Details Report of Fire Fighting on Main Deck for Reefere Trailer Socket on Commodoreclipper_compiled

7/28/2019 Details Report of Fire Fighting on Main Deck for Reefere Trailer Socket on Commodoreclipper_compiled

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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/


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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



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


9/1841

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.


13/1845

Figure1

SequenceofimagesrecordedbyCCTVcamera

no.7from0237BST(CCTVtimingsareinUTC)

Figure2

LayoutofCCTVcamerasonthe

mainvehicledeck

Camera

7

Camera6


14/1846

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


16/1848

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.


17/1849

Blu

estairs

Greenstairs

AOclass

deckboundary

Heat

affectedarea

Fire

Smoke

Smoke

Bluestairs

Greenstairs

Drenchersection6

Drenchersection4

Mainvehi

cledeck

Upperveh

icledeck

Figure4

GeneralarrangementofCom

modoreClipperandlocationo

fthere


18/18410

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


19/18411

Cloudofsteamfromtheuppervehicledeckas

boundarycoolingwasstarted

(CCTVtimingsareinUTC)

Figure5


20/18412

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


21/18413

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

Wight


23/18415

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.


24/18416

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.


25/18417

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


26/18418

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).


27/18419

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


29/18421

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

Details Report of Fire Fighting on Main Deck for Reefere Trailer Socket on Commodoreclipper_compiled

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