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MARINEA
CCIDENT
INVESTIGATIO
N
BRANCH
ACCIDENT
REPORT
Report on the investigation of
the fire on the main vehicle deck of
Commodore Clipper
while on passage to Portsmouth
16 June 2010
LESS SERIOUS MARINE CASUALTY REPORT NO 24/2011 NOVEMBER 2011
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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 great
ly 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 identied 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: [email protected]
Telephone: +44 (0) 23 8039 5500Fax: +44 (0) 23 8023 2459
M A R I N E A C C I D E N T I N V E S T I G A T I O N B R A N C H
Marine Accident Investigation Branch
Mountbatten House
Grosvenor Square
Southampton
SO15 2JU
The Bahamas Maritime Authority
120 Old Broad Street
LondonEC2N 1AR
http://www.maib.gov.uk/mailto:maib%40dft.gsi.gov.uk?subject=Enquiry%20mailto:maib%40dft.gsi.gov.uk?subject=Enquiry%20http://www.maib.gov.uk/7/28/2019 Details Report of Fire Fighting on Main Deck for Reefere Trailer Socket on Commodoreclipper_compiled
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CONTENTS PageGLOSSARYOFABBREVIATIONSANDACRONYMS
SYNOPSIS 1
SECTION1-FACTUALINFORMATION 3
1.1 ParticularsofCommodore Clipperandaccident 31.2 Background 41.3 Eventsleadinguptothere 4
1.3.1 CargooperationsinJersey 41.3.2 DeparturefromJerseyandreturnpassage 4
1.4 Fire 41.4.1 Earlyredevelopment 41.4.2 Initialresponse 61.4.3 Conrmation 61.4.4 Generalemergencystations 81.4.5 Musterstations 8
1.4.6 Containment 101.4.7 Firstassessment 121.4.8 EnteringtheSolent 131.4.9 Deterioratingcondition 131.4.10 Lossofpowertomachinery 14
1.5 Initialemergencyresponse 161.5.1 Commandandcontrol 161.5.2 Specialistre-ghtingsupport 161.5.3 Firstre-entrytothemainvehicledeck 171.5.4 Preparationsforenteringharbour 181.5.5 Secondre-entrytothemainvehicledeck 191.5.6 PlannedentrytoPortsmouthHarbour 20
1.5.7 Sternramphydraulics 201.5.8 Helicoptertransfer 211.5.9 Delay 221.5.10 EntryintoPortsmouthHarbour 22
1.6 EmergencyresponseonceCommodore Clipperwasalongside 241.6.1 Pedestrianaccess 241.6.2 Passengerevacuation 241.6.3 Assessment 25
1.7 Fire-ghtingtactics 261.7.1 Visibility 261.7.2 Escalation 261.7.3 Cargohandling 291.7.4 Statutorypowersofintervention 30
1.8 Fireextinctionandpassengerdisembarkation 311.8.1 Accesstotheseatofthere 311.8.2 MCAresponse 311.8.3 Removalofthelastburningtrailers 32
1.9 Keypersonnel 331.9.1 Crew 331.9.2 Companystaff 341.9.3 Training 34
1.10 Damagetostructureandsystems 341.10.1 Structuraldamage 341.10.2Steeringgear 351.10.3 Firedetectionsystem 35
1.10.4 Electricaldistributionsystems 361.10.5 Fire-ghtingandwatersprayingsystems 361.10.6 Ro-rohydraulicsystems 37
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1.11 Stability 371.11.1 Approvedstabilitybook 371.11.2 Damagestabilityinformation 371.11.3 Approvedonboardloadingcomputer 381.11.4 Loadingconditionfor15-16June2010 381.11.5 Effectofdrenchingwateronstability 381.11.6 Requirementsforpreventionofre-ghtingwateraccumulatingin ro-rospaces 40
1.12 Technicalinvestigation 401.12.1 Examinationoftherescene 401.12.2 Refrigeratedtrailersystem 431.12.3 Electricalexamination 481.12.4 Reefercables 501.12.5 Reactiontoretests 51
1.13 Portinformation 531.13.1 Portsmouthharbourauthorities 531.13.2 PortsmouthInternationalPort 551.13.3 Portinfrastructure 55
1.14 Commandandcontrolofemergencies 551.15 Othersimilaraccidents 56
1.16 OngoingdevelopmentworkattheIMO 571.16.1 Watersprayingsystems 571.16.2 Structuralreprotection 571.16.3 Stability 571.16.4 SOLASamendments2008and2009 58
SECTION2-ANALYSIS 59
2.1 Aim 592.2 Causeofthere 59
2.2.1 Reefercableassembly 592.2.2 Refrigeratedtrailerequipment 60
2.2.3 Electricalprotection 602.2.4 Trailerignition 612.3 Initialresponseandreescalation 61
2.3.1 Crewresponsetotherealarm 612.3.2 Effectivenessofthevehicledeckwaterdrenchingsystem 622.3.3 Abilityofcrewtoghtthereatsea 632.3.4 Containment 63
2.4 Firedamagetoshipssystems 642.4.1 Consequencesofredamagetosystems 642.4.2 Effectivenessofregulations 65
2.5 Stabilityissues 652.5.1 Deckdrainblockages 652.5.2 Marginofstability 66
2.5.3 Requirementsfordamagestabilityinformation 672.6 Useofspecialisedprofessionalreghters 68
2.6.1 Informationgatheringandassessment 682.6.2 Roleofthemaster 692.6.3 ConstraintsontheuseofMIRG 702.6.4 Specialisedplanning 70
2.7 Entrytoharbour 712.7.1 Pilotagerequirements 712.7.2 Planningandco-ordination 72
2.8 Passengerdisembarkation 722.8.1 Designfactorsandtheeffectofregulations 722.8.2 Portinfrastructure 73
2.8.3 Balanceofrisktothepassengers 732.9 Fire-ghtingtactics 742.9.1 Accesstotheseatofthere 742.9.2 Cargohandling 75
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2.10 Managementoftheemergencyresponse 762.10.1 Responsibility 762.10.2 Communicationandco-ordination 762.10.3 TheroleoftheSOSREP 782.10.4 Jurisdiction 782.10.5 Understandingspecialisedvesseltypes 792.10.6 Effectiveuseofavailableassets 802.10.7 Sharedstrategicplan 80
2.11 Widerrisks 812.11.1 Vulnerabilityofvehicledecks 812.11.2 Flammabilityofroadcargoes 812.11.3 Abilityofexistingmeasurestocontrolresinvehicledecks 81
2.12 Fatigue 82
SECTION3-CONCLUSIONS 83
3.1 Safetyissuesdirectlycontributingtotheaccidentwhichhaveresulted inrecommendations 833.2 Othersafetyissuesidentiedduringtheinvestigationalsoleadingto recommendations 83
3.3 Safetyissuesidentiedduringtheinvestigationwhichhavebeenaddressed orhavenotresultedinrecommendations 84
SECTION4-ACTIONTAkEN 87
4.1 MAIBactions 874.2 Actionstakenbyotherorganisations 87
SECTION5-RECOMMENDATIONS 90
FIGURES
Figure1 - SequenceofimagesrecordedbyCCTVcamerano.7from0237BST
Figure2 - LayoutofCCTVcamerasonthemainvehicledeck
Figure3 - Schematicdiagramoftheinitialsmokedetectoractivationandalarm silencingsequence
Figure4 - GeneralarrangementofCommodore Clipperandlocationofthere
Figure5 - Cloudofsteamfromtheuppervehicledeckasboundarycoolingwas started
Figure6 - Heatdamagetotheuppervehicledeck
Figure7 - AnnotatedchartofEasternApproachestotheSolent
Figure8 - Accessplatformatdeck4abovethemainvehicledeck
Figure9 - Cargostowagediagram
Figure10 - ChartwithinsetshowingtheberthsavailableatPIP
Figure11 - Viewofthemainvehicledeckafterthesternrampwasopened
Figure12 - PartiallyburntdebrisontrailerFS61
Figure13 - Stevedorewearingbreathingapparatusinordertoremovetrailersfrom thesmoke-lledvehicledeck
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Figure14 - TrailerCRF461continuingtoburnafterbeingremovedfromthemain vehicledeck
Figure15 - Blockedvehicledeckdrains
Figure16 - CharredanddelaminatedtyresontrailerGC13-1
Figure17 - TrailerCRF439
Figure18 - TrailerCRF461
Figure19 - TrailerCRF459
Figure20 - Insulatedcurtain-sidematerial
Figure21 - Dieselgenerator,refrigerationcompressorandfueltank
Figure22 - Electricalcontrolandpowerdistributionboxes
Figure23 - Externalpowersupplysocket
Figure24 - DamagedexternalpowersupplyconnectionontrailerCRF459
Figure25 - Reeferpowersupplycable
Figure26 - X-rayoftheexternalpowersupplyconnectionontrailerCRF459
Figure27 - Examinationofthereeferpowersupplyplugattachedtotrailer CRF459
Figure28 - StarToppluginstructionleaet
Figure29 - OtherStarTopplugconnectionsassembledonboard CommodoreClipper
Figure30 - IgnitionoftheStarTopplugaftersustainedinternalheating
Figure31 - Ignitionofthecurtain-sidematerial
Figure32 - DivisionofStatutoryandCompetentHarbourAuthorityareasof jurisdiction
Figure33 - Linesofcommunicationduringtheresponsetotheincident
ANNEXES
AnnexA - Classicationsocietysreportofthedamagecausedbythere
AnnexB - IMOResolutionA.123(V)
AnnexC - Reportoftheexaminationoftheelectricalcomponents
AnnexD - Reportsonthereactiontoretesting
AnnexE - MAIBSafetyBulletin3/2010
AnnexF - MAIByertoro-rovesseloperatorsandtheportsindustry
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GLOSSARYOFABBREVIATIONSANDACRONYMS
ABB AseaBrownBoveri
ALP AerialLadderPlatform
ARCC AeronauticalRescueCo-ordinationCentre
BA BreathingApparatus
BMA BahamasMaritimeAuthority
BST BritishSummerTime
CCTV ClosedCircuitTelevision
CGLO CoastguardLiaisonOfcer
CHA CompetentHarbourAuthority
CMS CondorMarineServices
CPSO CounterPollutionandSalvageOfcer
DAO DutyAreaOfcer
DNV DetNorskeVeritas
DOD DutyOperationsDirector
DPA DesignatedPersonAshore
DQHM DutyQueensHarbourMaster
ECR EngineControlRoom
EEBD EmergencyEscapeBreathingDevice
FLM FireLiaisonManager
HFRS HampshireFireandRescueService
HMCG HerMajestysCoastguard
Hz Hertz
IDC InsulationDisplacementConnector
IEC InternationalElectrotechnicalCommission
IMO [The]InternationalMaritimeOrganization
IP IngressProtection[rating]
ISM InternationalSafetyManagement[Code]
kW kilowatt
MCA MaritimeandCoastguardAgency
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MIRG MarineIncidentResponseGroup
MOD MinistryofDefence
MOU MemorandaofUnderstanding
MSC MaritimeSafetyCommittee
OOW OfceroftheWatch
OSB OuterSpitBuoy
PEC PilotageExemptionCerticate
PIP PortsmouthInternationalPort
PMSC PortMarineSafetyCode
QHM QueensHarbourMaster
RAF RoyalAirForce
SAR SearchandRescue
SHA StatutoryHarbourAuthority
SLF IMOSub-CommitteeonStabilityandLoadLinesandFishingVesselsSafety
SOLAS InternationalConventiononSafetyofLifeatSea
SOLFIRE SolentandSouthamptonWaterMarineEmergencyPlanSOSREP SecretaryofStatesRepresentative
STCW InternationalConventiononStandardsofTraining,CerticationandWatchkeepingforSeafarers
VCG VerticalCentreofGravity
VDR VoyageDataRecorder
VHF VeryHighFrequency
Times: Alltimesusedinthisreportarelocal(UTC+1)unlessotherwisestated.Timingstakenfromautomatedshipandcoastguardsystemsareallcorrectedtomatchvoyagedatarecordertime
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SYNOPSIS
At0242(BST)on16June2010,arewasdetectedonthemainvehicledeckoftheBahamasregisteredro-roferryCommodoreClipper. ThevesselwasonpassagefromJerseytoPortsmouthandthevehicledeckwasloadedwithmanyfreighttrailers.Thecrewidentiedthatanunaccompaniedrefrigeratedtrailerunit,poweredfromtheshipselectricalsupply,hadcaughtre.
Thecrewcontainedthereusingthevehicledeckwaterdrenchingsystemandboundarycoolingfromabove,butwerenotabletoextinguishit.Firedamagetounprotectedcablesandpipeworkinthemainvehicledeckcausedextensivedisruptiontosystems,affectingthevesselsabilitytomanoeuvreandcontainthere.Fire-ghtingeffortshadtobesuspendedascargodebrisblockedvehicledeckdrains,causingwaterfromthere-ghtingefforttoaccumulateandreducethevesselsstability.
AlthoughCommodore ClipperwasclosetoPortsmouthharbour,berthingwassignicantlydelayedthroughineffectiveco-ordinationbetweenshoreagenciesandbecauseofequipmentdefects.Oncealongside,thehighdensityofcargoandconstraintsinthedesignofthevessellimitedaccesstobothghtthereandtodisembarkthepassengers.Asaconsequence,freighttrailershadtobetowedoffthevesselbeforetherecouldbeextinguished.Thelastofthe62passengersdisembarkedfromthevesselnearly20hoursaftertherestarted.
Theinvestigationidentiedthattherestartedduetooverheatinginanelectricalcablethatprovidedpowerfromtheshiptooneoftherefrigeratedtrailerunits.Thematerialsusedbothinthecurtain-sidesandthecargopackagingburntreadily.
Thevesselmanagersandportauthoritieshavetakenarangeofactionsduringtheinvestigationwhichshouldreducethelikelihoodofasimilaraccidentrecurring,andimprovetheirabilitytorespondtofutureemergencies.TheMaritimeandCoastguardAgency(MCA)hasundertakentoimplementanumberofrecommendationsresultingfromaninternalreviewofitsresponsetotheincident.
TheMAIBhasmaderecommendationstotheMCAandthePortMarineSafetyCode(PMSC)steeringgroupregardingtheresponseto,andmanagementofsimilarincidentsinthefuture.
TheChiefInspectoroftheMAIBhaswrittentotheSecretaryGeneraloftheInternationalMaritimeOrganization(IMO)requestingthatthisreportandthereportsoftheinvestigationsintotheresonboardAl Salaam Boccacio 98,Und Adriyatik,Lisco GloriaandPearl of
Scandinavia,arereviewedwiththeaimofidentifyingimprovementsthatcanbemadetothereprotectionstandardsappliedtoro-ropassengervesselsconstructedbefore1July2010toenhancetheirsurvivabilityandsafereturntoportintheeventofavehicledeckre.
TheBahamasMaritimeAuthority(BMA)hasagreedtomakeasubmissiontotheInternationalMaritimeOrganizationonprovidingimprovedstabilityinformationtomastersofvesselsandtoworkwiththeMCAonajointsubmissionregardingpedestrianaccesstoro-roferries.
TheMAIBissuedasafetybulletininJuly2010identifyingtheriskofpowersupplycablestorefrigeratedtrailersoverheating,andhaspublishedayertoraiseawarenessofthesafetyissuesintheferryandportmanagementsectorsoftheindustry.
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CommodoreClipper
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SECTION1-FACTUALINFORMATION
1.1 PARTICULARSOFCommodore ClipperANDACCIDENT
SHIPPARTICULARS
Flag Bahamas
Classicationsociety DetNorskeVeritas(DNV)
IMOnumber 9201750
Type Ro-ropassenger
Registeredowner CondorLimited
Manager(s) CondorMarineServices
Construction Steel
Lengthoverall 129.14m
Registeredlength 118.7m
Grosstonnage 14000
Minimumsafemanning 13
Authorisedcargo Notapplicable
VOYAGEPARTICULARS
Portofdeparture StHelier,Jersey
Portofarrival Portsmouth,UK
Typeofvoyage Shortinternationalvoyage
Cargoinformation Carsandroadfreighttrailers
Manning 39crew
MARINECASUALTYINFORMATION
Dateandtime 16June2010,0242
Typeofmarinecasualtyorincident LessSeriousMarineCasualty
Locationofincident 50o18.87N,001o29.76W
Placeonboard Deck3,specialcategoryspace
Injuries/fatalities None
Damage/environmentalimpact Materialdamagetothevessel
Shipoperation Onpassage
Voyagesegment Midwater
External&internalenvironment Dark,goodweatherconditions
Personsonboard 62passengersand39crew
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1.2 BACkGROUND
Commodore ClipperprovidedapassengerandvehiclefreightservicelinkingSt.PeterPort,GuernseyandSt.Helier,JerseyintheChannelIslandswithPortsmouth.Oneroundtripofallthreeportswascompletedineach24-hourperiodfromMondaytoSaturday.Atthetimeoftheaccident, Commodore Clipperwasontheovernightleg,fromSt.HeliertoPortsmouth.Thevesselwascertiedtocarry500passengers,but62wereonboardatthetime.Thevehicledeckswerealmostfulltocapacity,mainlywithunaccompaniedroadfreighttrailers.
1.3 EVENTSLEADINGUPTOTHEFIRE
1.3.1 CargooperationsinJersey
On15June2010, Commodore ClippersailedfromSt.PeterPortat1747andarrivedatSt.Helierat1940.ThemainseasonforexportingJerseyRoyalpotatoeswasreachingitsend;24ofthe77trailersthatwereloadedonboardwererefrigeratedunits,carryingpre-packagedpotatoesfordeliverystraighttosupermarkets.Thereweretoomanyrefrigeratedtrailerstoallowthemalltobeloadedontheupper
vehicledeck(deck5),whichwasintheopenairandwouldhaveallowedtheirdiesel-poweredfridgeunitstoberun.Consequently,thoserefrigeratedtrailersthatcouldbepoweredfromtheshipselectricalsystemwereloadedontothemainvehicledeck(deck3).Thesetrailerswereconnectedtopowersocketsondeck3bystaffworkingforthehaulagecompany,usingcablesprovidedonboard CommodoreClipper.
1.3.2 DeparturefromJerseyandreturnpassage
Cargooperationsandshipstabilitycalculationswerecompletedand CommodoreClipperdepartedfromSt.Helierat2145.Theweatherwasfair,theshipmadegoodprogresstoPortsmouthandwasabletoreducetoamoreeconomicalspeed.Crew
conductedreandsecuritychecksoftheaccommodationthroughthenighthours.TheOfceroftheWatch(OOW)andlookoutmaintainedaperiodiccheckonthevehicledecksfromthebridge,bymonitoringtheclosedcircuittelevision(CCTV)andredetectionsystems.
Masters,deckofcersandmanagershadidentiedthatthevesselsrepetitivedailyscheduledidnotprovidebridgewatchkeeperswiththebestopportunitiestorestiftraditionalwatchhandovertimeswerekept.Accordingly,thetwosecondofcershandedoverthebridgewatchat0230.Navigationaltrafcwaslightandtherewerenoindicationsofanyproblemsonboard.Atabout0240,theoff-goingsecondofcermadehiswayfromthebridgetothemessroom.Hedidnotnoticeanythinguntowardorsmellanysmokeashepassedthroughtheaccommodation.
1.4 FIRE
1.4.1 Earlyredevelopment
At0237,thepicturerecordedbyCCTVcamera7ontheportsideofthemainvehicledeckstartedtogethazy(Figure1).Thevehicledecklightingbegantoappearmorediffusedandthepicturegraduallyfadedgrey.Shortlyafterwardsamachinerycontrolalarmshowedanearthfaultatthebus-tiebreakerlinkingthetwopartsofthemain400Velectricaldistributionsystem.Thethirdengineer,ondutyintheenginecontrolroom,alsoheardthenoiseofthebreakeropening.Twominuteslater,at0241,theimagerecordedonCCTVcamera6,atthecentrelineofthemainvehicledeck(Figure2),begantodarken.
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Figure1
SequenceofimagesrecordedbyCCTVcamera
no.7from0237BST(CCTVtimingsareinUTC)
Figure2
LayoutofCCTVcamerasonthe
mainvehicledeck
Camera
7
Camera6
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1.4.2 Initialresponse
Theshipsredetectionsystemhadcontrolstationsonboththebridgeandintheenginecontrolroom(ECR).Thesystemhadnoparticularhistoryofspurious,nuisancealarms,andcompanyproceduresallowedeithertheOOWordutyengineertorespondtoanalarmandco-ordinatetheinitialresponse.Thealarmactivatedinbothlocationsat0242:36,indicatingthatsensorD24ontheportsideatthemidshipssectionofthevehicledeckhaddetectedsmoke.SensorsoneithersideofD24activatedwithinthenext30seconds (Figure3).ThethirdengineerhadgonetotheauxiliaryengineroomandhereturnedtotheECRtoinvestigatethealarm.Hesilencedthealarmandcontactedthesecondofceronthebridgebytelephone,toreportthealarm.At0243,thesecondofcerinstructedthelookouttotakeaportableveryhighfrequency(VHF)radioandgoandcheckthemainvehicledecktoconrmiftherewasare.
Thethirdengineerhadnotsmelledanysmokeandsuspectedthatthealarmmightbeduetoafaultycomponentinthedetectionsystem.Aftercallingthebridge,hetelephonedtheelectricaltterandaskedhimtoinvestigateiftherewasafaultwiththeredetectionsystem.Thethirdengineercontinuedtosilencethealarmafurther
sixtimesduringthenextthreeminutesbeforeresettingthesystemat0245:42.
Aftertheredetectionsystemhadbeenreset,thesensorsreactivatedandtherealarmsoundedagain.Thesecondofcersilencedthealarmonthebridgeat0246:20andresetthesystemfromhiscontrolstationimmediatelyafterwards.Bythetimetheredetectionsystemhadreactivated,10differentsensorsontheportsideofthemainvehicledeck,rangingfromtheoriginallocationmidships,allthewayafttothesternramp,haddetectedsmoke.
1.4.3 Conrmation
Thelookoutknewthattheportableradiothathewasassignedwasnotreliable,
andwasconcernedthathemightbecomeinjuredortrappednearthereandnotbeabletosummonhelp.Afterleavingthebridge,ratherthangostraighttothemainvehicledeckhewenttothepassengerrestaurantondeck7andmetthetwonightstewards.Theycouldsmellsmokeinthearea,andthelookoutreturnedtothebridgeat0248.Meanwhile,thesecondofcerwastalkingtothethirdengineerintheECRusingthebridgetelephone.Itwaspossibletodetermine,fromlisteningtothesecondofcerssideoftheconversationonthevoyagedatarecorder(VDR),thatthetwoofcershadconcludedthatthelikelycauseoftherealarmwasaproblemwiththedetectionsystem.Thethirdengineersubsequentlytelephonedthechiefengineertoreportthattherewasaproblemwiththeredetectionsystemandthatitcouldnotbereset.
Theredetectionsystemceasedtofunctionat0249:12;6minutesand54seconds
aftertherstalarm.Duringthisperiod,16sensorsdetectedsmoke,activatingacombinedtotalof81times.Thesystemhadbeensilenced11timesandreset7timesbythecombinedinputsfromthebridgeandECRcontrolstations.
Thelookoutreportedtothesecondofcerthathehadsmelledsmokeintheaccommodationarea,butthathehadonlybeenasfarastherestaurant.Thesecondofcertoldhimtogotothemainvehicledeck;thelookoutleftthebridgeatabout0250.Overthenext7minutes,thesecondofcerreceived8distortedandunreadablecallsonhisportableVHFradio,allofwhichhethoughtwerelikelytohavebeenfromthelookout.
Throughoutthisperiod,theelectricaltterhadbeenattemptingtogainaccessto
themainvehicledecktochecktheredetectionsensors.Hewasbeatenbackbysmoke,andwenttotheECRinstead.Theelectricaltterreportedthesmoketothethirdengineer,andthetwomenisolatedtheelectricalpowersuppliestotherefrigeratedtrailerunitsonthemainvehicledeck.Thethirdengineeralsostartedanauxiliarygeneratortotaketheelectricalloadfromtheshaftgenerator.
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Figure3
Schematicdiagramo
ftheinitialsmokedetectoractivationandalarms
ilencingsequence
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RecordingsfromalltheCCTVcamerasonthemainvehicledeckshowedincreasinglyheavysmoke;visibilitywaslostby0254.ThesecondofcerreportedthathelookedattheCCTVpicturesofthemainvehicledeck,butdidnotseeanyindicationofare.Machineryalarmrecordsindicatedthattheventilationfansonboththemainanduppervehicledeckswerestoppedatabout0255.However,thesystemhadanin-builtdelayof5minutesbetweenthefansstoppingandthemachineryalarmbeingactivated.Consequently,thevehicledeckfanswouldhavestoppedatabout0250andthiswascloselyfollowedbyasecondearthfaultbeingrecordedatthebus-tiebreaker.Thedampersontheventilationinletswerearrangedtoshutautomaticallybutpre-datedtherequirementfortheirpositiontobeindicatedremotely.
Atabout0258,themachinerycontrolsystemrecordedfailalarmsonbothsteeringgearno.1(port)andsteeringgearno.2(starboard).Therewasnoapparentfaultwiththesteering;themachineryrecordsshowedthatthealarmswereacceptedshortlyafterwardsandtheydidnotrecur.
1.4.4 Generalemergencystations
Thechiefengineerhadbeenasleepinhiscabinondeck9whenthethirdengineerreportedtheactivationoftheredetectionsystemandhisconclusionthatitwasafalsealarm.Thechiefengineerdecidedtogototheclosestredetectionsystemcontrolstationonthebridgetotryandndoutwhatwaswrong.Hesmelledsmokeassoonasheopenedhiscabindoor,andwentstraighttothebridge.Thesecondofceronwatchreportedthatmanyredetectionsensorsonthemainvehicledeckhadbeenactivated,butthathewasnotsurewhy.Thechiefengineerconcludedthemostlikelyreasonwasthattherewasare,ratherthanafaultwiththeredetectionsystem.At0259:20,thelookoutcalledthesecondofcerbytelephoneandconrmedthattherewasareonthemainvehicledeck.Thechiefengineeractivatedthecrewalertsignalat0301andthen,concernedthatthesituationwasseriousanddevelopingrapidly,activatedthegeneralemergencysignalimmediately
afterwards.Atthesametime,thesecondofcertelephonedthemasterandchiefofcerintheircabinsandtoldthemtherewasareonthemainvehicledeck.
Thechiefengineerturnedtheswitchonthebridgetoensurethatthevehicledeckventilationfanshadbeenshutdown.Hethenstartedthevehicledeckdrenchingsystem1insection4,theimmediatelocationofthere(Figure4).Atabout0306,mainvehicledeckwaterleakagealarmsweretriggered,indicatingthatwaterfromthedrenchershadstartedtodrainoverboardfromthecompartment.
1.4.5 Musterstations
Themasterandchiefofcerarrivedonthebridgesoonafterthealarmwassounded,andwerebriefedbythechiefengineer.Themastermadean
announcementonthepublicaddresssystemforallthepassengerstomusterattheassemblystations,andtherescreendoorswereshut.Thechiefengineeractivatedthedrenchersinsection6inadditiontosection4andleftthebridgetogotohismusterpointatthesafetystationondeck3.Thechiefofcerwenttohismusterpointatthesafetystationondeck9.
Hotelstaffcheckedeachcabininturnanddirectedthepassengerstotheassemblystationsateithertherestaurantondeck7orthebarondeck8,wheretheywereissuedwithlifejackets.
Crewinemergencyteam1musteredatthesafetystationondeck9andbegantoputonre-ghtingsuitsandbreathingapparatus(BA).Smokefromthemainvehicle
deckhadgatheredinthecentralstairwell,andcrewinemergencyteam2,whowere
1Anapprovedmanuallyoperatedxedpressurewatersprayingsystemwasttedinthemainvehicledeckas
requiredbySOLASChapterII-2,Regulation20andresolutionA.123(V).Thiswasknownonboardasthe
vehicledeckdrenchingsystem.
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Blu
estairs
Greenstairs
AOclass
deckboundary
Heat
affectedarea
Fire
Smoke
Smoke
Bluestairs
Greenstairs
Drenchersection6
Drenchersection4
Mainvehi
cledeck
Upperveh
icledeck
Figure4
GeneralarrangementofCom
modoreClipperandlocationo
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assignedtomusteratthesafetystationondeck3,wereunabletogetthrough.Theymusteredattherelockerondeck7andsubsequentlyjoinedupwithemergencyteam1.Thechiefengineer,realisingthatno-oneelsewascomingtojoinhim,leftthesafetystationondeck3andwenttotheECRtocheckonthemainmachineryandconrmthatelectricalpowertotherefrigeratedtrailerunitshadbeenturnedoff.
Thelookouthadusedanemergencyescapebreathingdevice(EEBD)toenterthevehicledeckfromboththestarboardforwardandcentrelineaccessdoorsinordertoconrmthelocationofthere.Aftertelephoningthesecondofcer,hereturnedtothebridgeandreportedtothemasterthatoneoftheunaccompaniedtrailers,ontheportsideataboutthemidshipsposition,wasonre.
At0307,Commodore ClippersmastercalledSolentCoastguard 2onVHFchannel16.HistransmissionwasmixedwithotherradiotrafcandSolentCoastguardaskedhimtocallagainonVHFchannel67.Whenthemastermadecontact,hereportedthattheshiphadareonboardandthatthecrewwereinvestigating.Nodistressorurgencymessageprexeswereused.Twominuteslater,SolentCoastguardcalledbackrequestingthenumberofpeopleonboardandotherinformationabouttheincident.Thesecondofcerprovidedthesedetailsandaskedfortheemergency
servicestomeettheshiponitsarrivalinPortsmouth.At0313,thecoastguardactivateditssearchandrescue(SAR)plansandmadepreparationstonotifytheMarineIncidentResponseGroup(MIRG)incasereghtersfromHampshireFireandRescueService(HFRS)neededtobesentoutto Commodore Clipper.
Allthepassengershadnowmusteredineithertherestaurantondeck7orthebarondeck8.Astairwell,knownonboardasthegreenstairs,ledallthewayupfromthestarboardforwardcornerofthemainvehicledeck(deck3)totherestaurant.Smokefromthevehicledeckhaddriftedupthegreenstairsandhadbeguntomaketheatmosphereintherestaurantunpleasant.Thecrewdecidedtodirectthepassengerswhowereintherestauranttomovetothebarviaadoorontotheupperdeckandsomeexternalstairs.Allthepassengerswereaccountedforandmustered
togetherinthebar.Althoughnotallthecrewwereabletoreachtheirdesignatedmusterpoints,theywereaccountedforquicklyandnoinjurieswerereported.
CondorMarineServices(CMS)DesignatedPersonAshore(DPA)wastravellingonboardasapassenger.Hewenttothebridgetoofferhissupporttothemaster.Themasterhadactivatedcompanyemergencyplansandacall-outsystemtoinformkeyshorestaffwasinitiated.Someshorestaffgatheredinthecompanysofcetoprovidesupportfromashore,whileothersbegantravellingtoPortsmouthtomeettheshiponarrival.TheDPAmaintainedcommunicationswiththeofcethroughouttheincident.
1.4.6 Containment
Thechiefengineerknewthattheventilationinletdampersclosedautomatically,andherequestedthatthebridgeteamsendsomeonetoclosethemanualexhaustdampersattheaftendofthemainvehicledeck.Theoff-watchsecondofcerandadeckcadetwenttothesternviatheuppervehicledeckand,takingEEBDsetsasaprecaution,closedthedampers.
Thechiefofcerledcrewfromemergencyteams1and2totheforwardpartoftheuppervehicledecktoprovideboundarycoolingabovethere.Theystartedtorigtworehosesat0319,andcouldseethatthedeckwasveryhotandstartingtobuckle.Theinitialowofwaterfromthehoseswasdescribedasbeingsteaminghotandmadethemetalnozzlesuncomfortablyhottohold.CCTVcamerasondeck5recordedaverylargecloudofsteambeinggeneratedat0324aswaterwas
sprayedontothedeckareaimmediatelyabovethere (Figure5).
2 HerMajestysCoastguards(HMCG)SolentMaritimeRescueCo-ordinationCentre,referredtobyitsshorttitle,
SolentCoastguard
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Cloudofsteamfromtheuppervehicledeckas
boundarycoolingwasstarted
(CCTVtimingsareinUTC)
Figure5
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ThesecondofceronthebridgecalledSolentCoastguardat0327toupdatethemonthesituation.Healsorequestedthatare-ghtingteambesentouttoCommodore Clipperbyhelicopter.Thecoastguardofcerconrmedthisrequestandagreedtomakethenecessaryarrangements.
Afterabout30minutesofdrenchingandboundarycooling,thechiefandthirdengineersmeasuredthetemperatureoftheuppervehicledeckusingaportableinfra-redthermometer.Theyrecordedaveragedecktemperaturesabovethereof180oC,andnotedthatthesteelplatinghadbuckledandthepaintcoatinghadgone.Theheatdidnotcauseanyofthecarsparkedintheimmediateareaabovetheretoignite(Figure6).
1.4.7 Firstassessment
Commodore Clipperhadcontinuedonitsnormalcoursethroughouttheperiodsince
therehadbeendiscovered,butthemasterhadincreasedtofullservicespeedwhenhearrivedonthebridge.Consequently,by0335thevesselwasabout12nauticalmilestothesouthoftheIsleofWight.
SolentCoastguardofcershadpagedtheMCAsFireLiaisonManager(FLM)andDutyAreaOfcer(DAO),andby0336bothhadtelephonedthecoastguardstationandbeenbriefedonthesituation.TheFLM,areandrescueserviceofceronsecondmenttotheMCAtoco-ordinateMIRGactivity,askedthecoastguardwatchmanagertoconrmifCommodore ClippersmasterhadspecicallyaskedforaMIRGteamtobesenttotheship.Adifferentcoastguardofcerhadcommunicatedwiththeship,andthewatchmanagercouldnotconrmifthemasterhadspecicallyrequestedassistancefromtheMIRG,orjustdiscussedtheoptionsavailable.At
0339,theFLMaskedSolentCoastguardtoobtainmoredetailsabouttherefromCommodore Clipperand,particularly,toconrmifthemasterwantedaMIRGteamtobesenttotheship.SolentCoastguardinterpretedthecommunicationsfromtheshiptomeanthattheMIRGwasnotrequiredimmediately,butshouldbeaskedtostandbyincaseitwassubsequentlyneeded.
Figure6
Heatdamagetotheuppervehicledeck
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Afewsecondslater,justbefore0340,Commodore ClippersmastercalledSolentCoastguardreportingthathethoughtthedrenchersystemandboundarycoolingwerehavingagoodeffectandthattheremighthavebeenextinguished.ThemasteragreedwiththecoastguardthataMIRGteamwasnotrequired,butrequestedthatHFRSmeettheshiponceitwasalongsideinPortsmouth.Themastergaveanestimatedtimeofarrivalof0600,conrmedthattheshipwascarryingnohazardouscargo,andthattheburningtrailerhadbeenidentiedasoneoftheunaccompaniedrefrigeratedtrailerunits.
1.4.8 EnteringtheSolent
By0340,theamountofsmokeescapingfromthemainvehicledeckhadreducedsignicantly,andcrewreportedthattheuppervehicledeckfeltcomfortablywarmastheycheckeditstemperaturewiththebacksoftheirbarehands.At0344,theFLMandDAOhadatelephoneconferencecallwiththecoastguardwatchmanagertoreviewthesituation,anditwasconcludedthattheincidentcouldbedealtwithbyHFRSoncetheshipwasalongside.Themastercalledwithanotherupdateat0352;no-onehadbeenintothemainvehicledecktoconrmthestateofthere,buthewascondenttherewasundercontrolandpossiblyextinguished.Immediately
afterwards,SolentCoastguardcalledtheportcontrolofceoftheQueensHarbourMaster(QHM)Portsmouth.ThecoastguardbriefedtheQHMportcontrolsupervisoronthesituationand,havingconsideredtherisktothedockyardport,thesupervisoragreedtoallowCommodore Clippertoentertheharbour.ResponsibilityforPortsmouthharbourisdividedbetweenQHMandPortsmouthContinentalFerryPort3(PIP).QHMhasstatutoryresponsibilitiesforprotectingthedockyardportandsocontrolstrafcenteringtheharbour.QHMinformedPIPaboutthereat0356.
By0400,thesituationonCommodore Clipperappearedtobeundercontrolandthemasterallowedthepassengerstoreturntotheircabinsiftheywished.Hotelstaffbeganpreparingbreakfastandtheresafetydoorswerereset.
1.4.9 DeterioratingconditionCommodore ClippercontinuedonitsnormalpassagethroughtheSolenttowardsPortsmouthuntilabout0443,whenthemasternoticedthatthevesselwasdevelopingalisttoport,whichreachedanangleofabout5o.Themasterandbridgeteamlookedoutfromthebridgewingstocheckthatwaterwasowingfromthevehicledeckdrains.Somewatercouldbeseenowingoverboardfromthedrains,butatamuchslowerratethanwhenthedrencherswererststarted.Thebridgeteamconcludedthatdebrisfromtherewaspartiallyblockingthevehicledeckdrainsand,becauseofconcernabouttheadverseimpactanaccumulationofwateronthevehicledeckcouldhaveonthevesselsstability,thedecisionwastakentoturnoffthedrenchersystem.Withthedrenchersturnedoff,Commodore Clippergraduallyreturnedupright,andthecrewbeganacycleofactivatingthedrenching
systemuntilthelistreached2-3 oandthenstoppingwhilethelistreduced.Eachtimedrenchingwasstopped,crewontheuppervehicledecknotedthatthetemperatureofthedeckbegantoincrease.
Atabout0445analarmsounded,indicatingthatsomeofthesteeringpumpshadfailed.Oneminutelater,theportruddermovedoverto20tostarboardandtheshipbegantoturn.ThemastertookwayofftheshipandreportedtheproblemtoSolentCoastguardwhilethechiefengineerwenttothesteeringgearcompartmentandcentredtheportrudderusinglocalhydrauliccontrols.Thechiefengineerattemptedtoreconnecttheportcontrolsystem,buttheportrudderwasdrivenbackovertostarboard.Theportcontrolsystemwasdisconnectedandtheportrudderwasleftcentralised.Thestarboardruddercontinuedtorespondtosteeringcommands
and,at0503,Commodore Clippercontinuedonpassage.QHMPortsmouthhadoverheardthereporttothecoastguardandofferedtosenditsdutytugtoassist.
3 PortsmouthCommercialPort,alsoknownasPortsmouthContinentalFerryPort,wasrenamedinJanuary2011
toPortsmouthInternationalPort(PIP).
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Themasterwasconcernedthatsteeragewasnowreducedandthattheremightleadtocontrolofthestarboardrudderbeinglost.HecalledQHMPortsmouthandagreedthathewouldonlyattempttoentertheharbourwithtugassistance.Thestandbytug,SD Bustler,wasalertedandtoldtomeetCommodore ClipperinthevicinityoftheOuterSpitBuoy(OSB) (Figure7).
Figure7
AnnotatedchartofEasternApproachestotheSolent
ReproducedfromAdmiraltyChartBA2037bypermissionoftheControllerofHMSOandtheUKHydrographicOfce
SaintHelens
RoadAnchorage
OuterSpitBuoy
Portsmouth
Portsmouth
Harbour
Isleof
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By0523ithadbeenreportedthatmoresmokewasenteringtheaccommodationfromthegreenstairsandtheliftshaft.Allthesectionsofthedrenchersystemwereactivatedandthechiefofcerleftthebridgetoclosetherescreendoorsandassesstheamountofsmokeintheaccommodation.Furtherearthfaultswererecordedonthemachineryalarmsystem,andthechiefengineerreturnedtothebridgetodiscusstheproblemswiththesteeringgearcontrols.
1.4.10Lossofpoertomachinery
Commodore ClipperwasstillonpassageandexpectingtoarriveinPortsmouthatbetween0630and0640.Atthisstageofthevoyage,theusualprocedurewastostartandtestbothbowthrusters.Afaulthadoccurredwithoneofthebowthrusterstarterswitchesonthebridgeafewdaysbeforetheaccident.Thecrewhadbeenunabletorepairtheswitchandhadre-arrangedthestartingcircuitsothatthebowthrustercouldbestartedfromthebowthrustercompartment.Thechiefofcerhadbynowreturnedtothebridgeandreportedthatthegreenstairs,theaccessroutetothebowthrustercompartment,wereheavilysmoke-logged.At0546,thechiefengineerandchiefofcercollectedBAsetsandusedthesetoenterthebowthrustercompartment.
Withallthedrenchersectionsactivated,thevesselslistincreasedmorequickly.At0552,theDPAnotedthatthelisthadreached6 andthedrencherswerestopped.Themastercommentedthathewasnolongerwillingtoattempttoentertheharbour,andcalledQHMbytelephonetodiscusswherehecouldanchorintheSolent.Afewminuteslateritwasagreedthat Commodore ClipperwouldanchorinStHelensRoad(Figure7)eastoftheIsleofWight.
TheQHMdutyofcer(DQHM)hadbeeninformedaboutthereandcametotheharbourcontrolofcetomonitortheincident.HewasconcernedthatCommodoreClippersconditionwasdeterioratingmorequicklythanhadbeenanticipated.HecalledSolentCoastguardat0600toinformthemthatthemasterwasnolonger
willingtoentertheharbourandthatthevesselwasgoingtoanchor.DQHMaskedSolentCoastguardiftheMIRGwasstandingby,andifitshouldbesentouttothevesseltoassesstheextentofthere.SolentCoastguardagreedthattheywoulddiscusstheoptionsfordeployingtheMIRGwiththeFLM.
OnboardCommodore Clipper,thechiefengineerhadbeenunabletostartthebowthrustersandhadgonetochecktheforwardmooringequipmentwhichwaspoweredfromthesamepartoftheelectricaldistributionnetwork.Nopowerwasavailabletoeitherthebowthrustersortheforwardmooringequipment,soalthoughtheanchorcouldbeletgo,itcouldnotberecovered.Consequently,themasteradvisedQHMthathenolongerwantedtogotoanchor. Commodore ClipperwasnowinthevicinityofOSB,andSD Bustler,thedutytug,wasstandingbytoassistifnecessary.
ThechiefengineerreturnedtothebridgeanddiscussedthesituationwiththemasterandDPA.ThemastercalledSolentCoastguardbyradio,andat0618updatedthemofCommodore Clippersdeterioratingcondition.Heaskedfora readvisortobesentouttothevesselbyhelicopterasaccessbypilotladderwasontothemainvehicledeck,andthereforenotusableduetothere.Thecoastguardofceraskedthemastertoconrmthathewantedtorequestareadvisor.Themasterreplied,yes, I think so.
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1.5 INITIALEMERGENCYRESPONSE
1.5.1 Commandandcontrol
SolentCoastguardwasresponsibleforco-ordinatingtheSARresponse,butcommandoftheemergencyonboard Commodore Clipperremainedwiththemaster.WhileherequiredpermissionfromQHMPortsmouthtoentertheharbour,andpermissionfromPIPtoberth,itwasforthemastertorequestfromSolentCoastguardwhatassistancehefeltherequired.TheSecretaryofStatesRepresentative(SOSREP)hadnotyetbeeninformedabouttheincident,andthestatutorypowersofintervention,exercisedbyhim,hadnotbeeninvoked.
Co-ordinationofemergencieswithintheSolentandsurroundingareasrequirestheco-operationofanumberofdifferentagencies,includingtheemergencyservices,localgovernmentandportauthorities.AsystemknownasSOLFIREhasbeendevelopedtoprovideaninfrastructureforthecommand,controlandcommunicationsneededtomanageemergencies.Intheearlystagesoftheincident,SolentCoastguarddidnotconsiderthereon Commodore ClippertobeseriousenoughtowarrantactivatingSOLFIREprocedures.
SolentCoastguardhadinformedtheHFRScontrolcentreaboutthereonboardCommodore Clipper,andarrangedforHFRSunitstomeetthevesselatPIP.HFRSunitsbegantoassembleatPIPfrom0450,andreofcersmetwithCMSsoperationsdirectorandtechnicalsuperintendentstostudytheshipsplansanddiscusshowtoattackthere.
1.5.2 Specialistre-ghtingsupport
TheMIRGisapartnershipbetweentheMCAandthe15coastalreandrescueservices4,anditsfunctionistodealwithres,chemicalreleaseandindustrialaccidentsatsea.TheMIRGdoesnothaveauthoritytounilaterallydeploytovessels
indistress;itisthereforenecessaryforthemasterofavesseltospecicallyaskforMIRGassistance.
SolentCoastguardcalledtheFLMat0621,updatedhimonthedeterioratingsituationonCommodore Clipper,andinformedhimthatthemasterhadasked fora re crew. TheFLMaskedtobeputincommunicationwiththemaster,andaradiotelephonecallwasarranged.ThemastergavetheFLMasummaryofwhathadbeendone,butwasunabletoconrmiftherewasstillburning.Themasterreportedthatcrewcouldre-enterthemainvehicledecktodeterminetheextentofthere,andtheFLMadvisedthemasterthatitwouldtake60-90minutesbeforeaMIRGteamcouldbemustered.
BoththemasterandFLMinterpretedthesubsequentdiscussiondifferently:the
masterrelayedtotheDPAthattheFLMdidnotwanttodeploytheMIRGuntiltheextentoftherewasknown,andtheFLMthoughttheopposite;thatthemasterdidnotwanttheMIRGtodeployuntilthecrewhaddeterminedtheextentofthere.TheconversationwasconcludedwithbothmenagreeingthatthedecisiontoactivatetheMIRGshouldbedeferreduntilafterthecrewhadre-enteredthemainvehicledecktoassessthere.
Immediatelyaftertheconversationwiththemaster,theFLMstartedmakingpreparationstoassembleanddeployaMIRGteamincasetheywererequired.HeaskedSolentCoastguardtoidentifythenearesthelicopterthatwascapableofcarryingsixreghtersandtheirequipmenttoCommodore Clipper.Thecoastguard
4 ThefollowingFireandRescueServicescontributetotheMIRG:Cornwall,Guernsey,Hampshire,Jersey,Kent,
EastSussex,Suffolk,Lincolnshire,Humberside,HighlandsandIslands,Strathclyde,LothianandBorders,
Northumberland,NorthWales,andMidandWestWales.
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helicopterstationedatLee-on-the-Solentwasnotlargeenoughtolifttheteaminonego,andSolentCoastguardaskedtheAeronauticalRescueCo-ordinationCentre(ARCC)atKinlosstoidentifyamoresuitablehelicopter.ASeaKinghelicopterfromRoyalAirForce(RAF)Wattisham,49minutesyingtimeawayinSuffolk,wasputonstandby.
DQHMhadlistenedtotheconversationbetweentheFLMand Commodore ClippersmasterandtelephonedSolentCoastguardtoreportthatheintendedtodeclareSOLFIREinhisareaofresponsibility(East).SOLFIREEast,categoryB,wasformallydeclaredbyQHMat0635.QHMexpectedthatpersonnelfromtheotherorganisationsrespondingtotheincidentwouldautomaticallycometoQHMscontrolcentreaspartoftheSOLFIREplanstoco-ordinateactivities.SolentCoastguarddiscussedtheimplicationsoftheBcategorisationandcheckedtheSOLFIREprocedures.CategoryBwasintendedformoderatescaleincidents,anddidnotrequirepersonnelfromdifferentagenciestoco-locateattheleadauthoritys(QHM)controlcentre,unlesstheywerespecicallyasked.Accordingly,thecoastguard,FLMandHFRSremainedintheirownseparatelocations.
1.5.3 Firstre-entrytothemainvehicledec
Thechiefofcerandoff-watchsecondofcerdressedinreghterssuitsandBA,andbegantore-enter5themainvehicledeckatabout0640.Theyusedanaccesstrunkontheportsideofthevesselthatwasslightlyaftofthere.Thetrunkledfromtheuppervehicledeckallthewaydowntothestabiliserroomandhadadoorandsmallhalflandingatdeck4,slightlybelowtheleveloftheroofsofthefreighttrailers(Figure8).
5 Re-enter/re-entry:usedinthiscontexttodescribetheactivityofenteringacompartmentinwhichareis,or
was,burning.UsuallyinvolvesteamsofpersonnelwearingBA.
Figure8
Accessplatformatdeck4abovethemainvehicledeck
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Findingthestabiliserroomsmoke-logged,butundamagedbyre,thetwoofcersopenedthedoorontothelandingatdeck4level.Supportedbythesecondofcerandconnectedbyalife-line,thechiefofcerclimbedontotheroofoftheclosestfreighttrailerandcrawledforward.Hecouldseeabout1mthroughthesmokeandwasabletomoveforwardsapproximately5-7m,totheendofthetrailer.Therewasnotmuchheatandnosignofglowingorickeringlightthatwouldindicatethattherewereamesnearby.Decidingnottojumpontotheneighbouringtrailerandgetcloser,thechiefofcerreturnedtothelanding;heandthesecondofcerleftthemainvehicledeck.At0655theytoldthechiefengineer,whowaswaitingnearby,whattheyhadfound.
Theseniorofcersgatheredonthebridgeshortlyafter0700toreviewthesituation.Despitethechiefofcernotseeinganyames,therewasaconsiderableamountofpersistentsmokeandhecouldnotconrmiftherewasout,orifitwasstillburning.Thechiefandsecondofcersstartedplanningasecondre-entry,thistimefromthegreenstairsattheforwardendofthemainvehicledeckonthestarboardside.
1.5.4 Preparationsforenteringharbour
TheDPAandmastercheckedthestabilitycalculationsthatwerecompletedwhenCommodore ClippersailedfromJersey.Theysatisedthemselvesthatthevesselhadasubstantialmarginofstabilityandcouldtoleratesomedrencherwateraccumulatingonthemainvehicledeckwithoutbecomingunstable.Therewasnowayofcalculating,eitheronboardorinCMSsofceashore,whattheactualreductiontotheshipsstabilitywas,orthemaximumamountofwaterthatcouldbeallowedtoaccumulateonthevehicledeckbeforethevesselsstabilityreducedtoadangerouslevel.CMSdidnotemployanemergencyresponseservicetoassistwithstabilityanddamageassessments,andtherewasnoregulatoryrequirementforthecompanytohavesucharrangementsinplace.
DQHMwasgrowingmoreconcernedthatCommodore Clippermightloseall
powerandrequireasecondtugtoconductacoldmove
6
tobringthevesselintoharbour.ColdmovesofwarshipsandRoyalFleetAuxiliaryvesselswithinthenavaldockyardarecommonplace.TheyareroutinelyconductedbyanAdmiraltypilotwhocontrolsthetugsand,undertheQueensRegulationsfortheRoyalNavy,takesresponsibilityforthemovefromthecaptainofthevessel.At0642,DQHMdecidedtomakepreparationstodespatchasecondtugandembarkanAdmiraltypilotonCommodore Clipper.DQHMsintentionwasthatthepilotwould:fulltheroleofforwardcontrolofcer(inaccordancewiththeSOLFIREplan),supportthemaster,provideassurancethattheconditionofthevesselwouldnotposeunduerisktothenavaldockyardand,takecontrolofthetugsifrequired.
HFRShadagreedtotheFLMsrequesttoputthelocalMIRGteamonstandby,andat0705theFLMreportedthatallthearrangementswereinplaceshouldthe
MIRGberequired.CoastguardofcerswouldnormallyinformtheMCAsdutyCounterPollutionandSalvageOfcer(CPSO)aboutapotentiallyseriousincidentassoonastheycould.TheyrealisedthattheyhadoverlookedthisandbriefedthedutyCPSOat0711.ThedutyCPSOsrolewastomonitortheincidentinordertoanticipateandreacttorisksofpollution,requirementsforsalvageassistanceorother,widersupport.TheCPSOsrolewasalsotobrieftheSOSREP,discussingifhisinvolvementwasmerited,identifyingifoneoftheMCAsspeciallytrainedMarineCasualtyOfcersneededtobedeployedtothevessel,orifstatutoryintervention
6 coldmovetomanoeuvreavesselwithouttheuseofitspropulsionsystem(s).
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neededtobeconsidered.However,theCPSOwascontentwiththewaytheincidentwasbeingmanagedandrequirednofurtherinterventionatthatstage,andsodidnotnotifytheSOSREPoftheongoingincident.
Commodore ClippersmasterheldaPilotageExemptionCerticate(PEC)forPortsmouthharbourandhewouldnotnormallyhaverequiredtheassistanceofeitheranAdmiraltypilotforthetransitthroughthenavalbase,oracommercialpilottoberthatPIP.Theusualmeansofembarkingapilot(throughadoorinthehullplatingthatledontothemainvehicledeck)couldnotbeemployedbecausethecompartmentwasseverelysmoke-logged.Asanalternative,apilotcouldeitherbehoistedonboardusing Commodore Clippersfastrescueboat,orwincheddownfromahelicopter.QHMconsideredthatthequickestoptionwastotransfertheAdmiraltypilotbycoastguardhelicopter;at0718DQHMaskedSolentCoastguardifthiscouldbearranged.Thecoastguardofcerswereintheprocessofhandingovertotheoncomingwatch,butagreedtoaskthehelicoptercrew.Inthemeantime,theAdmiraltypilotstartedtravellingtothecoastguardhelicopterbaseatLee-on-the-Solent.
1.5.5 Secondre-entrytothemainvehicledec
Ataround0720,theoff-watchsecondofcerreportedtoCommodore Clippersmasterthatmorehotspotsweredevelopingontheuppervehicledeckattheforwardendoftheramp.Itwasalsoreportedthatmoresmokewascomingintotheaccommodationfromthegreenstairwell.
A4-manteamwasassembledanddressedinre-ghtingsuitsandBA,andthesecondre-entrytothemainvehicledeckbeganat0735.Theteamenteredfromthegreenstairsattheforwardendofthemainvehicledeck,ontheoppositesidefromthere.Connectedbylife-lines,butwithouthosesorreextinguishers,theteammadeitswaythroughthedenselypackedcargobycrawlingunderthetrailers.Theteamreportedthattheycouldnotfeeltoomuchheatatdecklevel,butthatvisibility
waslimitedandprogresswasextremelyslow.LargenumbersofJerseyRoyalpotatoeshadspilledfromthere-damagedtrailers;movingthroughthis,thetrailerlashingchains,andotherdebrisfromtherewasfoundtobeverydifcult.
TrailerCRF459andtheoneimmediatelyaheadinthesamelane,trailerCRF461,werebothseentobeonre(Figure9).Thecurtain-sidesonthetrailerswereburning,withtheplasticcurtainmaterialdescribedasdrippingdown,givingtheappearanceoflotsofcandleamesandleadingtomultipleseatsofre.Thechiefofcerwasabletoliftpartofthecurtainononeofthetrailers,andsawthatthepackagingmaterialsandplasticcratescontainingtheJerseyRoyalpotatoeswerealsoonre.Therewaslittleevidencethatwaterfromthevehicledeckdrenchershadpenetratedinsidethetrailerorofhavingmucheffectontheres.Theteamwithdrewandreportedtheirndingstothemasterat0755.
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1.5.6 PlannedentrytoPortsmouthHarbour
PIPscrisisteamhadbeenalertedabouttheincidentat0710,andacceptingthatthevesselwouldneedtoberth,begantomaketheirpreparationsforsupportingCommodore Clipperonarrivalintheport.ThePIPcrisisteamsetupintheportsconferenceroom,closetotheferryberths.
DQHMandotherkeyQHMstaffhadrelocatedtotheirmajoroperationsroom,anticipatingthatpersonnelfromotheragencieswouldstartarrivingtoco-ordinatetheresponsetotheincident.At0736,DQHMcalledSolentCoastguardtoaskforanupdateandwastoldthatthecoastguardwatchofcerwasalreadyinconversation
withQHMsportcontrolofce.DQHMaskedthatallcommunicationsnowbedirectedthroughQHMsoperationsroom,whichshouldnowbethecommandcentrefortheSOLFIREresponse.TheDAO,FLMandseniorofcersfromHFRShadgonetoSolentCoastguardscontrolroom,andasSOLFIREBproceduresdidnotrequirethemtorelocate,theyallremainedthere.CMSstaffandotherHFRSofcersstayedinCMSsofcesinPIP.
Thesecondtug,SD ReliablebeganstandingbyCommodore Clipperat0812.ItwasanticipatedthatoncetheAdmiraltypilothadbeenwinchedonboardbythecoastguardhelicopter,Commodore ClipperwouldreachOSBatbetween0830and0845andentertheharbourshortlythereafter.
1.5.7 Sternramphydraulics
Thechiefengineer,awarethatothersystemshadbeendamagedbythere,wenttotheengineroomtocheckandtestthehydraulicsystemthatoperatedthesternrampunlockingandloweringmechanism.At0838,hereportedtothemasterthat
Figure9
Cargostowagediagram
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thesystemcouldnotbestarted.Withnootherwaytolowerthesternramponcealongside,thechiefengineerassistedbythesecondandthirdengineers,andtheelectricalttersetaboutresolvingtheproblem.
Suspectingthatrehaddamagedelectricalcontrolcircuits,thechiefengineerdirectedtheteamtoconductacompletecheckofthesystem.Theyfoundthat,coincidentaltothere,anisolatingswitchthatprovidedelectricalpowertothehydraulicpackhadfailed.Theswitchwasreplaced,butthesystemstillwouldnotrun,sotheteamcheckedallthecontrolcircuits.Firedamagetocablesconnectingemergencystopbuttonsonthevehicledeckhadcausedastopsignaltobegenerated,whichpreventedthesystemfromrunning.Theemergencystopcircuitwasisolatedandthechiefengineerbrieystartedthehydraulicpacktocheckitwouldrun.
1.5.8 Helicoptertransfer
TheAdmiraltypilotwastransferredbypilotboattoGosportandwascollectedbyoneofthecoastguardofcersfromtheoff-goingwatch.TheyarrivedattheLee-on-the-Solentcoastguardhelicopterbasetondthatthehelicoptercrewwerenot
expectingthemandhadnoknowledgeoftheneedtoytheAdmiraltypilotouttoCommodore Clipper.ThecoastguardofcercalledSolentCoastguardat0801totrytoobtaintheproperhelicoptertaskinginstructions.
By0815,thechiefhelicopterpilotwasconcernedthathisaircraftmightnothavethecapabilitytoremainwithintheoperatingrulesfornormalpassengertransfersintheprevailingwindconditions.TheaircraftcouldachievethetaskifSARruleswereapplied,butcoastguardofcerswouldneedtodeclarethattransferringtheAdmiraltypilotwasaSARtask.
AcommercialpilotfromPIPwentouttoCommodore Clipperbypilotboattoassist,andarrivedonsceneat0825.Ataboutthesametime,DQHMandSolent
CoastguardwerediscussingtheproblemsofyingtheAdmiraltypilotinthecoastguardhelicopter.DQHMnotedthat Commodore Clippersconditionwasdeteriorating,andthatitwascriticaltogettheAdmiraltypilotonboardsothatthevesselcouldbebroughtalongsideassoonaspossible.
InordertoprovideapotentialmeansofembarkingthecommercialpilotontoCommodore Clipper,thesecondofcerbegantopreparetherescueboatsothatitcouldbeloweredatshortnotice.Thechiefengineeralsopreparedwatercoolingattachmentsfortheoutboardenginesothatitcouldbestartedandwarmedthroughbeforebeingputintothesea.TheplanwastolowertherescueboatsothatthecommercialpilotcouldclimbontoitfromthepilotboatandthenbehoistedonboardCommodore Clipper.
Thehelicopterwasformallytaskedat0827withinstructionstoywiththeAdmiraltypilottoHaylingIsland,embarkaCoastguardLiaisonOfcer(CGLO)andthenytoCommodore ClipperandwinchboththeAdmiraltypilotandCGLOonboard.ThisplanshouldhavehadtheAdmiraltypilotonboardbyabout0850.TheplanwasrelayedtoCommodore Clipperandthemasterdecidedthatitwasnotworthexposingthecommercialpilottothepotentialriskofbeinghoistedupintherescueboat,particularlyasQHMhadsaidthatanAdmiralty,ratherthanacommercial,pilotwasrequired.
At0845,thewatchmanagerfromtheoncomingshiftatSolentCoastguardupdatedARCCKinlossonthelatestsituation.ThewatchhadalsorecentlychangedatARCCKinlossandbothofcersagreedthat,withhindsight,itwouldhavebeenprudentto
haverepositionedthelargerhelicopterfromRAFWattisham(R125)toLee-on-the-SolentandembarkedtheMIRGteamtoassessthesituation.ItwasacceptedthatthiswindowofopportunityhadnowclosedandthepriorityshouldnowbetogetCommodore Clipperalongsidewithoutfurtherdelay.
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Figure10
ChartwithinsetshowingtheberthsavailableatPIP
ReproducedfromAdmiraltyChartBA2631bypermissionof
theControllerofHMSOandtheUKHydrographicOfce
Berth5
Berth4
Berth2
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ThemasterconnedCommodore ClipperthroughoutthetransitofPortsmouthharbour.DiscussionaboutwhichberthshouldbeusedcontinuedbetweenSolentCoastguard,QHMandPIP.ItwasagreedthatBerth2couldbeused,butQHMwasconcernedthatthevesselcouldbeunstableandthatthe180 oturnmightleadtoariskofcapsize.Consequently,itwasrecommendedthat Commodore Clipperberthbowontothelinkspan(shipsheadeast).Asthevesselonlyhadasternrampandwouldnothavebeenabletodisembarkthepassengersorcargo,themaster,supportedbyCMSmanagersandDPA,electedtoturnherandberthsternto(shipsheadwest).
Themastercommencedtheturnat1037and Commodore Clipperwassecuredalongsideat1055.UnitsfromHFRShadbeentoldtoexpectthevesseltouseeitherBerths4or5andtheyhurriedtorelocatetoBerth2.
1.6 EMERGENCYRESPONSEONCECommodore ClipperwASALONGSIDE
1.6.1 Pedestrianaccess
ThedesignofCommodore Clippermeantthattheonlyaccessroutefromthevessel
toshorewasviathemainvehicledeck(deck3)andthroughthesterndoor.Innormalservicethisworkedwell;themajorityofpassengersdrovetheirvehiclesonboard,andanyfootpassengerswerebroughtonbyminibus.Therelativelyfewfootpassengersthatwerecarried,andthesignicantchallengespresentedbythelargetidalrangesintheChannelIslandports,meantthataseparatepedestrianaccesswasnotrequiredandwouldhavebeendifculttoarrange.Therewasnoregulationthatrequiredthevesseltohaveaprotectedroutetoapositiononboardwhereasecondaccesspointorgangwaycouldberigged.
CMSandPIPstaffhadidentiedthatitwouldnotbepossibletogainaccesstothevesseloverthesternramp,andagreedtouseagangwaythathadbeenconstructedtoservevisitingcruiseships.Thegangwaywasliftedbycraneandrestedon
guardrailsontheuppervehicledeck(deck5).HFRSofcers,CMSstaffandthePIPharbourmasterwereabletoboard Commodore Clipperatabout1130.
ThegangwayarrangementwasnotconsideredsatisfactoryforfurtheruseandpermissionwasgivenforPIPstafftocutawaytheshipsguardrailsothattheupperendofthegangwaycouldberestedonthedeck.Thegangwayandtemporaryguardrailsweresecuredat1145.MAIBinspectorsboardedthevesselat1200andfoundthatwhilethegangwayitselfwasadequate,thehighdensityoffreightvehiclesontheuppervehicledeckmadeitdifcultnotonlytogetoffthegangway,butalsotomoveacrossthedeckinordertoaccesstheaccommodation.
1.6.2 Passengerevacuation
ThepassengershadallbeenmusteredagaininpreparationforenteringPortsmouthharbour.Somediscomfortfromsmokewasreported,butallthedomesticandgalleyservicesremainedavailableandpassengerswereprovidedwithfoodandrefreshments.
CMS,PIP,HFRSandSolentCoastguardallrecognisedthatitwouldbeprudenttodisembarkthepassengersassoonaspossible,particularlyastherisingtidemeantthatthegangwaywouldsoonbecometoosteeptouse.Membersoftheemergencyservicesandmarinepersonnelwhohadboardedthevesselhaddonesowithoutsustaininganyinjuries,butfoundmovingacrosstheuppervehicledeckdifcult.Thedistancesbetweenfreightvehicleswere,inplaces,aslittleas150mm,andatbest450mm.Inmanycasesitwasnotpossibletowalkbetweenvehiclesandthe
onlyroutewastocrawlundertrailerswheretheyweresupportedbytrestles.Freightvehicleswerelashedtothedeckwithchains,causingtriphazards.Obstructionsfromshipsttings,cargoandtrailerspresentedmanyadditionalhazardsandahighdegreeofawarenesswasrequiredtoavoidinjurywhenmovingacrossthedeck.
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MAIBinspectorslaterfoundaroutethroughthetrailersontheuppervehicledeckthatcouldhavebeenmoreacceptableforable-bodiedpassengerstouseiftheywerecarefullysupervisedandescorted.Aslightlywidergapexistedbetweenthetrailersandthecentre-linecasing.Itmighthavebeenpossibletohavefollowedthisgapaft,thencrossthemooringdecktothestarboardsideofthevesselandwalkforwardtothegangwayposition.
BoththelifeboatandtheMarineEvacuationSystemontheport(outboard)sidewereavailableforuseifthesituationdeterioratedsuddenly.Thereisariskofpersonalinjurywhenusingtheseemergencysystemsonanyvessel,anditwasagreedbetweenCMSseniorstaff,thePIPharbourmaster,HFRSofcersandtheCGLOonCommodore Clipperthatthepassengerswouldbeatleastriskiftheyremainedonboarduntiltherewasconrmedashavingbeenextinguished,andthendisembarkedoncetherewasaclearroutetowalkthroughthemainvehicledeck.
1.6.3 Assessment
HFRSofcersconcludedthatthebestmeansofattackingtherewastoopenthesternrampandallowthesmoketoclearbeforereghtersenteredthe
compartment.Thepossibilityoftheredevelopingduetotheincreasedventilationwasacknowledged,andhosesweresetupatthesterntoprovideawatercurtaintocontainthere.HFRSmanagersrecognisedthatitwouldtakeasignicantamountoftimeandresourcestodealwiththeincident.Theycalledforamobilecommandcentre,BAservicingworkshopandcateringunittocometoPIPtosupportthere-ghtingeffort.At1219,theCGLOinformedSolentCoastguardthatHFRSbelievedthatitwouldbeaprotractedincident.
Commodore Clipperssternrampwasopened,usingcontrolsontheuppervehicledeck,byabout1mshortlyafter1230andthenslowlyopenedtoitsfullextentoverthenextfewminutes(Figure11).Theredidnotappeartobesignicantamountsofsmokeinthemainvehicledeckandnoamescouldbeseenfromthelinkspan.
Itwasagreedthatasmuchcargoaspossibleshouldberemovedfromthemainvehicledecktoimproveaccesstowheretherehadstarted.Figure11
Viewofthemainvehicledeckafterthesternrampwasopened
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Asthesternrampopened,itwasnotedthatitdidnotmakecontactwiththelinkspanoverthefullareathatwasneededtospreadtheloadproperly.ThePIPharbourmasterwasconcernedthatthesternrampandlinkspanmightbedamaged,orworse,thatinthisstatethestructuresmightnotwithstandtheloadfromthevehiclesascargowasdischarged.Atabout1300,thesternrampwaslifted,thegangwayremovedandCommodore Clippermovedastern.Thevesselwasre-positioned,thesterndoorre-opened,andfrom1315onwardsitwaspossibleforsometradecarsandatrailercontaininghandbaggagetodisembark.
Thelevelofsmokeintheafterpartofthemainvehicledeckwastolerableinitiallyandcrewwereabletobeginunlashingthefreighttrailersnearestthestern.TheCCTVsysteminPIPrecordedtherstthreeroadfreighttrailersbeingremovedfrom1320to1325.Theamountofsmokeincreasedsignicantlyaspersonnelmovedfurtherintothemainvehicledeckandoperationstoremovefreightwerestopped.
1.7 FIRE-FIGHTINGTACTICS
1.7.1 Visibility
Fireghtersriggedhosesandledthemintothemainvehicledecktowardstheforwardendoftheship.Visibilitywasseverelyreducedassmokelevelsincreasedclosertotheseatofthere.This,combinedwiththedifcultyofmovingbetweentrailersandthebuildupofdebrisonthedeckfromspilledcargo,madeitextremelyslowandhazardousforthereghterstogetclosetothere.
Thevehicledeckdrenchingsystemwasveryeffectiveatreducingthelevelsofsmoke,butreducedvisibilityfurtherwhileitwasoperating.Itwasfoundthatdrenchingforabout20minutesandthenturningthedrenchingsystemoff,gaveaperiodofabout15minutesofimprovedvisibilitybeforethesmokebuiltupagain.Thistacticwasusedmanytimesduringthenextfewhours,andeachtimethereghterswithdrewfromthevehicledeckbeforethedrencherswerestarted.This
wasreportedtoSolentCoastguard,butthewithdrawalofreghterswasinterpretedasbeingduetothemhavingbeenbeatenbackbythere,ratherthanaspartofaplannedstrategy.
Firedamagetopowercablesandventilationfansinthemainvehicledeckpreventedanyofthevesselsventilationsystemsfrombeingusedtoclearthesmoke.Theaccessdoorstothegreenstairsontheuppervehicledeckwereopenedandanoff-dutychiefengineerfromCMS,whohadcometohelphiscolleagues,donnedaBAsetandwentdownthegreenstairsandopenedupthedoorontothemainvehicledeck.Thewindwasblowingfromthestern,andstartedtoforcesmokeupthegreenstairsandintotheuppervehicledeck.Theforward,semi-enclosed,partoftheuppervehicledeckbecamesmoke-logged,butvisibilityinthemainvehicledeckbegantoimprove.
1.7.2 Escalation
Openingupthesterndoorandthegreenstairsallowedmoreairtogettothereanditstartedtoburnmoreintensely.Duringtheperiodfrom1330to1430,thetemperatureoftheuppervehicledeckgraduallyincreasedandmoresmokewasproduced.Thevehicledeckdrenchingsystemwasturnedonagain,andtopreventanyfurtherstabilityproblems,Commodore Clipperwastrimmedbythesternsothatallthedrencherwatercouldowoutoftheopensterndoor.Somewaterhadaccumulatedononesideofthemainvehicledeckandfromabout1400to1415,andagainfrom1445to1500,theheelingsystemwasoperatedtomakethevessellistfromsidetosidetohelpdraintheremainingwater.Boomswereriggedaround
thevesseltocontainthesmallamountofoilresiduesthatdrainedoverboard.The
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combinedeffectofusingtheheelingsysteminthiswayandseeingwaterowingaboutinsidethemainvehicledeckgavetheappearanceofthevesselbeingunstableandpotentiallyinastateofloll.
MCACoastguardandsurveyingstaffwereobservingthevesselfromthelinkspan.Theyhadnotbeenbriefedonthere-ghtingtactics,theuseofthedrenchers,orheelingsystemandtheybecameincreasinglyconcernedaboutthestabilityofthevesselandsafetyofthepassengers. Commodore Clipperhadmovedabout2masterntomakepropercontactwiththelinkspan,butbuildingsontheberthnowobstructedthecruisepassengergangwayandpreventeditfrombeingputbackinposition.Substantialttingsontheuppervehicledeckofthevesselwouldhavehadtobecutawayinordertore-positionthegangway;asithadbeendecidednottodisembarkthepassengersimmediately,itwasnotreplaced.HFRShadriggedaladderfurtheraftfromthegangwayposition,andat1500anAerialLadderPlatform(ALP)wassetuponthelinkspantoliftpersonnelandequipmentonandoffthesternofthevessel.
At1510,MCArepresentativesrequestedCMSstafftoarrangeforthepassengerstobedisembarkedusingthelifesavingapparatus.Thiswasdeclined.Solent
CoastguardtelephonedQHMat1515withasimilarrequest.Thecontentofthecallwaslogged,anditwasnotedthatseniorMCAstaffwerekeenforQHMtoputpressureonCMStodisembarkthepassengers.QHMrelayedthecontentofthemessagetothePIPcrisisteam.
Smokefromthemainvehicledeckhadalsopenetratedthebluestairwell,whichledupfromthecentrelinecasingonthemainvehicledecktotheaccommodation.Makingare-entryontothemainvehicledeckfromthispositionhadseveraladvantages:theentrypointwasclosertothere;and,reghterscouldfollowthecentrelinecasing,whichnotonlygavethemawell-denedroute,butalsoshieldedthemfromthere.HFRSreghterscouldonlymakeare-entryfromthispositionifthesmokecouldbecleared,andtheoff-dutychiefengineerincreasedthespeed
oftheengineroomventilationfansandheldopenthedoorsfromtheengineroomintothebluestairwelltoallowtheexcessairtoescapeandforcethesmokeout.ThismethodhadbeensuccessfullydevelopedduringanearliertrainingexerciseconductedwithHFRS.
Withthesmokeremoved,reghterswereabletomakere-entriesontothemainvehicledeckfromthebluestairwell.Debrisfromre-damagedtrailerswasmovedtoimproveaccess,butseveralnewresdevelopedaspartiallycombustedmaterialwasexposedtotheair.Itwasobservedthatthemainseatoftherehadspreadtotwomoretrailers,CR439andFS61inlane1ontheportsideofthemainvehicledeck(Figure9).TherehadspreadtotrailersGC13-1andFS61,asburningcargofellfromtheneighbouringtrailers.ApartiallyburntpotatocratewasfoundstucktothesideoftrailerFS61 (Figure12).Theconstructionofthetrailersandtheir
proximitytooneanotherpreventedthereghtersfrombeingabletoreachalltheresthatwereburninginsideandaroundthetrailers.
HFRSusedtheALPtoloadmoreequipmentandreghtersontothevessel.Therewasattackedfromboththesternandthebluestairwelluntilshortlyafter1600,whenvisibilitybecameunacceptablylowandthedrencherswererestarted.
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PartiallyburntdebrisontrailerFS61
Figure12
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1.7.3 Cargohandling
WhentherewasrsttackledviathesterndoorithadbeenpossibleforcrewtounlashthetrailersnearthesternwithoutanyneedforthemtowearBA.Similarly,thesmokelevelswerelowenoughforthestevedorestooperatethetrailer-handlingtractors(knowngenericallyastugmasters)inthenormalway.
By1630,thedrenchershaddampeddowntheresandvisibilityhadimproved.Themainvehicledeckwasstillsmoke-loggedfurtherforward,anditwasnolongerpossibletounlashandremovethecargowithoutwearingBA.HFRSofcerswereuneasywiththeprincipleofallowingthecrewtoenterthemainvehicledeckwhiletherewasburning.However,theyrecognisedthatthecrewwereneededtounlashthetrailersandthatthecrewallhadbasicre-ghtingtrainingandwerecompetenttoworkinBA.Commodore Clipperhadonly26cylindersfortheBAsetsonboard,theseweresoonusedupandthevesselhadnomeanstorechargethem.ThevesselsBAsetswerecompatiblewiththoseusedbyHFRS,anditwasagreedthatcrewcouldborrowchargedcylindersfromHFRStottotheirBAsetsandworkinpartnershipwiththereghterstoprogresstheremovalofthecargo.
Thestevedoreshadnoexperienceofworkinginsmoke-lledenvironmentsorwearingBA,andwerenotabletogetfarenoughintothemainvehicledecktoreachtheremainingcargo.Therehad,bynow,beenburningforabout14hoursandCMSsoperationsdirectorwasincreasinglyconcernedthatthetyresonthetrailerscouldhavebeendamaged,resultinginthetrailersbecomingunstableandcausingthesupportingtrestlestocollapse.CMSbeganmakingarrangementstocontractaheavyvehiclerecoverycompanytobringequipmentthatcouldbesetuponthelinkspanandthenbeconnectedtoeachtrailerinturntodragthemoutofthevessel.
Therewasstillcontainedbythecombinationofthedrenchersandattacksfromthereghters,butitcouldnotbecompletelyextinguishedwithoutremovingthetrailersfromthevehicledeck.HFRSofcersconsideredusingareghterwitha
heavygoodsvehiclelicencetooperateatugmaster.However,tugmastersarehighlyspecialisedvehicles,withrotatingdrivingpositionstooperateinthereversemode,anditwasconsideredunlikelythatanyonewithoutpriorexperiencewouldbeabletooperateonesatisfactorily.
Oneofthestevedoreshadpreviouslytriedscubadivingwhileonholiday,andatabout1700hevolunteeredtoputonBAandcontinueusinghistugmastertoremovethecargo(Figure13).HFRSofcerswereextremelyconcernedabouthimworkinginthisway,butprogressinghtingtherewaslimited.
FireghtersgavethestevedorebasictraininginhowtowearBA,andseveralreghterswerepositionedtomonitorhissafetyandassisthimifrequired.CrewenteredthevehicledeckusingBAand,withreghterscontainingthere,started
tounlashthetrailers.Oncethetrailerswereunlashedandanyrefrigeratedunitsunpluggedfromtheelectricalsockets,crewclearedtheareaandthestevedoredrovethetugmasterintothemainvehicledeck.
Visibilityfromthecabofthetugmasterwaspoor,andreducedtozerointhethickestsmoke.Duetothelimitedspaceinthecab,theBAsethadtobeputtoonesideratherthanwornconventionally,andthelengthofthehosebetweenthecylinderandthefacemaskfurtherlimitedthestevedoresmovement.Thestevedoreusedhisknowledgeofthevesselandthemotionofthetugmasterasthetyresbumpedoverthelashingsecuringpointsinthedecktomanoeuvreintothecorrectpositionandattachtoeachtrailer.
Thestevedorereportedthatheremoved11trailersinthismannerandused7BAcylinders.Eachtrailertookbetween10and15minutestoremove,comparedwithabout5-6minutesinnormalcircumstances.
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1.7.4 StatutorypoersofinterventionAt1710,theDAObriefedtheMCAsDutyOperationsDirector(DOD)onprogresswithghtingthere,andinformedhimthatthepassengerswerestillonboard.MCAstaffhadformedtheviewthatCommodore ClipperwaspotentiallyunstableandthatHFRSwerehavinglittlesuccessinghtingthere.TheyconsideredthatthereasonforkeepingthepassengersonboardmightbeduetoCMSwantingtoavoidunfavourablemediacoverageofpassengersbeingevacuatedfrom CommodoreClipperinalifeboat.
TheDODdirectedthattheDAOandCPSOshouldreviewhowthepowersofinterventionexercisedbytheSOSREPundertheMarineSafetyAct 7mightbeappliedtoinuencehowtheincidentwasbeingmanaged.From1730onwards,
theCPSOandDutySOSREPstartedconsideringhowpowersofinterventionundertheMarineSafetyActmightbeusedtocompelCMSandHFRStoevacuatethepassengersfromCommodore Clipper.Atthesametime,theDAObeganpreparingplanswithSolentCoastguardtousehelicoptersR104andR106towinchpassengersoffthevessel.
By1800,theCPSOanddutySOSREPhadconcludedthatpowersofinterventionshouldnotbeusedasHFRSwasnowtheleadagencyfordealingwiththeemergencyandwouldnotintentionallyallowthepassengerstobeleftonboardatgreaterrisk.TheDODtelephonedSolentCoastguardtohavehisdissatisfactionandobjectionstothedelayinevacuatingthepassengersrecorded.
7 MarineSafetyAct2003,Chapter16,Schedule1,NewSchedule3AtotheMerchantShippingAct1995
SafetyDirections
Figure13
Stevedorewearingbreathingapparatusinordertoremovetrailers
fromthesmoke-lledvehicledeck
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At1810,theCPSOrelayedhisconclusionstotheCGLOonboardCommodoreClipper,notingthattheincidentwasunderthecontrolofHFRS,themasterofthevesselandQHM,allofwhomwerereportedtobesatisedthatthepassengersweresafe.TheroleofPIPwasnotacknowledged.TheCPSOalsodiscussedthesituationwithCMSsOperationsDirector,whoexplainedthere-ghtingstrategyandtheconsiderationgiventothebalanceofriskofevacuatingthepassengersagainstleavingthemonboard.ThelogkeptbystaffinCMSsofcerecordedtheOperationsDirectorsviewat1839,thattheCPSOwascontentwiththecurrentplan.
ThedutySOSREPcontactedtheSOSREPtoadvisethattheDODhadrequestedtheuseofstatutorypowersofinterventiontobeconsideredinordertocompelthepassengerstobeevacuated,butthattheCPSOconsideredthatthepassengersweresafeandwouldbeputatgreaterriskiftheywereevacuatedbyemergencymeans.TheSOSREPaskedthedutySOSREPtoconrmthiswiththeportauthoritiesandarrangedforoneofhisindependenttechnicaladvisorstoassessthesituation.At1915,theSOSREPtelephonedtheDODdirectlytoupdatehimanddiscussthesituationfurther.
1.8 FIREEXTINCTIONANDPASSENGERDISEMBARkATION
1.8.1 Accesstotheseatofthere
Cargoremovalcontinuedandtherstburningtrailer,CRF459,wasremovedfromCommodore Clipperat1855,10hoursafterthevesselhadmooredalongside.Cargowasstillalightinsidethetrailerandreghterscontinuedtodousetheamesforanother10minutesafterthetrailerhadbeenremovedfromthevehicledeck.HFRSbeganaplannedwatchchangeoverat1900,re-ghtingandcargoremovalcontinuedwhilepersonnelconductedtheirhandovers.Fire-damagedtrailersCR439andFS61wereremovedat1910and1927respectively.
Asmoretrailersanddebriswereremoved,additionalresstartedandtwoteams,
eachcomprisingfourreghters,continuedworkingonthemainvehicledeck.Asystemofcommunicationhadbeensetuptowarnthereghterswhenthetugmasterwasmovinginthevehicledeck,sothattheycouldkeepwellclear.However,atabout1930,tworeghterswerefollowingahosetowardsthere,whentheysawthetugmasteroperating.Theyretracedtheirstepsandwaiteduntiltheysawnomoremovement.Astheyfollowedthehosebacktowardsthere,theyheardrushingwaterandfoundthatthehosehadbeencutbythemovementofthetugmasterandtrailer.Whiletheyweretryingtopassamessageforthewatertobeshutoff,theysawthelightsofthetugmasterreturningandhadtomovequicklyunderneighbouringtrailerstoavoidcollision.Thenear-misswasreportedandcargoremovalandre-ghtingwasthensuspendedwhiletheremaininghandoverswerecompletedandtheoncomingincidentcommandermadeafullassessmentofthesituation.
1.8.2 MCAresponse
TheMCAsurveyorstationedonthelinkspanissuedaprohibitionnoticetotheCMSsOperationsDirectorat1945,requiringthat all operational activities (excludingthose necessary for the immediate safety of the ship, safety of life, or the preventionof pollution of navigable waters)ceasedimmediately.
By2015theSOSREPsindependentadvisorhadreportedbacktotheCPSO,statingthathewassatisedthat Commodore Clipperwasinnoimmediatedangerfromlossofstabilityandthattherewasbeingtackledappropriately.
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From2100to2130reghtersextinguishedthelastremainingresinthemainvehicledeck.Paramedicsboarded Commodore Clipperviathemainvehicledeckatabout2125,totreatonepassengerwhowassufferingfromtheeffectsofapre-existingmedicalcondition.Debriswasremovedfromaroutethathadbeencleareddownthestarboardsideofthemainvehicledeckandpassengerswereassistedoffthevesselandontoawaitingcoachat2155.AllthepassengershadleftCommodore Clipperby2230,nearly20hoursaftertherstindicationsoftherestarting.
1.9 kEYPERSONNEL
1.9.1 Cre
ThemasterofCommodore Clipperwasaged52,hadspenthiswholecareeratseaandthelast25yearsworkingonferries.Hehadspent17yearsonthePortsmouth-ChannelIslandroutes,thelast8ofwhichhehadservedasmasterwithanunlimitedmasterscerticateofcompetency(STCW 8II/2).HestartedworkingonCommodoreClipperinApril2010,havingtransferredfromanothervesseloperatedbyCMS.Thiswasaroutinepracticeinthecompanytobringafreshperspective,bothtosenior
ofcersworkingpracticesandtheoperationofthevessels.Likemostoftheotherofcers,themasterworkedacycleof2weeksworkand2weeksleave.HehadalsobeenthroughaprogrammeofunderstudyandhandoverwiththeexistingmasterofCommodore Clipperbeforetakingcommandhimself.ThemasterhadpreviouslyspentseveralyearsworkingasthechiefofceronCommodore Clipperwhenthevesselwasrstbuilt,andwasveryfamiliarwithitslayoutandoperation.
Thechiefengineerwasaged53andhadavariedcareeratseaandashorebeforejoiningCMSin1988.Heheldanunlimited(steamandmotor)STCWIII/2certicateofcompetencyandhadworkedonmanyofthedifferentvesselsinCMSseetandalsoashoreasasuperintendentforthecompany.HereturnedtoseatobecomethechiefengineerofCommodore Clipperwhenitwasrstbuilt,andhadworkedon
boardthevesseleversince.Thechiefofcerwasaged39,heldanunlimitedmasterscerticateofcompetency(STCWII/2)andnormallyworkedforanothercompanyasamasteronitsro-rovessels.Hehadprovidedshort-termseasonalcoverforCMSduringhisnormalleaveperiodsseveraltimesoverthelast2years.Onthisoccasion,hejoinedthevesselthedaybeforetheaccident.HehadpreviouslycompletedCMSsinductionandfamiliarisationtrainingonCommodore Clipper.
Thesecondofcerwhowasonwatchatthetimeoftheaccidentwasaged25,andkeptwatchesfrom0230-1030and1830-2230.Hecompletedhiscadetshipin2006,heldanSTCWII/1certicateofcompetencyandhadsinceworkedasathirdofceronabulkcarrierandseveralcontainerships.HejoinedCMSon26May2010,
andbeforestartinghisdutieshadspent3daysonboardcompletingfamiliarisationtrainingandunderstudyingamoreexperiencedsecondofcer.HewasduetoleaveCommodore Clipperonthedayoftheaccidenttobegin2weeksleave.
Thethirdengineerwasalsonewtotherank,havingpreviouslyworkedfor25yearsatseaasatter.Hehadworkedonboard Commodore Clipperfor3yearsasatter,andhadveryrecentlybeenpromotedaftergaininganSTCWIII/1certicatethatenabledhimtoworkasanofcerinchargeofanengineeringwatch.Heworkedadifferentpatternof12weeksonboardfollowedby6weeksleave,andworkedfrommidnightto0500and1200to1900.
AlltheofcersheldtheappropriateendorsementsfromtheBahamasMaritime
Authority(BMA).Themaster,chiefengineerandchiefofcerallheldadditionalqualicationsinadvancedre-ghting.Theregulartradingpatternandworkschedulesforallthekeycrewmembersinvolvedintheaccidentprovidedthemwithadequaterestperiods.
8 InternationalConventiononStandardsofTraining,CerticationandWatchkeepingforSeafarers,knownbythe
shorttitleSTCW
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1.9.2 Companystaff
TheDPAhadworkedasamasteronCMSvesselsformanyyearsbeforemovingashore.Hemaintainedhismastersqualicationandpilotageexemptioncerticates,notonlyasameansofassessingtheperformanceofstaff,butalsotoprovideemergencycoverintheeventofsicknessorotherstaffabsence.
Theoperationsdirectorwasalsoamastermariner,withexperienceonavarietyofvesseltypes.Healsomaintainedhisqualicationsandsailedoncompanyvesselsregularlytoassesstheeffectivenessofoperationsandcrewperformance.
1.9.3 Training
CMStookaveryproactiveapproachtotraining,andhadconductedanumberofmajorevacuationexerciseswiththeemergencyservicesoverpreviousyears.TheseexerciseshadincludedthedeploymentofMIRGteamsbyhelicoptertovesselsoperatedbyCMS.SeniorCMSstaffhadbuiltupagoodrelationshipwithanumberofreofcersinthecourseoftheseexercises,andthiswasreportedbybothCMSandHFRStobebenecialduringtheincident.
Crewfamiliarisation,asrequiredbytheInternationalSafetyManagement(ISM)Code9,followedadetailedsyllabusthatincludedtheresponsetovesselemergencies.Thesecondofcerwhowasonwatchwhentherestartedhadrecentlycompletedthistrainingandhadsuccessfullypassedthecompulsoryoralexaminationwiththemaster.
RecordsoftheemergencydrillsconductedonCommodore Clippershowedthattheresponsetovehicledeckreshadbeenpractisedmostrecentlyon21Februaryand3May2010.Intheshortperiodthatthesecondofcerhadbeenonboard,threeredrillshadbeenconducted:inthegalley,bow-thrustercompartmentandforecastlestore.Itwasreportedthatredrillswerenormallyinitiatedbythemastertellingone
ofthedutyofcersthatarehadbeendiscoveredinacertainlocation.Whiletheredetectionsystemwasincludedinthefamiliarisationtrainingsystemsyllabus,itwasnotnormallyusedindrillsandwouldusuallyonlybeactivatedwhenitwasbeingtested.
1.10 DAMAGETOSTRUCTUREANDSYSTEMS
Thedamagerecordedbytheclassicationsocietyssurveyafterthere,issummarisedbelow.Thecompletereportisreproducedat AnnexA.
1.10.1 Structuraldamage
ThemainvehicledeckofCommodore Clipperwasdenedasaspecialcategory
spaceinaccordancewithSOLAS10ChapterII-2,Regulation3.46.Thefollowingstructuraldamagewasrecorded:
Theuppervehicledeck(deck5)deckplatingwasfoundbuckled,fromframe74toframe86,ontheportside,outboardfromtheinternalramp.
Thesupportingstructurefortheuppervehicledeck(deck5)(i.ethemainvehicledeck-head)wasdamagedontheportside,outboardfromtheinternalrampwith:
multiplelongitudinalstiffenersbuckledbetweenframes71and89;
thewebandlowerangeofframe77buckled.
9 InternationalSafetyManagementCode(ISM)Code,ResolutionA.741(18)asamended10 InternationalConventionfortheSafetyofLifeatSea(SOLAS)consolidatededition2009
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ThedeckboundarybetweenthemainanduppervehicledeckswassteelandwastoA0standardinaccordancewiththeprovisionsofSOLASChapterII-2Regulation20.5.Consequently,ithadnothermalinsulationproperties.
1.10.2Steeringgear
Theportandstarboardrudderswereseparatelydrivenbytheirownrotaryvanetypehydraulicunits.Thepowerpackforeachrotaryvaneunitwasttedwithtwopumps,eachttedwithitsownsolenoidvalves,whichcouldbeoperatedlocally,tocontrolmovementoftherudder.
Separatesteeringcontrolcableswererunthroughtheportandstarboardsidesofthemainvehicledeck,mountedincabletraysinthedeck-headstructure.Thesteeringsystemonthebridgeconsistedofawheelthatcontrolledbothrudders,andtwoseparatejoysticktillersthatprovidedsecondary,independent,controlofeachrudder.Therudderscouldalsobecontrolledlocallyfromthesteeringgearcompartment.Allfoursteeringpumpscouldbestartedandstoppedeitherfromthebridgeorfromthesteeringgearcompartment.
Defectswerefoundthataffectedallfoursteeringpumpsandbothcontrolsystemsduetodamagetothe48coresteeringcontrolcablethatwasroutedthroughthedeck-headontheportsideofthemainvehicledeck.Incommonwiththeothercablespassingthroughthemainvehicledeck,ithadtheappropriatereretardantpropertiesthatwererequiredbytheclassicationsocietysrules.Thecableswerenotrequiredtohaveanyotherprotectionfromre.
Thefollowingpowerandcontrolfaultswerefoundontheportsteeringgear:
No.1pumpforcedtherudderhardtostarboard,whenoperatinginremotecontrol.
No.2pumpautomaticallystartedandcouldnotbestoppedbythecontrolsystem.Thepumpwasunabletoprovideanydirectionalcontroloftherudder,eitherinremoteorlocalmodes.
Powerandcontrolfaultsfoundonthestarboardsteeringgear:
No.3pumpwashunting(oscillatingeithersideofthedesiredposition)whenintheremotecontrolmode.
No.4pumpautomaticallystartedandcouldnotbestoppedbythecontrolsystem.Thepumpwasunabletoprovideanydirectionalcontroloftherudder,eitherinremoteorlocalmodes.
1.10.3Firedetectionsystem
Inadditiontothesmokedetectionsensorsimmediatelyabovetherebeingdamagedbyheatandame,damagetocablesthatwereroutedthroughthemainvehicledeckmadethefollowingloopsoftheredetectionsysteminoperative:
Mainvehicledeck(deck3)
Steeringgearcompartment
Enginecontrolroom
Bowthrustercompartment.
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Lineisolators,thatwereintendedtoprotecttherestofthesystemifonepartwasdamaged,werefoundtohavebeenincorrectlytted.Theredetectionsystemcablesinthemainvehicledeckwereinstalledclosetomainpowercablesand,astheinsulationdegradedinthere,thesystemwasexposedtohighvoltages.Withnoprotectionfromthelineisolators,highvoltagespassedthroughthesystemandburntoutasectionofthemotherboardinthecontrolunitonthebridge.
1.10.4Electricaldistributionsystems
Themainelectricalpowerdistributioncabletrayrunningthroughthedeck-headstructureontheportsideofthemainvehicledeckwasdamagedbetweenframes74and77.Thisledtothefollowingdisruptiontoelectricalsystems:
Bothpowersuppliestotheforwardswitchboarddamagedandinoperable.
Powersuppliestobothforwardandafterbowthrustersdamagedandinoperable.
Powersuppliestotheanchoringandmooringequipmentdamagedand
inoperable.
Theinternalramp(mainvehicledecktouppervehicledeck),controlandindicationcircuitsdamagedandinoperable.
Powersuppliestobothnavigationsternlampsandthecontrolcircuitsindicatinglampfailureweredamagedandinoperable.
Powersuppliesandcontrolcircuitstomainvehicledeckventilationfansdamagedandinoperable.
CCTV,publicaddresssystemandlightingcircuitsdamagedandinoperable.
Inaddition,anumberofdistributionboxesandsocketsprovidingpowertorefrigeratedtrailersonthemainvehicledeckweredamagedbywaterusedinthere-ghtingoperation.
1.10.5Fire-ghtingandatersprayingsystems
Commodore Clipperwasttedwithanapproved,manuallyoperated,xedpressurewatersprayingsysteminthemainvehicledeckasrequiredbySOLASChapterII-2,Regulation20.6andResolutionA.123(V)(AnnexB).Thesystemwasdividedintolongitudinalandlateralsections,eachcoveringadiscreteareaofthemainvehicledeck,andwaterwasprovidedfroma360m3/hourcapacitypump.Thesystemcouldbeoperatedremotelyfromthebridge,orlocallyfromthedrenching roomjustoff
thebluestairsondeck4.Thechiefengineerwasawarethatthevalvesneededtobeopenedinthecorrectsequencetoensurethatthepumpprimedcorrectlyanddidnottrip.Hecontrolledtheoperationofthesystemthroughouttheincident.
Theintensityoftherecausedtheremaindistributionpipeworkrunningthroughthemainvehicledeck-headtobucklebetweenframes74and77.Thedistributionpipeworkforthewatersprayingsystemwasalsofoundtobebuckledinthesamelocation.Thewatersprayingsystemwastestedafterthere,beforerepairswerestarted,andwasfoundtoworksatisfactorily,withwatercomingfromallthedrencherheadsandnoleaksinthedamagedareabeingevident.Itwasconrmedthatroutinetestsofthesystemweredonewiththedrencherheadsremovedtoensurethatdebriswasushedthroughandnotlefttoaccumulateandcauseblockages.
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1.10.6Ro-rohydraulicsystems
Anumberofhydraulicpipeswereroutedthroughthedeck-headstructureofthemainvehicledeck.Pipesandcouplingsealsimmediatelyabovetherewerefoundtohavebeenaffectedbyhightemperatures,butthepipeworkhadremainedintact.
1.11 STABILITY
1.11.1 Approvedstabilityboo
Commodore ClippersstabilitybookwasapprovedbyDetNorskeVeritas(DNV)on20December1999,andincludedthefollowingwarningregardingthedrainageofvehicledecks:
The Masters attention is drawn to dangers of ooding. The Master must beaware of the adverse effect that water trapped on the Vehicle Decks has onstability, for example when the drenching system is in operation. Therefore, itmust be ensured that the drainage deck drains