Commodore Clipper - Marine Accident Investigation Branch

More documents

Recommendations

Info

Pursuant to Regulation 6 of Chapter XI -1 of the International Convention for the Safety of Life at Sea (SOLAS) and the Code of the International Standards and Practices for a Safety Investigation into a Marine Casualty (Casualty Investigation Code) (Resolution MSC.255 (84)), the MAIB has investigated this accident with the co-operation and assistance of the Bahamas Maritime Authority. Their contribution to this investigation is acknowledged and greatly appreciated. Extract from The United Kingdom Merchant Shipping (Accident Reporting and Investigation) Regulations 2005 – Regulation 5: “The sole objective of the investigation of an accident under the Merchant Shipping (Accident Reporting and Investigation) Regulations 2005 shall be the prevention of future accidents through the ascertainment of its causes and circumstances. It shall not be the purpose of an investigation to determine liability nor, except so far as is necessary to achieve its objective, to apportion blame.” NOTE This report is not written with litigation in mind and, pursuant to Regulation 13(9) of the Merchant Shipping (Accident Reporting and Investigation) Regulations 2005, shall be inadmissible in any judicial proceedings whose purpose, or one of whose purposes is to attribute or apportion liability or blame. © Crown copyright, 2011 You may re-use this document/publication (not including departmental or agency logos) free of charge in any format or medium. You must re-use it accurately and not in a misleading context. The material must be acknowledged as Crown copyright and you must give the title of the source publication. Where we have identified any third party copyright material you will need to obtain permission from the copyright holders concerned. All MAIB publications can be found on our website: www.maib.gov.uk For all enquiries: Email: maib@dft.gsi.gov.uk Telephone: +44 (0) 23 8039 5500 Fax: +44 (0) 23 8023 2459 The Bahamas Maritime Authority 120 Old Broad Street London EC2N 1AR M A R I N E A C C I D E N T I N V E S T I G A T I O N B R A N C H Marine Accident Investigation Branch Mountbatten House Grosvenor Square Southampton SO15 2JU
CONTENTS GLOSSARY OF ABBREVIATIONS AND ACRONYMS Page SYNOPSIS 1 SECTION 1 - FACTUAL INFORMATION 3 1.1 Particulars of Commodore Clipper and accident 3 1.2 Background 4 1.3 Events leading up to the fire 4 1.3.1 Cargo operations in Jersey 4 1.3.2 Departure from Jersey and return passage 4 1.4 Fire 4 1.4.1 Early fire development 4 1.4.2 Initial response 6 1.4.3 Confirmation 6 1.4.4 General emergency stations 8 1.4.5 Muster stations 8 1.4.6 Containment 10 1.4.7 First assessment 12 1.4.8 Entering the Solent 13 1.4.9 Deteriorating condition 13 1.4.10 Loss of power to machinery 14 1.5 Initial emergency response 16 1.5.1 Command and control 16 1.5.2 Specialist fire-fighting support 16 1.5.3 First re-entry to the main vehicle deck 17 1.5.4 Preparations for entering harbour 18 1.5.5 Second re-entry to the main vehicle deck 19 1.5.6 Planned entry to Portsmouth Harbour 20 1.5.7 Stern ramp hydraulics 20 1.5.8 Helicopter transfer 21 1.5.9 Delay 22 1.5.10 Entry into Portsmouth Harbour 22 1.6 Emergency response once Commodore Clipper was alongside 24 1.6.1 Pedestrian access 24 1.6.2 Passenger evacuation 24 1.6.3 Assessment 25 1.7 Fire-fighting tactics 26 1.7.1 Visibility 26 1.7.2 Escalation 26 1.7.3 Cargo handling 29 1.7.4 Statutory powers of intervention 30 1.8 Fire extinction and passenger disembarkation 31 1.8.1 Access to the seat of the fire 31 1.8.2 MCA response 31 1.8.3 Removal of the last burning trailers 32 1.9 Key personnel 33 1.9.1 Crew 33 1.9.2 Company staff 34 1.9.3 Training 34 1.10 Damage to structure and systems 34 1.10.1 Structural damage 34 1.10.2 Steering gear 35 1.10.3 Fire detection system 35 1.10.4 Electrical distribution systems 36 1.10.5 Fire-fighting and water spraying systems 36 1.10.6 Ro-ro hydraulic systems 37
Page 1: ACCIDENT REPORT M A R I N E A C C I
Page 5 and 6: 2.10 Management of the emergency re
Page 7 and 8: GLOSSARY OF ABBREVIATIONS AND ACRON
Page 9 and 10: SYNOPSIS At 0242 (BST) on 16 June 2
Page 11 and 12: SECTION 1 - FACTUAL INFORMATION 1.1
Page 13 and 14: Figure 1 Sequence of images recorde
Page 15 and 16: Figure 3 Schematic diagram of the i
Page 17 and 18: ‘AO’ class deck boundary Green
Page 19 and 20: Figure 5 Cloud of steam from the up
Page 21 and 22: A few seconds later, just before 03
Page 23 and 24: By 0523 it had been reported that m
Page 25 and 26: helicopter stationed at Lee-on-the-
Page 27 and 28: needed to be considered. However, t
Page 29 and 30: the system could not be started. Wi
Page 31 and 32: Reproduced from Admiralty Chart BA
Page 33 and 34: MAIB inspectors later found a route
Page 35 and 36: combined effect of using the heelin
Page 37 and 38: 1.7.3 Cargo handling When the fire
Page 39 and 40: At 1810, the CPSO relayed his concl
Page 41 and 42: From 2100 to 2130 firefighters exti
Page 43 and 44: The deck boundary between the main
Page 45 and 46: 1.10.6 Ro-ro hydraulic systems A nu
Page 47 and 48: Deck drain blocked by potatoes Deck
Page 49 and 50: Heat damage to tyre Charred and del
Page 51 and 52: 1.12.2 Refrigerated trailer system
Page 53 and 54:
Three electrical control and power
Page 55 and 56:
Damaged external power supply conne
Page 57 and 58:
X-ray of the external power supply
Page 59 and 60:
The three other examples of reefer
Page 61 and 62:
The webbing strap, curtain-side and
Page 63 and 64:
Commodore Clipper’s master held a
Page 65 and 66:
During the night of 8/9 October 201
Page 67 and 68:
SECTION 2 - ANALYSIS 2.1 AIM The pu
Page 69 and 70:
likely that a high resistance fault
Page 71 and 72:
appropriate for special category sp
Page 73 and 74:
vessel’s ability to berth without
Page 75 and 76:
Although the vertical position of t
Page 77 and 78:
2.6.2 Role of the master The master
Page 79 and 80:
2.7 ENTRY TO HARBOUR 2.7.1 Pilotage
Page 81 and 82:
Another possible option might have
Page 83 and 84:
2.9.2 Cargo handling It was evident
Page 85 and 86:
Instead, local control centres prol
Page 87 and 88:
the vessel’s arrival could be int
Page 89 and 90:
2.11 wIDER RISkS 2.11.1 Vulnerabili
Page 91 and 92:
SECTION 3 - CONCLUSIONS 3.1 SAFETY
Page 93 and 94:
8. The deck boundary between the ma
Page 95 and 96:
SECTION 4 - ACTION TAkEN 4.1 MAIB A
Page 97 and 98:
Hampshire Fire and Rescue Services
Page 99 and 100:
The Bahamas Maritime Authority is r
Page 101 and 102:
Name of vessel COMMODORE CLIPPER Na
Page 103 and 104:
Page 105 and 106:
Name of vessel COMMODORE CLIPPER Lo
Page 107 and 108:
Name of vessel COMMODORE CLIPPER Fi
Page 109 and 110:
Page 111 and 112:
Page 116 and 117:
Report of the examination of the el
Page 118 and 119:
Cobham Technical Services ERA Techn
Page 120 and 121:
Page 122 and 123:
Page 124 and 125:
Page 126 and 127:
Page 128 and 129:
Page 130 and 131:
Page 132 and 133:
Page 134 and 135:
Page 136 and 137:
Page 138 and 139:
Page 140 and 141:
Page 142 and 143:
Page 144 and 145:
12 November 2010 Dear Commodore Cli
Page 146 and 147:
Side curtain webbing Figure 2 Exper
Page 148 and 149:
Figure 4 Localised damage to inner
Page 150:
Figure 7 Ignition of curtain materi
Page 175 and 176:
Bahamas Maritime Authority 20 Old B
Page 177 and 178:
BACKGROUND At 0242 (BST) on 16 June
Page 179 and 180:
MAIB flyer to ro-ro vessel operator
Page 181 and 182:
With tugs standing by, Commodore Cl
Page 183 and 184:
Safety Lessons Ro-ro ferry operator
show all

Commodore Clipper - Marine Accident Investigation Branch

Create successful ePaper yourself

Delete template?

Save as template?