Incident directory

2014 - DFDS Seaways - MV Dieppe Seaways

01/05/2014

Country:

UK

  • Ship/ Maritime Incidents

Severity:

Near miss

Description

Date of event

1st May 2014                 

Time of event

Approximately 12:40 HRS UTC. Call to Kent FRS 14:12 BST (INITIAL CALL)

Name of premises

DFDS Seaways - MV Dieppe Seaway.

Location

Initial fire detection and firefighting actions 3 Miles offshore from Dover then Port of Dover alongside for Kent Fire & Rescue Service (KFRS) additional actions.

Service area

Kent FRS.

Nature of incident

Fire.

Property type

Ship, 203.9m long and 30,551 gross tonnage.

Premises use

Roll on roll off passenger ferry.

Construction type and materials

Steel frame and plate.

Occupancy

Passengers (1,200 max) and crew (minimum safe manning 49). Occupancy at time of incident 315 passengers, 65 crew and 6 contractors.

Fire source and location of fire

Port thermal oil heater within port boiler room.

Synopsis

Brief Synopsis

On the 1st May 2014 at around 12:31, a fire broke out within the port side thermal oil heater within the port boiler room between deck 7 to 9. The ship was approximately 3 miles offshore at the time. The ship’s crew attempted to tackle the fire. After further investigation it was realised assistance from the local fire service (Kent Fire and Rescue Service ((KFRS)) would be required and the ship docked alongside at Dover at around 13:21. KFRS officers met the crew and a joint (KFRS & Ships firefighting team) tactical plan and forward control point was established (MAIB, 2014 and King et al, 2014).

Sometime after, during preparations for firefighting teams to enter into the port boiler room via the deck 9entrance door, a ship’s (DFDS) breathing apparatus (BA) crew opened the door. A rapid fire development event occurred which knocked a number of personnel to the floor and also burnt some of the firefighters present. 6 ships crew (DFDS) firefighters and 4 KFRS firefighters were injured, 3 seriously (MAIB, 2014 and King et al, 2014). All were injured from what is understood, but not confirmed, to have been a either a fire gas explosion or a backdraft.

Photo 1

Image from MAIB (2014).

Photo 2

Image from MAIB (2014).

Photo 3

Image from MAIB (2014).

Photo 4

Fire damage to thermal heater control panel. Image from MAIB (2014).

Photo 5

Image from MAIB (2014).

Photo 6

Image from MAIB (2014).

Main findings, key lessons & areas for learning

Further information hoping to be identified and still to be located.

Fire & Rescue Service summary of main conclusions & recommendations from Kent FRS Accident Investigation Report (King et al, 2014)

Further information hoping to be identified and still to be located.

Taken from: Kent Fire and Rescue Service.  King, C. Brown, M. Adams, C & Wales, D. (2014).  Accident investigation report injury or near miss; ID number 6111 

--subaccordion--

7  CONCLUSIONS

**It is important to note that this report may need to be modified if further evidence comes to light through the MAIB report, as the KFRS Investigation Team have not been able to interview DFDS crews.

7.1  These conclusions are based on the facts and verified by them, and provide details of unsafe practices and/or actions identified.

The operational crews attending the incident put in place an incident command structure which matches the national incident command model. There were no more than five spans of control for each level of command. Communications were established by hand held radios and a command support officer was established to prevent the incident commander becoming overloaded.

The level 1 and 2 Incident commanders on ship took the time to observe the boiler layout on the opposite deck before briefing crews. Thermal Image Cameras were used to try and establish the temperature inside the compartment.

Kent Fire and Rescue Service Breathing Apparatus procedures were followed with emergency crews briefed and nominated before crews opening the compartment.

7.2  Immediate Causes

Opening the compartment door leading to the boiler compartment led to a backdraught within the boiler room on deck nine portside of the MS Dieppe Seaways. This led to six DFDS crews and four Kent Fire and Rescue Service crews receiving flashburns.

7.3  Underlying and Contributory Causes

No warning was given by the French DFDS crew when they opened the compartment door.

The Incident Commander did not visit the Bridge of the Ship and discuss the incident with the Ships Master.

The Incident Commander was not made aware of a misting system in the boiler room until after the occurrence.

An inner cordon was not established and there was not a clear identification of a risk area on the deck.

The wearing of full Personal Protective Equipment was not enforced on the deck.

Fire and Rescue Control Centre did not follow the action plan which states that a Marine GM and SM are mobilised on the initial attendance.

There was only one English speaking DFDS crew member and therefore this limited communication between crews. This led to a lack of coordination between crews on deck.

The information given to Kent Fire and Rescue Service throughout the Incident from DFDS was that it was a small fire contained within the boiler. No further information was provided to indicate that this had changed.

Crews were drawn closer to the risk area due to the failure of a dry powder extinguisher.

8  RECOMMENDATIONS

Full detailed recommendations for remedial actions that in the view of the AIB are required to prevent a recurrence.

8.1  Information and instruction changes

Consider a review of Technical Bulletin F1, providing clear instructions to crews that matches the current Fire Service Manual on Marine firefighting and/or adopt the regional Tactical Operational Guidance which is due to be published on 30 November 2014.

Although it is not considered a contributory cause the investigation established that the Entry Control Board used at the Incident had not been sufficiently charged. Consideration should be given to providing guidance to operational crews on the importance of effective taking over routines.    

8.2  Training changes

A review of training should be conducted to evaluate the need for marine firefighting training. This review should identify the foreseeable risk for personnel and who should receive marine training.

All operational Officers and Tactical Advisors should be included in the review above. The need for refresher training should be included in the review.

All relevant training courses should be reviewed to ensure the need to establish an effective inner cordon and to limit the numbers of personnel within the inner cordon is sufficiently emphasised.

All relevant operational training courses should be reviewed to ensure the need to wear full PPE within the inner cordon as an identified risk area is sufficiently emphasised.

8.3  Supervision changes

Consideration should be given to reviewing the training for Officers conducting the Tactical Advisor role. Ensuring that all officers when attending incidents ensure that the inner cordon is being managed effectively and the correct Personal Protective Equipment is being worn at all times within the inner cordon.

A review should be undertaken to establish the appropriateness of the first attending Officer/Tactical Advisor at Marine incidents being Fire & Rescue Marine Response qualified officer.

8.4  Procedural changes (including safe systems of work)

A review should be conducted to establish the degree to which Fire and Rescue Control Centre should apply professional discretion when dealing with Ship incidents, due to the frequency of this incident type and the nature of the risk.

8.5  Management systems changes

A review should be conducted into Competency recording and establish the requirements for all operational roles regarding Marine Incidents.

8.6  Policy changes

A review of attendances at Marine Incidents should be considered to establish the more effective use of Kent Fire and Rescue Service resources, especially those who have received specialist training for marine incidents.

The findings of this report are shared with other FRS through the CFOA National Operations Committee

--end--

FBU summary of main findings, key lessons & recommendations

No information identified to date and/or still to be located.

Marine Accident Investigation Branch (MAIB) report main conclusions and recommendations

Taken from: MAIB. (2014). Marine Accident Investigation Branch (MAIB) report No 20/2015. Report of the investigation on a fire on board The RoPax Ferry Dieppe Seaways on the approach to, and subsequently alongside, the Port of Dover, UK on 1st May 2014.

--subaccordion--

SECTION 3 - CONCLUSIONS

3.1 SAFETY ISSUES RELATING TO THE ACCIDENT THAT HAVE BEEN ADDRESSED OR HAVE RESULTED IN RECOMMENDATIONS

1.  The coil in the port thermal oil heater on board Dieppe Seaways failed as a result of stress caused by the weld securing the refractory insulation support plate to the coil. [2.3]

2.  The section of coil that failed was particularly difficult to inspect visually due to the refractory insulation in the vicinity. In such circumstances it would have been more appropriate to pressure test the coil, as recommended in DNV GL Rules for Classification of Ships, during the intermediate survey earlier in the year. [2.4]

3.  The lack of detailed maintenance records and no evidence that classification society approval had previously been given for repairs to the port thermal oil heater might have prevented DNV GL from issuing pertinent advice to its surveyors. [2.4]

4.  Adverse conditions within the port boiler room prevented manual operation of the coil pressure relief valve. Remote operating positions for the coil pressure relief valve would have allowed the oil pressure to be reduced without risk of supplementing the fuel supply to the fire. [2.6, 2.7.1]

5.  The chief engineer’s previous experience of a thermal oil heater fire appears to have unduly influenced his evaluation of information that was available to him. A comprehensive review involving all of the key ship’s staff might have identified that the fire had, or had the potential to, spread to the port boiler room. [2.7.1]

6.  The absence of a standard operating procedure for dealing with a fire on the thermal oil heating system installation meant that such a scenario had not been exercised as part of the training programme on board Dieppe Seaways. [2.7.1]

7.  Had a thorough situational risk assessment been conducted by KFRS, the risk of backdraught conditions should have been identified and have resulted in a revised entry plan. [2.7.2]

8.  The serious injuries resulted from a lack of FCP cordon control. Although KFRS routinely engages in maritime exercises, the lack of combined command and control in this case suggests that more specific shipboard fire-fighting training may be beneficial. [2.7.3]

9.  The failure of the retro-fitted furnace dry powder fixed fire-extinguishing system to extinguish the fire inside the port thermal oil heater furnace demonstrates the unsuitability of dry powder as a fire-extinguishing medium for this purpose. [2.8]

3.2 OTHER SAFETY ISSUES RELATING TO THE ACCIDENT

1.  It is probable that the burner unit of the port thermal oil heater opened as a result of not being properly latched down following previous maintenance or inspection. This allowed smoke and fire gases to amass at the top of the port boiler room, resulting in a backdraught when the port boiler room entrance door was opened. [2.5, 2.6]

2.  The port boiler room’s A-60 structural fire protection masked the internal compartment temperature and prevented an accurate assessment of conditions within the compartment. [2.7.2]

SECTION 4 - ACTION TAKEN

Kent Fire and Rescue Service has:

Conducted an internal investigation which recommended additional emphasis on cordon control during leadership training for incident commanders.

DFDS A/S has:

Developed a standard operating procedure to be followed in the event of a thermal oil heater furnace fire.

Issued a Fleet Safety Alert that highlights this incident and recommends that all applicable staff:

  • Re-familiar themselves with incident reaction procedures relating to shutdowns and fire suppression systems.
  • Use fire drills to identify safe compartment entry procedures highlighting the dangers of backdraught and flashover.
  • Reinforce to all personnel that the master has overriding responsibility for command and control of any incident on board.

Dieppe Seaways ship’s staff have:

Made temporary arrangements to allow remote operation of the thermal oil heater coil pressure relief valve.

Dover Harbour Board has:

Carried out an internal investigation.

SECTION 5 RECOMMENDATIONS

Prozess-Wärmeträgertechnik GmbH is recommended to:

2015/148 Investigate alternative methods of securing the refractory insulation support plate on PWT DW III thermal oil heaters.

Det Norske Veritas Germanischer Lloyd is recommended to:

2015/149 Provide guidance to its surveyors on:

  • Previous incidents involving PWT DW III thermal oil heaters; and
  • Appropriate and effective methods for examining welded connections on thermal oil heater coils, to reinforce its existing recommendation for hydraulic pressure testing where coils are not accessible for visual external inspection.

Kent Fire and Rescue Service is recommended to:

2015/150 With regard to shipboard fire-fighting:

  • Emphasise to its firefighters the available guidance provided in GRA5.8 and the Fire and Rescue Manual with regard to backdraught conditions with particular emphasis on the need to conduct a thorough situational risk assessment before developing an entry plan.
  • Issue guidance to FRS OIC on the need to liaise effectively with the ship’s master, recognising that the ship’s master is responsible for the safety of the ship and its crew.
  • Provide more specific shipboard fire-fighting training to exercise combined command and control, and enhance risk perception in respect of ship construction and associated hazards.

Det Norske Veritas Germanischer Lloyd and DFDS A/S are recommended to:

2015/151 Review the suitability of dry powder as a fixed fire-extinguishing medium for use in thermal oil heater furnaces.

Safety recommendations shall in no case create a presumption of blame or liability

11 These safety issues identify lessons to be learned. They do not merit a safety recommendation based on this investigation alone. However, they may be used for analysing trends in marine accidents or in support of a future safety recommendation.

--end--

IFE Commentary & lessons if applicable

None produced at this time.

Known available source documents

Further information hoping to be identified and still to be located.

FRS Incident Report/s

Further information hoping to be identified and still to be located.

King, C. Brown, M. Adams, C & Wales, D. (2014). Accident investigation report injury or near miss; ID number 6111  [pdf] Kent Fire and Rescue Service.

FBU Incident Report/s

No information identified to date and/or still to be located.

Health & Safety Executive (HSE) Incident Report/s

No information identified to date and/or still to be located.

Kent Police Incident Report/s

No information identified to date and/or still to be located.

South East Coast Ambulance Service Incident Report

No information identified to date and/or still to be located.

Building Research Establishment (BRE) Reports/investigations/research

No information identified to date and/or still to be located.

Coroner’s report/s

Not relevant.

Other information sources

MAIB. (2014). Marine Accident Investigation Branch (MAIB) report No 20/2015. Report of the investigation on a fire on board The RoPax Ferry Dieppe Seaways on the approach to, and subsequently alongside, the Port of Dover, UK on 1st May 2014 [pdf]. Available at https://www.gov.uk/maib-reports/fire-on-board-ro-ro-passenger-ferry-dieppe-seaways-resulting-in-3-people-injured [Accessed 23rd August 2016].

MAIB. (2014). Marine Accident Investigation Branch (MAIB) report No 20/2015. Report of the investigation on a fire on board The RoPax Ferry Dieppe Seaways on the approach to, and subsequently alongside, the Port of Dover, UK on 1st May 2014. ANNEXES. [pdf]. Available at https://www.gov.uk/maib-reports/fire-on-board-ro-ro-passenger-ferry-dieppe-seaways-resulting-in-3-people-injured [Accessed 23rd August 2016].

Service learning material

Further information hoping to be identified and still to be located.

Brown, D. (circa 2014). DFDS Ferry fire port of Dover 1 May 2014 TOC 14 12 hrs. [PowerPoint]. Available here. Kent Fire and Rescue Service.

Videos available

No information identified to date and/or still to be located.

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