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:


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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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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


21 | P a g e

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


22 | P a g e

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.


23 | P a g e

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.


24 | P a g e

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.


25 | P a g e

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.

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