TABLE OF CONTENTS - Marine · Initial report by the owner via Borang Laut/Kem 1 mentioned that they...
Transcript of TABLE OF CONTENTS - Marine · Initial report by the owner via Borang Laut/Kem 1 mentioned that they...
MT BUNGA ALPINIA EXPLOSION INVESTIGATION REPORT
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TABLE OF CONTENTS:
1) Executive summary: PAGE 2
2) Ship Particulars: PAGE 3
3) Investigation Objectives: PAGE 4
4) Investigation Obstacles: PAGE 5
5) FACTS:
a) Ship Facts: PAGE 6
b) Terminal Facts: PAGE 7
c) Weather Facts: PAGE 9
d) Cargo Facts: PAGE 10
e) PV Valve Facts: PAGE 12
6) Fire Triangle and the explosion: PAGE 13
7) The Bunga Alpinia Fire and Remnants: PAGE 15
8) Chronological Sequence of Events: PAGE 17
9) Analysis: PAGE 20
10) Recommendation: PAGE 24
11) Photos: PAGE 26
12) Attachments:
MT BUNGA ALPINIA EXPLOSION INVESTIGATION REPORT
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Executive Summary:
The vessel MT Bunga Alpinia arrived at Petronas Methanol (Labuan) Sdn. Bhd. on
25th July 2012. Her last port of call was Jubail, Saudi Arabia, where she load
methanol into tank no. 3W, 4W, 7W and 8W. In Labuan, she was scheduled to load
methanol into tank 1P, 2W, 5W, 6W and 9W.
She dropped anchor at 0712hrs and commence cargo loading preparation. At
1600hrs, the vessel was safely alongside. Initial loading (first foot) commenced at
1945hrs. At 2115hrs, full loading commenced.
At about 0200hrs, 26th July 2012, rain started to fall, duty AB report to the duty officer
(2nd Officer) whom standing by in the Cargo Control Room (CCR). According to
terminal shift superintendent, the thunder flash was visible in a distance. The cargo
loading was still ongoing.
At about 0230hrs, a bolt of lightning struck the vessel, most likely generate sparks
and causing fire to PV valve (believe to be from tank no. 1P). AB on duty
immediately informs duty officer about the fire via walkie-talkie, who later
immediately informed the terminal to stop loading via walkie talkie (set to same
frequency as terminal’s frequency). Once the terminal personnel received the called,
the loading’s ESD system activated.
The fire was believed to break out from tank no. 1 P, followed by explosion of tanks
1P and 2W. The resulted fire ball engulfed tanks no. 5W and 6W, spreading the fire
to those tank. Within few seconds, tank no. 5W and 6W explode. At about 0700hrs,
tank no.9W exploded.
Fire alarm raised and all crew immediately muster at the aft poop deck, away from
the inferno. They are later rescued by stand by tug and taken to shore.
This accident took five lives; all of them were the ship crews. It also causes oil
pollution which later controlled by Marine Department and appointed contractor. The
resulted explosion rendered the vessel total lost.
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Ship Particulars:
Ship Name : BUNGA ALPINIA
Type of Vessel : 38000 DWT Product Oil/ Chemical Tanker
Builders Hull No. : S-2047
Port of Registry : Port Kelang, Malaysia.
Call Sign : 9 MLE 4
Official Number : 334147
IMO Number : 9389538
Classification : DNV
DNV Ship Id no. : 27841
Length Overall : 180.00 meters
Length B.P : 171.20 meters
Breadth (Mould) : 32.00 meters
Depth (Mould) : 16.20 meters
Gross Tonnage : ± 24818
Net Tonnage : ± 13215
Cargo Hold : 20, including the slop tank.
Type of main engine : STX Man B&W 6S50MC-C (MK V11)
12900 BHP (9,620kW) X 127 RPM (MCR).
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Investigation Objectives.
The MT BUNGA ALPINIA, 38000GRT Oil/Chemical Tanker belongs and managed
by Malaysia International Shipping Corporation Berhad (MISC Berhad) was exploded
on 26th July 2012 at approximately 0245hrs. Initial report by the owner via Borang
Laut/Kem 1 mentioned that they suspect the cause of fire was lightning.
Information gathered from the Department of Ocean Meteorology and
Oceanography, Malaysia Meteorology Department, there was thunderstorm starting
from 0110hrs until 0300hrs. After that, the rain gradually slows down until 0400hrs.
Even with the small size of the Labuan Island, it is not necessarily mean that the
thunderstorm blanketed the whole island. Initial information shows that, only rain
reported, not thunderstorm in the Rancha-Rancha Industrial Area where the
Petronas Methanol (Labuan) Sdn. Bhd. terminal located.
This investigation aims to conclude the cause of fire, whether the lightning was the
only factor or one of various factors. It also aims to suggest improvement to prevent
such accident in future.
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Investigations Obstacle.
The facts that the accident took place during early morning whereby most of the off
duty crew member were fast asleep limit the eye-witness availability. This condition
was made worst due to the fact that the only eye-witnesses were perished in this
unfortunate accident. Only hand-full of the crew was awake to take their “sahur”.
During the accident, Sr. Pumpman Zahari Bin Hasim, A/B Colangoy Errol Calalu-an
and O/S Mohamad Hanafi Bin Kalil were on duty. The O/S was standing by at the
accommodation ladder entrance as part of the vessel ISPS stand by watch duty. The
A/B was still on deck and was the first person to report that PV valve port caught fire.
This is evidence when the 3rd Engineer heard via Sr. Pumpman walkie-talkie when
he found him in the deck changing locker on the starboard side of the main Deck,
just before he went out. Together with him (Sr. Pumpman) was the Greaser Shahril
Azmi Bin Baharuddin, who actually off duty. The Greaser, described by many fellow
crew members as diligent person, most probably wanted to assist the Sr. Pumpman.
The Deck Cadet Muhammad Nazrin Bin Khamsani was actually excused by the 2nd
Officer and just about to have his “sahur” (meal taken early morning before one
observes the fast). Upon hearing from his walkie talkie about the fire, immediately
when back on deck to assist.
All of these five people were the key witness of the unfortunate accident. Sadly, they
were also the casualties, leaving the investigation in the dark.
The 4th Engineer Ku Mohd Ashraf Bin Ku Yaacob was off duty and happens to in on
the bridge to serve the internet using his personal broadband modem. However,
most of the time, he was sitting on the sofa, starboard aft of the bridge, limiting his
view to the incident on deck.
The Loading Masters who normally standing by at the Jetty Cabin was away making
his round check. His colleague was in the terminal cargo control room (CCR).The
nearest CCTV camera was in auto panning mode, at the time of explosion/first fire, it
was pointing toward the aft of the ship, further complicating the matter. However,
after thorough inspection of the recording, it was found out that one small fire was
detected, coming out from PV valve tank no. 1.
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Ship Facts:
The MT Bunga Alpinia was constructed by STX Offshore and Shipbuilding Co. Ltd. in
Jinhae, Republic of South Korea, first steel cut on 24th April 2009, and keel laid on
30th September 2009 and launched on 15th November 2009.
She was propelled by STX MAN B&W 6S650MC-C (MK VII), 12,900 BHP X 127
RPM (MCR) and classed under Det Norske Veritas AS.
The vessel was owned and managed by Malaysia International Shipping Corporation
Berhad (MISC Berhad). With her, there are 3 others sister vessel, namely, Bunga
Akasia (O.N. 334119), Bunga Alamanda (O.N.334120) and Bunga Allium (O.N.
33416).
The vessel was manned by 29 seafarers, 6 of them was Filipino, mainly the officers,
including the Master. Other crew members were Malaysian.
Prior loading in Petronas Methanol (Labuan) Sdn. Bhd. , Labuan, the vessel already
loaded in Jubail, Saudi Arabia. The loaded tank was 3W, 4W, 7W and 8W, up to
98%. The vessel was scheduled to load tank 1P, 2W, 5W, 6W and 9W, total quantity
of 15700MT. Prior to that, last cargo was Crude Palm Oil. During loading in Labuan,
the terminal’s loading arm was smaller than the ship’s cargo pipe, thus, a reducer
was fitted.
This vessel was fitted with inert gas system. Base on our observation, the system
produce the inert gas by combustion of diesel oil in a special boiler. Due to the
nature of the methanol, which is colourless, this type of inert gas not suitable as the
inert gas will contaminate the cargo.
There is no vapour return connection provided from terminal. However, a vapour
separator was fitted just before the loading arm to remove vapour. The vessel has to
manage their tank pressure by themselves, by mean of Pressure/Vacuum valves
(PV valve). The valves set point was 2000mmHg, while the tank high pressure alarm
was 2200mmHg.
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Terminal Facts.
The Petronas Methanol (Labuan) Sdn. Bhd. (PML), a subsidiary of Petronas
(Petroliam Nasional Berhad) was formed in 1992 when Petronas bought over the
methanol plant from the Sabah Gas Industries. The plant was commissioned under
Sabah Gas Industries in 1984 to produce AA Methanol using Lurgi’s Low Pressure
Combined Technology.
The headquarters of this companies located in the Petronas Twin Tower, Kuala
Lumpur. Its plant was located in Rancha-Rancha Industrial Area, Federal Territory of
Labuan.
In 2008, the company commissioned Mega Methanol Plant, using Lurgi’s Mega
Methanol Technology. This advance technology allowed the natural gas converted to
methanol at low cost in large quantities more than double that of the existing plant.
The Labuan Fuel Terminals that belong to Petronas Dagangan Berhad share the
same compound and berth area with the Petronas Methanol (Labuan) Sdn. Bhd.
To the north of these berths, terminal for Antara Steel Mills Sdn. Bhd. is located. The
PML has long term charter contract for the Antara Steel Mills Sdn. Bhd. tug boats
that used to assists the vessel berthing and unberthing. Upon berthing completion,
the tugs returned to the Antara Steel Mills jetty. During the accident, tug boat Badang
9 was standing by.
The Asian Supply Base Sdn. Bhd., an integrated logistic hub for oil and gas industry
was located further north to the PML. This company provides support to the oil and
gas exploration in this part of Malaysia, as such, plenty of fi-fi equipped Anchor
Handling Tug anchored nearby, able to assist in the fire. Without their assistance, it
is very difficult to extinguish the fire. Even so, the fire took five days to extinguish the
fire on board.
The terminals consist of three berth area, two of which in deep area whilst the later
was at shallow area. Few units of lightning arrestors fitted to the production plant
area, but no evidence of such device fitted at the berth area. The stacked ladder and
loading arm was properly grounded. Inspection on the other jetty found out that only
electrostatic grounding cable provided, with very small cable diameter. However,
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according to various international guidelines, the usage of the grounding cable not
recommended.
Inspection also shows that the quick release mooring hooks fitted to the ill fated
terminal was badly corroded. Their quick release mechanisms believe to be seized
by the corrosion. The facts that only one or two loading master on-standby further
forbid the vessel from being quickly towed away. The loading master cabin located
directly behind the stacked ladder, blocking the loading master field of view toward
the ship.
Also, only one stand by tug made available throughout the loading time. The vessel
need to two tugs to moor; it should require the same to be safely unmoored.
There is no vapour return connection provided. However, a vapour separator was
fitted just before the loading arm to remove vapour. The vessel has to manage their
tank pressure by themselves, by mean of Pressure/Vacuum valves (PV valve).
Upon completion (loading), the terminal will purge the loading arms using nitrogen
gas. At this point, the ship’s loading valve was remained open. After that, the loading
arm drained until no trace of methanol present or the procedure repeated until no
methanol detected before both side shut of their loading valve (manifold valves for
vessel). No procedure for blanketing the methanol inside the cargo tank sighted
during the investigation.
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Weather Facts:
Base on information gathered from Ocean Meteorology & Oceanography
Department, Malaysia Meteorology Department, base on the radar images in their
library, there was heavy downpours in various part of Labuan Island on 26th July
2012, starting from 0110hrs until 0300hrs, the rain gradually reduce until 0400hrs.
However, in the Rancha-Rancha Industrial Area, where the Petronas Methanol
(Labuan) Sdn. Bhd. only slight rain observed.
The only noticeable thunders were those two thunders that strike the vessel’s
vicinity. After the vessel caught fire, no further lightning in that area reported.
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Cargo Factors:
Methanol is a clear, colourless liquid with slight alcohol odour; It is soluble in water at
minimum temperature of 20°C, flash point at minimum 12°C/53.60°F, auto ignition at
455°C(851°F), explosion limits, lower : 6.0 vol %, upper : 31.00 vol %. All of these
characteristics made the methanol highly combustible.
Its vapour was heavier than air. If air is 1, the methanol vapour is 1.105 @
15°C/59°F. Should the methanol vapour continuously vented through the vessel PV
valve, especially in still air, it will fall down onto deck, spread around and trapped in
between the deck stringers, pipes, etc. Its vapour may explode when exposed to
heat or flame.
Should it burn, it will produce a clean clear fire, making it difficult to spot at a
distance, especially in the day. Small fire could be extinguished by using dry
chemical, CO2, water spray and alcohol resistance standard foam. For large fires, it
could be extinguished by using water spray, aqueous film foaming foam (AFFF),
alcohol resistant type with 6% foam proportioning equipment. Jet of water should not
be used since it may displace the fuel and further spread the fire.
When handling this type of cargo, extra care should be taken to prevent fire. No
smoking or open flame should be allowed, all electrical and electronic equipment
should be intrinsically safe (spark/explosion proof) type. Also, precautions against
electrostatic charges should be carried out as well.
The methanol storage tanks should have bundle walls, must be grounded and
nitrogen blanket.
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The methanol also highly toxic to human and other living creature. It may enter body
through inhalation, ingestion, skin contact, absorption and eye contact. Repetitive
exposure by inhalation or absorption may result in visual impairment and complete
blindness and systemic poisoning.
The effected organs are central nervous system, eyes, skin and digestive tract.
Ingestion of 100 – 250ml could be fatal.
When fighting the methanol fire, fire fighters should always wear self-contained
breathing apparatus (SCBA) with full piece operated in positive pressure mode. Full
protective clothing must also be worn. Protective fire fighting structure clothing is not
effective protection from methanol fires.
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PV Valve Facts: The PV valves were fitted to each of the cargo tanks to regulate the air path. During
loading cargo, the valve will allow the air (including the cargo’s vapour) from inside
the tank to be release, thus maintaining the tank pressure. During unloading, the PV
valve will allow the air from outside to enter, preventing vacuum inside the tank.
However, it also should not allow flame passage into the tank.
The PV valves fitted onboard Bunga Alpinia were type approved by class in 2002. In
order to verify the operations, the identical valves taken from sister vessel and send
for testing in independent testing facility in Europe by the owner.
The testing revealed that the valves did not comply the requirement set by MSC/Circ.
677, Chapter 3.3 whereby the valves suppose to follow. The valve did not prevent
flash back into the tank through its pressure side as well as vacuum side (even
though flame screen was fitted).
It also worth to take note that the Danish Authorities already highlighted to EU that
the PV valve did not fully comply the IMO requirement MSC/Circ. 677, Chapter 3.3
above. However, their recommendation not to use the valve was not adopted by the
EU. Nevertheless, the usage of such valve was not permitted on Danish Flag
vessels.
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MT BUNGA ALPINIA EXPLOSION INVESTIGATION REPORT
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wind blowing, the vapour, which is heavier than air, may accumulate on the ship
deck, trapped in between deck stringers, pipes and other structure on deck.
The lightning strike ignited the flammable vapour vented through PV valves tank no.
1P and 2W. This is evidence from CCTV footage. Upon sighting the fire, the duty AB
immediately alert the ship’s Cargo Control Room. The officer on watch immediately
stopped the loading. This cause vapour pressure from the tans to dropped
drastically, causing flashback of the fire into the cargo tank through the PV valve.
The fire intensifies and caused the tank no. 1P and 2W to explode. The resulted
fireball engulfed tank no. 5W and 6W, spreading the fire. Further fireball spread the
fire throughout the ship.
As the ship on fire, namely tank no. 1P, 2W, 5W, 6W and 9W, the adjacent tanks
heat up, causing more methanol vapour vented on deck, intensify the fire. It is also
observes that, manholes and sampling point cover were lifted by pressure from
inside the tank, further venting the methanol vapour. Inspection by salvage team
revealed that certain amount or methanol still retained in cargo tank no. 4S (mixed
with sea water), 7W (tank still intact) and 8W.
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The Bunga Alpinia Explosion and Remnants.
The Fire.
The fire onboard broke out at about 0230hrs on 26th July 2012, given the intensity of
fire, the duty shift superintendent decided to by-pass tier 2 and commence to
upgrading their fire fighting status to tier 3 by informing the Emergency Control
Centre and local government agencies. State Bomba officially took over the
command at 0340hrs.
The fire started at tank no. 1 port, almost immediately followed by explosion of tank
no.1P and no.2W. This explosion triggers fire on tank no. 5W and 6W and
immediately explodes.
At around 0700hrs, 26th July, tank no.9W exploded, which described by many, was
the biggest explosion. At this point, foam truck from RMAF was just about to enter
the jetty, thus, all the fire fighters has to clear the way to allow the truck to enter.
Should those fire fighters still at the jetty vicinity, many will injured or, worst, killed.
At about 0841hrs, the vessel started to drift toward Antara Steel Jetty nearby. All of
the mooring rope, except the stern line was burned off. Fire fighting efforts continue
from the jetty and assisted by fi-fi equipped offshore vessel that anchored nearby.
On 27th July, at about 0653hrs, the fire was reported to be almost extinguished,
however, the vessel remain very hot, thus unsafe to approach. Prior to that, at
0540hrs, oil spill was confirmed.
On 29th July, aided by Jabatan Laut vessel, Tg Klias, Bomba spray foam into the
exposed cargo tanks to prevent re-ignition. After all victims accounted, the Bomba
declare stand down and dismissed on 1st August, just before noon.
The Remnants.
The investigation team manages to board the vessel at noon, 1st August 2012. At
this time, salvage team already onboard and survey the vessel conditions. The main
hull was badly deformed while the accommodation deck, toward the aft was
unaffected. The smell of methanol fumes was still present. Original plan was to
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board the vessel together with Bomba forensic personnel so that we may share the
use of intrinsically safe Camera.
The explosion of tank no. 1P and 2W ruptured the deck plating, which nowhere to be
seen as well as the tanks sectional bulkhead. Same happen to the tank no. 5W and
6W. The deck plating peeled off to the port side of the vessel with the deck crane
now underwater. The sectional bulkhead also ruptured. Tank no. 9S, its deck plating
was missing. Deck plating for tank no. 9P was peeled forward. The sectional
bulkhead was torn off as well. The vessel was loading these tanks during the
accidents. Other tank already fully loaded in Jubail, Saudi Arabia days before. These
tanks (no. 3W and 4W as well as 7W and 8W) were mainly intact, only the top deck
crack open and buckle upward. Survey carried out by the salvager, cargo tank no.
3W most likely contain cargo, tank no. 4S, contain mixture of cargo and sea water,
tank 4P, contain HFO and sea water mixtures. Cargo tank no. 7W and 8W still
contain cargo. Both of the tanks still intact except tank no. 8P which leaked into tank
9P.
Most of cargo pipes and heating coils, either peeled off and blown away or rolled
together toward the aft, port side of the vessel. On the ship side, at the exploded
tanks, the plating was badly buckled in irregular fashioned. Underwater survey by
salvage personnel found 9 holes in various places.
It was observed that the accommodation potholes was laminated glass type, only the
outer layer broke, the inner layer unaffected, thus protecting the inner compartment.
Damage was only caused by vibration caused by the explosions. The CCR remain
unaffected.
The bridge glass, which a single pane glass type, about 7mm thick, stand no
change. All of them broke, causing fire to spread inside the bridge, leaving nothing at
all.
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Chronological Sequence of Events:
1. M.T Bunga Alpinia arrived Labuan on 25 July 2012 after loading in Jubail Saudi
Arabia and anchorage at 0618Hrs. The Vessel sending notice readiness at
1712Hrs and would be loaded with a cargo of Methanol in bulk to tank 1P, 2W,
5W, 6W and 9W in Petronas Methanol Labuan.
2. Saybolt (M) Sdn. Ltd. surveyor board the vessel at 0830hrs. At 0900hrs until
0935hrs, wash wall test of the tanks carried out. Analysis carried out from
0950hrs until 1050hrs terminal and the agent informed.
3. The pilot board the vessel at 1410hrs, 1428hrs at aweigh anchor and the vessel
proceed to berth. Later, the vessel secured at 1536hrs. The surveyor boarded the
vessel at 1605hrs. Pre-loading carried out and respective meeting checklist filled
up. Further inspection carried out, completed successfully at 1625hrs which is
loading arm and earthing wire connected.
4. However, the interview revealed that none of the officers aware about the
earthing / grounding connection. Only deck crew aware about the grounding
connection. Terminal is quite old and it does not have the vapour return line. It
was agreed by both party that the loading arrangement will utilized the ventilation
valve PV procedure. 650ltr/hour was agreed rate and quantity was 17500MT.
5. First foot loading was commenced at 1750hrs and completed at 1945hrs. Further
samples taken in between 1950hrs until 2050hrs. The test was passed and the
full loading resumed later.
6. At approximately 0200 hours, drizzly rain-watered and signage lightning.
Currently, liquid methanol loading operations is progressing as planned, i.e., at a
flow rate about 650tan/hours. All tanks are involved, the tank 1P, 2 W, 5W, 6W
and 9W loaded simultaneously and to facilitate the operation of the ballast.
7. Reliable, navigational watch on deck done by Sr. Pumpman, AB, OS and Deck
CDT Second Officer on was duty in Cargo Control Room for loading operation. At
0100Hrs Chief Officer with other 4 crew went out ashore during accident and
been granted by Master.
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8. Not long after, around 0230Hrs there is heard the sound of lightning (the first) is
very strong, reliable, very close to the ship. Moments later, suddenly there is
lightning (the second), which strikes front of the ship.
9. At the moment, Second Officer, hearing AB informed about the fire, Able Seaman
on duty saw the fire in the PV valve no. 1 port, then spread it through the walkie-
talkie to that crew on duty .Officer on duty contact the CCR terminal to stop the
loading operation immediately.
10. Sr. Pumpman, which at that time was in Deck Changing Locker (Main Deck,
Stbd) rushed out, followed by Greaser which is has rest after off duty 0000hrs.
Likely, Grease with Sr. Pumpman to assist deck crew on duty instantly after
heard fire on deck. Believe on deck during that time were OS, Deck CDT and AB
attempt to fight the fire.
11. Second Officer, informing Master by ship phone about the fire later after
reported to Terminal. Master just wakeup from sleep and seen on porthole the
deck on fire and then few second later big explosion occurred.
12. Master went on bridge to raise alarm and SSAS to alert all ship crew there is
fire. Unfortunately PA system wasn’t work and with walkie-talkie announces
Abandon ship and believes only few crews having radio listen the order. Some of
engineer announce the fire via PA system for alerting and there is confirm alarm
been trigger by master during that time.
13. With fire on deck, all crew should assembly in Master Station but all crew
went straight to aft of the ship (the best place to protect own self from flying
object). Master commences crew to have head count deck and engine
department.
14. Then master command crew to lower down Life Boat (Port) to waterborne.
The moment preparation been doing some of crew doesn’t agreed cause last
tank 9W still not explode and possibility is high. Cause of some of radian heat
/fire cause difficulty to lower down.
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15. All decide to launching Life raft (port) cause potential explosion is high, 1st
Lifeboat trough by crew to overboard and inflect as normal. Followed 2nd Life Raft
and it is fall straight on top of the 1st Life raft and cause lip punched to 1stlife raft.
16. Some of crew try to have attraction which ship anchorage on the area and
passing trough for saving them. Tug Boat (Badang 9) charters by Petronas
Methanol come closed and alongside on the aft of the ship.
17. Badang 9 successfully rescued all survivors from the ship.
18. Not long after, the fire brigade arrived and use a foam fire extinguisher. State
Fire department is then immediately sprayed water on the fire ship. Nearly
0700hrs, the truck's foam from RMAF has reached. Then there was a third
explosion is huge.
19. Marine Department officer arrived, he immediately seek assistance AHTS
vessels nearby to help extinguish the fire. A new fire began to be controlled.
20. On July 27, besides the first victim was found on the jetty and only one
mooring rope only to be intact. Ship is spinning follow the tide. AHTS vessels still
continued to fight fire and meanwhile, the boats of the Marine Department to
monitor the oil spill. Two casualty were to be found floating at sea, between the
jetty Steel and PML
21. On July 28, the third victim was found. Meanwhile, contractor PIMAG has
been actively carrying out cleaning oil spills.
22. On July 29, occasionally, visible black smoke out of the hot tank (cold) water
spraying work is still underway. The fire departments, with boat aboard the
Marine Department have to spray foam into the tank.
23. On July 30, the last victim was found in the tank.
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Analysis:
The ship.
1. The cause of the explosion was the fire that broke out in tank 1P. The fire was
most likely caused by lightning strike, as witness by of duty 4th Engineer who
happens to be on the bridge at that time. The officer on watch failed to stop
the cargo loading when the weather turned. The company’s SMS did require
the cargo operation should be stopped during electrical storm. However, it did
not specifically spell out at what stage of such storm, i.e. thunder flash or
thunder clap (sometime, during thunder storm, one can only see the flash, but
unable to hear any sound) which requires the cargo operation to be stopped.
The officers were left with their own judgments, whether to stop or to continue
loading.
2. Since the loading was allowed to continue and no inerting provided prior
loading, clouds of combustible methanol vapour keep on vented out through
the PV valve. If no wind blowing, the vapour may accumulate on the ship
deck, in between deck stringers, pipes and other structure on deck.
3. For the ship, the highest point forward was the forward masthead, which
located rather close to the PV valve tank 1P. Lightning strike the masthead;
sparks will be created and cause fire at the PV valve outlet. The fire built up
rapidly. Tank no. 1P and no. 2W exploded. The resulted fire ball engulfed
other tanks, immediately spreading the fire to tank no. 3W and 4W, which
later exploded.
4. When the officer on the watch heard voice on the radio, informing that fire on
PV valve, his immediate action was to call the terminal to stop loading
operation. His next action was to shut relevant loading valves remotely from
the CCR. Instead of activating the fire alarm, he immediately contacts the
master, who later raised the fire alarm. By this time, most of the off duty crew
member were rudely awaken by the explosion.
5. Prior to that, Sr. Pumpman, AB, OS and Deck Cadet were believed to be on
deck. It was believed that they attempted to fight the fire when it first broke out
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at PV valve. However, investigation revealed that, there was no mean to
manually close the valve provided.
6. The fact that the fire broke out very fast and followed by tremendous
explosion causing all of other crew member instinctively takes refuge at the aft
poop deck, ignoring the fire alarm raised by the master. They later saved by
stand by tug boat.
7. The combustible methanol vapour can be prevented from venting out from the
tanks by using nitrogen blanket. Similarly, the lightning can be prevented from
causing spark should lightning arrestor fitted onboard and/or terminal. Same
applied if the cargo operation halted when the weather start to change.
The procedure:
1. The respective part of the company’s SMS was reviewed and found to be in
good order. Officers are reminded to monitors the weather conditions and
stop the operation in event of electrical storm. It was observed that, during the
accident, the 2nd Officer, who was on duty, failed to re-act to the weather
change. He also failed to raise the alarm at earliest possible moment when
the duty rating called, “PV valve on fire”. This action resulted in disorganize
attempt to fight the fire by the sr. pumpman, greaser and AB, causing them
their life.
2. None of the officers aware about the electrostatics grounding wire handed
over by the terminal personnel at the same time the loading arm connected.
Only the deck crew aware of such wire, this situation shows incorrect attitude
towards safety culture by the ship’s officer.
3. These conditions show that the safety cultures onboard need to be re-
established and reinstate the mind of every crew and officers onboard.
The Terminal.
1. At any given time, maximum two persons only standing by at the terminal
cabin, located on the terminal itself. Their main duty is to monitor the cargo
operation, on shore side. It was noted that all of the quick release mooring
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wire hooks at the terminal was badly rusted, making it is impossible to quickly
unmoor the vessel.
2. The methanol production plant was festooned by lightning arrestors, but none
fitted to the terminal area. The stacked ladder and loading arms were
grounded only. The terminal also did not provide nitrogen blanket for the
ship’s cargo tanks.
3. It was observed that terminal security procedures as well as commercial
pressure prevent the terminal personnel to take part in ensuring the ship
safety calling their terminal.
The Ship:
1. No nitrogen blanket provided to the tanks to be loaded with Methanol at the
PML.
2. The cargo operation was not stopped when the weather turned.
3. The PV valve for tank no. 1P and 2W caught fire due to lightning strike.
4. Once the cargo loading ceased, the resulted vapour pressure dropped cause
the fire to flashback into the cargo tank and caused the explosion.
5. The PV valve failed to prevent flashback into the tank or, they were kept open.
6. The fire spread to adjacent tank. Tanks that was loaded prior calling Labuan,
breached due to intense heat, but did not exploded completely. It only caught
fire. It was noted that those tanks was blanketed with nitrogen.
7. The BOMBA only fight fire from the terminal. Later, the Marine Department
mobilized the off hired AHTS that anchored nearby to fight the fire from sea.
8. The stand by tug does not have fire fighting capability.
9. The ship does not fit with lightning arrestor or lightning detector.
10. None of the officers aware about the electrostatics grounding wire handed
over by the terminal personnel at the same time the loading arm connected.
Only the deck crew aware of such wire, this situation shows incorrect attitude
towards safety culture by the ship’s officer.
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The Terminal:
1. No lightning arrestor fitted to the terminal area. It only fitted to the production
and storage area. Also, no lightning detector installed.
2. The facility in the terminal, i.e. the quick release mooring hook was poorly
maintained.
3. It was observed that terminal security procedures as well as commercial
pressure prevent the terminal personnel to take part in ensuring the ship
safety calling their terminal.
4. Nitrogen inerting or blanketing facility not available at the terminal.
5. Close loading facility also not available at the terminal.
Direct Cause:
1. The lightning strike cause the flammable vapour came from the PV valve to
ignite.
2. When the cargo loading stopped, the resulted sudden pressure drop cause
the flash back to ignite the methanol vapour in the tank, escalate the fire and
cause the explosion.
3. The PV valve failed to prevent the flash back, either due to defects or kept
open.
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Recommendations:
The ship.
1. The Company shall enhance the safety practices amongst all shipboard
personnel. It was evidenced during the interview, the safety consciousness
amongst the ship crew grossly inadequate. Amongst the observation noted
during the conduct of the interview;
a. The officers were unaware about the need and the significant
electrostatic bonding cable from the terminal forming part of the
ship/shore safety interface.
b. There would appear that was severe breaches during cargo operation
safety protocols in accordance to establish and accepted industry
guidelines.
c. It was evident there is acute non management of fire containment/fire
fighting operation during the accident.
2. It is also noted that since the Company has other similar vessel within the
Chemical fleets comprising of similar tank configuration, cargo loading
composition; it is recommended that the company shall adapt and adhere to
nitrogen blanketing procedure within their fleet.
3. The Company shall issue clear instruction and adopt established safety
protocols whilst loading and/or discharging giving due regards to all external
factors which will impact or impair the safety integrity of the ship, the crew or
cargo.
4. The Company shall consider introducing adequate safety trigger mechanism
or fire suppression system to adequately address and prevent all future re-
occurrence of the accidents.
5. The Company shall forward the entire joint investigation reports with Petronas
Methanol (Labuan) Sdn. Bhd.
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The Terminal.
1. The terminal shall consider appropriate lightning suppression devices within
the terminal area. It was also noted that similar unit was fitted within the
production facility.
2. It was observed from the Material Safety Data Sheet of the cargo, that the
methanol shall be stored and contained in a nitrogen blanketed tank. The
terminal shall ensure straight compliance to recommendation made with
regards to containment of the methanol as per the Material Safety Data
Sheet.
3. Both the terminal shall undertake appropriate and immediate ship shore
safety response and establish operating parameters in which immediate
suspension of cargo operation in the event the set parameters has been
breached.
4. The terminal shall ensure that adequate resources are available to render
assistance to vessel during emergency; this shall include the continuous
testing and certification of appropriate quick release devices for such
purposes.
5. The Material Safety Data Sheet (MSDS) issued by the Terminal mentioned
that the most suitable medium to fight large fire was water spray and Aqueous
Film Forming Foam (AFFF) alcohol resistance type with 6% foam
proportioning equipment. Since the State Bomba does not have this type of
foam, it should be provided by the Terminal so as to be used by the Bomba in
such incident. It is not feasible for Bomba to kept stock of such substance
since normal foam was good enough to fight fire involving liquid.
Investigation Team:
1. It is further recommended that the investigation team shall undertake a
detailed and thorough investigation jointly with relevant appropriate authority
to establish the essential causation factors and recommend further actions.