Even tragic accidents have learning potential providing the root causes are identified during the subsequent investigation.
CHIRP Maritime has a Memorandum of Understanding (MOU) with the International Seafarers Welfare Assistance Network (ISWAN) whereby CHIRP will refer any specific welfare reports to ISWAN, whilst ISWAN will refer any safety-specific reports to CHIRP. The following report was a referral by ISWAN.
What ISWAN told us:
We were contacted by the reporter requesting assistance. Apparently, there was a fire on board his ship and two crew members died of smoke inhalation. The reporter had contacted the authorities on account of (alleged) errors in the account of the incident by the captain and the company. It was also stated that some of the records and logs of the incident had been falsified.
CHIRP contacted the reporter to clarify some details of his report and to learn anything further.
The reporter alleged that:
- A planned fire drill, the day before the fire broke out, did not take place but a remedial entry was made in the on-board logs stating that it was completed satisfactorily.
- On the day of the fire, the fire alarm was cancelled shortly after it was activated but no Tannoy announcement was made and the alarm was not re-activated.
- A second remedial entry was made in the ship’s logs showing that, on the day of the fire, 3 minutes after the initial alarm the crew muster was completed, and two persons were known to be missing. According to the reporter that was not the case – the muster was not completed properly, and initially only one person was unaccounted for. It was only when the terminal fire brigade recovered a body that was not the person thought to be missing that the crew realised a second person was unaccounted for.
- After the fire, when giving a written statement, the reporter was pressured to change his statement (which he refused to do). At subsequent meetings on board the reporter was verbally abused and harassed about refusing to change the statement.
- Although it was known that the source of the fire was electrical in nature, the vessel managers suggested and promulgated a cause of the fire, implying it was in some way the responsibility of the victims before the shore investigators had arrived on board the vessel to inspect the scene. The inspection by the shore authorities did not support the company’s view and pointed to an alternative seat of the fire.
- Two days after the fire and the day after the shore authorities attended the vessel the reporter was landed ashore for medical tests. On discharge from the medical facility the reporter was refused access to the ship, personal belongings were landed by the agent and subsequently the reporter was repatriated by the vessel managers.
- The reporter has lost employment, credibility, and livelihood.
CHIRP was able to confirm independently that the named vessel had been alongside a loading terminal on the date reported and had suffered an accommodation fire which had tragically resulted in the death of two crew members. Furthermore, the flag state administration were contacted and confirmed that “as for all reported ‘very serious’ casualties, a safety investigation into this occurrence is being undertaken, in accordance with the IMO Casualty Investigation Code”, but due to the ongoing investigation no further comment was possible.
As stated earlier even tragic accidents serve a purpose so that lessons learned can be shared and thereby prevent similar tragedies happening, but only if a full and thorough investigation is carried out, the immediate and underlying causes are identified, and the subsequent report is published and placed in the public domain.
Mandatory drills are the minimum required but more frequent training can only lead to better and more proficient teams better able to deal with an actual emergency.
Muster lists and station bills are there for a reason and are based on a tried and tested formula adapted to meet the specific requirements of a vessel and the crew numbers available on board. Deviation from training can lead to poor choices being made and while musters may appear to be time consuming, a correct muster is essential.
Lessons cannot be learned, root causes of incidents cannot be found, and systems to prevent any reoccurrence cannot be put into place if records are falsified, and if there is such a poor safety culture running throughout the whole of a company from top to bottom. The reporter is thanked for his courage in promulgating the various issues discussed above which are generic simply because the incident is under flag state investigation and thus CHIRP must not interfere in this process. However, from the information above it is clear there are many human element aspects to consider, Alerting, Communication, Pressure, Local Practices, Distractions, Complacency, and Teamwork are all factors to address.
CHIRP Maritime looks forward to the publication of the full and complete accident investigation report by the flag state.
Report Ends ……….