Caroline Maersk Fire: Crew Resourcefulness Praised
The Danish Maritime Accident Investigation Board (DMAIB) has released its report into the August 2015 container fire on board Caroline Maersk off the coast of Vietnam citing crew resourcefulness and the limitations of procedures.
The fire broke out as a result of charcoal self-igniting in a cargo container below deck. The cargo carried in the burned container was of a nature that was not expected to be stowed in that particular position in the hold below deck. The container had not been correctly declared as dangerous goods in accordance with the IMDG Code, which would have prompted a different stowing position or a ban from being transported at all due to its hazardous nature.
As the cargo was not declared as IMDG cargo, the crew was not able to immediately identify the contents of the container from a cargo manifest, but relied on assistance from the shore-based organization.
Despite a number of challenges related to knowledge about the contents of the cargo container and the nature of the formal fire emergency preparedness, the crewmembers managed to successfully contain the fire for several days and prevent it from spreading excessively.
This achievement was the result of the shore and shipboard organization’s ability to adapt to the unfolding emergency situation by filling the gaps between the formal emergency preparedness and the actual emergency scenario, states DMAIB. In other words, the organization ‘finished the design’ of the emergency preparedness to match the situation they faced.
The crew was faced with some technical challenges during the accident. The CO2 system failed as a main distribution valve did not open, resulting in a near-explosion in the CO2 room, which presented a serious risk to the crew who had mustered in the area. Another consequence was that very little CO2 actually reached the cargo hold.
At the time of the fire discovery, the crewmembers did not know the source of the fire nor the extent and therefore had no way of knowing the most effective way to fight it before assessing the situation. As they also did not know the contents of the cargo in the containers, they had no chance of knowing whether releasing CO2 into a cargo hold would be the most effective approach, or if manual extinguishing would be effective or even possible.
For some fire scenarios, such as a smouldering fire inside a container, CO2 is not a particularly effective method, as the fire will often flare up again when oxygen levels in the hold are restored.
During the manual firefighting, the compressor for filling BA bottles broke down and in effect left the crew without any means of fighting or further assessing the fire. Furthermore, the container firefighting equipment did not work as expected. The DMAIB tests showed that a particular set of preconditions needed to be in place for the equipment to work as intended. These preconditions may not be present in a real-life situation, as on Caroline Maersk.
What eventually secured a successful outcome, in spite of failing equipment, was the shore and shipboard organization’s ability to adapt to the situation, by departing from the formal ways of work and applying their own resourcefulness, i.e. making a temporary replacement valve for the compressor, using an angle grinder instead of an ineffective power drill, using anti-piracy fire equipment and adapting the formal shipboard organization
Firefighting is not the primary function of the crewmembers and actual emergency situations are rare, states DMAIB. This means that for most crewmembers such a situation is a once-in-a-lifetime experience. Seafarers cannot be expected to hold a level of experience equal to that of professional firefighters.
These conditions place additional strain on the firefighting preparedness on board ships and need to be carefully considered when designing equipment and work procedures to be used in an emergency situation. Procedures, checklists and decision support systems alone cannot ensure a successful outcome of an emergency situation. Procedures are static tools, whereas emergency situations are dynamic and unpredictable. Many procedures, emergency procedures in particular, bear an inherent assumption that the crew has extensive knowledge of the situation or is able to quickly gain such knowledge, which they in most cases are not.
Safety management procedures address a variety of topics besides safety. Often a safety procedure will also contain items relating to insurance issues, internal documentation, general company policies, ordering information, etc., which has no relevance to the crew in an emergency situation.
Over the past decades, container ships have increased considerably in size, enabling contemporary ships to carry significantly larger numbers of containers, stacked higher than earlier. The upscaling of the ships and their cargo capacity has partly been accompanied by corresponding amendments to regulations, procedures, equipment, etc. The subsequent regulation amendments have, however, merely added more of the existing equipment, e.g. an increased number of fire hydrants and hoses for larger ships, but have not included a reconsideration of the strategies and methods used in emergency situations such as fires, states DMAIB.
The report is available here.