................................................. 149

4.7 Further evidence acquired ...................................................................................... 149

5. CONCLUSIONS .......................................................................................................... 151

5.1 Shipboard organization .......................................................................................... 151

5.1.1 Loading and lashing ......................................................................................... 151

5.1.2 Inspections on garage decks and patrols during navigations .......................... 152

5.1.3 Emergency management ................................................................................. 153

5.2 Fire ......................................................................................................................... 155

5.2.1 Fire detection and considerations on insulation ............................................... 155

5.2.2 Containment .................................................................................................... 155

5.2.3 Extinction ......................................................................................................... 156

5.3 Propagation, fire origin and structural criticalities ................................................... 156

5.4 Normal and emergency power supply on board ..................................................... 157

5.5 VDR ........................................................................................................................ 159

5.6 Evacuation ............................................................................................................. 159

5.7 Considerations on the condition of reefer trucks .................................................... 160

6. RECOMMENDATIONS ................................................................................................ 161

6.1 COMPANY ......................................................................................................... 161

6.1.1 VISEMAR DI NAVIGAZIONE S.R:L: ............................................................... 161

6.1.2 ANONIMI NAFTILIAKI EFTERIA KRITIS S.A. ................................................. 161

6.2 IMO ..................................................................................................................... 161

6.3 GREEK MARITIME ADMINISTRATION (PORT FACILITIES IGOUMENITSA AND PATRAS) ...................................................................................................................... 163

6.4 GREEK MARITIME ADMINISTRATION ............................................................. 163

6.5 FLAG STATE ...................................................................................................... 163

7. ANNEXES .................................................................................................................... 164

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The aim of the present investigation, which was carried out in accordance with the above mentioned

Decree, is that of preventing any possible future accident of this kind, by ascertaining and analysing

the related causes and circumstances.

The inquiries, performed pursuant to the discipline established by the mentioned Decree, are not

design to determine any kind of liability.

The inquiries reports, even in relation to the findings included and the conclusions drawn, cannot be

considered as a source of evidence in any administrative or penal proceeding.

Disclaimer:

Some contents of chapter 4 “analyses” were extracted from the TECHNICAL REPORT OF THE

CONSULTANTS APPOINTED BY THE GIP (PRELIMINARY INVESTIGATIONS MAGISTRATE) OF

THE COURT OF BARI” concerning the casualty of the M/V NORMAN ATLANTIC

Issued by:

Ministry of Infrastructure and Transport

Directorate-General for Rail and Marine Investigations

3rd Division – Marine Investigations

Email: [email protected]

Tel: +39 06 4412 6133

Pag. 6



GLOSSARY

AIS: Automatic Identification System. Automatic system - prescribed by Regulation 19 of Chapter V

of SOLAS - automatically sending and receiving travel data, the IMO identification number for

each ship and other relevant information;

A.M.: Maritime Authority (Harbour office or Consulate);

ANEK: Anonimi Naftiliaki Eteria Kritis;

CD: Compact Disk;

COG: Course Over Ground;

COMPANY: Reference is made to the managing company VISEMAR DI NAVIGAZIONE;

STCW 78/95 CONVENTION: Standards of Training, Certification and Watchkeeping;

C/P: Charter Party;

DAU: Data Acquisition Unit;

D.O.C.: Document Of Compliance, namely the Certificate issued by the Managing Company,

pursuant to the ISM Code and made compulsory by Chapter IX of the SOLAS convention;

DMM: Data Management Module;

DPR 435/91: the Regulation for navigation safety and the safeguard of human life at sea issued

through the Presidential Decree dated 8 November 1991, n. 435;

DPU: Data Processing Unit;

ECDIS: Electronic Chart Display and Information System;

FRM: Final Recording Medium. It is the information stored in the so called “black box”, namely in the

armoured box which can be recovered even in case of accident;

GMDSS: Global Maritime Distress and Safety System;

GMT: Greenwich Mean Time. It basically corresponds to UTC;

HDG: Heading;

IMO: International Maritime Organisation;

IP: Internet Protocol;

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ISM: International Safety Management;

SMS MANUAL: Safety Management System Manual;

MB: Mega Byte;

MES: Marine Evacuation System

MHZ: Mega Hertz;

M/V: Motor vessel;

NM: Nautical Miles;

NMEA: National Marine Electronics Association. Data communication standard used, in particular,

in navigation and in the communication of GPS satellite data;

PC: Personal Computer;

PSC: Port State Control;

R.O.: Recognized Organization;

RSM: Remote Storage Module;

SMC: Safety Management Certificate;

SMS: Safety Management System;

SOG: Speed Over Ground;

SOLAS: Safety Of Life And Sea. International Convention for the Safeguard of Human Life at sea

adopted on 1 November 1974, as amended, ratified by Italy through Law 313/80;

SSO: Ship Security Officer;

SPD: Speed;

TLC: Telecommunication;

UTC: Universal Coordinate Time. Reference time zone used to calculate all the other time zones in

the world. It is derived from the GMT, to which it corresponds, with the exception of infinitesimal

approximations, that’s why it is sometimes still called GMT;

VDR: Voyage Data Recorder. HW and SW system recording travel data, prescribed by Regulation

20 of Chapter V of SOLAS;

VGA: Video Graphics Array;

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VHF: Very High Frequency;

VRM: Variable Range Marker.

Pag. 9



1. SUMMARY

In the night between the 27th and 28th December 2014, during the navigation between Igoumenitsa

and Ancona, a very serious fire broke out in the ship M/V NORMAN ATLANTIC, carrying on board

417 passengers, 55 crew members and at least 3 ascertained illegal immigrants. When the fire

started, the ship was in the Strait of Otranto, 15nm from the Albanian Coast, 25nm from the Italian

coast and 30nm from the Greek coast but she was still in the Greek Search and Rescue Region -

SRR..

The rescue operations were performed by three SAR authorities, the Greek one, at an early stage,

the Italian one, which after few hours, became the leader in the rescue operations and, marginally,

even the Albanian one. Overall 452 people were rescued and the bodies of 11 victims were

recovered (nine victims, who died at sea because of hypothermia or drowning, were found in water

during the rescue operations, while two completely burnt bodies were found on board of the ship,

respectively on the 2nd and 13th February 2015), while 16 passengers and presumably 6 illegal

immigrants are still missing.

People were rescued between the 28th and the 29th of December, 88 of whom were rescued by the

many ships which arrived on the area, through lifeboats and life rafts, the remaining people were

rescued instead by helicopters and patrol vessels sent on the spot.

During the rescue operations, several attempts were made to tow the ship; the wreck of the Norman

Atlantic was initially moved to Brindisi, where it arrived on January 2, 2015, through the tug boat

“Marietta Barretta”, with the help of other two tug boats, “Tenax” and “Asmara” all owned by the

Company F.lli Barretta. The wreck was later moved to the port of Bari, where it is currently docked

and is available to the Italian Judicial Authority, which controls and regulates the access modalities

on board by the parties concerned.

This investigation report was carried out by DIGIFEMA in an independent and impartial manner,

pursuant to the provisions established by Legislative Decree n. 165/2011 and by Directive

2009/18/EC. Homologous investigating bodies from Germany and Greece (HBMCI and BSU) took

part in this investigation, pursuant to article 12 of Directive 2009/18/EC within the framework of

cooperation between member states having relevant interests.

On December 11, 2015 the BSU communicated the interruption of its participation in the investigation

activities. HBMCI continued its participation although communicated their complaints about not

having been able to perform certain investigation activities on board the vessel due to restrictions

posed by the Italian Judicial Authority.

On July 25, 2016, DIGIFEMA asked to HBMCI for available documentation from Greek Judicial

Authorities and on July 26, 2016, HBMCI communicated that the access to the requested documents

could not be shared.

On August 31, 2017 the HBMCI definitely communicated that even having participated to many visits

on board and meetings, its participation had not to be considered as cooperation due to the above

mentioned restrictions even if affecting only the first stages of the investigation.

Pag. 10



The evidence underlying this technical investigation was gathered during the many inspections made

on board, as soon as the ship was made safe and accessible, according to the information provided

by the Flag State Authority, to the interviews made to the crew members and the concerned staff of

the ship company. The documents made available by the Italian judicial Authority were also used.

DIGIFEMA has appointed two engineers from the National Fire Brigade as technical consultants, for

investigating the development and spread of fire and the electrical systems, their technical reports

were duly considered during the following phase of careful evidence evaluation, when drawing the

conclusions and the recommendations.

Pag. 11



2. FACTUAL INFORMATION 2.1 Photo of the ship NORMAN ATLANTIC

2.2 Ship details

Name: NORMAN ATLANTIC

Flag: ITALY

IMO Number: 9435466

Registration number: Nr. 56 R.I. of the Port of Bari

Ship typology: PASSENGERS and RO-RO CARGO

Call sign: IBUM

Owner and manager: VISEMAR DI NAVIGAZIONE S.r.l.

Charterer (Deck & Engine): ANEK LINES

Shipbuilder/Year of construction 2006 – Cantiere Navale Visentini Srl

Keel laying: 2006

Length, f.t.: 186.45 mt

Width: 25.60 mt

Height: 9.15 mt

Pag. 12



Draught: 6.79 mt

Gross/net tonnage: 26904 GT / 8912 NT

Length between pp.: 177.4 mt

Hull material: Steel

Number of passengers: 852

Type of propellers: 2 controllable pitch propellers

Main engines: 2

Electric generators: 3 X 1800 Kw Diesel Electric CATERPILLAR + 2 X Shaft generators 15800 Kw

+ 1 EGD 370 Kw

Bow thruster: 1 x 1300 KW

Max speed: 23.5 kts

Pag. 13



2.2.1 Minimum Safe Manning

Operating area A: short-range international navigation

Operating area B: long-range international navigation

Grade/qualification1

Certificate (STCW Regulation) Certificate (STCW Regulation)

Personnel – Operating area Personnel – Trading area

A B

Up to 12 passengers

Up to 399 passengers


Up to 12 passengers


Master/ Captain II/2 – V/2 1 1 1 1 1

Chief Mate II/2 – V/2 1 1 1 1 1

Deck Officer II/2 – V/2 1 1 1 2 2

Chief Engineer III/2 – V/2 1 1 1 1 1

2nd Engineer III/2 – V/2 1 1 1 1 1

Engine Officer III/1 – V/2 1 1 1 2 2

GMDSS Operator IV/2 – VI/1 – V/2

(**) (**) (**) (**) (**)

Boatswain VI/1 – V/2 1 1 1 1 1

Able seaman II/4 – VI/1 – V/2

3 4 4 3 4

Ship Boy (Deck – Engine) VI/1 – V/2 1 2 2 1 2

Motorman VI/1 – V/2 1 2 2 1 2

Electrician VI/1 – V/2 1 1 1 1 1

Engine Boy VI/1 – V/2 1 1 2 1 1

Steward VI/1 – V/2 1 2 2 1 2

Cabin Steward VI/1 – V/2 // 2 5 // 2

Crew Cook VI/1 – V/2 1 1 1 1 1

Assistant Cook VI/1 – VI/2 1 2 2 1 2

Ship’s doctor VI/1 – V/2 // // 1(1) // 1

Total Number of persons 17 24 29 19 27

1 The full table is provided in the annex 1.

Pag. 14



2.3 Voyage details

Departure: Patras

Port of call: Igoumenitsa

Destination: Ancona

Travel typology Ro-Ro – pax Italy/Greece connection line

Number of passengers: 417

Other persons on board: 3 (passengers not included in the list)

Crew members: 55

Pag. 15



2.4 Information on the accident

Type of event: Very serious marine casualty (Fire on board)

Date and time2: 28/12/2014 - 04:23 3

Accident place or area: Open sea - Southern Adriatic

Position: Lat. 40°17’ N - Long 019°01’ E

Weather and sea conditions: Very rough sea - SE 6;

Storm wind 8 - 55 knots SW

Discrete visibility

Phase of the journey: In navigation

Part of the journey: from Igoumenitsa to Ancona

Part of the ship affected: Mainly deck 4 (open ro-ro cargo spaces) but also deck 3 (main garage)

was heavily affected and 5,6,7

Consequences:

People dead or missing: 23 People injured: 31 (to be included among the

survivors). Survivors: 452 (including also 3 illegal immigrants) Unit loss

2.5 Intervention by the competent authority and emergency measures

2.5.1 Intervention team members Authority / Body JRCC PIRAEUS

MRCC ROME

JRCC DURRËS

UCG BRINDISI

UCG CROTONE

MRSC BARI

84°C/SAR GIOIA DEL COLLE

85°C/SAR PRATICA DI MARE

61° STORMO LECCE GALATINA

41° STORMO SIGONELLA

384° C/SAR/SAR ELEUSI

2 The times of the whole report refer to the “A” time zone. 3 Time of the first alarm obtained through VDR data

Pag. 16



2.5.2 Actions taken

Immediate coordination between the Italian and Greek SAR national centres. Due to the position of

the vessel, at the initial phase of the casualty, JRCC PIRAUES coordinated the rescue operations

until 09:00 when the coordinating role was taken up by the MRCC ROMA. It should be noted that

the Captain of Norman Atlantic was mainly communicating with Italian Authorities via VHF, during

the first stages of the emergency. The coordinator was immediately identified on the SAR operation

spot (OSC/CSS), it was firstly the M/V SPIRIT OF PIRAEUS later, at 0815, the M/V CRUISE

EUROPA and lastly, from 19:00, the ship NAVE SAN GIORGIO of the Italian Navy. Several Italian,

Greek and Albanian ships and airplanes arrived on the spot, as well as many merchant vessels and

tug boats, which, at a first stage, tried to cool down the unit down, during the rescue operations of

the persons involved and which later, after some attempts succeeded in dragging the ship to the

Port of Brindisi. The M/V NORMAN ATLANTIC was seriously damaged by fire.

2.5.3 Results achieved

The rescue operations of the shipwrecked persons lasted until 14:53 of the following day, when the

Captain of the unit – the last who left the ship – was moved by means of an Italian Navy helicopter

on board of the NAVE SAN GIORGIO.

The towed unit arrived in the Port of Brindisi on January 2, 2015.

During the rescue operations, 452 persons were rescued, of whom 449 were included in the crew /

passengers list and 3 were illegal immigrants, 11 persons died, 12 are missing and 31 were injured.

In addition, based on the claims submitted by the families to the competent authorities, 6 other

persons could be missing.

Pag. 17



3. THE EVENTS

On Sunday night, on December 28, 2014 a very serious fire suddenly broke out on board of the RO-

Ro pax Norman Atlantic.

The vessel, owned by the Italian shipping company “Visemar di Navigazione”, had been chartered

with the “deck & engine” formula by the Greek group Anek Lines for the connection lines between

Italy and Greece.

The ship started its service for the new route Patras - Igoumenitsa - Ancona just a few days before,

precisely on 20.12.2014, whilst most of the personnel of the charter company for commercial and

lashing operations boarded from 12.12.2014

The incident took place during navigation, on the route line between Igoumenitsa and Ancona, it

seriously damaged the ship and caused at least 11 documented victims, while 12 persons among

the passengers of the Norman Atlantic are still missing.

In addition, other 2 victims shall be included: 2 members of the crew of one of the Albanian tug boats

which reached the area, following the break of the towing line when removing the wreck.

Following the vast rescue operations, in which Italian, Greek and Albanian authorities and SAR

means took part, together with several military and merchant ships from different countries, 452

persons were rescued, although the weather and sea conditions were extremely unfavourable and

the problems caused by such a great fire were huge.

Damage caused to the ship:4:

- Deformation and/or damage due to fire /heat of the ship structures (plating and deck and side

reinforcements) starting with deck 3 (Main deck) for a total weight of about 2,000 t, and

damage to insulations (about 38,000 m2).

- Destruction of all communication and navigation equipment of the navigation bridge, of the

accommodations of both the crew and passengers and of the common areas (reception,

restaurant, sofa areas etc.), kitchen, pantry and cold storage rooms, on decks n. 5-6-7,

including the flooring (approximately 6,500 m2), dividing walls, ceilings, doors, windows and

portholes, furniture, etc.).

- Evident damage to the main electric panel, to the control panel in the ECR, to the distribution

boards supplying power to refrigerator, ventilation systems etc.

- Damage, due to fire, heat and extinguishing water, to all electrical equipment (distribution

boards, starters, uninterruptible power sources, batteries, etc.) and electrical cables,

including the emergency electrical panel placed on deck 8.

- Damage to the air-conditioning and ventilation system.

4 The damage list is a partial summary, for a more precise and complete description, see Annex 2a-b.

Pag. 18



- Destruction of service rooms in the Engine area on deck 3.

- Loss of rescue means (lifeboats and rescue boats, auto-inflatable lifeboats, MES) starboard side

- Damage to the following systems on decks 3-4-5-6-7-8-:

Waterbased fire-fighting equipment

Sprinkler in the accommodations

Drencher in cargo decks n. 3-4

CO2 for the Engine room

Fire detection system (automatic and manual)

Automation system

Door handling hydraulics, cover, internal ramps, etc.

- Damage to the anchor winches, warping winches and cable gland winches, equipment for

the berth of both forward and stern.

PHOTO 1 DECK 4 –CARGO AND STRUCTURES SITUATION

Pag. 19



3.1 The emergency

The Norman Atlantic, at 16:50 of December 27, 2014, departed from the port of Patras to reach

Ancona, where the ship arrival was scheduled for 19:30 of the following day. After the stopover in

Igoumenitsa, the ship restarted its journey at 00:50 on the 28th, with 417 passengers on board, 55

crew members and at least 3 illegal immigrants. During its navigation, in the Strait of Otranto (with

position Lat. 40°17’ N - Long 019°01’ E), a serious fire broke out. The fire was detected by the alarm

system at 04:23, in the ship open garage - deck 4 - close to frame n. 156.

FIGURE 1 APPROX POSITION OF FIRST FIRE ALARM (DECK 4 – FRAME 156)

The cargo on board consisted of: 129 trucks, 90 cars, three buses and one motorcycle. The Distress

signal was launched at 04:36 when the ship was in the Greek SAR area.

JRCC PIRAEUS coordinated the first stages of the SAR operations, however, as reported by HBMCI,

they reported some difficulties in establishing contact with Norman Atlantic (see above p. 2.5.2)..

Pag. 20



FIGURE 2 DISTRESS POSITION AND SHIP ABANDONMENT

FIGURE 3 THE SAME AS FIGURE 2 - DETAIL

Pag. 21



The interviews carried out with the deck staff and in general with the staff who participated to the

initial emergency phases, as well as the evidence gathered during the investigation, show that a first

fire alarm was activated approximately at 04:15.

In that moment, the second mate and a seaman were on duty. In addition, considered the difficult

conditions of the navigation, after departing from Igoumenitsa, the Captain decided to remain here

and keep on monitoring (see. par. 4.1.8). The deck officer on the bridge, applying the correct

procedure, immediately sent the seaman to the area concerned by the alarm to check its conditions,

but the seaman said that in the signaled position there was only a refrigerated truck, whose

combustion generator for the cooling system was working and there was no incipient fire. After about

15 minutes a fire pre-alarm was heard again and a Fire Alarm followed.

Thereafter, the Captain, who already was on the navigation bridge, after seeing the flames on the

starboard flying bridge deck coming out of the windows (the great side openings) of deck 4,

ascertained that a fire was developing on board, ordered to transmit the fire alarm (serious gravity)

and to issue the “crew call”. In the immediately following minutes, he ordered the first mate to go on

the spot (deck 4 frame 156) to check the situation and the deck officer on the navigation bridge to

immediately activate the Drencher (04:30) system. Based on the evidence gathered, following our

inspection on board, in the Drencher room the valves of deck 3, instead of those of deck 4 (which

was affected by the fire) were open.

In the meanwhile, at 03.38.27 UTC (VDR), a call was made on board via radio to the Brindisi

Coastguard, it was received by Crotone radio: “we need help …..there’s fire on board, at position

40° 17’ N; 19° 01’ E”.

After few minutes, the chief mate informed the Captain that the situation could not be dealt with by

the fire-fighting team which was on the spot and recommended the immediate intervention of the

tugboats to extinguish fire. The first black-out took place at 04:46.

3.2 The situation of life saving appliances

In the initial stages of the emergency, people could be gathered only on the upper decks 7 and 8, as

the rescue boat on the starboard side was destroyed in short time by the flames coming out of the

wide openings on deck 4, similarly the mini-chute on the starboard side could not be used, as it was

destroyed by flames.

The boat on the portside was instead lowered to the embarkation deck by the crew almost like

following Captain’s order5. Then without any specific order by the Captain 88 persons got on board

and the lifeboat that was lowered to the sea. Also the life rafts placed on the portside of the ship

were launched in water, without the Captain’s authorization and the control of the crew members

appointed. It is probable that some passengers used the MES, placed on the portside of the ship,

and boarded on the liferaft. However after a while the liferaft detached from the vessel and, two

5 the VDR audio records are not clear

Pag. 22



persons remained indeed blocked inside, as the life raft was missing. After that it was basically

impossible to use it. In this regard, it is possible to assume that the MES was not correctly used or

that the life raft detached, because of the adverse weather conditions.

The passengers blocked in the mini-chute were extracted at 13:20 by a helicopter of the Italian Navy,

with the help of a patrol boat of the Italian Coastguard, which cut the slipway with a knife and let the

unfortunate persons come out. Unfortunately, that intervention succeeded only partially, as the

second person did not survive and is still missing.

3.3 Rescue and evacuation operations

In the initial phases, precisely at 04:50 of the 28th, the SAR was led by the JRCC PIRAEUS, at 09:00

the MRCC ROMA took control of the rescue operations.

Several merchant ships, which were navigating in the nearby of the area concerned, were invited to

change course and reach the area, here below the list:

SPIRIT OF PIRAEUS 9204984 CONTAINER SHIP

CRUISE EUROPA 9351490 PASSENGER RO/RO SHIP

ABY JEANNETTE 9619804 BULK CARRIER SHIP

GENMAR ARGUS 9185530 OIL TANKER SHIP

FORZA 9458523 PASSENGER RO/RO SHIP

FEYZ1 8202757 GENERAL CARGO SHIP

CANNETO M. 9359583 CHEMICAL OIL TANKER

SHIP

SALVINIA 9419084 GENERAL CARGO SHIP

PLANA 9004176 BULK CARRIER SHIP

STELIOS B 9452490 BULK CARRIER SHIP

NISSOS SERIFOS 9592264 OIL TANKER SHIP

EVINOS 9667928 PRODUCT TANKER SHIP

BOW PILOT 9164732 CHEMICAL TANKER SHIP

BLANK 9466570 OIL TANKER SHIP

ERKAN K. 9366471 CONTAINER SHIP

The first patrol boat of the Coastguard (CP 809) left its moorings in the Port of Otranto at 05.00 and

reached the burning ship at 07.20, immediately after the other boats reached the emergency area.

Pag. 23



The first fixed wing aircraft which reached the area was a Greek military C130, while the first

helicopter was a HH 139 of the Italian Air Force, which arrived on the spot at about 08.30. The fixed

wing aircraft Manta 10-03 of the Coastguard, arrived on the operations area at 12.10, took over the

role of Air Coordinator, considered the complexity of the air rescue operations which went on until

the complete evacuation of the ship and required the intervention, with several sorties, of 16

helicopters (2 of the Coastguard, 7 of the Navy, 4 of the Italian Air Force, 3 sent by the Greek

authorities) and 4 airplanes (2 of the Italian Coastguard, 1 of the Italian Navy and 1 sent by the Greek

authorities).

The role of On Scene Commander was initially assigned to the merchant ship Cruise Europa, whose

role was then replaced by the Italian Navy ship NAVE SAN GIORGIO, which arrived on the spot at

19.00 of 28/12/14. Later at 14.00 of 30.12.2014, the role of OSC was given to the ship Durand de la

Penne, as the Ship San Giorgio had to go to the port of Brindisi for the arrival of migrants

PHOTO 2 A SHIPWRECKED PASSENGER BEING MOVED TO THE M/V SPIRIT OF PIRAEUS

The first persons to be rescued were those who tried to immediately escape, by using the few

remaining (usable) rescue means.

In total, the rescue means rescued 88 persons, the remaining persons were rescued by helicopters.

Pag. 24



Some passengers died of hypothermia, after they fell or jumped in water. The first engineer, who

also fell in water, was rescued by the oil tanker Genmar Argus at 14:13.

In the rescue operations, some tugboats were also used, the first one - the R/re MARIETTA

BARRETTA – departed from Brindisi at 6.40 to reach the spot at 12:25, at 0840 the R/re TENAX

departed and arrived on the spot at 13:00, with eight firemen on board divided in 2 teams.

When the alarm was launched, the sea and weather conditions in the area were particularly hostile,

with sea force 6 and wind with approximately 45 knots from SSW, such conditions further worsened

during the emergency. As a consequence of the weather conditions and of the serious fire on the

ship, the passengers still on board, after that lifeboats and life rafts were launched in water, could

be rescued exclusively by air.

The first 69 survivors, rescued by helicopters, were transferred to the ferry Cruise Europa, later when

the amphibious ship San Giorgio arrived, this latter ship became the helicopter landing pad. The

Cruise Europa could not rescue any person from sea, because of the highly adverse sea and weather

conditions, which also caused the loss of one of its recue lifeboats, precisely lifeboat number 4,

previously lowered in water in a rescue attempt. The lifeboat later ran aground on the Albanian coast,

as it was for the left-side lifeboat of the Norman Atlantic.

At 09:00 the coordination of the SAR operations was taken over by MRCC Roma, although the ship

was in that moment in Albanian waters. At 17:31 the tugboat Marietta Barretta (which, together with

Tenax, was trying to fight the fire with hydrants on board), succeeded, after many attempts and with

the help of a helicopter, in towing the Norman Atlantic6. Unfortunately, at 18:22 the tow rope snapped

and, only after several attempts made by the ship San Giorgio and other tugboats in the area, the

Marietta Barretta communicated, at 23:35, a new successful towing of the damaged ship.

The Captain of the M/V NORMAN ATLANTIC was the last person to leave the ship, at 14:49, rescued

by a helicopter of the Italian Navy.

On the ship there were also some illegal immigrants whose number is still unknown, coming from

the Middle East and hidden in the trucks in the garages, three of them were rescued.

The exact number of passengers on board could not be properly defined during the first phases of

the rescue operations, due to mistakes when providing their names in the boarding list provided by

the charterer company during SAR operations. In particular, initially forty more passengers were

expected to be on board, but, precise and detailed checks showed that only there were only three

more passengers.

6 When the towing operations started the ship was closer to the Albanian Coast,

Pag. 25



3.4 The wreck removal

For the removal of the Norman Atlantic, once abandoned, several tugboats were involved, including

five Italian boats (Marietta Barretta, Tenax, Asmara, Aline B. and A.H. Varazze), two Albanian

(Adriatik and Iliria) and a Greek one (Ionion Pelagos), two of the boats were part of the group Smit

Salvage and were sent by the ship owner Visemar di Navigazione. On December 30, after the tow

rope of Marietta Barretta snapped again, the Albanian tugboat Iliria tried to tow the ship to Valona,

but the rope snapped and two Albanian seamen were seriously injured and died shortly after.

The judicial authority of Bari ruled the seizure of the ship and ordered the group F.lli Barretta the

towing of the ship to the port of Brindisi; on December 31 the Marietta Barretta, with the help of

Tenax and Asmara, succeeded, after many failed attempts, in towing the ship again, which, due to

the adverse sea and weather conditions, was temporarily moved to the Valona Bay, waiting for an

improvement in the conditions.

The Norman Atlantic, towed by Marietta Barretta, convoyed by Tenax and Asmara, left Valona at

16:30 on January, 1, 2015; on January 2, in the morning, the ship arrived and docked at the Costa

Morena Nord pier in the Port of Brindisi.

3.5 Investigations

Investigation activities started on January 5, 2015 in the Port of Brindisi. At the initial stages of the

investigation participated also teams of investigators from HBMCI and BSU.

On February 14, 2015 the ship was moved to the Port of Bari, where a detailed investigation was

carried out, both by the judicial authority and by the investigative team of DIGIFEMA.

Due to the complexity of the events and since the different factors which caused the incident had to

be analyzed, an in-depth analysis during the investigation was needed. VDR data were made

available only in September 2015 and some areas of the ship were made accessible only after the

end of the unloading operations, which were concluded in July 2016.

In particular, the following investigative activities and analyses were carried out

- VDR analysis with direct encoding of NMEA codes;

- analysis of fire origin and propagation;

- black out analysis;

- analysis of the evacuation, emergency management and of SAR activities;

- mini-chute efficiency analysis;

- drencher efficiency analysis.

Pag. 26



3.6 Unloading operations

To enable a proper investigation activity, on January 8, 2016, the unloading operations of the burnt

cargo were started, with particular reference to decks 3 e 4. Before such operations, the main

structures of the ship, seriously damaged by fire, were reinforced so as to ensure the safe access of

people and means.

PHOTO 3: REINFORCEMENT STRUCTURES INSIDE DECK 3

During the unloading operations of the cargo decks, each single vehicle was removed, listed and

described in details.

Pag. 27



PHOTO 4 UNLOADING OPERATIONS

The unloading operations were concluded on July 5, 2016.

Pag. 28



4. ANALYSIS

4.1 Ship organization

In this chapter, the shipboard arrangement and organization is analysed, with reference to the related

regulatory framework and the internal procedures established by the SMS. The context, the

measures actually taken by the personnel on board and the kind of emergency will also be

considered. The following table summarizes the activities which will be described in the following

paragraphs.

Chronology Activity Ref. Reg. Requirement ISM Procedure

Shipboard

organization

Crew List Minimum

Safe Manning

SOLAS (em 99-

00) CV/R.14

DPR 435 Art.201

C.N. Art 317

R.C.N. Art 426

The presence of a

minimum number of

persons on board is

required so as to ensure

the safety of those at sea.

2.1.1

SMS –

Staff recruiting and selection

Shipboard

organization

Certificates of the

personnel on

board.

Familiarisation with

safety procedures

when boarding.

Familiarisation with

on board activities.

STCW R.I-14/A-I

14

A-V/3/A-VI/1-2

ISM 6

SOLAS (am 99-

00)

C II-2/R.15

SOLAS (am

2006)

C III/R.19

The Company shall ensure

that the personnel aboard

is duly certified, pursuant

to STCW and to the

national regulations. The

Company shall also

ensure that the personnel

gets familiar with the tasks

assigned on board and in

case of emergency.

2.1.6 1

SMS

“Certificates of the personnel

aboard”

2.1.8 Familiarisation with

safety measures when

boarding

SMS –

2.1.9 SMS Familiarisation

with tasks to be performed

on board

Shipboard

organization

Working language SOLAS (am. 99-

00) C.V – R.14

ISM.6

The Company shall

choose a working

language on board, so as

to ensure effective safety

performances and shall

provide proper information

on the SMS manual

2.9 SMS working and

command language

Pag. 29



Shipboard

organization

Muster list task SOLAS (am 96-

98) C.III – R.8

and 37

DPR 435 – ART

203

SOLAS C III R

19 e 20 – artt.

232, 233 and

DPR 435/

The personnel in charge of

the muster list shall be

certified and be familiar

with:

- Basic Safety

Training;

- have a proficiency

level in survival craft and

rescue boats” (MAMS)

- MABEV

- crew management

SMS -Crew training

SMS – Preparation of the

Muster List

Shipboard

organization

pre-

departure/arrival

activities – ship in

port safety of the

loading operations

and bunkering –

passenger

registration system

SOLAS C. II-I R.

20,21,22,23 – C.

III, R. 20 C. V R.

26 – artt

225,226,229 and

230 DPR 435/91

SOLAS C. II-I

regulation 20,

21, 22, 23 e C. III

R. 20 – C. V R.

26

12.2.10 SMS. Safety and

protection of the vehicle

storage deck

12.2.11 “regulation of the

ventilation of the vehicle

storage decks”

12.2.13 SMS – “Fire patrol of

the vehicle cargo decks”

12.2.15 SMS – “Access

control of the vehicle cargo

decks during navigation”

Pag. 30



Shipboard

organization

Operations on ro-

ro ships

Art. 297 Nav.

Cod.– Cargo0

Securing Manual

Circ. Series IV n.

7 of 13.3.1995 -

Mimerc – Ris.

IMO A 581(14)

M.D. 13/10/1999

(Directive

98/41/EC)

16.4.1 SMS “Cargo lashing”

16.7 SMS . “safety

precautions on the deck

designed for the storage of

vehicles – crew”

16.8 SMS. “safety

precautions on the deck

designed for the storage of

vehicles – passengers”

16.10 SMS “Operations with

mobile ramps, lifts and

platforms”.

16.11 SMS “Ventilation of

vehicle cargo decks”

16.12 SMS. Fire protection

system on vehicle cargo

decks

16.15 SMS. “Vehicles for the

transport of refrigerated

goods”

24.2 SMS : “Passengers

registration”

Pag. 31



4.1.1 Recruiting

In general, for the vessels which are part of its own fleet, the Company recruits the crew members

autonomously through the dedicated offices of Bari, although, in this specific case, only the Deck

and Engine personnel was equipped by the ship owner, while the cabins and some other services

were provided by the charterer.

The crew recruitment is regulated by the SMS procedures 2.1.1. and 2.1.2

Such procedure is in line with what is established by the regulation in force.

4.1.2 Minimum Safe manning - Crew organization

Pursuant to the provisions established by the reference legislation (SOLAS 74 C V R 14. Art. 317 of

the Nav. Code Art. 426 of Reg. C.N., art. 201 of DPR 435/91 as well as L. 27.02.199/8, n. 30 and

followings), the ship shall be manned in compliance with the Minimum Safe manning, as established

by the Flag State Administration, based on the regulation mentioned in the previous table.

In addition, on October 20, 2010, Italy issued Circular Letter n. 001, titled “Guidelines for drafting the

MSM for Italian ships and fishing vessels, in compliance with resolution IMO A. 890 (21) as amended

by Resolution IMO A. 955 (23)”. Such circular letter provides instructions concerning the draft of

minimum manning tables for both new and existing ships.

The M/V “NORMAN ATLANTIC” has the minimum safe manning table n. 025/014-A, issued on

10.05.2014 (day/month/year) by the Italian Coast Guard Headquarter (Annex 1), which, for this

specific case (Operational area A – up to 880 pax), provides for the following composition:

- Officers, nr. 6

- Deck staff, nr. 7

- Engine staff, nr. 7

- Cabin staff, nr. 10

- Complementary services, nr. 1

Pag. 32



The ship crew list includes instead 55 boarded crew members at the time of the accident (Annex 2c).

A total number of 22 members were provided by the ship owner for the “deck & engine” part, while

the remaining ones, recruited for cabin services and part of the staff in charge of the lashing

operations, together with a Supercargo officer (in charge of cargo supervision) were provided by the

Charterer, as established by the charter party contract.

The crew is therefore divided as follows:

Shipowner

- Officers, nr. 10

- Deck staff, nr 7



Charterer

- Officers, nr. 1

- Deck staff, nr 6



The staff nationality was Italian and Greek.

Pag. 33



4.1.3 Working language on board

The working language on board shall be chosen by the Company, according to the provisions of

Solas (em.99/00) – Chapter V – Regulation 14, and ISM code, paragraph 6.6.

Each crew member shall be able to understand the working language and, for some activities, to

give orders and instructions, and consequently answer in the working language.

The working language shall enable a level of communication such that:

1) The crew performance level, with reference to safety activities, is adequate;

2) The information needed for implementing the SMS procedures are received;

The Company, with reference to the “SAFETY MANAGEMENT SYSTEM (SMS 2.9 – Annex 3a-b),

established, in paragraph 2.9, that the working language on its ships shall be Italian or English,

depending on the situation, based on the crew nationality.

In particular, in this specific case, the working language was English, although, during the interviews,

it was noticed that low-rank crewmembers, it was noted that few of them could not have a good

knowledge of the English language, this could have led to some difficulties in the performance of

their duties, during the lashing operations / when connecting the sockets to reefers and/or during the

emergency management.

4.1.5 Safety certificates and operational restrictions

The ship left the port of Igoumenitsa, with all the ship certificates being valid.

The analysis of the ship documents (statutory certificates) didn’t reveal any shortcomings or

irregularities, already shown or "operational restrictions" (annex 4a-b-c) limiting the ship navigation.

Although, the ship had a “double certification”, respectively 499 and 852 passengers, the certificate

for the navigation with a maximum of 499 passengers was currently used, as required on September

18, 2014.

The ship was examined, ex Directive 99/35, on 19/12/2014 in the Port of Patras, by the Greek

Coastguard, which reported 6 deficiencies, 2 of which were fixed before the departure and 4 which

had to be fixed within 14 days (annex 5). Although, none of the shortcomings found was relevant for

the purpose of the accident examined.

Pag. 34



4.1.6 Loading and lashing operations

Chapter 12 of the SMS manual, regulates the loading and the related operations and establishes

several times that the direction and coordination of such operations – as under regulations and

procedures - is assigned to the Chief Mate, who shall then inform the Captain. In this case, the

Charterer appointed an “excess” First Mate (as per Muster-roll – Annex 2d) as Supercargo with the

sole supervision of commercial aspects on behalf of the Charterer.7

The Captain before leaving, in case of adverse weather forecasts, shall ensure and confirm in a

specific check-list that the decks where vehicles are stored are safe enough to face the expected

adverse weather forecasts. The Check-list was, in this case, destroyed during the fire, although, the

inspections made on board showed that (with sole reference to decks 2 and 3, as deck 4 was

completely destroyed by fire), even though all the vehicles were secured, in some cases the lashing

was not fully compliant with the provisions and was often made only on one side, as proved also by

the interviews made.

In general, Chapter 12 8 regulates the loading and the related operations and establishes several

times that the direction and coordination of such operations – as under regulations9 and procedures

- is assigned to the First Mate, who shall then inform the Captain. Although, in this case, the Charterer

appointed a First Mate, qualified as Supercargo – who was officially in charge of the sole supervision

of commercial aspects on behalf of the Charterer, and whose role was not identified within the

context of the related SMS procedures. As a consequence, his continuous presence on the cargo

deck during the loading operations could have caused confusion when performing such tasks, as

inferred from some interviews.

In addition, as the ship, owned by VISEMAR, was chartered by ANEK, the Captain had to consider

all the commercial terms deriving from the chartering contract signed with the owner (see Annex 6)

and all the other safety measures which had to be taken for the embarking, disembarking and cargo

transport by sea.

Lastly, the ship Captain and/or first mate should, whenever not previously communicated by the

charterer – see clause 5.13 of C/P (annex 6) – have demanded and asked the shore-based

personnel for information on the typology of goods transported, sufficiently in advance, before

starting the vehicle loading operations, so as to place vehicles in the right position on board and

prepare an adequate loading plan, also considering the expected sea and weather conditions, in

7 As inferred from some interviews, the presence of the Supercargo during the loading operations could have caused confusion when

performing such tasks.

8 Extract from SMS procedure 12.2.4: …The first mate (or the designated “Cargo Officer”) shall make an inspection on the vehicle cargo,

after the loading operations are completed and before the departure, so as to ensure that the cargo is properly secured. That same officer

shall make a pre-departure check-list (Deck check list n°5) and shall inform the Captain as a pre-departure procedure; in addition, in case

of adverse weather forecasts, he shall ensure and confirm in that check-list that the decks where vehicles are stored are safe enough to

face the expected adverse weather forecasts.…

9 Artt. 297 – 392 -393 - Nav. Cod.; Solas ’74 Cap VI Reg 2 and 5.

Pag. 35



compliance, more in general, with the provisions laid down by Chapter 16 of the SMS manual of the

Company concerning loading operations on Ro/Ro ships, such as the Norman Atlantic.

Situation of the cargo at the time of the accident

Cargo loaded in Patras:

n. 75 articulated trucks (each up to 16.5 m long);

n. 4 tractor trailers (each up to 18 m long);

n° 1 semi-trailer (up to12.5 m long);

n.1 motorcycle;

n. 32 passenger cars;

the ship departed from Patras with 172 passengers on board, destination Igoumenitsa. Before

leaving, the articulated trucks, the tractor trailers and the semi-trailer were not secured as established

by the related ship manual. All the cargo on the ship was addressing the Port of Ancona.

Arrived in Igoumenitsa at about 22:19(UTC) of the 27th of December 2014, other 239 passengers

embarked on the ship and the following vehicles were loaded:

n. 43 articulated trucks (each up to 16.5 m long);

n. 4 tractor trailers (each up to 18 m long);

n°3 buses;

n° 1 trailers (up to 2.5 m long);

n.1 car + trailer (up to 7 m long);

n. 56 passenger-cars;

After completing the embarking operations for passengers and loading operations for vehicles, the

ship left the Port of Igoumenitsa at about 23:28 on December 27, 2014 to reach the Port of Ancona.

The reconstruction of the loading plan, following the unloading operations, showed that:

- On deck 4 the following items were embarked: 41 refrigerated trucks full of goods + 3

refrigerated articulated trucks full of goods + 2 articulated trucks with live fish + 1 truck

with live fish.

- On deck 3 the following items were embarked: 26 refrigerated trucks full of goods + 1

refrigerated articulated truck full of goods.

Pag. 36



Situation of decks 3 and 4

The analysis of the cargo on deck 4 shows that out of a total of 61 heavy vehicles, net of empty

vehicles, at least 47 connections to the electrical grid on board were needed to ensure the correct

functioning of refrigerators on board (see the plans attaches, Ann. 7 and 8a-b).

So, since only 40 connections to the electrical grid were possible on that deck, at least 7 vehicles

had no connection and were probably refrigerated through refrigeration systems fuelled by

combustion generators. The above on the condition that the content of all refrigerated trucks was

such that refrigeration was required, which condition cannot be ascertained. In any case, it was

ascertained that three functioning plugs at deck 4 remained unused

FIGURE 4: OVERVIEW OF THE POSSIBLE CARGO SITUATION ON DECK 4

FIGURE 5 POSSIBLE CARGO SITUATION ON DECK 3

Pag. 37



4.1.7 Further procedures concerning the loading operations

Procedure 12.2.10 of the SMS, “Safety and protection of the vehicle storage deck”, also establishes

that an inspection is to be performed for the purpose of safety and, in particular, to check that “there

are no unauthorized persons on the vehicle storage decks”. In this regard, it shall be noted that some

evidence show the presence of unauthorized persons on the cargo decks, in particular on February

2, 2015 a burnt body was found inside deck 3, close to the pilot embarking staircase.

Another procedure, which is relevant for the analysed case, is procedure n. 12.2.11 “regulation of

the ventilation of the vehicle storage decks”, establishing that the ventilation regulation shall be set

on “navigation”, after having ascertained that no passengers are on that deck.

Fire safety on cargo decks during navigation is also ensured through procedure 12.2.13 SMS – “Fire

patrol of the vehicle cargo decks”, establishing that cargo decks are to be checked every 4 hours by

a patrol. Based on the interviews and VDR recordings, patrol checks were performed regularly,

although, no authorized personnel was identified, nor fire hotspots. On this regard, it should be noted

that the navigation from the last port of call, had started from less than 4 hours at the moment of the

fire. The presence of smoke was noticed just once and was attributed to the combustion generator

of a compressor of a refrigerator truck.

Procedure 12.2.15 of the SMS - “Access control of the vehicle cargo decks during navigation”

establishes that the access to the garage decks is not allowed at sea but, if required, the passengers

could be authorized, following a specific procedure, only at the presence of a member of the staff

In addition, the evidence gathered suggests that at least 3 drivers slept inside their truck cabs.

4.1.8 Watchkeeping on the navigation bridge

Watchkeeping on the navigation bridge is regulated by procedure under Chap. 3.1.8 SMS and form

VIS/P/10. At the time of the accident, the second watchkeeping team was on the navigation bridge

(04.00 -08.00) and was made up of the following crew members:

- Seaman (Ship’s wheel)

- 2nd mate

Such composition was compliant with the above mentioned procedure.

In addition, the Captain was still on the navigation bridge, since, as he declared “the navigation in

that area required particular attention, as it was quite challenging” (see related interview with the

Captain).

Pag. 38



4.1.9 Working hours on board

The working hours on board are regulated by the specific regulation (MLC 2006, from Leg. Dec.

271/1999 art. 11, as amended and by the Convention STCW (A-VIII/1 – as amended by the Manila

Conference).

All the staff members in charge of watchkeeping or safety related tasks, tasks concerning marine

environment protection and security shall have the following average rest periods:

- At least 10 hours out of a period of 24;

- At least 77 hours out of a period of 7 days.

The working hours on board may be divided into two main time slots, one of which shall be of at

least 6 consecutive hours; the time lapse between the two slots cannot be over 14 hours .

On board of the M/V NORMAN ATLANTIC, such aspects are regulated by procedure SMS 13.26.

The evidence concerning the rest and working hours made, and in particular both the record and the

personal sheets of each crew member were lost during the fire.

4.1.10 Procedures for passenger boarding

The management of passengers on board, with reference to their registration and the controls to be

performed during the embarking, disembarking, and when counting passengers, are regulated by

the SMS procedures 24.2 and 24.2.1. In this case, although the mentioned procedures were all

compliant with the regulation and approved, during the emergency there were problems in

determining the exact number of persons on board, such problems were mainly due to the confusion

generated by the wrong registration of passengers’ data (for ex. maiden name for women) and/or

transcription errors.

Moreover, regarding the number of passenger on board, at departure from Igoumenitsa, following

information have been provided:

- through the list provided from the person appointed on shore 422 passengers and 56

crewmembers;

- while through the list provided by Pireus Maritime Authorities: 419 passengers and 55

crewmembers. Two passengers never embarked, so the final number of people on board was

reduced.

As a result of this, shortly after, the Italian Coast Guard Headquarter, issued Circular N. 106 dated

22.01.2015 with the aim of removing /mitigating such problems.

Pag. 39



4.1.11 Organization on board according to the Charter Party Agreement

At the time of the incident, the ship M/V Norman Atlantic was chartered by the company Anonimi

Naftiliaki Efteria Kritis S.A. (Greece) from the Visemar di Navigazione s.r.l. of Bari, by means of a

Charter Party Agreement dated November 28, 2014.

According to the above mentioned agreement, some activities were to be performed by the charter

and by the personnel embarked by the Charterer on the ship, such activities included also:

- The spaces for the embarking of passengers, for loading the equipment/ public and private

technical areas for passengers were made available to the charterer;

- The lashing team was provided by the charterer;

- The charterer had the possibility to hire security service staff at its own expenses;

- Part of the team in charge of the connection of the reefer sockets was provided by the

charterer.

4.2 Analysis of the emergency management and Muster list

The provisions of the SOLAS Convention and of DPR 435/91 (art. 203) establish that a muster list

shall be made for the ship, where all the tasks concerning the management of the different kind of

emergencies are listed and assigned.

The muster list of the Norman Atlantic consisted of 52 persons (out of a total of 55 crew members).

These persons are in charge of different tasks, depending on the kind of emergency at issue,

according to procedures n. 9.1 and followings of the SMS manual. The abandonment of the ship is

instead regulated by procedure 10.4 of the above mentioned manual.

When the fire broke out, the watchkeeping teams were composed as follows:

Deck:

Second mate, with the help of a seaman. The Captain was also on the deck.

Engine:

First engineer with the help of a fitter

According to the VDR, before the fire detection at 03:16:49 UTC a fire prealarm was probably

activated at the system’s console on the bridge. Moreover, based on the conversations of the bridge

watch, at 03:09:51 UTC smoke was seen through the bridge windows but the OOW thought that it

was the reflection of the sea. Nonetheless, AB went to check the area at 03:14:12 UTC and at

03:17:14 UTC informed those on the navigation bridge that a truck, whose engine was running, had

some smoke:

Pag. 40



(P.I.) Can you hear me?

Yes, go on (P.i.)

Ok here..there’ s a compressor engine running, which is producing smoke

ok is that on the starboard, isn’t it?

Yes, that on the starboard (P.I.)

ok so it’s coming from it

eh yes, it comes from it ..it is running and produces smoke, do you understand? It’s that one ..but

the direction leads to the portside towards the exit…on the starboard towards the windows

However this was not considered important or dangerous by the crew, even though it indicates a

problematic operation of the reefer engine. Therefore no actions were taken, such as calling the

driver of the reefer to stop the operation or enhance the monitoring of the area.

Later on, the fire alarm sounded on the bridge for the area of Deck 4. Although it appears that the

AB was sent to check again the area, the Master and the OOW believed that it was the smoke

coming from the reefer engine that locked the sensors.

In addition, almost 2 minutes after the fire alarm the AB reports again to the bridge about a lot of

smoke coming out from a reefer track engine, confirming the Master’s and the OOW preexisting

belief. Consequently the signs of the developing situation were not duly taken into account by the

two Officers.

It should be noted that comparing the times of the reports of the AB to the bridge it appears that the

first report was at 03:17:14, that is almost 3 minutes from when he left the bridge (03:14:12) to check

at Deck 4 for the smoke they saw from the bridge windows, while the second report was given at

(03:24:49) only 2 minutes after the activation of the fire alarm.

The analysis of the evidence (VDR, machinery automation, Autronica), shows that the only

ascertained fire alarm was recorded on the VDR at 03:23:05 (UTC) by a connection to the relay K21

which is probably referred to loop num. 9 namely the garage room on deck 4.

The first alarm on the Kongsberg printout (found in the engine control room) was recorded at

05:21:03, time zone UTC+2, while the one recorded by the VDR is at 03:23:05 UTC.

So, if the time zones are aligned, we can see that the physiological drift between the reference time

of the Kongsberg system and the VDR system is of +02m:02s.

Shortly after (see VDR recording/transcription), at 03:26:55 UTC the Captain realized, when looking

abaft from the starboard wings, that a fire was breaking out on deck 4, with flames coming out of

the windows abaft of the lifeboat.

Pag. 41



So the “crew call” (at 3.28) was issued and the first mate was immediately called 1, as advised by

the second mate, as fire-fighting team manager in the Muster List, who, in that moment, was in the

cabin.

Shortly after (at 03:29 UTC) the ECR was ordered to open the Drencher on deck 4 frame 156.

Recap of the fire alarm chronological sequence (UTC):

03.28 crew call

03.29 order to activate the Drencher pump

03.30 information on the fire position is provided several times (frame 156 deck 4) to the ECR

03.31 Captain’s confirmation request for the Drencher opening

03.31 1st Engineer confirms that the Drencher has been started

03.36 the first mate communicates that he cannot intervene, because there is too much smoke and

the fire has already broken out

The inspection made by the first mate confirmed the presence of a vast fire on deck 4, although the

exact fire location, as well as the Drencher functioning were not confirmed - despite the repeated

Captain’s requests - in that area there was indeed so much smoke and the fire was so serious that

the area was unapproachable.

4.2.1 The emergency phase

Following the crew call, (in compliance with the Muster list) the following crew members reached the

navigation bridge:

Navigation bridge:

2nd mate, off going (replacing the watchkeeping officer)

3° mate in charge of GMDSS communications

Off going seaman (who replaced the helmsman working in the fire-fighting team)

Captain

-

Engine:

1° Engineer

Mechanic worker

Chief engineer (arriving few minutes later)

Pag. 42



Remaining staff:

among10 the remaining staff, the following shall be mentioned: the second engineer went on board

of the left lifeboat, as lifeboat chief, supported by the seaman identified in the Muster List.

The boatswain, who was initially in charge of supporting the fire-fighting team, was then, after few

minutes, called on deck 5 to prepare the rescue means (MES and left lifeboat), after that the situation

went from “Fire on board” to “general emergency”. In this regard, there is no clear evidence of the

switch from the first situation to the second one, probably because of the extreme gravity of the

emergency.

At 03.42 the Captain spoke directly with the boatswain via radio to be informed on the situation, he

said that the hose could not be used and provided, shortly after, information on the situation of the

lifesaving appliances in his area (life rafts, left lifeboat and mini-chute).

… Captain, Captain...

….. Boatswain

Boatswain can you hear me?

Yes, I can, go on.

…..Also on the main deck!

Go on.

The hose melt because of the heat, on deck 5 (P.I.)

Ok, understood, but in these conditions we can’t put the lifeboat at sea

…. We try it because here… (unintelligible)

That’ s ok, ….

(P.I.) we can’t work because... (P.I.) fire-fighting (P.I.) water

We need to abandon the ship!

……

Both the statements made and the VDR records clearly show that the fire-fighting team could not

make any intervention.

10 On this regard, it should be highlighted that personnel was called initially for the fire incident and not for the vessel’s abandonment.

Pag. 43



It seems that procedures 9.2 and 9.3 of the SMS were not applied in a correct and integral way,

considered that the emergency phases are quite confused.

4.2.2 ECR situation and activation of the Drencher pump Around 5 minutes passed from the moment when full awareness of the fire was reached until the

Drencher pump activation order.

FIGURE 6 DG3 - AT 03:32 APPROXIMATELY (UTC) THE DIESEL GENERATORS HAVE A SUDDEN PEAK IN

THE LOAD VALUE, HIGHLY PROBABLY DUE TO THE ACTIVATION OF THE FIRE-FIGHTING DRENCHER PUMP.

As shown above, the order to activate the Drencher pump was given at 03.31 by the first engineer,

who, in the meanwhile, had reached the Drencher room, as provided for by the navigation bridge.

The same first engineer, during the interview, which was made quite after the accident, said he

opened the valves in the areas on frame 156 deck 4, as ordered by the navigation bridge

Pag. 44



Although, based on the evidence, valves 4,5,6 and 7, namely those on deck 3, forward area, were

opened.

PHOTO 5 SITUATION OF THE DRENCHER VALVES, VALVES ON DECK 3 OPENED (4 ZONE)

FIGURE 7 IDENTIFICATION OF THE DECK SERVED BY ZONES/AREAS 4, 5, 6 AND 7, EXTRACT FROM

“MANUALE OPERATIVO DI ADDESTRAMENTO E MANUTENZIONE ANTINCENDIO” - MANUAL OF

OPERATIONS FOR ANT-FIRE TRAINING AND MAINTENANCE

Besides the wrong opening, it shall be noted that the anti-fire manual of operations shows that the

Drencher system enables to intervene on two adjacent areas at the same time.

Pag. 45



In addition, the Chief engineer - albeit acting regularly, pursuant to the provisions established in the

Muster List - left the ECR/engine room together with the staff in charge of its supervision after about

10 minutes, without informing the Captain/navigation bridge.

Such behaviour made it impossible to take any further action and to intervene in the Engine /

Drencher system/ main electrical supply of the ship.

4.2.3 Analysis of the human factor and influence over the emergency management The human factor has negatively influenced the situation, under some point of views.

Although the organization on board was theoretically in line with the regulation, it was not perfect

due to the following aspects:

The emergency was highly serious (presence of smoke, alarms …)

The human machine interface was not appropriate (valves not clearly identified

because of possible smoke presence that could have limited the visibility in the

Drencher room)

The time available (the measures taken were late, if we consider when the fire broke

out, so the time available to face the emergency was reduced)

Time of the day (the emergency took place at night)

The stressful situation generated by the fire, the behaviour of the some crew members

was not appropriate (sometimes they acted without abiding by the procedures

established despite the training and familiarization carried out when they joined the

vessel

Cooperation among the crew members (the personnel hired by the ship owner and the charterer’s

personnel were not always in sync. The above mentioned factors probably had a negative

impact on the emergency.

-

Analysis of the following events

Here below the sequence of events which followed the emergency is provided:

03:41-46 likely interruption of the main power supply (radar screen “frozen”, then it disappears)

03:48 preparation of the left lifeboat given by the Captain

03:52 embarking of passengers on the lifeboat (in this regard there is no evidence of orders issued

by the navigation bridge)

04:03 The boatswain communicates that the lifeboat is hanged

04.03 The Chief Mate communicates that the fire cannot be extinguished

04:06 the lifeboat is released at sea

04:21 the Captain informs via VHF Crotone Radio that one lifeboat was already at sea

Pag. 46



04:24 DGE activation, VDR

04:30 the First engineer says he is in water

During the emergency, as inferred from the VDR records, the Captain ordered immediately to

transfer the passengers abaft and then to the higher decks, based on the developments of the

situation

4.2.4 Other issues related to the emergency management

The statements of some passengers highlighted that:

there was no audible alarm or a public announcement in the area of passenger cabins;

there was not any announcement via the public address system on a later stage;

it seems the alerting of the passengers happened solely by themselves;

there was no help from any crew member in the area of passenger cabins and only very

minor help in the area of the rescue means;

the passengers were not able to identify the crewmembers, because they did not wear

special jackets or vests.

These issues could be addressed to the damages that affected the ship electrical system since the

early stages from one side and on the other hand to a not proper application of the emergency

procedures by the cabin crew combined with the difficulties related to the nightime.

However, interviews of the crewmembers and other evidences gathered during the investigation do

not confirm fully the above mentioned criticalities.

Pag. 47



4.3 VDR data extraction and analysis and problems encountered

The VDR of the M/V Norman Atlantic is a Rutter mod. VDR-100 G2, whose modules were recovered

in two phases. On January 2, 2015 the FRM module was first recovered, while on January 5, 2015

the DMM was recovered, however this latter module was so damaged by heat that its data could not

be recovered.

PHOTO 6 DMM – M/V NORMAN ATLANTIC

PHOTO 7: COMPLIANCE MARK VDR NORMAN ATLANTIC (RUTTER RUT-010036)

On January 22, 2015 the first attempt of data recovery from the FRM (VDR capsule) of the Norman

Atlantic was successfully made, although the audio of the recording was not working. Only later, on

September 25, the audio was restored thanks to a new procedure and so a complete data analysis

was made possible.

Pag. 48



PHOTO 8 MODULE FRM M/V NORMAN ATLANTIC

TABLE 1 NMEA EQUIPMENT LIST– M/V NORMAN ATLANTIC

Pag. 49



Also for AUTRONICA an analysis was carried out, although no relevant data were recovered,

considered that the recordings started few minutes after the fire broke out, as the initial data were

already overwritten.

The “Performance Standards” which the VDR of the M/V Norman Atlantic shall comply with, are

established by the IMO resolution A.861(20) or rather by the supplementary resolution IEC61996.

The amendment to A.861(20) which shall be kept in mind, is resolution MSC.214(81), while

resolution MSC.333(90) is not applicable, as the VDR was installed before June 2014.

In the latest certificate of compliance (Fig.10) the following “Applied Directives” are mentioned:

• MSC.214(81): ADOPTION OF AMENDMENTS TO THE PERFORMANCE STANDARDS FOR

SHIPBORNE VOYAGE DATA RECORDERS (VDRS) (RESOLUTION A.861(20)) AND

PERFORMANCE STANDARDS FOR SHIPBORNE SIMPLIFIED VOYAGE DATA RECORDERS (S-

VDRS) (RESOLUTION MSC.163(78))

• A.694(17): GENERAL REQUIREMENTS FOR SHIPBORNE RADIO EQUIPMENT FORMING

PART OF THE GLOBAL MARITIME DISTRESS AND SAFETY SYSTEM (GMDSS) AND FOR

ELECTRONIC NAVIGATIONAL AIDS

• A.861(20): PERFORMANCE STANDARDS FOR SHIPBORNE VOYAGE DATA RECORDERS

(VDRs)

• MSC.191(79): PERFORMANCE STANDARDS FOR THE PRESENTATION OF NAVIGATION-

RELATED INFORMATION ON SHIPBORNE NAVIGATIONAL DISPLAYS

Pag. 50



FIGURE 8 CERTIFICATE OF COMPLIANCE, INSPECTION OF 13 MAY 2014

Pag. 51



It is important to highlight that the MSC.214(81) requirements concern, in particular, the “replay

software”, while the instructions for encoding non standard strings are among the requirements of

resolution A.861(20), which is compulsory for all VDR installed after June 1, 2008. The problems

concerning the replay software and the encoding of data will be analysed in Paragraph 4.3.1. The

connections between the VDR and the power supply, the primary or emergency ones, could not be

verified, nor could the input channels connected to the device be checked, as no relevant

documentation was available. Power sources are chosen, pursuant to regulation IEC 61996-1, as

follows:

“According to the regulations (IEC 61996-1) the power source of the VDR has to be the ship's

emergency source of electrical power. If the ship's emergency source of electrical power fails, the

VDR has to continue to record bridge audio from a dedicated reserve source of power for a period

of 2 h. At the end of this 2 h period all recording shall cease automatically.

4.5.2 Power source

(A.861/5.3.1)

To ensure that the VDR continues to record events during an incident, it shall be capable of operating

from the ship's emergency source of electrical power. Whenever electrical power is available the

VDR shall operate, except as permitted in 4.5.4. (see 6.1.15)

4.5.3 Dedicated reserve power source

(A.861/5.3.2)

If the ship's emergency source of electrical power supply fails, the VDR shall continue to record

bridge audio (see 4.6.5) from a dedicated reserve source of power for a period of 2 h. At the end of

this 2 h period all recording shall cease automatically. 61996-1 Ed.2 CDV © IEC:2007(E) - 1 3 -

80/470/CDV

4.5.4 Recording period and duration

(A.861/5.3.3)

Recording shall be continuous unless interrupted briefly in accordance with 4.5.1 or terminated in

accordance with 4.5.3. The time for which all stored data items are retained shall be at least 12 h.

Data items which are older than this may be overwritten with new data.

Recording may also be terminated, by means of a key or other secure method.

NOTE This may occur under the following circumstances:

a) during essential maintenance purposes whilst the vessel is in port;

b) when the vessel is laid-up;

c) upon request by an investigation authority, for example after the vessel had been involved in a

marine incident.”

Pag. 52



IEC61996 (in particular, for this installation, IEC 61996-1 Ed1 2007) lists all the "data items to be

recorded". In particular, in annex B of the IEC the "mandatory alarms" are listed. To this list the

BNWAS alarm shall be added, since it has later become compulsory in the CoC and is to be

connected to the VDR pursuant to IEC 62616 - namely through the NMEA serial connection.

With reference to the "mandatory alarms", it shall be noted that, for the smoke detector (see “item”

19 and 20), the IEC only requires the recording of "alarm activation" and of "system failure". As a

consequence simple digital warnings can be used. Serial data shall not necessarily be recorded by

the fire alarm control unit with the alarm sensor information.

All the data required by the mentioned regulations in force are stored in the VDR system and

extracted in NMEA format as “strings”. The “Standard Interface IEC 61162 – NMEA 0183”, which

will be further described later, establishes that some kinds of data shall be documented by the

standard, while other kinds of data, known as “proprietary” are documented by the producers of

devices generating them for the storage in the VDR.

Circular MSC 1024 is very clear about the IMO requirements, the first paragraph of the document

explains indeed: "The owner of the ship should make available and maintain all decoding instructions

necessary to recover the recorded information” and in this case no other interpretations look

possible. Having said that, to further strengthen and make the provisions of circular MSC 1024

compulsory, in the footnote of regulation 20 of Chapter V of the Solas, the General Series Circular

n° 59, dated 31 October 2005 is mentioned, here the following is stated: "the software for the reading

and encoding, as well as the possibly necessary hardware, shall be provided by the producer,

pursuant to circular IMO SN/Circ/246, dated 17 June 2005. Such software and hardware shall be

made available to the shipowner”.

It shall be noted that the final responsible for the Annual Performances Test is always the VDR

producer, in this case Netwave which, after having analysed the data downloaded by the auditing

company during the Annual Performance Test, issued the Certificate of Compliance (CoC) shown in

Fig. 8. Such certificate is however issued not only following the data sample analysis, but also in

view of the declarations in the “Annual Performance Test Report”, which for this ship is represented

by the publishing of the Netwave RUT-TD Rev. 1.2, available for the years 2011 to 2014, duly filled

in and signed. Another extract from the same report (Fig 9) shows that the auditing shall also check

and certify that the VDR configurations are in line with any adjustments made to the ship, in the

device installation.

Pag. 53



FIGURE 9 EXTRACT I OF THE PUBLICATION NETWAVE RUT-TD REV. 1.20 NAMELY OF THE ANNUAL

PERFORMANCE TEST REPORT ATTACHED TO THE COC OF THE NORMAN ATLANTIC DATED 13 MAY 2014

FIGURE 10 EXTRACT I OF THE PUBLICATION NETWAVE RUT-TD REV. 1.20 NAMELY OF THE ANNUAL

PERFORMANCE TEST REPORT ATTACHED TO THE COC OF THE NORMAN ATLANTIC DATED 13 MAY 2014

Pag. 54



4.3.1 Netwave software for viewing and converting data in NMEA

Due to a malfunctioning of the VDR system, several download operations were needed for the

contents of FRM module so as to obtain the audio tracks initially available. It shall also be noted that

the “Video Contents”, namely the “radar screens” start and end in slightly different times. The “NMEA

Contents” remain here unchanged and include, according to the software, all the strings between

16:46:49 of 26/12/2014 and 18:22:29 of 28/12/2014, so for over 48h.

FIGURE 10 SCREENSHOT PLAYER VDR M/V NORMAN ATLANTIC

For this kind of investigations, the “Replay” software typologies provided by the producers are not

the optimal solution, as they often provide results which are not in line with later readings of the same

data in fixed timeframes. Systems sometimes show also hysteresis errors and slowdowns during

which data were not updated on the graphic interface. For this particular installation, the following

information is completely missing:

• Engine RPM, whose documentation was not available to the shipowner or to SIRM.

• All the wheelhouses data, whose documentation was not available to the shipowner or to SIRM.

• True wind, only the apparent wind is indicated

Pag. 55



• Speed Over Ground

• Information on the autopilot

• Echosounder

• Fire doors: data are partly non-reliable, door 125 is mentioned twice for example, in addition

drawing "P270-401" shows a higher number of fire doors on the navigation bridge than the number

in the "mimic panel" placed in the navigation bridge, drawing 219-2317.

• Alarms: are reported in a textual format, so difficult to use

Analysis of the data collected to identify the cause of the fire

To determine the cause of the fire as accurately as possible, by considering the data of the digital

storage devices, the following sources were selected:

- Audio recorded in the navigation bridge, extracted from the FRM capsule of the VDR system

- NMEA data.

- Paper printing of the ship automation system of the Kongsberg company, as found in the

engine control room [Annex 9]

- Data extracted (during the experts’ inspections on July 2, 2015) at SHIP SYSTEM s.r.l. of

Genoa from the Autronica fire board and made available:

i. in binary and txt format [available upon request]

ii. in txt format, integrated with the related configuration data, [available on request]

iii. as a report drafted by the Autronica technician, following the experts’ inspections made in Genoa

2 July 2, 2015 [available upon request].

Data obtained from the recorded audio

The data obtained from the recorded audio enable to hear the pre-alarms, but cannot be easily

distinguished from other acoustic signals. The data recorded include also the navigation bridge

personnel reading out loud the information on the display of the Autronica panel. The audio tracks

show that the first information on the pre-alarms is at 03:16:48 (UTC), while the first frame indication

is provided at 03.29.39 (UTC) by the second mate, watchkeeping officer, who, when calling the

engine motorman on duty, said: “yes, there is a fire on deck 4, forward side, … tell him the area is

frame 156, ok bye”.

Data obtained from the “Autronica panel”

Pag. 56



Information concerning the pre-alarms or whatever detail concerning the frame are found also in the

data extracted from the panel and available in the report. The storage of events in the Autronica

system is divided in 4 memory blocks: when the last block is full, the first block is cancelled and re-

used. The maximum number of events which can be recorded is between 3600 and 4800, in this

case the register contains a total of 3972 events. The first event recorded in the Autronica panel is

at 3:39:54 (UTC), it means that the first alarm heard in the navigation bridge at 03:16:48 (UTC)

was cancelled. It shall be noted that the Autronica panel records information with the UTC+2 time

zone, reference time of the data attached referred to this system. To sum up, with the UTC+2 time,

the first event stored was recorded on Sunday, December 28, 2014 at 05.39.54, while the latest

event stored was recorded on Sunday, December 28, 2014 at 17.11.11. The beginning of the fire is

not included among the events recorded and it is now difficult to say how many events were

cancelled.

Data obtained from the NMEA strings

With reference to the data concerning the beginning of the fire, searched in the VDR, the “Autronica–

VDR” interface, made pursuant to the relative schemes and documents (available on request), was

analysed, in particular the documents “VDR RUTTER 100G2 IMPIANTO” and “Documentazione

relativa alle Interfacce a contatti (DATA DISCRETE)” were considered. Such documents were

drafted and provided by the installer, but after a precise and careful analysis it turned out that they

do not precisely reproduce the ship configuration and are often incompatible with the NMEA data

analysed, so that they can’t be easily and completely interpreted, particularly with regard to the

alarms and the position of fire doors.

More specifically, the Autronica unit is connected to the VDR through 16 “free contacts” to the “DATA

DISCRETE” number 05 and then to the VDR through MUX number 1. Such contacts energise as

many relays and, pursuant to the regulation in force, indicate:

- fire alarm for each “loop”

- generic fault

The information obtained by the VDR have therefore a granularity “by loop” so they cover large

areas, which, in this ship, include several decks. The first alarm was recorded at 03:23:05 (UTC) by

the contact connected to the relay K21 which is probably referred to loop number 9, namely to the

garage area on deck 4. To better compare this information with the other one recorded as NMEA

data, a table of 6.169.013 lines and 681 columns was prepared, with data starting from 14:30:00 of

27/12/2014. Other reduced and specific versions of this table were then created for the experts’

inspections. The data from the Kongsberg printout and the time alignment drift (found in the engine

control room) show that the first alarm was recorded at 05:21:03, with UTC+2 time zone, while the

one recorded by the VDR is at 03:23:05.

So, if the time zones are aligned, the physiological drift between the reference time of the Kongsberg

system and the one of the VDR is of +02m:02s (in other words, the time indicated by the Kongsberg

Pag. 57



system, in UTC time, is two minutes and two seconds back, if compared to the time indicated by the

VDR).

Because of such time drift, it is important to check if the two events recorded by the Kongsberg

system and by the VDR are or not the same event, namely if the drift found is the real one. In few

seconds the Kongsberg system records a sequence of alarms (A) and “Return” (R) of the A, R, A,

R, A typology, where the first A event is the one which occurred at 03:21:03 UTC; so it would be

logic to check such a sequence in the VDR data to obtain the real drift value. Unfortunately, in the

VDR data, only the first A alarm occurring at 03:23:05 was included, as already mentioned, while all

the following events are missing. This is due to the fact that the command “Return” is not recorded

by the VDR, nor is recorded the following alarm, as the system is already in alarm status because of

the first alarm recorded. Alarms in the VDR system “reset”, namely go back to the “0” value,

as shown in the NMEA tables, only when the RESET button on the panel is pressed. So it is

necessary to find another event which was recorded by both systems. At 03:24:38 UTC, precisely

01m:33s from the first alarm, the VDR records a “FIRE CONTROL PANEL FAULT”. At 03:22:36

UTC, precisely 01m:33s from the first alarm, the Kongsberg system records an alarm which can

probably be classified as a “FIRE CONTROL PANEL FAULT” and can be so associated with the

same alarm recorded by the VDR. Such information is realistic, the FAULT in the Kongsberg printout

can indeed be associated with contact D4 of DATA DISCRETE 05 being energised; such contact,

pursuant to the documentation available, should not be connected to anything, yet it was linked to

the K1-FAULT, namely to the “FIRE CONTROL PANEL FAULT”, and was probably mistakenly

connected to contact D4 instead of D5, as written in the documentation. It is surprising that this and

other mistakes in documenting the “contacts” were not revealed during the tests and for the

compulsory annual certifications, similarly it is surprising that most of the compulsory documentation

concerning the NMEA sentences - which were not immediately available to the shipowner nor to the

auditors - was completely missing.

Based on the observations above, it is possible to state that the time drift between the Kongsberg

system and the VDR is exactly of 02 minutes and 02 seconds.

Description of the automatic fire detection system

During the inspections made on July 2, 2015, at the Ship System of Genoa, the system mode of

operation was described, as written in the experts’ inspection report, which can be found in Annex

10 and which is completely reported here below.

Pag. 58



FIGURE 11 DISTRIBUTION OF THE FIRE DETECTION SYSTEM ON THE LOWER DECKS

COMPOSITION OF THE “AUTRONICA” FIRE DETECTION SYSTEM

The detection system (called “system”) is made up of:

N. 1 main panel BS320: the one extracted from the position on the left of the GMDSS on the

navigation bridge;

N. 2 controller BC320: they are still on board, hidden under the BS320. They have no display

and no storage;

N. 1 BV320 repeater: still on board, in the engine control room. It simply repeats what goes

on in the BS320.

Pag. 59



The controllers are simply expansion modules of the BS320. Detectors can basically be of two

different typologies:

SD: Smoke Detector (only smoke)

MD: Multi Detector (smoke and/or heat). At a software level, it is possible to set either the

AND or the OR condition. For the system analysed, a technician of the Company Ship System

stated that the latest configuration set was the logic OR. With reference to the sensors BH

520, installed in the garage area of deck 4 - as shown in the letter dated 5 May 2016 (Annex

11) where the functional features of the above sensor are provided by the expert appointed

by the shipowner- they can be set for three different “Operation Classes”:

o Multi sensor only: the sensor turns on, mainly if the smoke alert thresholds is exceeded;

o Heat only: the sensor turns on, only if the heat alert threshold is exceeded;

o Multi sensor w/heat: the sensor turns on, if the heat alert threshold is exceeded or if the

smoke alert threshold is exceeded.

In particular, based on what an engineer consultant appointed by the shipowner documented, the

“Ship System” set these sensors in the “Multi sensor w/heat” modality, as shown through a

freeze-frame of the software “AutroSafe Configuration Tool”.

The sensors installed on open decks and those on enclosed decks are, in their functional features,

the same (so there is no specific sensor for deck 4, ventilated).

The detection system manages overall 15 loops, divided as follows:

from LOOP 0 to LOOP 5: managed by BS320;

from LOOP 6 to LOOP 11: managed by a BC320 controller;

from LOOP 12 to LOOP 14: managed by the other BC320 controller.

Whatever card of BS320 and of BC320 manages 1 LOOP. In each card 4 cables are plugged (double

power supply, as provided for by the law).

It shall be noted that the system doesn’t record the opening/closure of fire dampers and fire doors.

Pag. 60



FIGURE 12 DISTRIBUTION OF THE FIRE DETECTION SYSTEM ON THE HIGHER DECKS

CONNECTION TO THE VDR SYSTEM

The system is connected to the VDR and automation through general signals: so the VDR will record

only the FAULT or FIRE events, without any further details (which is instead indicated in the system

LOG file).

The FAULT or FIRE signal for the VDR is in real time (namely “simultaneous” to smoke/heat

detection). Clearly in the VDR, data are recorded with the VDR time.

DETECTED EVENTS AND ALARM DETECTION THRESHOLD

Pag. 61



The events detected by the system are the following ones:

FAULT: fault in the system. Ex: loop interrupted for a breakdown in the detector (with

indication of the broken detector)

o Non-responding unity (with indication of the non-responding detector)

o ground (the entire loop goes ground): it normally doesn’t affect the detection

PRE-ALARM: when a sensor detects a certain quantity of smoke (or of smoke and/or

temperature, for “multi detectors” MD), the buzzer of the main panel sounds. The “pre-alarm”

remains active, until an operator turns it off.

ALARM: when a sensor detects a great quantity of smoke (or of smoke and/or temperature

for MD), the buzzer sounds and the 2 minutes countdown starts, at the end of which the ship

sirens sound. The ship sirens can be silenced both before and after the end of the countdown.

The difference between the pre-alarm and the alarm lies in the activation thresholds.

The pre-alarm thresholds were not disclosed by the Norwegian technician, who was in Genoa on

behalf of Autronica: they were set by the producer (sometimes in agreement with the shipowner), as

there is no legal requirement for the pre-alarm. It’s just a safety margin set by the producer.

The alarm thresholds have instead specific reference regulations. The technicians involved agree

that the following thresholds were set:

Temperature threshold = 55 °C

Smoke threshold= 2.5 % Light Abatement out of 1 metre

Such thresholds shall be found in the reference regulation, that is the SOLAS. In its 2014 version,

the SOLAS refers to the Fire Safety Systems Code for detection system requirements.

The FSS Code11 (Chapter 9 – Par. 2.3.2.1) indicates the value 54°C as temperature threshold and

"2% obscuration per meter" as the lower limit for the heat and smoke threshold. Such values are in

compliance with the ones indicated by the technicians and by the producer.

11 FFS Code – C.9: “…..2.3.1.2 Smoke detectors required in all stairways, corridors and escape routes within accommodation spaces shall be certified to operate before the smoke density exceeds 12.5% obscuration per meter, but not until the smoke density exceeds 2% obscuration per meter. Smoke detectors to be installed in other spaces shall operate within sensitivity limits to the satisfaction of the Administration having regard to the avoidance of detector insensitivity or oversensitivity….”

Pag. 62



On this regard it should be noted that FSS Code does not indicate specific parameters for smoke

detectors to be installed in open ro-ro cargo spaces.

SAFETY LEVELS FOR HUMAN INTERVENTIONS ON THE SYSTEM

To silence the buzzer, no particular safety procedures are needed: basically anyone can do it.

The following operations require instead a greater safety level, a key shall indeed be inserted in the

BS320 (2nd safety level):

Alarm reset

Silencing the general sirens

enable/disable the single loop sensors (they can also be disabled for a limited pre-established

time interval)

A password (together with the key) is also required for the following operations (3° safety level):

disable (namely disconnect the power supply) an entire loop.

According to an interview, such password could possibly be known by the crew member.

ACKNOWLEDGEMENT OR RESET OF A FAULT - RESET OF AN ALARM

Consider the case of a fault. In the LOG file, the “FAULT” event is recorded. The operator can restore

the original function in two different ways:

Acknowledge the fault and silence the buzzer. The LOG file records an “ACKNOWLEDGE

FAULT” and the fault will no longer be included among the LOG file strings;

In case the operator chooses the RESET, the LOG file records “RESET FAULT” and it is as

if that fault never happened. If the fault occurs again, it will indeed reappear in the LOG file.

For the alarms, the “acknowledgement” is formally not possible. If sensor X goes in alarm status, the

operator may just silence the ship sirens. If another sensor Y goes in alarm status, sirens turn on

again, otherwise they keep silent.

Pag. 63



As an alternative, the operator can reset the alarm of sensor X. If the alarm of sensor X is triggered

again, that will be considered as a completely new event and will be written again in the LOG file.

TIME

Time is set on board: for this operation the key is needed (2nd safety level). It could be changed

during navigation, but it unlikely in this case, also in view of the intervention timing and of the following

operations.

The Norwegian technician ensures that the maximum time error in the system is of ± 30 s in 30 days.

LOG FILE

The LOG file indicates the loop, the number and typology of detector, the deck number and its side

(right or left).

Here the following events are recorded: pre-alarms, alarms, faults, interventions by the operators,

enabling and disabling actions.

Data are recorded on a 32 MB flash memory. About 4000 events are recorded. The oldest data are

cancelled to record new data.

LOGs may also be displayed on the BS320 panel, with a 3° safety level.

The main panel BS320 is also provided with a mini printer (like sales receipt), whose printing may

be enabled or disabled.

For further details, see the manuals, which are here attached (Annex 12 - 13)

The drawings concerning the distribution of sensors of the fire detection system are available in the

Annex 14a-b. The approval by RINA can be found in Annex 15.

The list of sensors is available in Annex 16.

Pag. 64



4.3.2 Sequence of events

Alarm “K21” recorded on the VDR by the Autronica detection system refers only to loop 9 (namely

the garage area on deck 4). The reference frame is instead inferred from the audio file. In this regard,

the first information was provided at 03.29.39 (UTC) by the 2nd mate on duty, who, when calling the

engine worker, states: “yes, there is a fire on deck 4, forward side ,… tell him (the second engineer)

that the area is frame 156, ok bye”.

FIGURE 13 KONGSBERG PRINTOUT FOUND IN THE ENGINE CONTROL ROOM WHERE THE FIRST FIRE

ALARM CAN BE SEEN

Alarms recorded on the VDR:

NMEA

TIME CONTACT LOOP NOTES/LOCATION

3.23.05 K21 9 Deck 4 garage

3.23.38 K27 FIRE CONTROL PANEL FAULT

3.25.56 K16 4 Deck 5 restaurant

3.26.05 K23 11 Engine Room deck 2

3.26.39 K23 11 Reset Engine Room deck 2

Pag. 65



3.26.41 K16 4 Alarm Reset deck 5 restaurant


3.26.51 K23 11 Engine Room deck 2

3.26.55 K12 0 Navigation bridge

3.27.15 K24 12 Deck 3 and 4 funnel

3.27.17 K14 2+14 Infirmary + stairs shops bus

3.28.07 K21 9 Reset Deck 4 garage

3.28.09 K21 9 Deck 4 garage

3.28.09 K12 0 Navigation bridge Reset

3.28.11 K14 2+14 Infirmary + stairs shops bus Reset

3.28.15 K16 4 Alarm reset deck 5 restaurant


3.28.19 K14 2+14 Infirmary + stairs shops bus

3.28.26 K12 0 Navigation bridge

3.30.00 K18 6 Deck 5 forward corridor

3.30.17 K15 3 Deck 6 pax sb

3.33.47 K21 9 Deck 4 garage Reset

3.34.10 K26 15 Deck 3 garage

TABLE 2 SEQUENCE OF ALARMS VDR M/V NORMAN ATLANTIC OF 28/12/14

4.3.3 Fire doors status

Based on the data obtained from the VDR, the following table was created, here an extract of the

fire door activities, recorded on the VDR and concerning the door status is provided.

In the following table:

“A” means that the door has been opened;

“C” means that the door has been closed;

“A/C” means that the door has been opened and then closed;

“C/A” means that the door has been closed and then opened.

Pag. 66



NMEA

TIME

REPLAY

TIME DOOR A/C DECK OBSERVATIONS

3.04.10 3.04.08 107 A/C 5 kitchen

3.04.52 3.04.51 8 A/C E.R. Short visit in the purifier room

3.05.36 3.05.36 WT 3 C Refrigerators room

3.10.46 3.10.44 WT 4 C ER Purifiers room

3.12.50 3.12.48 WT 5 C ER Engine storage

3.14.14 3.14.12 135 A/C 7 staircase frame 144

3.15.58 3.15.56 60 A/C 4

Access from the garage port

side

3.16.37 3.16.36 107 A/C 5 kitchen

3.18.58 3.18.56 107 A/C 5 kitchen

3.20.08 3.20.08 60 A/C 4 garage port side

3.22.04 3.22.04 107 A/C 5 kitchen

3.23.58 3.23.56 135 A/C 7 Staircase access frame 144

3.25.26 3.25.24 31 C/A 3 Short visit in ECR A/C

3.25.26 3.25.24 39 C/A 3 Pilot boarding SB SIDE

3.25.50 3.25.48 31 A/C 3 Short visit in ECR A/C

3.26.00 72,70,73,

75,81 A/C 5

Stern staircase, corridor SB

SIDE ad ,staircase ad port

,corridor port ,

3.26.04 73,72,81,75 A/C 5 cs.+ Funnel door

3.26.08 73,72,81,75 A/C 5 cs.+ Funnel door

3.26.24 75 C 5 Funnel door

3.26.28 72,70,73,81 A/C 5

A/C rapid sequence, not to be

considered as reliable

3.26.52 53 C 3,4 access E.R. port.

3.26.56 107 A 5 kitchen

3.27.08 54 C 5 Staircase frame 62

3.27.08 81 C 5 Corridor SB SIDE

Pag. 67



3.27.12 81 C/A 5 Corridor SB SIDE

3.27.20 70 A/C 5 Opens and closes for

3.28.08 70 A/C 5 5 times

3.28.08

Information on watertight

doors get lost

3.27.04 73 C 5

stern staircase cn.port frame

26

3.27.28 72 C/A 5

stern staircase cn.SB SIDE

frame 25

3.27.28 135 A 7 Staircase access frame 144

3.28.00 140 C 7

Navigation bridge access,

starboard

3.28.55 pilot stb. Open

3.29.20 140 A/C 7

Navig. bridge access,

starboard

3.29.28 82 C 5

End of corridor SB SIDE deck

5

3.29.40 140 A/C 7


starboard

3.29.40 40 C 3 Short visit to forward deck 3

3.29.44 32 C 3 staircase frame 35 deck 3

3.29.44 113 C 5 Forward kitchen door

3.29.44 122 C 5 Starboard kitchen door

3.29.44 125 C 6

door dk.6 accommodations

SB SIDE.

3.29.48 3.29.48 34 A/C 3 drencher room

3.29.48 36 A/C 3

Staircase access door cn. Dk

3

3.29.48 134 C 7 Infirmary access

3.29.48 119 C 5 dumbwaiter

3.29.56 3.29.56 34 A/C 3 drencher room

3.29.56 96 C/A 5 door ad. Central stairs dk.5

Pag. 68



3.29.56 140 A/C 7


starboard

3.29.56 122 A/C 5 Starboard kitchen door

3.30.00 123 C 6

Access staircase area pax.ad

dk.6

3.30.00 114 C 5 restaurant SB SIDE dk. 5

3.30.04 96 A/C 5 door ad. Central stairs dk.5

3.30.04 140 A/C 7


starboard

3.30.04 108 C 5 kitchen

3.30.04 125 C 6


SB SIDE.

3.30.08 31 C/A 3 Short visit to ECR

3.30.08 B1 C/A hatch exit to cargo hold

3.30.08 B8 C/A hatch exit to water treat.

3.30.12 114 A 5 restaurant SB SIDE dk. 5

3.30.20 140 A/C 7


starboard

3.30.32 114 A/C 5 restaurant SB SIDE dk. 5


3.30.36 114 A 5 restaurant SB SIDE dk. 5

3.30.36 134 A 7 Access to infirmary

3.30.44 123 A/C 6


dk.6



3.31.08 139 C 7 bridge port

3.31.16 140 A/C 7


starboard

3.31.16 114 C 5 restaurant SB SIDE dk. 5

3.31.20 123 A/C 6


dk.6

Pag. 69





3.31.20 140 A/C 7


starboard

3.31.24 31 C/A 3 Short visit to ECR

3.31.24 38 C 3 port Pilot boarding

3.31.24 39 C 3 SB SIDE Pilot boarding

3.31.24 22 C/A 3 local protection

3.31.28 122 A/C 5 Kitchen door


3.31.36 134 C 7 Infirmary access

3.31.36 125 A/C 6


SB SIDE.


3.31.40 61 A/C 4

Forward access SB SIDE

garage dk 4

3.31.44 122 A 5 Starboard kitchen door

3.31.56 123 A/C 6


dk.6

3.32.00 61 A/C 4


garage dk 4

3.32.04 61 A/C 4


garage dk 4


3.32.36 61 A/C 4


garage dk 4

3.33.44 24 A/C 3 Stern access E.R.

3.33.48 24 A/C 3 Stern access E.R.

3.33.52 25 A 3 access E.R.

3.34.40 several

3.34.40 26 C 3 Staircase door AD

3.36.04 24 A 3 Stern access E.R.

Pag. 70



3.36.04 31 A/C 3 Short visit to ECR

3.36.08 25 C 3 access E.R.

3.36.40 26 C 3 Staircase door AD

3.37.12 31 A/C 3 Short visit to ECR

3.38.20

ALL THE DOORS

REPORTED AS OPEN

TABLE 3 FIRE DOORS STATUS

At 03:15.58 UTC, door n. 60, which is on deck 4, was opened and then closed. It probably confirms

the inspection made by the seaman, who was sent to check the situation on that deck.

The situation of fire dampers

The inspections made on board by the investigating team show that fire dampers were not closed in

the garage areas.

4.3.4 Data recorded by Kongsberg

On the Norman Atlantic the K-Chief 500 version of the Kongsberg is installed, it includes 4

computers (ROS 1, ROS 2, ROS 3 and ROS 4), which are interconnected via LAN and which,

through the DPU (Digital Processor Unit) acquisition modules, a variety of channels and sensors

from different systems in the ship refer to.

The simplified system scheme can be found in the following figure.

Pag. 71



FIGURE 14 AUTOMATION SYSTEM SCHEME

In particular, in the ECR (Engine Control Room) there are the computers ROS 1 and ROS 2, placed

inside a rack cabinet.

Pag. 72



FIGURE 15 RACK CABINET IN ECR

The Kongsberg K-500 system and the data it recorded were carefully analysed and the experts

carried out their investigations. Here below the conclusions.

During the activities made on board of the M/V Norman Atlantic the computers of the “Kongsberg”

automation system in ECR were recovered. After having extracted the data, it was found that both

data and data carriers were undamaged.

To read and decode them, a desktop workplace was specifically prepared by the Kongsberg branch

office of Rome,

With reference to the decoding operations made, the following clarifications shall be made:

Data concerning time are expressed in UTC (that is 1 hour before Italian time and 2 hours after Greek time. Ex: 03:34 UTC, 04.34 Italian time, 05:34 Greek time)

Based on what was mentioned before, with reference to the time drift between the VDR time and the ship time, the ship automation system time, although expressed in UTC, differs from the UTC time of the VDR, the difference between the UTC time and the real time of the Kongsberg system is approximately of 8 minutes. So the total difference between the UTC time of the VDR and the automation system time is of about 6 minutes (v. Figure 16) .

ROS (Remote Operator Station - IT area controlling the Konsberg automation of the M/V “Norman Atlantic” and constantly querying the DPU). ROS 1 – ROS 2 (Installed in the Engine Control Room (ECR), gathering as much data as possible (log), ROS 3 (installed in the cargo room), ROS 4 (installed on the navigation bridge). All the ROS are connected through LAN and power cables.

Pag. 73



DPU (Distributed Processing Unit – electronic elements sending to the ROS digital signals (log) referred to the different sensors of the ship automation system. They are powered by specific UPS Konsberg). The operating range of DPU, as mentioned in the monograph, is included between -40° and +70°, if these temperatures are exceeded, they stop working. For the purposes of the present analysis, considering the level of thermal entropy and, so, the factor temperature, is crucial.

The IT station (hardware and software and entered logs) which is under analysis, is similar to the one installed on the Norman Atlantic, including the software version. It is, in particular, the software KONSBERG K-Chief OS500, ver.60052.10.

FIGURE 16 KONGSBERG SCREEN CONCERNING THE “DG1 LOAD” WITH INDICATION OF THE THREE DIFFERENT TIMES. NOTE THE

PEAK WHICH PROBABLY OCCURRED WHEN THE DRENCHER WAS ACTIVATED

ROS1 – ROS2 DATA ANALYSIS

As mentioned before, the ROS1 and ROS2 stations were installed in the ECR (engine control room)

of the M/V “Norman Atlantic”, deck n.3 starboard. Such IT stations constantly queried the DPU of

the ship automation system and received the same data by the automation transducers.

At the beginning, the logs referred to the load parameters (tag) of the propulsion endothermic engine

for SX n.2 were analysed. The latest data available is the one referred to the time 03:42 UTC

(automation system time), concerning the rpm: 500 rpm. From 03:42 UTC on, no more data were

recorded, the ROS1 and ROS2 interrupt the communication with the DPU. It shall be noted that, out

of this information, it is not possible to say if the engine on the left, after 03:42 UTC, was still working.

Pag. 74



The only certain information is that the ROS lost connection (LAN and Power) with the DPU.

Furthermore, in view of the above mentioned drift, the actual time is 03:37UTC (6 minutes earlier),

so before the black out, as it was estimated pursuant to the interpretation of VDR data (03:41UTC).

Later the logs referred to the tags for the load of the propulsion endothermic engine for SX n.2 were

analysed. The recordings are the same which were made by the main left engine.

After reviewing the data concerning the two main engines, the parameters for the 3 (three) diesel

generators were analysed:

at the time of the incident, D.G. 1 and D.G.3 were operating, while D.G.2 era was in stand-by

modality.

Also in this case, the automation recording for the DD.GG. data is interrupted at 03:42 UTC, when

the ROS lost their connection to the DPU. Both DD.GG 1 and 3 had a load of approximately 670 kw.

With reference to the production of electricity on board and to the navigation arrangement at the time

of the incident, the analysis of automation shows that the M/V “Norman Atlantic” was navigating with

DD.GG. n.1 and 3 in operation, n.2 was in stand-by, and the two shaft generators were disconnected.

With regard to the functioning of the two shaft generators, ROS 1 and 2 recorded, at 00:13 UTC,

their disconnection, which is highly probably immediately after the departure from the port of Patras,

the generated electric power ensures indeed the functioning of the manoeuvring thrusters used for

the unmooring operations.

The analysis of data in ROS1 and ROS2 has also provided information on the working pressure of

the main fire manifold. Also in this case, the related recording stops at 03:42 UTC, however, at 03:31

UTC a fast increase of pressure inside such manifold is recorded, particularly from about 8 bar to 18

bar. Such pressure increase is probably due to the activation of one of the 3 (three) fire pumps on

board of the M/V “Norman Atlantic”. Furthermore, at 03:35 UTC a pressure decrease is recorded in

the above mentioned manifold, approximately 15 bar, it was probably caused by the opening of some

fire hoses.

ROS 3 DATA ANALYSIS

As stated in the introduction, ROS 3 was installed in the cargo room, deck n.3 starboard. The data

contained in the IT station, including those on time references, are the same as those recorded in

ROS1 and ROS2. For information purposes, the logs referred to the status of stabilizers were

displayed. In this regard, with the exception of a recorded alarm on the left stabilizers circuit at 03:31

UTC, which is considered completely negligible by the current board, it is possible to say that the

mentioned system was never activated. Stabilizers “retracted”.

ROS4 DATA ANALYSIS

As already said, ROS4 was installed on the navigation bridge of the “Norman Atlantic”, deck n.7. No

data are recorded.

Pag. 75



OBSERVATIONS

As noticed before, the different ROS installed on that unit recorded the ship automation data until

03:42 UTC. In this regard, we can’t say whether the different utilities liked to the automation system

(main engines, diesel generators etc.) actually stopped functioning at 03:42 UTC. However it is

possible to state that the connection between the DPU and the different ROS interrupted at 03:42

UTC. Such failure was probably due to the fact that the operating temperature (+70°) of DPU was

exceeded, so their functioning was made impossible, as the connection cables (LAN and power)

between DPU and the ROS4 station (navigation bridge) was physically interrupted. Following the

previous inspection on that unit, it was found that such interruption occurred close to the stringer of

deck 3 between frames n.75 and n.78, portside.

To provide a better understanding of the connection failure between the stations ROS1 and ROS 2

and ROS4, a picture of their placement on the ship is given here below,

FIGURE 17 –ROS PLACEMENT ON THE M/V NORMAN ATLANTIC

After having acquired the wiring diagram of the Norman Atlantic from the Company, the wiring

conditions were checked on board.

Pag. 76



During the inspection on board, with the support of a wiring expert made available by the ship owner,

the cable routing was followed and the interruption on deck 3 was indeed confirmed, in particular

around frame 79 the main flow of cables (for electricity and data) - which from the engine rooms

branch off to the whole ship, as shown in the following image - was interrupted.

FIGURE 18 CABLE ROUTING INTERRUPTION

Here below a detail of the inspection.

Pag. 77



PHOTO 9 DETAIL OF THE CEILING ON DECK 3

As a general observation on the status of cables, it is possible to state that:

The fire had devastating effects on data transmission and control system, as it developed in

key areas which are very important in the cable distribution. Cables were indeed damaged

and the communication between the navigation bridge and the engine room was interrupted.

The fire had devastating effects on the general electrical system of the ship, as the

conductors, because of the contact with flames and the heat generated, could no longer carry

the energy and caused a series of short circuits downstream of all switchboards.

The recorded conditions are shown in the following images which confirm what is stated above. In

the picture the effect of a bolted short circuit in the electric lines is shown.

Pag. 78



PHOTO 10 DETAIL OF THE SHORT CIRCUIT IN THE ELECTRIC LINES

In the following picture a detail of a main flow of cables damaged directly by the fire is provided.

Similar observations – with reference to the damage caused by fire and heat to cables - can be found

in the technical report on engines, shown in Figure 23 and made by the MAN technicians.

Pag. 79



PHOTO 11 DETAILS OF THE DAMAGED CABLES

FIGURE 19 SITUATION WHEN CONTROL WAS LOST (03:42 UTC)

Pag. 80



When analysing the automation system data, it was also noticed that from 3:42.40 on (UTC time),

the K-500 system, while operating perfectly, lost control with the field, as it was recorded by the DPU

(see the diagram above).

All the diagrams provided by the system from this moment on are basically “flat”, here below the

latest valid value is provided:

FIGURE 20 DATA FLOW INTERRUPTION

Pag. 81



The sudden lack of communication may be due to the increase in the ambient temperature, such

devices operate indeed up to a temperature of 50°C. In that room such temperature was well

exceeded, as the melting of plastic devices shows (here below a picture showing the melting).

PHOTO 12 EFFECTS OF TEMPERATURE IN THE ECR

No data registered concerning the emergency diesel generator (EDG) installed on deck n.8,

starboard, was found. The mentioned lack of data is probably due to the fact that the emergency

generator was started after the DPU broke down.

4.3.5 Situation of the Quick Closing Valves

During the inspections made on board to gather evidence, the status of the Quick Closing Valves

was checked.

Pursuant to the prescriptions established by SOLAS 1974, Chapt II/2 regulation 4.2.2.3.4, Every oil

fuel pipe, which, if damaged, would allow oil to escape from a storage, settling or daily service tank,

situated above the double bottom, shall be fitted with a cock or valve directly on the tank capable of

Pag. 82



being closed from a safe position outside the space concerned in the event of a fire occurring in the

space in which such tanks are situated.

FIGURE 21 EXTERNAL ROOM REMOTE CONTROLS QCV

PHOTO 13 REMOTE CONTROLS QUICK CLOSING VALVE

Pag. 83



The Fire Control Plan shows that the external room, where the remote controls of the mentioned

valves are located, is on deck 5 inside the fire control station (Photo 13)

During the inspection carried out in that room, it was found that the valves remote controls levers

were in the “open” position.

Later, the status of the above mentioned valves was checked directly in the engine room, where, it

is was possible to see that all the valves were closed, with the exception of the one referred to the

Diesel service tank 1 which was open, so the Diesel Generators were correctly fuelled.

PHOTO 14 DETAIL OF THE QUICK CLOSING VALVE OPEN

Pag. 84



PHOTO 15 QUICK CLOSING VALVE

The oil pneumatic valves were not blocked by devices or accessories, which are non-compliant with

legal provisions.

In view of the evidence and declarations gathered and of the inspection findings, it is not possible to

state what actually lead to the closing of valves, the closing of valves, although, it may be due, highly

probably, to the intervention of engine crewmembers before leaving the engine rooms.

Other causes, although they are remote possibilities, are the particularly adverse weather conditions

which may have led to the closing of valves, as a result of high temperatures reached in the engine

room. Such condition shall be verified through specific tests on the mentioned devices, however they

couldn’t be carried out, because of the serious damage suffered by the unit and because of the

impossibility to reproduce the same operating conditions.

In addition, it shall be noted that, the QCVs are designed so as to prevent their unintentional closing,

due to adverse weather conditions.

Pag. 85



4.3.6 The engine shutdown hypothesis

By analysing the VDR data, it is only possible to infer that starting from 03:33 the engine load was

reduced (from 83 to 74 RPM) to later reach 43RPM at 03.35, and within few minutes it reached zero

(before the engine on the left and then the one on the starboard side).

In this regard, considered the condition of the QCVs explained in the previous paragraph, it is clear

that the main engines could not be operating, as there was no fuel supply.

The QCVs were probably closed by the engine staff, even though the interviews/declarations

gathered do not prove anything in this regard, similarly the Kongsberg data do not confirm this. Only

in the VDR recordings, during the initial stages of the emergency, the possibility of switching the

engine off (03.33UTC) is mentioned and confirmed slightly after (03:41).

03:33:15 “Bridge, bridge” “yes” “here we only see smoke and there are flames on deck 5……… “

“Do we have to stop the engine?” “there are flames from, from the fan” (Extract from the VDR

transcriptions)

To provide a complete analysis, here below some extracts of the MAN technicians’ report, within the

context of an ATP, are made available:

FIGURE 22 – EXTRACT OF THE MAN TECHNICAL REPORT ON THE ECR CONDITION.

Pag. 86



FIGURE 23 - EXTRACT OF THE MAN TECHNICAL REPORT ON THE ECR CONDITION.

Pag. 87



4.3.7 Video surveillance system

The video surveillance system installed on the Norman Atlantic is of analogue type. All the cameras

transmit the video signal recorded to a video matrix which is connected to two analogue monitors.

The basic “architecture” is represented in the following image.

FIGURE 24 DIAGRAM OF THE VIDEO SURVEILLANCE SYSTEM

The main feature of such a system is its very limited recording ability, as it is mainly designed to

show operators remotely controlled areas. The recording is made exclusively on VHS (cassettes) or

with a DVD recorder. This system is also designed to enable – as provided for - the monitoring of

accesses of non-authorized persons to the garage areas (namely for security purposes) and not

really for the purpose of monitoring the whole garage area.

Pag. 88



So in the system there are no digital memories to collect and analyse in case of need.

Such system, fully in compliance with the applicable rules, according to DIGIFEMA opinion, would

need to be reviewed, as no post-incident video analyses (which could have provided important

information for the event reconstruction) are possible.

During the inspections on board, the display monitors and the video matrix placed in the “saletta

nautica” (navigation room) in the navigation bridge were found in the following conditions:

PHOTO 16 VIDEO SYSTEM IN THE NAVIGATION ROOM

The video matrix was found instead in the following conditions:

Pag. 89



PHOTO 17 VIDEO MATRIX OF THE VIDEO SURVEILLANCE SYSTEM

namely completely disconnected from the system, probably because removed by other experts

during previous inspections when searching for evidences.

Later, during another inspection on the sister-ship Dimonios, it was found out that such system was

integrated with a digital system, namely the analogue images are converted into a digital format and

sent to a computer where they are displayed and analysed.

Pag. 90



FIGURE 25 M/V DIMONIOS VIDEO SURVEILLANCE SYSTEM

In the following picture the digitalization station connected to the video matrix is represented.

PHOTO 18 M/V DIMONIOS DIGITALIZATION STATION

Pag. 91



In the following picture, it is possible to see the station for displaying and analysing images, a station

which is additional to the two analogue monitors and is located as well in the “saletta nautica” in the

navigation bridge.

PHOTO 19 M/V DIMONIOS DISPLAY STATION

The presence of such a system on the Norman Atlantic could have provided useful images

for the event analysis, it could have also enabled a more immediate contextualisation of what

was taking place on the decks before the fire broke out.

Pag. 92



4.4 The situation of the rescue equipment

The M/V NORMAN ATLANTIC was equipped with the following survival craft:

- - N. 2 Lifeboats (cap. 150 pax)

- - N. 1 Fast Rescue Boat + N. 1 M.O.R.

- - N. 1 Rescue Boat

- - N. 8 life rafts (n. 2 for 25 pax and n. 6 for 101 pax)

- - n. 24 lifebuoys

- - N. 2 MES mini-chute Viking (one for each side) with raft for 101 pax

Individual survival equipment:

- n. 1082 adult lifejackets

- 3+3 (watchkeeping staff)

- 82 infant lifejackets

- 114 children lifejackets

- 44 lifejackets for overweight people

The above equipment is in line with the documentation approved and regulation in force.

Situation

FIGURE 26 GRAPHIC REPRESENTATION OF THE SITUATION OF THE RESCUE MEANS

Pag. 93



Starboard: All evacuation means and safety equipment on this side were unusable

Portside: Captain of Norman Atlantic reported that the rafts were launched into the sea directly by

passengers without a specific order, although, as it emerges from the radio communications, the

Captain was probably aware of what was going on, as he was periodically informed on the situation

of rafts by the crew on the spot.

The chute was unusable because obstructed by two people who had remained trapped, as the

related raft, necessary for the evacuation, was missing. In addition it was also damaged by the

adverse weather conditions and by flames after some hours of rescue operations.

4.4.1 Efficiency of lifeboats

Only the lifeboat on the portside was usable, although, also in this case, it seems it was launched

into the sea without a specific order of the Captain. However, the radio communications show that

he was informed of latest developments with regard to this lifeboat.

4.4.2 Mini chute – critical aspects

The second engineer, within the context of the communications made before, at 04.04 (VDR),

provided the following additional information on the MES, with regard to the launch of the lifeboat :”

we have two rafts at sea; the MES here is unusable, the pipe broke and people cannot jump; Captain,

can you hear me?” Captain: “yes, understood”.

At 04.06 (VDR), the 2nd engineer told the navigation bridge: ”the MES here is blocked, we have

two open rafts in water, but the MES tunnel is blocked, … .one raft is adrift and we are losing another

one”. Navigation bridge: ” lifeboat free, MES blocked”.

The staff in charge of launching the MES at sea, the one placed on the portside of the ship,

included:

• 1° operator (queue leader) boatswain-;

• operator on the liferaft- engine boy .

The MES on board was a particular evacuation system, made of a vertical slipway connected to a

raft (raft with slipway) for 101 persons.

The MES used in this case was the one placed on the portside, as the one placed on the starboard

side, could not be used because of the flames.

In case of evacuation, the people on board should get out through the slipway and reach the raft;

later, other rescue rafts were connected to the slipway raft so that people could move from a raft to

another, with the help of the safety crew (on each raft there was a queue leader and an operator).

The system is designed to enable the evacuation of all those, who are on board and cannot be

evacuated through the lifeboats.

Pag. 94



The specific instructions for preparing the MES, as described in the training manual for using the

rescue means, include in particular:

Preparing the mini-slipway –operators: slipway queue leader & operator at raft 1

The queue leader and the operator at raft 1 shall, in line with the modalities indicated on the manual,

open the chute/slipway frame covering, launch the mini-slipway, connect the life raft under the ship

side and open the plastic bag, where the following items are included:

a measure belt, 2 warning horns (to be used by the raft operator and queue leader on the

chute/slipway) harness and rope to lower people to be evacuated through the chute.

Preparation of the chute-raft – operator: operator of raft 1

-The operator on raft 1 lowers the chute with the warning horn;

-connects the belt with the rack on the chute;

- when the belt is fixed and the mooring rope checked, blows twice in the warning horn to inform the

chute is ready.

People can now jump down.

Evacuation – operators: chute queue leader and raft 1 operator

-The evacuees go down the chute, by following the queue leader’s instructions. An audible signal

informs that a person is on the upper part of the chute.

When the signal stops, the following person can enter the chute. The queue leader shall count the

number of evacuees, by using the counter under the stool;

-the raft operator “receives” the evacuees at the chute exit and brings them to the raft until it is full;

-the chute queue leader warns with the horn when 100 evacuees have climbed down.

Instructions to passengers

The following instructions shall be given to passengers:

1. wear the lifejacket;

2. empty the pockets of keys and other sharp objects;

3. wear warm clothes;

4. remove high-heeled shoes;

5. put glasses on the pockets;

6. wear shoe-coverage.

Persons who cannot use the Chute

Very overweight persons shall be measured with the lifejacket on to prevent the chute from being

obstructed. A special measure belt, which is in the chute kit, (under the stool) shall be used. If the

belt can easily be wrapped under the body, in its broader point, the evacuee can enter the chute. If

the belt cannot be wrapped around the person, the evacuee shall use an alternative rescue means.

Pag. 95



Preparation of the additional raft (this operation shall be repeated for each raft)

The raft 2 operator, with the help of raft 1 operator, lowers the raft at sea and links it to raft 1,

according to the procedures described in detail in the manual.

Conclusion of the evacuation – operator: chute queue leader

1. The chute queue leader enters the chute section and pulls the rope through the chute access;

2. The chute queue leader goes down through the tube;

3. The chute queue leader (or raft 1 operator) cuts the chute ends.

Analysing the several declarations of the staff in charge of launching at sea the MES, as well as the

declarations of the other crew members involved, the following is noticed:

-the Second engineer states that, after leaving the engine room, following the chief engineer’s

recommendations, he took the VHF waterproof radio and a battery-powered torch and went to the

rescue means embarking station, where, according to the muster list, had to embark on the first raft

available in case of ship abandonment (according to the muster list, he had to embark, instead, on

the last raft together with the Captain and the chief mate). Arrived on deck 5, he saw many

passengers crowded in a disorganized way; he realized that, when the MES was activated, the

responsible staff was missing, so he stood there, close to it, waiting for the Captain’s orders. He also

states that, when he saw the lifeboat being prepared and passengers starting to climb on it, he

thought that it was ordered to abandon the ship, so he was waiting for the lifeboat to be completely

lowered at sea, so as to ensure a smooth launching of both means, before unfastening the MES

(actually the rescue means – MES and lifeboats - are placed, pursuant to the SOLAS provisions -

Regulations. 13.1.1 and 15. 4 Chapt. III- in such a way that they do not interfere each other when

launched at sea. The VDR communications sequence clearly shows that the MES deployment was

made at the same time of the lifeboat launching).

After this one was launched, the second engineer told the Captain that the MES had been prepared

and asked for the authorization to start the embarking operations. After having received the Captain’s

authorization, he started to move passengers down (jump down).

The VDR doesn’t show any authorization request by the second engineer, as well as any

confirmation by the Captain.

The second engineer informs also that, after the second passenger, several passengers jumped

down, without his authorization, and with the lifejacket on, in contrast with the launching procedure,

he says, which establishes that those, who jump down, shall not wear lifejacket and shoes (on the

contrary, as written in Chapt. 8, it was correct to wear safety belt and shoes, with the exception of

high-heeled shoes). The second engineer realized then, at the third launch, that one of the

passengers, who jumped down, remained trapped in the tunnel, so he decided to interrupt the

launching operations and informed the Captain of what happened, however without receiving any

indication in this regard. He kept on being close to the MES and prevented anyone from jumping

down.

The second engineer went down in water by using a rope ladder, placed abaft 10 meters far from

the MES, to help the two persons on the raft to get the other two persons trapped out, but an

Pag. 96



undertow wave pushed him away; he made a last attempt at reaching a small raft in the nearby, but

is was unsuccessful, so he remained at the mercy of waves, until the ship Genmar Angus, about 5

hours later, rescued him.

The mini-chute was therefore unusable, as it wasn’t prepared correctly, namely the related raft,

which was necessary for the evacuation, detached, furthermore the body of the rescue mean was

later (after few hours’ rescue) damaged by the adverse weather conditions and by flames. As a

consequence, two persons remained trapped therein, one of whom died.

Only thanks to an EH-101 helicopter of the Italian Navy and an air rescuer on board, the MES tube

was cut and, after many attempts, one of two persons trapped was rescued, the other one had

unfortunately already died.

With reference to the minimum requirements which the mini-chute shall comply with, the LSA-Code

establishes in particular that:

…..A marine evacuation system shall be:

.7 capable of providing a satisfactory means of evacuation in a sea state associated with a wind

of force 6 on the Beaufort scale ;

So the MES shall be designed to work in a condition where wind is up to 25 knots.

FIGURE 27 PART OF THE MES NORMAN ATLANTIC CERTIFICATION

Pag. 97



-------- EPIMETEO METAR messages ----

Station: Santa Maria di Leuca

Coordinates: MO: ICAO:LIBY LAT:39.82 LON:18.35

H:104m

Period: from 27/12/2014 to 29/12/2014 Frequency: half-

hourly

---------------- --- --- ------ ----- --- ---- ---- -----

Dta Tar Tru MSLP VIS Vdi Vmd Vmd2 Vmrf

---------------- --- --- ------ ----- --- ---- ---- -----

28/12/2014 03:00 12 9 1005 >10km SW 44,4 24 n.r.

28/12/2014 04:00 12 9 1004 >10km SW 53,7 29 75,9

28/12/2014 05:00 13 9 1003 >10km WSW 55,5 30 74

28/12/2014 06:00 13 11 1002 >10km WSW 53,7 29 n.r.

28/12/2014 07:00 13 11 1001 >10km WSW 57,4 31 79,6

28/12/2014 08:00 13 11 1001 8000 W 59,2 32 79,6

LEGEND

[Dta] The time indicated is referred to the Greenwich mean time (U.T.C.). Conversion

criteria :

U.T.C. time + 1 = Central European Mean

Time

U.T.C. time + 2 = Italian daylight saving

time

[Tar] Air temp. [°C]

[Tru] Dew point [°C]

[MSLP] MSLP [hPa]

[VIS] Visibility [Km]

[Vdi] Wind direction [Degrees] [360=North

0=Calm]

[Vmd] Wind Int.

[Km/h]

[Vmd2] Wind Int.

[Knots]

[Vmrf] Wind gust [Km/h]

Pag. 98



[Vmrf2] Wind gust [Knots]

[PW] Present time

n.r.= no gusts

FIGURE 28 EXTRACT FROM THE METAR OF S.MARIA DI LEUCA DATED 28/12/2014

As the weather data recorded on the VDR show values of around 50/60 Knots, while those recorded

by the surrounding weather stations (see above), the wind speed on the spot reached 79 Km/h.

Pag. 99



4.5 Fire propagation analysis

The fire intensity, the high temperatures reached and the long time of action have made the

identifications of fire causes and origin place very difficult, although, with the support of the objective

data obtained from the VDR and of the inspections on the spot, the fire propagation and its possible

origin could be reconstructed in a quite reliable way. For the purposes of the reconstruction, the

evidence gathered on the spot was analysed and simulations were made with the support/guidance

of the National Fire Service Department, based on mathematical models and specific software

(FDS).

4.5.1 Origin of fire and analysis of the causes

It has to be said that the analysis of a fire dynamic is based on the research of evidence from places

and/or objects, which, because of the high thermal stress and, sometimes, due to the many

interventions made immediately after the event, have been subject to severe alterations;

To investigate the fire causes, an analytical method is needed. Such method is basically based on

the knowledge of combustion mechanisms and uses a systematic and scientific approach when

being applied, it uses the so called “semiotics of fires“, namely a discipline which studies the marks

left by fire.

Once the point of origin is established, its possible causes are analysed.

In this specific case, the fire was unfortunately particularly destructive, with high temperatures for a

long time, as a consequence the marks left by the fire could not be easily analysed, so it was very

difficult to identify its point of origin and cause.

So, as established by the NFPA 921 (National Fire Prevention Association) ed. 2001 in par. 18.17,

in case the cause cannot be easily identified, the possible causes are analysed and the most likely

is selected.

The causes which, even in the most diverse situations, lead to a fire breakout are always grouped

in a series of well-known categories, which are listed here below:

a) abnormal functioning of gas-powered machineries,

b) cigarette butts,

c) use of flammable liquids,

d) use of open flames,

e) defect in n the electric system,

f) abnormal functioning of devices consuming electricity

So, also in the case analysed, the most reasonable method for identifying the origin of the fire, is to

examine each of the above mentioned categories.

Having said that, in view of the alterations, which places were subject to, from the beginning of the

fire and of its particularly destructive power, considered the temperatures generated, it was deemed

Pag. 100



appropriate to analyse the possible causes of the fire by progressive exclusion, until the

identification of the most likely, if not certain, cause.

a) Abnormal functioning of gas-powered machineries: no gas-powered machineries

have been found in the garage, even though the possibility that a non-authorized

passenger remained in the garage and used his own equipment for cooking and eating

purposes cannot be excluded. So, such category of causes cannot be excluded.

b) Cigarette butts: the real dangerousness, in terms of causing a fire, of a smoking

discarded cigarette butt, was examined, with particular reference to what has been said

in the Italian or foreign literature..

In the publication “Investigazione sulle cause d’incendio” (investigation on fire causes) published by

the Centro Studi ed Esperienze del Corpo Nazionale dei Vigili del fuoco (Centre for Studies and

Experiences of the national Fire-fighting Department) it is written that the temperature of

incandescent tobacco “is too low to cause the small portion of incandescent tobacco, in contact with

wood or paper or cotton, do something more serious than a simple scorching, like causing the

material to reach the ignition temperature”.

In addition to above, it is also stated: “A different evaluation is needed in case the cigarette butt ends

up in an upholstered piece of furniture (for example between the armrests and backrests, sufficiently

isolated, yet in the presence of a combustive agent): in such case (the cigarette) the isolation would

prevent heat dispersion, so that temperature can reach up to 480° C. However, in such a case, the

piece of furniture would need no less than an hour and a half to burn with open flames”.

The conclusions above are accepted by technical authorities in all countries, although, in absence

of other explanations, the cigarette butt is often empirically and easily identified as the origin of many

fire events, while it is not always the case.

Anyway, considered that any cigarette butt falling on the floor wouldn’t have found easily inflammable

material, it is possible to state that the possibility that a cigarette could have triggered the fire

can be excluded.

c) Use of flammable liquids: with reference to the presence of any inflammable liquids on

the scenario, such liquids can be only the ones contained in truck cisterns and tanks. No

other containers of inflammable liquids were found nor could they be manipulated. On

deck 4, stern side, there is a room for small repairs, but the presence of inflammable

liquids here is to be excluded. The observations above lead to state, with reasonable

certainty, that in this specific case, if a malicious act (spilling inflammable liquid) is

excluded, the possibility that the presence of inflammable liquid caused the fire is

to be ruled out.

d) Use of open flames: there is no evidence that in the garage, particularly in that

navigation phase, equipment or machineries requiring the use of open flames were used.

So, this category of causes is to be excluded.

e) Defect in n the electric system: through an electric system, regularly functioning,

electrical currents flow. Such currents are defined by the number, power and features of

loads. Such currents are defined operating currents and are the value which, when

planning the system, is used to choose electrical cables equipment. In particular,

Pag. 101



electrical cables shall be able to permanently withstand the operating currents without

enabling temperature to reach dangerous values for insulation materials.

When electricity runs through a conductor, due to the resistance encountered, heat is developed and

that leads to a temperature increase in the conductor; such temperature is included in the normal

range of values when the operating current doesn’t exceed the conductor capacity in conditions of

installation considered. So, it is always necessary to check that the operating current is either the

same or lower than the conductor capacity.

The electrical breakdowns which may arise in a system, regardless of their cause, are always

characterized by variations of the normal values of two fundamental electrical parameters, namely

current and voltage. So, in theory, all possible cases of variations (of these two values) may occur,

that is:

- overcurrent occurring in two particular breakdown situations: overload and short-circuit;

- overvoltage which can be transitional

- undersupply of current or voltage, which as extreme case, may lead to the out-of-service status.

In abnormal functioning situations, due to particular breakdown conditions, if protection devices

aren’t carefully designed, the system can potentially be a serious danger. The outbreak of fire, of

electrical origin, is basically the consequence of the development of heat and so of temperature

increase as a consequence of electrical current running through a circuit (Joule effect) or through air

following its ionization (electric arc).

The Joule effect causes a temperature increase in the conductor which is proportional to the square

of the current passing through it and to the circuit electrical resistance which increases proportional

to temperature. In presence of high currents in conductors, in electrical equipment or switchboards,

the quantity of heat generated may lead to a temperature increase, which, if exceeds the component

maximum permissible temperature, can:

- damage the insulating component up to cause a short-circuit;

- ignite the combustible material of the component or of the cable, if the ignition temperature is

exceeded;

- ignite the combustible materials in the nearby of cables or inside the equipment.

So the Joule effect is a consequence of: overcurrent (overload and short-circuit); earth fault currents;

localized resistance (poor contact).

In the ship garage there were an electric lighting system and a system of sockets for the supply of

refrigerated trucks, so as to prevent that autonomous cogeneration groups, with combustion engines,

were left on for refrigerating.

Pag. 102



Detail of the electrical switchboard Detail of the electrical switchboard

PHOTO 20 DETAIL OF THE ELECTRICAL SWITCHBOARD, REEFER SOCKETS

Each socket designed for the purpose mentioned was connected to an electrical switchboard. During

the second inspection, only one of the two switchboard control rooms could be visited, the second

room was indeed made inaccessible by the event. The electrical switchboards in the visited room

had no signs of damage the position of switches was not helpful for the investigation. Taking into

account the “closed” position of the switches at the main switchboard, the possibility that a

defect in the electric system may have caused the fire can be excluded.”.

f) Abnormal functioning of devices consuming electricity: in the garage, the only

devices consuming electricity are placed on trucks, which, for different needs (for ex.

refrigerators supply), shall be connected to a power supply.

PHOTO 21 DETAIL OF THE REFRIGERATOR

Pag. 103



In case of malfunctioning of even just one of the devices (consuming electricity), or of overload

current or of short-circuit, the switches in the switchboards would have moved, however, as said

before, some of these were not checked, as the second room was inaccessible.

In addition, a fire can often be triggered by surface pollution and tracking. Each environment is indeed

subject to pollution (particles, fine dust, etc.), these substances deposit even inside electrical

equipment and, together with humidity in the atmosphere, may generate a conductor pathway on

the surface of insulating components. In such cases, a small current may arise and alter the material

insulating properties up to the tracking and to the generation of an electric arc (“tracking” or “track”).

The phenomenon of tracking involves the plastic materials used for the insulation of electrical

equipment.

Such event is more likely to happen, if materials are subject to natural ageing and are placed in wet

environments; in this specific case, as the watchkeeping seaman of the “Norman Atlantic” said during

the interview, the truck, from which smoke was coming out, with the engine on, was outdated :

“Arrived in the second one, I realized there was a light green truck, I’d say a quite outdated model,

precisely at the fifth pillar with the engine, I guess the one for refrigerating, in operation. The engine

was on and produced excessive and clearly visible smoke, on the truck there was a white writing

“FISH”, I didn’t see any connected sockets around it. I informed the navigation bridge of it, precisely

the second officer. Anyway it was the first time I saw a refrigerator of this kind” .

In any case, the malfunctioning of even one of the devices consuming electricity (ex. in case of

overheating), could have provided the truck with enough heat to trigger the fire. So, this typology

of cause is to be considered highly probable.

The analysis made shows great uncertainty around the fire origin and cause (points a, e, f) which is

also due to great destruction caused by the fire and high temperatures.

The missing or, anyway, non-effective extinguishing action has caused all the combustible materials

on deck 4 to be affected by the fire, has enabled the propagation of fire to the deck below and all the

decks above, as a consequence the temperatures reached were very high and so they remained for

a long time.

Having said the above, although the possible fire causes were analysed, although we reasoned by

exclusion and among the possible causes the following ones have been identified:

abnormal functioning of gas-powered machineries;

defect in n the electric system;

abnormal functioning of devices consuming electricity;

each cause can be hardly investigated and, in such conditions, also the semiotics of fire, isn’t helpful

in determining the point of origin.

So the study moved on with a different method, aimed at analysing the event which occurred,

assuming a potential ignition and analysing its evolution. Lastly the criticalities encountered in

managing the emergency were analysed and possible plant/management solutions to mitigate the

fire effects were identified.

Pag. 104



FIGURE 29 STEPS OF THE STUDY

Method of study for analysing the fire

The study was further extended and enriched with engineering elaborations of fluid dynamics made

with the use of computational mathematical models. These studies were performed by the engineers

appointed by the National Fire Brigade Corp. The results of such studies are available in the annex

(Annex 17) to this report.

ANALYSIS OF THE EVOLUTION AND COURSE OF THE PLUME OF SMOKE SUBJECT TO THE

TRANSVERSAL ACTION OF WIND

In general, in case of fire, wind plays a fundamental role, not only in the fire development, but also

in its propagation. In this specific case, the weather conditions, in particular wind, as well as the

speed of the ship, were considerable and cannot be ignored. Such parameters have certainly played

a relevant role both for the smoke detectors and in the first phases of the fire and in its propagation.

So in the preliminary analysis of the evolution and course of the plume of smokes subject to the

transversal action of wind, the garage is considered particularly important, as the fire developed here

(deck 4) and in this room there are wide lateral windows and a whole side, stern side, is completely

open, without doors or windows.

1° step

• Analysis of the evolution and course of the plume of smoke subject to the transversal action of wind

2° step

• Study of the evolution of a fire in a truck, in absence of estinguishing attempts

3° step

• Analysis of the fire evolution and of its propagation from the first truck to the others

4° step

• Analysis of the consistency of the times described above with the times inferred from the events and the evidence gathered

5° step• Analysis of the criticalities encountered when managing the emergency

6° step

• Identification of possible plant/management solutions to mitigate the fire effects

Pag. 105



FIGURE 30 STARBOARD SIDE OF M/V NORMAN ATLANTIC

Number of openings per shipside: 20 Size for each single opening 1,9 x h=3,185 m Opening total surface per shipside: 121 m2

FIGURE 31 SIZE OF WINDOWS ON DECK 4 NORMAN ATLANTIC

Pag. 106



The high relative speed of wind and its direction have certainly influenced the plume course and the

layering of smokes. Because of these factors, the fire development and evolution was certainly

different from the ones in a stationary state.

Due to the action of wind, the plume of smoke of the flame are lowered, following the wind direction.

In such condition, smokes and flames are dragged outside. These conditions may also influence the

functioning of smoke and heat detectors, which are placed on the ceiling.

FIGURE 32 EFFECT OF WIND ON THE PLUME

FIGURE 33 WIND INSIDE THE GARAGE

Pag. 107



Ventilation schemes

What is outlined above, was investigated in detail and analysed with the help of mathematical models

of fluid dynamics.

The simulation was conducted assuming, with the input data here below, the start of a fire on deck

4 frame 156 where, the seaman and the watchkeeping second mate (04:00 – 08:00) of the “Norman

Atlantic” noticed the presence of smoke.

INTERVIEW WITH, Watchkeeping Seaman (04:00 – 08:00) OF THE SHIP “NORMAN ATLANTIC”

…arrived in the second one, I realized there was a light green truck, I’d say a quite outdated model, precisely at the fifth pillar with the engine, I guess the one for refrigerating, in operation. The engine was on and produced excessive and clearly visible smoke, on the truck there was a white writing “FISH”, I didn’t see any connected sockets around it. I informed the navigation bridge of it, precisely the second officer. Anyway it was the first time I saw a refrigerator of this kind… INTERVIEW WITH THE WATCHKEEPING SECOND MATE OF THE “NORMAN ATLANTIC” (04:00 – 08:00)

…there was a pre-alarm before 5 a.m. I immediately sent the seaman to check, he made an inspection and told me that on deck 4 frame 156, there was a heavy goods vehicle (like a refrigerated truck), whose refrigerator engine turned on probably for a decrease in the load temperature ….

FIGURE 34 INTERVIEWS EXTRACT

Pag. 108



Volume = 18,000 mc

Windows opening = 242 sq. m.

Stern opening = 153 sq. m.

H = 6 m

Length = 155 m

Width = 26 m

Navigation direction = SE about 304

Wind direction = SSO about 201

Wind speed = 43 N

Relative wind speed recorded by the ship = 30 Knts

External T= 0° C

The start of the fire considered in the simulations was an anomaly in the cogeneration system serving

the refrigerated truck, placed in the front upper part of the truck.

In particular, two fire curves in the refrigerator were considered. One represents the fire with a slow

growth rate, as described by the eurocode, fire part, and one corresponding to the curve of heat

release of a standard refrigerator. More details are available in the annex to this report.

As written in the introduction to this paragraph, in this step of the study, the focus was on the analysis

of the initial course of smokes and the related activation status of detectors.

So, some simulations were made with the software FDS (Fire Dynamic Simulator), the results of

such simulations are grouped in these diagrams. The complete elaborations can be found in the

annex.

Pag. 109



FIGURE 35 FREEZE-FRAME FDS

It shall be highlighted that, although in the simulation the smoke produced by the refrigerator

activates the smoke detector immediately above, it shall not be excluded that, under particular

conditions, the smoke and heat flows, instead of activating the detectors immediately placed above,

activate the farthest ones, according to the wind direction.

4.5.2 Study of the fire evolution, in a truck, in absence of extinguishing attempts.

The interviews made with the ship crew members, who have intervened in the first phase of the

event, until the general emergency, proved that, following the sighting of some smoke from deck 4

-1

0

1

60 90 120 150 180 210 240 270 300 330 360

Sm

ok

e D

etec

tor

act

iva

tio

n

time [s]

Comparison between the two simulations

with regard to the Smoke Detector

activation speed

status SD up status SD 3mstatus SD 6m status SD upstatus SD 3m status SD 6m

-1

0

1

660 780 900 1020 1140 1260 1380 1500 1620

Hea

t D

etec

tor

act

iva

tio

n

time [s]

Comparison between the two simulations

with regard to the Heat Detector

activation speed

Frigo HD UP Frigo HD 3m

Frigo HD 6m inc. lento HD UP

inc. lento HD 3m inc. lento HD 6m

Pag. 110



windows, a seaman was invited by the second mate to check the presence of fire on deck 4 frame

156. The seaman went to the spot “I entered deck 4 with some difficulties, as the trucks were placed

very close to the bulkhead and there was little space for the passageway. Once reached the safety

lane, I could easily pass only through the first two rows of parked vehicles, then the passageway

became narrower up to 20 cm till abaft”, where he noticed “an engine was running and was producing

an excessive and clearly visible smoke”. He later informed of it the second mate, but no measure

was taken.

The second mate also said “after about 20 minutes, a new pre-alarm went on and then followed a

Fire Alarm. At this point, the Captain, who, in the meanwhile, had arrived there, ordered me to send

the crew call and ordered the Chief Mate to check the situation, by adding in this regard that the

situation could not be controlled by the fire-fighting team”.

Although the indicated times cannot be considered as certain, the information provided above may

help estimate the time elapsed between the activation of the first alarm and the FireAlarm, when,

according to what was declared, smoke and flames were coming out of the lateral windows “The

Captain went to the wing on the starboard side to see the flames”.

The time elapsed, in minutes, will therefore be the sum of:

ttotal = t0 + t1 + t2 + t3 = 30 m

where:

t0 = 0 m Time elapsed from the first alarm to the communication to the seaman

t1= 5 m Time needed by the seaman to reach deck 4 frame 156, after receiving the

communication

t2= 5 m Time needed by the seaman to inform the second mate of what he saw

t3= 20 m Time elapsed from the previous communication to the FireAlarm

Considering the involvement of a single refrigerated truck in the fire, the estimated times above can

help us determine the heating powers at stake, according to time.

The analysis of the fire evolution and so of the RHR will indeed enable to estimate the speed of fire

propagation, as well as to determine the heat power and the related thermal flow generated.

To this end, it shall be noticed that the best way to represent a fire is the one based on the Heat

Release Rate (HRR) or heat release curve, which measure the quantity of energy provided in a heat

flow, in the context of a fire, by a specific fuel.

Under the point of view of physics, the HRR is a power, it represents the energy rate per time unit,

is measured in Joule per second, namely in Watt, or more frequently in kW (1000 W).

The Heat Release Rate, unlike the traditional concept of fire load, enables to better identify the

dangerousness of an ignited material. Indeed, while the fire load represents the potential energy

which may be released by the material, the HRR represents the energy actually generated (the area

under the fire curve) and the speed with which it is produced over time and provides also important

Pag. 111



information on the power peak which the material may generate. So, if two materials develop the

same quantity of energy (same area under the fire curve) but express the power peak in different

times, the material expressing the peak before is the most dangerous.

FIGURE 36 TYPICAL TREND OF A HRR CURVE

The HRR is influenced by the fuel chemical and physical characteristics: mass/surface ratio, position,

geometry, deposit modality etc..

FIGURE 37 DIAGRAM FOR THE FIRE GROWTH SPEED

The fire growth speed depends on the ignition process, on the propagation of flames which define

its perimeter and on the combustion rate. In case of fires involving furniture, objects or diverse goods,

the phenomenon cannot be described with simple formulas. Anyway, any object involved in the

combustion has its own growth rate. Customarily, such time has been identified as the one needed

to obtain a peak in the heat release rate equal to 1MW. Several tests, on different scales have

enabled the compilation of tables with materials and objects with this value. It was also found that

the heat release rate follows approximately a law, which is proportional to the square of time:

where is a constant associated with the object. The quadratic relation turned out to be helpful for

a first classification of the fire typology and was adopted by NFPA 72B and NFPA 92B to standardize

fires in relation to detection systems and to smoke management systems.

2tQ

Pag. 112



The classification adopted establishes:

Slow growth t1=600 s

Medium growth t1=300 s

Fast growth t1=150 s

Super-fast growth t1= 75 s

When the HRR increases, both temperature and temperature growth rate increase, so the fire

development is boosted. The increase of the HRR causes a reduction of oxygen concentration and

an increase of gas products, in particular of the particles generated by the incomplete combustion.

In the specific case of the event which occurred on the M/V Norman Atlantic, a mathematical

modelling was made to reconstruct the evolution of a fire in truck, without any fire extinguishing

attempt and based on the above mentioned data.

In particular, in this phase the ignition propagation was analysed, assuming a fire was smouldering

in the refrigeration system located in the front part of a truck on deck 4 frame 156. The evolution of

the time/temperature curve was studied.

Also in this case, for the refrigerator, two fire curves were considered in the simulation.

The curve growth time analysis will help estimate the heat flow released by the fire in the truck,

during the time elapsed before the Fire Alarm communication and so before any fixed extinguishing

system could be activated.

FIGURE 38 FDS EXTRACT

Pag. 113



The analysis of results shows that the fire curve of a standard refrigerator - being the fire

development even slower than the one of a fire with slow growth rate, as established in the Fire

Eurocode - implies only a delay in the fire development.

In the simulation we noticed that, once the truck is ignited, the fire reached such heat release and

temperature levels that any intervention of the fire-fighting teams was useless and that there is no

more point in talking of safety for passengers, as the only issues to be evaluated at this point are –

beside the importance of early detection and efficiency of Drencher system - structural resistance,

compartmentalization capacity and smoke exhausting.

4.5.3 Analysis of the fire evolution and of the propagation from the first truck to the other vehicles.

In this phase of the study, particular attention has been paid to fire propagation, from the first truck

it extended to the trucks nearby and later involved the whole deck 4 and the rest of the ship.

The heat transfer mechanism is very important in the fire investigation, through this mechanism the

fire propagates indeed, from its point of origin to the other fuel sources.

Heat can be transferred through three processes:

- conduction, occurring through the transmission of molecular vibrations, mainly among solid

objects by direct contact. The transfer rate depends on factors such as the material thermal

conductivity and the temperature difference among the bordering objects;

- convection, where heat is transferred by the movement of fluids (only fluid materials). Warm

gases rise and carry heat towards the walls and the ceiling. It is one of the primary mechanisms

of fire propagation;

0

5

10

15

20

0 200 400 600 800

RH

R [

MW

]

time[s]

innesco da curva di incendio con

sviluppo lento

0

20

40

60

0 300 600 900 1200 1500 1800

Tem

per

atu

re [

°C]

time [s]

Temperature variation in proximity of

detectors

inc. lento HD up inc. lento HD 3m

inc. lento HD 6m Frigo HD up

Frigo HD 3m Frigo HD 6m

Pag. 114



- radiation, which is the transfer of heat by means of electromagnetic waves from an object to

another. Any object that is warmer than absolute zero will emit heat radiation. Radiation sustains

combustion, as part of the energy released by radiation “sees” the fuel and contributes to its

pyrolysis.

In the following chart the effects of thermal radiation are listed with some reference values:

Thermal radiation (kW/ m2)

Corresponding effect

1-1,5 Solar radiation

1,4 Safety limit for dressed persons exposed to it for a long time

5 Damage to operators wearing protection clothes exposed to it for a long time

9,5 Pain which can be tolerated by persons only for few seconds

12,5 Damage to or melting of plastic components

25 Ignition without pilot light of wooden elements

26 Fire ignition of flammable materials

40 Damage to steel structures

60 Damage to structures made of concrete

TABLE 4 THERMAL RADIATION (KW/ M2) (FROM AN INTRODUCTION TO FIRE DYNAMICS – DRYSDALE)

The heat transfer normally needed to ignite solids is around 10 kW/m2 corresponding to a layer of

warm smokes at the temperature of about 400˚C. The flashover start, namely the start of the

generalized fire occurs when the layer of warm gases radiates at about 20 kW/m2 (~ 600˚C).

During the many fire development steps, heat transfer occurs with the values indicated in the

following chart:

Fire step Thermal radiation (kW/m2)

Ignition 10

Flashover 20–40

Fully developed fire 50

Serious fire 100

The evolution of a fire, as already described before, can be grouped in 5 steps:

- ignition

- growth

- flashover

- fully developed fire

Pag. 115



- cooling.

The temperature variation caused by a fire in a confined space has a trend over time like the one

represented in the following figure, where the 5 steps described above are also represented:

FIGURE 39 FIRE STEPS

In the context of a fire in a confined space, even when there are no flames, the layer of warm gases

generates heat radiations in the compartment volume. This leads to a progressive temperature

increase of the objects in the compartment and when the layer reaches the temperature of about

600˚C, it generates approximately 20 kW/m2. With these temperatures, a simultaneous ignition

phenomenon occurs, that is the flashover (or generalized fire). The flashover is a phase of transition

from a fire involving some isolated combustible objects to a fire involving all the possible combustible

materials in a specific compartment. The flashover represents also the transition from a fuel-

controlled fire to a ventilation-controlled fire.

Indeed, the quantity of materials burning strongly increases, as a consequence also the production

of smoke and warm gases rises. As the ventilation of rooms is ensured by the openings to the outside

available in that moment (ventilation factor), the area available for letting fresh air entering from

outside decreases, because the openings are more obstructed by the smoke flowing outside. In this

way the amount of fresh air available for the combustion decreases and unburned pyrolysis gases

leave the compartment together with smokes, when they are close to the openings, they find enough

oxygen to burn and generate the usual flames coming out of windows, as it normally happens when

the fire is in the generalized or postflashover step).

The extension of flames depends on the presence of a ceiling, according to the fire diameter, as it is

shown in the following diagram.

Pag. 116



FIGURE 40 EXTENSION OF FLAMES UNDER A CEILING

Fire propagation is possible if the thermal flow of an object ignites other materials and sustains

therefore the natural fire evolution. The temperature of a material hit by a thermal flow rises and once

the self-ignition temperature is reached, the oxidation reaction is triggered and heat is released. The

energy needed for the ignition varies according to several parameters, depending on the kind of fuel

and in particular:

- for solid fuels, on the size and humidity contained - for liquid fuels, on the exchange surface and on volatility - for gas fuels, on concentration The time needed to ignite a material subject to a variable thermal flow depends on the so called critical heat flux (CHF), which is specific for each material and based on which materials can be grouped as follows:

Materials CHF [kW/m2]

Easily flammable 10

Conventional 20

Hardly flammable 40

In literature there are reports which enable to calculate the thermal power needed for the ignition of

an object placed at an R distance from the source; three different cases can be identified according

to the kind of material involved.

In particular, regulation NFPA 555 “Guide on methods for evaluating potential for room flashover “

provides some expressions to calculate the minimum RHR values able to ignite materials:

1) easily flammable materials:

Pag. 117



RHRMIN = 30 * 10[(D + 0,08) / 0,89]

These materials (curtains, carpets, newspapers) burn when hit by thermal flows ≈ 10 kW/m2;

2) conventional materials, normally resistant to ignition:

RHRMIN = 30 * [(D + 0,05) / 0,019]

To this group belong materials with low thermal inertia which start burning when hit a thermal flow of

about 20 kW/m2 (value similar the flow on the floor in flashover conditions);

3) hardly flammable materials:

RHRMIN = 30 * [(D + 0,02) / 0,0092]

In this group there are wood and thermosetting plastics with thickness > 1, 2 cm. The fire threshold

is ≈ 40 kW/m2 where D is the distance from the source in metres.

So far the complex dynamics of a fire evolution has been described and it was highlighted that to

estimate the evolution dynamics, a primary role is played by the knowledge of both geometric factors

such as the room plan, ventilation surfaces, the fire load position and quantitative/qualitative factors

of the combustible materials in that room, as they can potentially be involved in the event.

In this specific case, almost all data necessary for analysing the propagation mechanism are

available, with the exception of the exact truck typology and of the related cargo. In the simulations,

such uncertainty was solved, by assuming a RHR curve of a medium-sized truck.

Another uncertain data, which has been well evaluated and estimated for the mathematical

modelling, was the “filling degree” of deck 4 and the distances among the parked vehicles inside the

garage.

So reference was made to the interview with the watchkeeping seaman of the “Norman Atlantic” who

said :”… I entered deck 4 with some difficulties, as the trucks were placed very close to the bulkhead

and there was little space for the passageway. Once reached the safety lane, I could easily pass

only through the first two rows of parked vehicles, then the passageway became narrower up to 20

cm till abaft”.

One of the factors which have definitely facilitated a faster fire propagation was the action of wind,

which, besides encouraging convective movements, moved and lowered the flame, which, instead

of moving upwards, hit directly the surrounding vehicles, by facilitating their ignition and accelerating

the propagation.

The effects resulting from the factors described above are proved by the deformations which can be

found on the ship .

Pag. 118



Evidence of the structure, almost intact, despite the heat due to the high fire load

Evidence of the major structure deformations caused by the heat, as a result of the high fire load and the wind direction

To assess what has been said above, two global simulations of the ship deck were made. One

without wind and the other one with wind.

Pag. 119



FIGURE 41 HEAT RELEASE CURVE WITHOUT WIND

FIGURE 42 HEAT RELEASE CURVE WITH WIND

The use of temperature slices (see annex) highlighted that wind has facilitated the fire propagation,

by constantly fuelling it.

In addition, as described more in detail in the annex, it shall be noted that, in absence of wind, the

flashover was reached, because of the lack of oxygen, in the following way:

0

1.000.000

2.000.000

3.000.000

4.000.000

5.000.000

0 200 400 600 800 1000 1200

the

rmal

po

we

r[kW

]

time [s]

0

1.000.000

2.000.000

3.000.000

4.000.000

5.000.000

0 200 400 600 800 1.000 1.200

the

rmal

po

we

r[kW

]

time [s]

Pag. 120



In this condition, the combustion with flames occurs only in the proximity of openings, where there

is oxygen.

In the simulation with wind, the post flash over configuration is instead the following

FIGURE 43 EXTRACT FDS (PRESENCE OF WIND)

The combustion with flame occurs also inside the ship.

The two simulations basically show that, once the first truck has been ignited, the temperature, heat

release and smoke production conditions are such that the only result is a great and devastating fire

with flames coming out the downwind openings.

The frames extracted from the simulations prove that the simulations are consistent with what was

observed by the first rescuers:

Pag. 121



PHOTO 22 STARBOARD VIEW OF THE NORMAN DURING THE RESCUE OPERATIONS

FIGURE 44 FDS EXTRACT (PRESENCE OF WIND)

Pag. 122



4.5.4 Analysis of the fire propagation through fds

In this report a significant extract is provided, the full study can be found in the annexes to this

document (Annex 17).

Analysis

Since wind caused the fire “behaviours” highlighted in the photographic

survey and explained in the report, the simulations were made both in

presence and absence of wind to show the related effects.

The first simulation was made to show the fire effect, once that a truck has

started burning in absence of wind. It was proved that, in absence of an

immediate and appropriate intervention, a fire which starts from a single

vehicle catastrophically develops in a greater fire which involves all the

vehicles in the garage. It shall be noticed that in this simulation the fire of

the first truck (already started, as under the chosen heat release curve) was

analysed, so the ignition step was not considered.

The second simulation is similar to the first one, but the presence of wind

is considered, as well as the related effects. This simulation showed that

the effect of wind was that of moving smokes and flames towards one side

of the ship, where they came out of windows, as some witnesses described.

The third and fourth simulation were made to investigate the intervention timing needed to prevent

the evolution represented in the first simulation.

In particular, in the first simulation the ignition assumed was the one resulting from a fire with a slow

growth rate, as described in the Eurocode, fire part, with a thermal peak of 1000kW. In this way, it

was proved how the precautionary approach, with reference to the evolution, suggested by the

Eurocode, fire part, may question the protection systems adopted and to be adopted in the ship.

In the third simulation, the assumed ignition was due to a refrigerator, as identified by the report

consultant. A conservative approach was chosen, in other words, in order not to choose a refrigerator

with an heat release rate such that the truck ignition may seem a bit of a stretch, it was decided to

simulate that the ignition originated from a fire in a standard refrigerator 0,55X0,65X1,20 which is

certainly smaller than the ones normally used in trucks.

Each simulation described in this report is provided with simplified calculations, code lines (duly

explained) and with the results obtained both as a screenshot of the main parts of the simulation

virtual representation and as diagrams.

In this report, besides the description of the FDS software, detailed information has been given on

how simulations were modelled, by motivating each choice, according to the different parameters.

Immagine simulazione 1

vista esterna

Pag. 123



4.5.5 Geometric modelling

When using the “Fire Dynamic Simulator”, geometric modelling is not only a

transposition of a real model in a model placed in a virtual space, represented

by quadrangular elements in the calculation MESH, as described in the

chapter “The FDS software”, it is also an a priori analysis influenced by

the sensitivity analysis through the calculation of the fire diameter,

the potentiality of the computer available and the number of threads

available

the choice of the fire scenario which is going to be modelled,

the quality and accuracy of the results which are to be reached,

the features of the model geometry.

any smoke and heat detector

An expert assessment of the influence and interaction, which such variables

may have, provides a good discretization of a real fire.

for the most subtle simulations, while the second one was used for test

simulations.

A thread, also named

execution thread, in IT, is

the subdivision of a

process in several sub-

processes, which are

executed simultaneously

by a single-core

processor elaboration

system (multithreading)

or multi-core processor.

Fire simulation in a multi-

storey building simulated

with FDS, by using a

Workstation HP z400

with 10GB RAM

processor XEON 3,06

GHZ of speed 4

dedicated threads. Total

2,3 million cells in 1

mesh 0,40 3 mesh 0,20

HRR peak 7MW 5 days

simulation.

Pag. 124



4.5.6 Geometric modelling of the ship and trucks

Ship modelling

The Norman Atlantic is a vessel owned by the company Visemar di Navigazione,

chartered by the Greek navigation company Anek Lines for connecting Italy to

Greece and vice versa.

In the ship there are several “decks” of which 6 are designed for vehicles and 2

for accommodations.

The ship is mainly made of metal, which, as widely known, is not involved in the

combustion, where it works as a casing. It shall be highlighted that, under the fire

point of view, the casing and openings geometry are strictly linked to ventilation

and flashover.

As the simulation concerns only deck 4, where the fire allegedly developed, this

area was modelled with particular attention.

The areas not included in deck 4 were discretized as single blocks

For deck 4 the geometry of the casing and openings was recreated.

FlashOver and Ventilation

factor

Pursuant to the regulation

NFPA 555, it is the fire step

when the temperature of

gases in the ceiling area

reaches approximately 600°C

and the heat flow on the floor

is equal to 20 kW/m2

Experimental studies prove

that when the fire reaches its

maximum development, its

propagation and progression

depend exclusively on the

ventilation factor, which in

turn depends on the casing

and opening geometry.

𝐹𝑣 =𝐴𝑤√ℎ𝑒𝑞

𝐴𝑡

Where

Aw is the total area of the

ventilation openings

At is the surface of the

compartment

heq the mean height of all

ventilation openings heq =∑Aihi

Aw

https://it.wikipedia.org/wiki/Anek_Lines

Pag. 125



Truck modelling

A truck is basically made of a trailer and a tractor. Its representation depends exclusively on the size

of cells used for the calculation. In this specific case, the minimum size of cells is of 0,30m. So an

orthogonal reference grid with such dimensions was used.

Sample truck

The FDS software associates a fire curve with an obstruction. If this parameter was to be considered,

the truck curve should have been broken up in several sub-curves, to the detriment of the simulation

time and without obtaining any improvement for the purpose of the study. To prevent this, a single

obstruction was used, defined SIMULATOR BOX, a transparent one which incorporates the truck

without losing graphic quality, which, although unrefined, is necessary to understand the fire

evolution.

The truck with refrigerator was also modelled.

Pag. 126



The vast majority of trucks with refrigerator have the refrigerator engine between the trailer and the

truck. To represent such model, the SIMULATOR BOX obstruction was divided in two parts and an

obstruction was placed in the middle, as shown in the following figure.

The refrigerator is represented by an obstruction whose size is 0,6X0,6*1,2

FIRE IN TRUCKS (visualization though smokeview)

on the right the fire without refrigerator and

below the fire with the first step in the refrigerator and second step in the truck

Inclusion of the truck on deck 4

The truck SIMULATOR BOXES were placed in such a way that the simulated distance between a

truck and the other was of 60 cm. We assumed indeed that corridors with a 60 cm width would

enable the passage of operators, in addition, to the benefit of the Mesh discretization, mesh cells of

60 cm can be used.

Pag. 127



Distribution of trucks on deck 4 of the ship

The most interesting area in the study of the fire is where it allegedly started. Position n. 156 where

the worker saw “(…) some smoke coming out (…)”.

Therefore, whenever possible and based on what has been said in the previous chapter, all the

calculation meshes in that area were intensified. Here below the meshes and their related

dimensions.

Pag. 128



Mesh distribution Simulation 1

The blue part represents the meshes, whose cell dimension is 0,60m while in the red part the cell dimension is 0,30m

Me

sh c

olo

ur

Ce

ll sid

e

Me

sh n

um

ber

0,30 14

0,60 4

0,60 1

1,20 1

2,40 4

As shown, the greater is the distance from the calculation area, the less thicker is the mesh. In

particular, the “pale-blue” mesh size is 2,40m. We are indeed only roughly interested in the fire

propagation in the upper part, while in the lower part they are necessary just to represent the ship

(blue and red meshes).

Mesh distribution Simulation 2

The greater complexity of the calculation, due to the simulation of air flows, lead to decrease the

mesh thickening in the area of greater interest.

Me

sh c

olo

ur

Me

sh s

ide

Me

sh n

um

ber

0,60 18

0,60 1

2,40 5

It shall be noted that the cell

dimensions were established

with full regard to the

POISSON solver based on

the FFTs ( Fast Fourier

transformation) according to

which the y and z mesh sides

shall be obtained from

2l3n5m as indicated in

chapter 6.3.1. of the FDS

user guide, and checking the

related alignment.

Pag. 129



Mesh distribution Simulation 3 and 4

Since the study mainly focused on the fire triggering the major fire and since the effects of air flows,

determined by the wind, significantly lengthens calculation times, for the simulations 3 and 4, a

smaller portion of the deck was considered.

At the beginning two test simulations were launched with the notebook

Me

sh c

olo

ur

Ce

ll sid

e

Me

sh n

um

ber

0,30 1

0,60 5

Later simulation 3 was launched with the computer at 24 threads with 24 meshes.

Me

sh c

olo

ur

Ce

ll sid

e

Me

sh n

um

ber

0,30 16

0,60 2

0,30 6

Pag. 130



Measurement devices in the simulation

The FDS software, besides analysing and visualizing through the smokeview the evolution

(reference to fire and flames), enables also the precise measurement of specific parameters, on

surfaces or volumes. The default measure is the total heat release of the simulated fire. The other

parameters shall be chosen by the user, according to his/her own study and calculation

requirements. Including such instruments causes indeed a calculation slow down.

The included measurement devices were :

temperature slice visualized only in smokeview

smokedetectors whose results can be read in a file excel

heatdetectors whose results can be read in a file excel

Temperature slices

They are planes, orthogonal to the axle, where temperature variation is

represented through a chromatic variation ranging from blue for the coolest

temperature to red for the hottest temperature, passing through the green and

yellow colours.

3 temperature measurement “slices” were used: one orthogonal to the axle Z at the height of 30cm

from the highest truck quota suitable to understand the temperature variation and the heat flow

course in the garage; one orthogonal to the axle y and one orthogonal to the axle x closed to the

alleged area of ignition, suitable to understand the temperature variation along the axle Z.

The smokedetectors get activated, according to some control functions which can be managed

through the FDS control lines, when smoke reaches a specific percentage obscuration value.

4 of these were included, starting with the truck which was allegedly ignited first until the window. It

is assumed that such distribution was similar to the real one. They were useful to understand how

wind may influence their functioning.

The heat detectors, which detect temperature, are placed in the same positions of smokedectors

and were useful to understand how temperature varies inside and outside over time.

It should be noted that the

chromatic variation is

related to the simulation.

Therefore different

simulations with different

maximum and minimum

temperature values

match the same colors.

Pag. 131



4.5.7 Comparative test of the Drencher pump made on board of the sister ship

On January 28, 2015, the investigation team made an inspection on board of the M/V DIMONIOS,

which belongs to the same class of the Norman Atlantic, to check the functioning, during navigation,

of the systems Autronica, Kongsberg and of the fire protection systems, with particular reference to

the Drencher pump, by simulating similar conditions to those occurred on board of the M/V Norman

Atlantic (fire in the garage and no supply from the MSB - main switch board).

The sequence of alarms activated was basically the same of the one on the Norman, in addition it

was proved that a power reduction in the Drencher system occurs when it is fuelled only when the

water – in emergency conditions - is supplied by the EFP.

Two photos proving the above are provided here below:

Position of

the truck

which was

allegedly

ignited first

Position of

the truck

which was

allegedly

ignited first

Smoke and heat detectors dist 3m






Smoke and heat detectors up

Smoke and heat detectors up

Pag. 132



PHOTO 23 M/V DIMONIOS DECK 3 - OPEN DRENCHER (4 AREAS)

PHOTO 24 M/V DIMONIOS DECK 3 - CLOSED DRENCHER

The test made highlights the ineffectiveness of the Drencher system, although it is in compliance

with the applicable rules, when the supply is of emergency typology, namely when water is provided

by the emergency fire pump, rather than by the dedicated Drencher pump

.

4.5.8 Checking the Drencher system on deck 4

The distribution of the drencher system (Annex 18) doesn’t really represent the actual situation,

namely the positions of heads shown in the drawing is not exactly the same as the one on board,

although, heads are distributed in such a way that each head covers, as required, an area of

Pag. 133



approximately 10 m2, and that the whole garage area is also globally covered: this is ensured, even

though the nozzle rows are placed as they are really on board, instead of as inferred from the graphic

elaborations.

During the unloading operations it was noticed that the drencher spray nozzles placed in the ramp

of deck 4 and on the rows close to frame 69 were not provided with the heads enabling the umbrella

spraying.

Considered the seriousness of the structural damage on deck 4, with considerable deformations,

and some broken pipes (which, as it was proved, was not connected to fire systems), the heads

probably fell down because of the fire, following thermal stress and the differential thermal dilatations

occurred.

Anyway, the possibility that they were not in their position since the beginning of the incident shall

not be excluded, as they were found neither intact nor in the form of debris. In any case, their

presence/absence is relevant for the purpose of the fire development dynamics, as the Drencher on

deck 4 was never activated.

Pag. 134



4.6 Electric system and black-out

4.6.1 General condition of the electric system on board

The electric system on board was severely damaged by fire (V. Par. 3).

Therefore, it can reasonably be assumed that the electric black-out was caused by this situation.

DIGIFEMA appointed a special consultant to analyse this matter, some of the following related

paragraphs are extracted by that report whose integral version can be found in Annex 19

4.6.2 Analysis of the electric black out and malfunctioning of the emergency generator

According to the interviews made with the ship crew members who managed the first phase of the

event, until the general alarm, after the sighting of smoke coming out from a deck 4 window, the

second mate invited a seaman to check whether a fire started on deck 4, frame 156. The seaman

went to indicated spot,

“I entered deck 4 with some difficulties, as the trucks were placed very close to the bulkhead and

there was little space for the passageway. Once reached the safety lane, I could easily pass only

through the first two rows of parked vehicles, then the passageway became narrower up to 20 cm

till abaft”, where he noticed “an engine was running and was producing an excessive and clearly

visible smoke”. He later informed the second mate of the above, although no action was taken.

The second mate also said “after about 20 minutes, a new pre-alarm went on and then a Fire Alarm

followed. At this point, the Captain, who, in the meanwhile, had arrived there, ordered me to send

the crew call and ordered the Chief Mate to check the situation, by adding in this regard that the

situation could not be controlled by the fire-fighting team”.

More information on the black-out can be inferred from the interviews made with the other crew

members.

The ship Captain said: “ …, I’d say that the blackout occurred approximately at 05.45. Then the chief

engineer arrived from the navigation bridge and I asked him explanations on the black out. He said

the situation was due to the excessive smoke in the engine, which caused a suffocation of the air

needed in the turbines. So I asked information on the Emergency Diesel Generator, as I realized

that the navigation bridge was exclusively supplied by batteries. Anyway, I shall add that I could hear

the generator engine working. He also said that the generator could not reach the utilities. In that

case it was also specified that the engine room was evacuated because of the excessive smoke.

Pag. 135



The person in charge of the generator was the Italian electrician. At this point the generator was

stopped after few minutes, by order of the Chief Engineer. Basically, approximately starting from

5.45 there were no more fixed extinguishing systems”.

So, based on the information given by the ship Captain, the black-out was caused by the excessive

smoke (produced by the ongoing combustion) which led to an air shortage (oxygen) and so turbines

couldn’t work properly.

In the interview with the Chief Engineer, when describing the measures taken to deal with the black-

out, further information is provided on the GDE (emergency electric generator) malfunctioning:

“…I went with the electrician, who was in the navigation bridge, to the GDE room. …. Where we

noticed that, although the generator was working, the was no supply to the network (“generator not

connected to the busbars”). Once checked that the parameters were in the normal ranges (frequency

60Hz, voltage 440V), we tried to manually “hook” it to the network, yet it disconnected immediately

after. At this point we tried to gradually exclude several sections of the system but without any

success. I believe the situation was due to the fact the whole network was of ground wire type. So I

went back to the bridge.

After many attempts, the electrician, who, in the meanwhile, went back to the electric emergency

generator together with another person, ..., managed to connect the generator with the lighting

system of the navigation bridge. I’d like to highlight that the black-out was just one, as, when pressure

was made, the concerned switch immediately disconnected”.

So, in his interview, the chief engineer said that, despite several attempts made on the electric

emergency generator (DGE) to fuel the network, it couldn’t power the load; even “manually” an

undefined “switch” immediately disconnected, when pressure was made.

Here below, starting with an analysis of the wiring diagrams of the ship systems, some assumptions

will be made to understand the causes of the non-intervention (or maybe of the “non-effective

intervention”) of “ordinary” and “emergency” diesel generators.

Pag. 136



4.6.3 Description and placement of auxiliary (AG) and emergency generators (EG).

The configuration of the system producing electricity in the ship includes several power stations:

o the Main Power Station (MPS) to ensure the services:

o operations in the port (loading and unloading operations);

o manoeuvring the vessel;

o operations during navigation.

During the manoeuvre, the generation of the two three-phase alternators of Shaft type (on the

driveshaft axis), moved by the turbines, which in turn move the bow thrusters, each with a power of

2250 kVA connected to the busbars of the general board, fuels the bow thruster (each alternator

fuels its own bow thruster).

In the port, during the loading and unloading operations and during navigation, the engine-generators

work, each of which is made up of a first Diesel engine, connected to an electrical generator, they

are named DG1, DG2 and DG3, each has a power of 2281 kVA, model 3516B by Caterpillar,

connected to the busbars of the general board.

All the generators are placed in the engine room.

The emergency power station (EPS), an autonomous source of electricity, which is

independent from the main one, designed to ensure the services:

of emergency and it get automatically activated, when voltage in the main switchboard is

missing (MS);

in the port (in stationary conditions).

The generation is ensured by an engine-generator made up of a first Diesel engine, connected to an

electric generator, which, in conditions of emergency, shall supply power to the so called non-

interruptible loads, power 462,5 kVA model 3408C by Caterpillar, – 1800 rpm turbocharged with

after-cooler, connected to the busbars of the emergency switchboard.

Pag. 137



This Diesel engine can start working, even when the main network cannot supply energy (black

start). A system of accumulators is also available to provide energy during the set-up time of the

emergency engine-generator. The system is made of two UPS (Uninterruptible Power Supply).

The emergency power station is placed on deck 7.

The omnibus busbars are divided in three sections connected by circuit breakers IS1, IS2, IS3, IS4,

which can be manually operated under load or remotely controlled by automation system.

The shaft alternators cannot work in parallel stable, coupled each other or with the engine-

generators. Only a transitional coupling with the engine-generators is allowed for the load transfer.

The engine-generators can work in parallel stable among each other.

The switchboard can be operated manually or automatically by the automation system.

To facilitate the operator’s actions and avoid wrong commands, a series of interlock and confirmation

switches have been integrated in the board functionality for the alternators and circuit breakers IS1,

IS2, IS3, IS4.

Lastly a selector “SB2”, unlocking locks, was included to overcome the interlocks implemented by

the circuit breakers IS1, IS2, IS3 and IS4.

The distribution, in low voltage with voltage 440 V - 60 Hz three-phase, with isolated neutral,

branches off from the MS of the main power station towards the relevant power loads and towards

the busbars of the emergency switchboard (ES) of the emergency power station, switch 110 input

and 910 output.

The sub-station for the transformation to 220 V - 60 Hz of “normal” loads and services is derived

from the MS busbars through two parallel circuits, switches 179 and 180 input.

The section with 220 V - 60 Hz of the ES is derived from the busbars of the emergency board through

two parallel circuits, switches 924 and 925 input. From the ES the supply line of the load board with

24 V - D.C. (Ship Services Battery Charging Board and Distribution, 24 V DC) also starts.

When voltage is missing on the MS and so also on the ES, with the emergency engine-generator

designed for the automatic set-up, the following automatic operations will take place:

1. opening of switch 910;

2. set-up of the emergency engine generator with signal by the voltage relay 27-901;

3. closing of switch 901, provided that the alternator is energized and has reached the

nominal rpm.

Pag. 138



FIGURE 45 SHIP POWER SUPPLY DIAGRAM WITH FOCUS ON THE MS AND ES

The following figure illustrates the power supply diagram with focus on the MS and ES.

The opening of switch 910 enables therefore the disconnection of emergency electric circuits from

the rest of the system which supplies ordinary electric circuits. The closing of switch

901 - which shall take place automatically, once the correct number of rpm of the emergency electric

generator has been reached - enables the sole supply of the emergency utilities.

In the following diagram, all the emergency utilities can be identified:

Pag. 139



FIGURE 46 : UTILITIES POWERED BY THE ES

Pag. 140



Here below the functions and loads powered by the ES are listed:

901: is the switch which, if closed, enables the emergency electric generator to serve the

emergency utilities;

910 is the isolation switch, if it is closed with the emergency electric generator not working,

the ES is powered by the

MS; if it is opened, the emergency electric generator shall work to supply the ES;

Note: It is possible to operate also with both switches, 901 and 910, closed. In such case, one of the

“ordinary” Diesel Generators may work in parallel with the emergency Diesel Generator, which can

operate in parallel with one generator among DG1, DG2 and DG3.

911 supplies pump n. 1 of the navigation system “PS Steering gear” (see Figure 3)

912 supplies pump n. 2 of the navigation system “ST.DB Steering gear” (see Figure 3)

FIGURE 47: POWER SUPPLY OF THE EMERGENCY PUMPS OF THE “STEERING GEAR”

913: supplies the emergency power distribution panel named “EM.CY POWER DISTRIB.

PANEL FZ/QF913”;

914: supplies the system named “WATERTIGHT DOOR PLANT D.P. FZ/QF91”;

915 and 916 are voltage probes for the monitoring of the voltage level on the MS busbars,

one placed on the left section and the other on the right section;

Pag. 141



FIGURE 48 POWER SUPPLY OF THE EMERGENCY UTILITIES 917 AND 918

FIGURE 49 EMERGENCY WINCH

917 supplies the “ACCOMODATION SPRINKLER PLANT”, which is also powered by the

supply of the MS through switch 123 (see Figure 4);

918 supplies the “EMERGENCY FIRE PUMP” (see Figure 4);

• 919 supplies the BILGE EMERGENCY PUMP;

• 920 supplies the pump for the “ELIPORT FOAM PLANT S.W. PUMO”;

• 921 supplies the DC battery charger for the emergency set-up;

• 922 supplies the emergency section at 24 V DC;

• 924 and 925 supply the single-phase emergency section at 220 V;

• 926, 927, 928 and 929 supply, each, the engines of: an emergency winch for a fast

rescue of the boat, a winch for the normal rescue of the boat and two engines for life boats

winches;

• 932 supplies the engine of fans in the battery room;

• 933 supplies the fan engine in the emergency electric generator room;

• 934 supplies the “GMDSS STATION (Global Maritime Distress and Safety System)”

which is also powered by the MS through switch 120, besides having a backup battery

(see Figure 6);

Pag. 142



FIGURE 50: POWER SUPPLY OF THE GMDSS STATION

• 935 supplies the sprinkler system in the engine room.

At the time of the fire, the Shaft Alternators were not activated and the groups DG1 and DG3 worked

in parallel.

This was also confirmed by the Chief Engineer: “…the power supply was set on the main generators,

nr. 1 and nr. 3, because the Captain warned me about the adverse weather conditions”.

4.6.4 Description of the mode of operation and automation of DG1, DG2, DG3 and of the emergency generator.

In the diagram on paper SH.3 of Dis. N. 216-2401, the mode of operation of SB, named

“SUPERAMENTO O SORPASSO BLOCCHI” (unlocking locks).

The SB pre-setter is placed on the MS and has two operating positions: the position “BLOCCHI

INCLUSI”, enabling the automatic set-up of the MS following the lack of voltage in the MS, as

described in the previous paragraph; the position “BLOCCHI ESCLUSI”, enabling the “Feed Back”

supply of the MS by the ES (the ordinary power supply is powered by the emergency power supply).

In this configuration the parallel switch from the DGE (emergency generator) to one of the main DGs

is possible – excluding the generators AA – in the following way:

The selector 43-901 shall be set to “MANUALE” while the selector PP (PP is on the MS) to

“MISURA SBARRE”;

One of the main DGs shall be set in sync with the DGE. When they are in sync, the related

DG switch shall be closed (102, 103 or 104);

Pag. 143



After the load has been transferred from the DGE to the selected DG, SB shall be re-set to

“BLOCCHI INSERITI” for the normal operation.

In addition, it shall be noted that the SB locks unlocking, on the MS, necessary to ensure the parallel

functioning of the DGE with one of the ordinary DGs, is possible only if pre-setter “29”, which is

instead on the ES, is in the “INSERITO” (inserted) position. In case of breakdown or in case it is not

possible to enter the SPC room, selector 29 shall be set to the position “SEZIONATO” (uncoupled).

This excludes the possibility that the SB function of locks unlocking may be activated.

UNCOUPLING the connections between the MS and ES. So, only in case of breakdown – 29 in

position SEZIONATO – it is possible to manually (in MANUALE) start the DGE and operate the

emergency services of the MS.

The evidence available didn’t help understand if the manual takeover occurred with selector 29 in

the “SEZIONATO” position: only this function ensures the opening of switch 910 for the ordinary

power supply uncoupling and the manual closing of switch 901 for enabling the DGE to serve the

ES.

The Second Engineer said indeed: “…When we arrived (to the DGE, editor’s note), although much

smoke was around us, we entered and the unit was working, but was connected. I tried to press

button 901 to have the generator hooked, but it disconnected”.

In the ES 2 there are flag relays for the overload report of the DGE and for reporting the return of

active power.

The continuous measurement of insulation on the busbars 440V/60Hz and 220V/60 Hz, through

tools and related alarm threshold mounted on each busbar system, are also part of the alarm system.

An output contact of the 2 tools is also reported on the MS.

Pag. 144



4.6.5 Hypothesis on the loss of power supply for the services and on the non-intervention of emergency devices.

In this chapter, starting with an analysis of the electric diagrams and of the functioning and

automation modes of operation, we will put forward some hypotheses on the loss of power supply

for the services and on the non-intervention of emergency devices. With regard to the loss of supply

for the services, according to the reconstructed sequence of events, based on the evidence, a fire

pre-alarm in the Autronica was recorded on deck 4 at about 05.15 and, after about 30 minutes,

around 05.45, there was a black out.

The Chief Engineer informed the Captain on the navigation bridge about the black out and attributed

the situation to the excessive smoke in the engine: this has allegedly caused “a suffocation of the air

needed by the engines”. In particular, the Chief Engineer said:

“…When I arrived, an engine was about to stop, so told me the Mechanical Worker, and I believe it

stopped slight after. The electric network was correctly fuelled…I believe it was due to the intake of

smoke by the turbines, they need indeed a well-defined and specific mixture of oxygen to properly

function”.

Such hypothesis is considered a possible cause of the loss of power supply, as pressure,

temperature and humidity of the inlet air in the engine, different from the reference values, play a

primary role in ensuring the power supply, particularly when variations are significant, if compared

to the nominal reference values and if over long periods. Although, more likely, it was due to the

general situation of the unit and to the damage it suffered, particularly to the damage to the systems

on board, cables and circuits, following the fire, as well as to the fact that the engine staff left

prematurely the engine control room, so any emergency measure/manoeuvre, which could be made

only there, was no longer possible.

So, the presence of excessive combustion smoke in the engine control room, as a consequence of

the fire, with the related temperature increase and reduction of the percentage of oxygen available

in the air, typical derating factors for diesel engines, may have caused a loss of power. A temperature

increase implies indeed a decrease of air density. So, if the engine displacement is the same, namely

the volume of air used as comburent, weight decreases, proportional to temperature increase. Such

phenomenon leads to an alteration of the mixture fuel/comburent, as a consequence the outpower

is reduced.

In addition, the presence of possible carbon and unburned particles in the smoke may have

worsened the situation, by clogging the air filters. The loss of mechanical power of the diesel engine

and the simultaneous increased need of power supply by the loads (for example due to the drencher

Pag. 145



TABLE 5 AIR FLOW NEEDED TO ENSURE THE FUNCTIONING OF THE DIESEL GENERATORS DG1, DG2 AND

DG3, CATERPILLAR MARINE 3516B

activation, etc.) may have triggered an “overload” which particularly affects turbocharged engines,

inter-cooled or post-cooled high performance engines. In such conditions the engine tends to use

more fuel oil to compensate for the shortage of air and maintain the same power. If this situation

goes on for a long time, the engine floods, then stops and, lastly, breaks down.

Also the Chief Engineer said that the engines were about to go overload: “…(By overload, editor’s

note) we mean an overload of fuel delivery. In such situations, the engine tends to use more fuel oil

to compensate for the shortage of air and maintain the same power, until it floods”.

In table 5, the load performances are indicated and show, in m3/min, the air flow needed to ensure

the functioning of the Diesel generators DG1 and DG3, Caterpillar MARINE 3516B 1825 and kW 60

Hz @ 1800 rpm, which were operating during the black out.

With reference to the non-intervention of emergency devices, according to the evidence gathered,

when the blackout occurred, the navigation bridge was powered only by UPS batteries, although the

emergency engine-generator regularly started, when there was no voltage on the MS.

Indeed, when the Chief Engineer was asked how long the DGE operated, he said: the flames

touched the DGE room, I went to the spot and from the outside I unlocked the emergency closure

valve. When I did it, it worked. “I don’t remember exactly, although in the afternoon of day 28, the

light was exclusively powered by the batteries which lasted until evening”.

Pag. 146



So, on the MS, switch 910 was opened and the voltage relay 27-901 gave the start signal, but,

although voltage and the number of rpm was correct, switch 901 was not closed and power was not

loaded.

The Chief Engineer and the electrician, who arrived in the emergency station, after having checked

the voltage and rpm (frequency 60Hz, voltage 440V), tried to make the operations manually and to

close switch 901, although unsuccessfully.

In regard to the causes which may have hindered the closing of switch 901 for the power load, also

the description of the event leads to think that the unsuccessful “load connection“ was probably due

to two problems:

Lack of control, due to a breakdown in the control system, of the emergency engine-generator

(so far, it hasn’t been possible to check that selector 29 was in the status SELEZIONATO -

selected, which is an essential condition for enabling the MANUAL operation of the DGE set-

up and the takeover of emergency services of the MS);

Fault to ground for the utilities powered by the ES. The fire may indeed have caused a short

circuit, in one or more sections powered by the ES. In the power networks, where the three-

phase system with three conductors and ground-insulated neutral is employed (IT system),

the first ground fault of any part of the network doesn’t represent a low-impedance fault and

doesn’t cause the immediate disconnection of the network section concerned. In addition,

the fault may have been perceived by the relay STR23SE as an overload, exceeding the

10% allowed, by preventing the closing of the load switch 901.

PHOTO 25 DETAIL OF THE MS (SWITCHES 901 AND 910)

Pag. 147



PHOTO 26 DETAIL OF THE ES

With reference to the DGE, within initial inspections the fuel level indicator related to the fuel tank

was not operated correctly and so it resulted empty; however according to later inspections

performed jointly by Judicial Authority’s appointed committee and DIGIFEMA personnel -it was

proved that the mentioned tank contained approximately 3.500 Lt of fuel, so about 500 Lt fuel were

consumed. In addition, the emergency stop valve (fuel stop) of the same device was found closed.

In this regard, the interviews made prove that it was closed by the crew after some hours of operation

of the generator for safety reasons.

Pag. 148



PHOTO 27 DGE CONTROL PANEL

Pag. 149



4.6.6 Black out time sequence

As shown in the previous paragraph 4.3.4, the analysis of the engine automation data doesn’t

provide enough data to define the blackout sequence, as the recording stops at 03:36UTC (correct

datum – there is a 6 minutes total drift between UTC rime recorded on VDR and that recorded on

automation12).

Besides the evidence gathered, the only reliable data is the one which can be inferred from the VDR,

in the sheet of the Radar screen recordings.

It shall be noted that Solas, reg. 74 Chapter II/1, establishes that, in case of black out, the ship can

be powered by alternative electric sources, such as batteries, which however serve a very limited

number of utilities, and the emergency diesel generator which – among the other things - is

connected to the navigation Radar.

The recordings in the VDR prove that the Radar screen of the M/V Norman Atlantic blocked at

03:41:30UTC, later, at 03:46:10UTC, it disappeared to appear again at 03:47:55UTC. The radar

image disappeared and appeared again other times until 04:18:19 UTC when it remained stable on

the screen for several hours.

Considered that, in case of black out, the radar is powered only by the DGE, that leads to think that

it started operating at about 03:36UTC to then fully align with the electric system on board, but only

limited to few utilities, at about 04:18 UTC.

4.7 Further evidence acquired

On April 5, 2017 following the pre-trial hearing, some emails (Annex 21) exchanged among the ship

Captain, the ship owner and the broker in the period between December 25 and 27, 2014 until few

days before the departure, were made available to the DIGIFEMA.

12 The Kongsberg screen shows three different values of time, that one to be taken into consideration is the “ship logged time” that when synchronized with the VDR UTC time has to be reduced of 2 Hrs and 2 minutes.

Pag. 150



PHOTO 28 PART OF THE EMAIL

After reading such messages, it becomes clear that the staff on board asked to limit the number of

embarked reefers, for load reasons, to a maximum of 60/70 units, considered that the absorption of

the single units was not known. The Owner, consequently, instructed to limit the number of reefers

and informed the Charterer accordingly.

Although, the maximum number of reefers, which may be carried, for which the ship is certified, is of

80 units. In addition, in the emails mentioned, possible problems of communication/language due to

the embarking of a Greek electrician are highlighted.

Furthermore, in this regard, it shall be noted that the transcription of the VDR dialogues, as well as

some conversations between the navigation bridge and the ECR, slightly before the fire alarm (ore

03.21), show that the engine confirmed there were “no problems linked to the electric load”.

03:21:59

“Ale”

“Yes Captain”

Captain: “Please check in the engine the situation with the refrigerators’ load.”

03:22:30

Ship internal call: “Hello, what’s the situation with the refrigerator’s load?.....It’s always safe, ok”

So, considering the information above and that the ship was navigating at full load, it is possible to

say that the problems feared by the staff on board with reference to the maximum number of reefers

to be embarked, were actually unfounded.

Pag. 151



5. CONCLUSIONS

5.1 Shipboard organization

The SMS management manual of the M/V Norman Atlantic and the related procedures are structured

almost in the same way as in other ship companies and naval units, and the procedures therein

included are in line the regulation.

In this particular case, the Company manual and the board manual are combined in a single

document, which was regularly examined and found compliant by the R.O. (see Rina communication

Annex 3c). Such configuration does not seem to have caused problems when managing board

activities.

Although, some procedures - referred to basic activities which however need greater attention when

being fulfilled, such as for example securing vehicles and making the related following checks,

inspections during navigation and the working language on board - were sometimes too much

general, as the staff in charge of specific tasks wasn’t properly identified and/or the related

implementing modalities not well defined.

With reference to the registration of the passengers embarked, the Italian Coast Guard Headquarter,

through Circular titled Sic. Nav n. 106 of 22/01/2015, issued detailing instructions so as to prevent

such situations from occurring again, namely situations in which people could not be properly

identified on board, immediately after the rescue operations.

5.1.1 Loading and lashing

Despite the company procedures, from the interviews and evidence gathered it was understood that

the loading operations would have been made according to “empirical” methods and that the staff in

charge of it was not properly informed of the specifications/problems of the vehicles to be embarked.

In addition, as it was proved during the rescue operations, also the list of passengers provided by

the Greek ports of call wasn’t completely corresponding to the passengers who really embarked.

The Captain, as Chief Authority on board, was expected to order, with detailed instructions, the Chief

Mate to make a list of the goods to be loaded and to prepare a ship loading plan for the transport of

vehicles carrying dangerous goods (Chap. 7.2 part A-1 SOLAS 74 as amended).

To this end, the Captain of the ship and/or the Chief Mate, in case the Charterer didn’t communicate

it before – see clause 5.13 of the C/P (Annex 6a-b) – shall ask and demand the ground-crew,

sufficiently in advance, before starting the loading operations of vehicles, the typology of goods

carried so as to place the vehicles in the most suitable position on board and prepare a suitable

loading plan, also considering the possible adverse sea and weather conditions, in compliance, more

in general, with what is established by Chap. 16 of the company’s SMS manual on loading on Ro/Ro

ships such as the Norman Atlantic (Annex 3a).

Pag. 152



In addition, as highlighted in the analysis made in Chapter 4, the lashing wasn’t really made in a

perfect way and was incomplete in several points.

This may be due to an incomplete implementation by the crew of the related Company procedures.

In addition, as highlighted in the Rider clauses of the charter-party, such operation was assigned to

rating crew (provided by the charterer) who, based on the interviews, seemed to act autonomously.

However, the said rating crew had all relevant competency certificates and, following the

ascertainments carried out, the lashing appears to have been excluded as a cause of the accident

Total mass of the vehicle

(VM)

Minimum number of anchor

points (ns) to be used (for

each side)

Minimum strength of the

anchor points (kN)

3,5t ≤ VM ≤ 20t 2

(VM x 12) / ns 20t ≤ VM ≤ 30t 3

30t ≤ VM ≤ 40t 4

TABLE 6 ANCHOR POINTS AS UNDER THE CSM.

Moreover, it shall be noted that during the loading operations a Supercargo officer was appointed by

the charterer to supervise the operations.

Also the team in charge of connecting the reefer sockets was made of two units, one provided by

the ship owner and the other by the Charterer. Although, the Greek unit seems to have acted

autonomously and not in sync with the latter unit.

The problems mentioned above, combined with the different nationality and the comprehension

problems for the English language, whose knowledge/comprehension level among lashing staff in

certain cases was low, as it was appreciated during the interviews, have probably caused some

difficulties/misunderstandings, which could have had a negative effect in the correct execution of

these tasks

For these reasons, a review of the lease agreements is recommended, the so called “deck & engine”,

where each person’s responsibility shall be better identified.

5.1.2 Inspections on garage decks and patrols during navigations

Patrols during navigation were made as planned (with reference to timing), although it seems they

were not and performed following a specific procedure by Deck, Engine and Hotel/Catering staff..with

the required attention.

Pag. 153



A specific inspection was carried out upon order of the Officer on duty and the Fire Door sequence

showed the A/B passing by the mentioned areas but he didn’t understand in time that a fire had

started, albeit some smoke was noticed fifteen minutes before the Fire Alarm

In view of the above, although the general management of the operations on the ship seems

to be performed overall safely, a review of the mentioned SMS procedures is to be evaluated,

with more frequent internal audits to check the implementation of the operational procedures

established and/or a specific training by the Company for the staff in charge of these

operations, clearer procedures for loading - lashing - socket connection operations. Similarly

a review of the way patrols during navigation are performed should be considered, in

particular roles shall be better defined, and - the knowledge of the English language, among

the staff in charge of these operations, shall be better checked by the Company (both the

ship owner and the charterer).

5.1.3 Emergency management

The first alarm signals (pre-alarm) of the fire, which was about to break out, were recorded on the

deck at about 03:15UTC, after which a crew member was immediately sent to the spot for an

inspection.

As highlighted several times in the report, the Fire Alarm started at 03.23UTC, from that moment on

the emergency management was undertaken by the Captain, who gave the necessary orders,

whenever possible, to deal with the fire and very serious situation.

Although the first communications show, in the first minutes of the emergency, a non complete

awareness of the seriousness of the situation and only at 03.53 the Captain communicated via radio

that the unit was involved in a very serious fire.

Anyway, it shall be noted that the Captain kept calm during the whole events.

The same is not true for the crew members, who sometimes acted autonomously, without really

helping dealing with the emergency.

The analysis above shows that:

- The staff on board was aware of the presence of some vehicles on the ship, which were not

connected;

- The patrols – both the one following the pre-alarms and the previous one – were not properly

made;

- The fire alarm activated later than the real fire ignition or, to be more precise, when the fire had

already broken out, which prevented the fire team from intervening on the spot;

- Although the Captain correctly indicated the area affected by the fire for the opening of the

Drencher , the First Engineer didn’t open correctly the valves in that area, so the situation was

further worsened;

Pag. 154



- The Chief Engineer and the engine staff left the ECR (Engine Control Room) without a specific

reason and without informing the navigation bridge, which, in this way, could not take any further

measure to mitigate the fire devastating effects;

- The crew members often acted out of personal initiatives, which were neither agreed upon nor

ordered by the Captain, also during the evacuation operations;

- It is not clear how the order to abandon the ship was given, even if the Captain gave to the crew

present on the bridge – at 04:13 - the abandon ship order, the following steps were indeed

recorded: a timely “crew call” for fire situation followed by a situation of general emergency without

any specific order to abandon the ship. However this can be related to the impact on

crewmember’s behaviour due to the stressful situation generated by the fire;

Pag. 155



5.2 Fire

5.2.1 Fire detection and considerations on insulation

The fire was detected by sensors belatedly, due to the technical issues described above, with

particular reference to the presence of side openings, which, combined with the wind blowing in that

area, enabled fire to develop so much that, when it was finally detected, it could no longer be kept

under control either by the fire fighting team or by the Drencher system, because interesting a too

large area of the garage. In addition, the CCTV systems available did not provide a complete

overview of the area, because, as established by the regulation in force, they were installed

exclusively for the purpose of checking the unauthorized accesses in that rooms, mainly for security

reasons, as well as to observe vehicle movements in adverse weather conditions.

With reference to the level of insulation (or fire resistance) of the area specifically designed for rescue

means, if compared with the surrounding spaces, the following considerations can be made: - it is

compliant with the provisions established by the applicable laws; - the regulation of the SOLAS

Convention II-2/3.1 defines the A class divisions as follows: "A" class divisions are those divisions

formed by bulkheads and decks which comply with the following criteria:.1 they are constructed of

steel or other equivalent material;.2 they are suitably stiffened;.3 they are insulated with approved

non-combustible materials such that the average temperature of the unexposed side will not rise

more than 140ºC above the original temperature, nor will the temperature, at any one point, including

any joint, rise more than 180ºC above the original temperature, within the time listed below: class

"A-60" 60 min class "A-30" 30 min class "A-15" 15 min class "A-0" 0 min...........omissis....

So an A-60 class division (which is the highest level of resistance to fire for a ship division) may

have, from time 0 of a fire start, an average temperature of 140° C on the surface which is not directly

exposed to flames (with peaks of 180°C).

Such a temperature certainly prevents a correct use of devices (such as rescue and life-saving

equipment) close to the areas affected by fire.

5.2.2 Containment

As highlighted in the declarations made, the fire-fighting team and those making the patrols could

not reach and easily move in the garage, because the fire was of huge dimensions and, furthermore,

as reported in some interviews, the F-team, faced difficulties for entering the garage area because

of the distance between the vehicles that - even if in compliance with regulation - can become

narrower when wearing firefighting suits/equipment.

The Drencher was opened in the wrong area and for four areas, furthermore, after few minutes it

became unusable, as the main power supply disconnected – probably because of the damage

caused by fire to the exposed cables on the ceiling of deck 4. In such conditions, the Drencher

Pag. 156



system could be powered only by the fire-emergency pump, which, however, didn’t provide enough

water to effectively extinguish fire.

The only effective action implemented to mitigate the fire effects was the intervention of the tugboats

which moved the ship head to wind and cooled the hull with water, by preventing the vessel from

being completely destroyed.

5.2.3 Extinction

As above reported, the performed theoretical simulation concluded that, the fire reached rapidly such

heat release and temperature levels that any intervention of the fire-fighting teams was useless.

In other words - notwithstanding “Norman Atlantic”, her system and its control apparatus are,

pursuant to the norm, fully compliant with the regulations in force - the system (in this case by

“system” the interaction between the extinguishing Drencher system, the related control system, the

activation by the staff in charge, is meant) was insufficient to fight a fire of such amplitude.

5.3 Propagation, fire origin and structural criticalities

The study and the simulations made to analyse the evolution of the fire which affected deck 4 of the

M/V Norman Atlantic have highlighted the following event features:

fast propagation;

high quantity of smokes produced;

high temperatures;

and the following causes and factors which certainly worsened such effects:

long time elapsed between fire detection, warning and manual extinguishing;

High response time of active protection systems;

High fire load;

Close distance among combustible materials;

Much ventilation;

High compartment volumes;

Absence of vertical compartments.

The factors above have therefore caused a fire with a very fast time/temperature evolution.

As already analysed in this report, the declarations and information gathered show that the time

elapsed from the first detection to the general warning of Fire Alarm with following Drencher

activation order to the Engine Room was, highly probably, of about 20 minutes. The fire development

time from its ignition is around 30-35 minutes.

Pag. 157



Out of a first comparison with the data resulting from the study made, this sort of value may seem

not perfectly congruent.

The study has indeed proved that the smoke generated started to significantly come out of the side

windows well before.

In addition, the congruence between what emerged from the study and from the crew members’

declarations can be found also in the description of the flames coming out of the windows: “when I

went back to the navigation bridge, after few minutes, I could see a red/pink flash, so I looked at the

starboard, where I could see open flames coming out of the first three windows on the forward side

as if they were “launched by a flamethrower” and I really couldn’t understand why, because the

trucks, although there was much wind coming from the left, acted as a protection. Immediately after,

the FIRE ALARM rang (serious fire)”.

The quantity of materials burning increases indeed enormously over time, as well as the production

of smoke and warm gases. As the room ventilation depends on the openings towards the outside

(ventilation factor), in that situation, where the direction and strength of wind was also a crucial

element, the openings available for letting fresh air come in were reduced, as they were obstructed

by smoke. In this way the quantity of fresh air available for combustion decreased, unburned

pyrolysis gases left the compartment together with smokes, when they were close to the openings,

they found enough oxygen to burn and generate the usual flames coming out of windows, as it

normally happens when the fire is in the generalized or postflashover step.

5.4 Normal and emergency power supply on board

Normal power supply on board was available only in the first few minutes of the emergency, indeed,

as recorded by the VDR for the radar display, already at 3:41UTC there was a block and the display

couldn’t be updated, later, at 03:46UTC it got completely blank.

Pag. 158



FIGURE 51 FIGURE 1 RADAR SCREEN DATED 28/12/14 AT 03:48: RADAR CONTROL PANEL WITH

TRANSCEIVER OFF

After about half an hour the radar re-launch countdown was recorded, his functioning is however

alternating. This may be due to the switch to the power supply provided by the DGE and is indeed

in line with what the Chief Engineer said during the interview. Although the power supply seemed to

be limited to the machineries in the navigation bridge, as many areas couldn’t be reached, because

of the huge damage caused by fire to the related cables. In particular, in this regard, the ceiling on

deck 4 is crossed by set of cables which, albeit fire-resistant, were destroyed by the violent fire in

short time, as they weren’t protected.

Lastly, it shall be added that the fire developed in a crucial area for electric junctions and for the main

supply, so the rapid development has deeply affected the functionality of panels.

The “cooking” of the copper conductor wires has enormously changed the electrical conductivity

features, and the insulation dielectrics were highly damaged so that “short-circuits” were recorded

by all breakers of the main power panels; the most widespread situation recorded was indeed that

of the presence of power supply in the panel, where the breaker got activated for a short circuit

downstream. Such situation was also confirmed in the interviews, when the staff tried to connect the

emergency electric panel with the emergency diesel generator.

Pag. 159



A greater protection of cables and/or their placement in different areas, for example on the

sides (for ships of recent construction) is therefore recommended.

5.5 VDR

The extraction of data was very complicated and intricate, so that several interventions and

measures were needed to get a complete and reliable result, however limited to the sole FRM, as

the DMM mass storage was irreparably damaged by heat and the data extracted were of very low

quality.

The integration of protections and of components of higher quality for the hardware is

recommended, as well as the use of standardized and updated player software to facilitate

data decoding is suggested. In addition, annual performance tests shall be performed with

greater attention.

5.6 Evacuation

With the exception of a limited number of shipwrecked passengers who could embark on the lifeboat

on the portside, evacuation was possible only through air rescue means, which gradually moved

passengers to the vessels arrived on the spot, mainly on board of the MMI San Giorgio, Coast guard

and the other merchant vessels therein diverted for the emergency.

In addition, the survival equipment on the ship starboard side were partly destroyed and/or damaged

by flames after few minutes. Also the mini-chute was unusable, due to the detachment/missing

connection of the related life raft and to the damage suffered during the emergency caused by both

fire and the adverse sea and weather conditions.

A different position or alternative solutions to protect them from direct contact with fire shall

be evaluated.

Additionally, with reference to the MES, its operational restrictions shall be reviewed according

to the navigation actually made, similarly the criteria for evaluating the functioning of such

devices shall be reconsidered, namely replacing them with other suitable survival craft.

Pag. 160



5.7 Considerations on the condition of reefer trucks

Reefer trucks that remain in operation in the garage areas during voyage are considered a serious

fire risk which has been identified by relevant studies13 and it is well known to the crew members of

Ro-Ro vessels. On the matter, the applicable EU and International legislation is:

Council Directive 77/143“on the approximation of the laws of the Member States relating to

roadworthiness tests for motor vehicles and their trailers”, as amended,

COUNCIL DIRECTIVE 96/96/EC “on the approximation of the laws of the Member States

relating to roadworthiness tests for motor vehicles and their trailers”, as amended,

The UN Treaty “Agreement on the International Carriage of Perishable Foodstuffs and on

the Special Equipment to be used for such Carriage” (ATP Agreement).

However, even if according to the legislative framework in force, reefer trucks have to comply to the

ATP agreement requirements and be inspected every 6 years and certified, such controls do not

include a specific inspection for their refrigerating units and their electrical equipment (power supply

plugs and cables etc.) in terms of ascertaining their good condition and safe operation. The same

stands also for the internal combustion engines of the reefer units which although are not permitted

to operate during voyage, they can start automatically when the power supply from the vessel is lost

due to a problem. Consequently reefer trucks are permitted to be loaded on Ro-Ro vessels and

remain in operation during voyage without any solid evidence that they have been properly

maintained and inspected in order to assure that they will not pose a risk to the vessel. The only

measures that can be applied by the crews to mitigate the risk from the operation of this equipment

are to perform a macroscopic inspection and most probable an electrical check on the plugs before

they are connected to the vessel’s power.

A periodical inspection/certification, aimed to verify the safe working conditions of the refrigerating

units installed on the reefers followed by controls carried out by ticketing offices - at the moment of

ticket purchase - of the validity of related certifications would increase safety.

Since not directly linked with the present investigation, the matter will be upscaled apart to the EU

Commission / International Organisations in order to consider an eventual amendments to the

existing rules.

131. IMO Working Document FSI 21/5 – Report of the Correspondence Group on Casualty Investigation, 28-11-2012

2. IMO Working Document SSE 2/INF.3 - Transport of electric vehicles and vehicles with refrigeration units on board ro-ro vessels

Pag. 161



6. RECOMMENDATIONS

6.1 COMPANY 6.1.1 VISEMAR DI NAVIGAZIONE S.R.L.

004/2015-01 Promoting a better coordination between port security and ship security, by introducing procedures aimed at ensuring a more effective control to prevent security problems;

004/2015-02 Integrating the existing procedures to improve the efficiency and effectiveness of patrols in the deck garages, particularly before the ship departure;

004/2015-03 Re-evaluate the frequency of internal audits aimed at checking the compliance with the applicable regulations and procedures, particularly with regard to stowage, lashing and connection of reefer sockets;

004/2015-04 Implementing measures aimed at ensuring that the staff on board is actually familiar with the working language and that this language is really used on board.

004/2015-05 In case on board there is more than one person with same role (for example Chief Mate) for which the ISM manual clearly establishes the tasks, the Captain shall specifically assign each person the related tasks.

6.1.2 ANONIMI NAFTILIAKI EFTERIA KRITIS S.A.

004/2015-06 For the registration of passengers, the use of the surname indicated in the identity card is recommended;

004/2015-07 A detailed list of the cargo to be loaded shall be provided in advance, considering the ship operational features, including size, weight and any other technical requirements (including the notification of the exact number of trucks that would require connection to the vessel’s electrical power etc…) so that the loading plan can be prepared before the departure;

004/2015-08 The complete list of passengers shall be provided before the departure, pursuant to the regulation in force, so that the Captain can ascertain that the number of passengers embarked doesn’t exceed the number allowed;

6.2 IMO

004/2015-09 A study / analysis shall be carried out to develop solutions, which are different from the existing ones, concerning the aspects and structural/constructive criticalities mentioned above:

Fire detection systems in the deck garages, which, considering the openings in the hull, shall be placed and designed/calibrated pursuant to the openings;

Pag. 162



Side openings of open cargo decks of ro-ro ships, to prevent/mitigate the devastating effects produced by the uncontrolled inflow of external air;

Passive protection of the areas where collective rescue means (including the MES and evacuation stations as defined by the Solas) are placed. Their placement shall also be made considering any hull opening of ro-ro areas, so as to prevent direct contact with open flames in case of fire;

Review of fixed fire-fighting systems protecting garages on decks, the implementation of alternative extinguishing/containment systems (Ex.: water barriers/water mist etc..) is recommended;

The passive protection of cables and electric circuits running through the garage shall be improved so as to extend the activity of emergency systems;

Obligatory installation of an adequate video surveillance system (equipped with temperature detectors) in the garages so as to enable a continuous and immediate remote control (navigation bridge, ECR, etc.);

For the existing ships, evaluate the redundancy of electric systems supplying the pumps for the fixed extinguishing system of “Drencher” type so as to ensure the full operation of the system also in emergency conditions;

FSS code, chapter 9 – par. 2.3.2.1, should be amended in order to include also the technical specifications for smoke detectors to be installed inside open ro-ro cargo spaces.

004/2015-10 The VDR (DMM) fire-resistance shall be improved also in the existing ships, by implementing protections against heat/smoke, in particular for mass memories designed for recording data;

004/2015-11 Integrating the possibility to record in the VDR the audio data originating from ECR and including, among the registered data, the whole set of alarms recorded by the fire detection system;

004/2015-12 Implementing software for VDR of standardized and open source type and upgrade the applications used for data playback;

004/2015-13 The minimum distance among the vehicles lashed in the garage and for enabling the operational and safe passage of the fire-fighting team on board shall be established;

004/2015-14 Providing simpler and more intuitive operational instructions for using security devices;

004/2015-15 Introducing the possibility to have a feedback, also from the navigation bridge, on the status of valves and on the functioning of the Drencher;

004/2015-16 Providing in advance, while considering the ship operative nature, a detailed list of the cargo which shall be loaded, including also sizes and weight and any further technical requirements (for ex. electrical connection on board etc…) so as to enable the compilation of the cargo plan before departing;

004/2015-17 Providing for the synchrony of times of monitoring devices on board (ECDIS, AUTRONICA, machinery automation etc.) based on the GNSS time.

Pag. 163



6.3 GREEK MARITIME ADMINISTRATION (PORT FACILITIES IGOUMENITSA AND PATRAS)

004/2015-18 A detailed review of the PFSP shall be performed aimed at preventing the unauthorized access of persons and vehicles to the terminals.

6.4 GREEK MARITIME ADMINISTRATION

004/2015-19 Check the passenger registration systems.

6.5 FLAG STATE

004/2015-20 In case on board there is more than one person with same role (for example Chief Mate) for which the ISM manual clearly establishes the tasks, the Captain shall specifically assign each person the related tasks.

Pag. 164



7. ANNEXES

Annex 1 – MSM Norman Atlantic;

Annex 2a – Norman Atlantic damages deck 3;

Annex 2b – Norman Atlantic damages deck 4;

Annex 2c – Crew List;

Annex 2d – M/N NORMAN ATLANTIC Muster-roll

Annex 3 – SMS Manual Italian Rev. 3;

Annex 3b – SMS Manual Re.1 – Letter of approval TS-BLU-817;

Annex 3c – 2012-RSSE-#TRIESTE-BLU-1475 – letter of approval rev n.3;

Annex 4a – SAFPASS n°04_2014;

Annex 4b – Class Certificate nr.84513-001 01 Sep 2014;

Annex 4c – Load Line certificate;

Annex 4d – Certificate of fitness for the carriage of motor vehicles;

Annex 4e – Document of compliance for the carriage of dangerous goods;

Annex 5 – Inspection-9435466-20141219-v2;

Annex 6a – Charter Party (lingua Italiana);

Annex 6b – Charter Party (English);

Annex 7 – Cargo plan DECK1;

Annex 8a – Cargo plan DECK3;

Annex 8b – Cargo plan DECK4;

Annex 9 – Kongsberg print;

Annex 10 – Ship System service report;

Annex 11 – Interprogetti letter;

Annex 12 – BS320 Installation Handbook;

Annex 13 – BS320 Operator Handbook;

Annex 14a – approved fire detection sensors plan RINa tav.1;

Annex 14b – approved fire detection sensors plan RINa tav.2;

Annex 15 – Autronica (fire detection system) approval;

Annex 16 – Autronica sensors list;

Annex 17a/b – Fire brigade technical report

Annex 18 – Drencher distribution;

Annex 19 – Tech report – on board Electrical installations

Annex 20 – Cargo Securing Manual (approved by RINa STRT23290)

Annex 21 – Mail exchange

ministry of infrastructure and transport directorate

Documents