THE FINAL REPORT OF THE SEA HORSE CONDUCTED BY MAIB( MARINE
ACCIDENT INVESTIGATION BOARD).
Having considered all the information gathered during the course of this investigation, the MAIB has established the following:
1. Proper loading practices with regards to petroleum products were not followed by IDC and the Prison Authorities. The onus is on the master of the vessel to ensure that cargo is properly loaded and stowed.
2. SEYPEC as the distributor of petroleum fuel should not have loaded Mogas in IBCs. It is to be noted this practice is not acceptable in their depot, yet this was allowed outside of their facility.
3. Volatile fuel (Mogas), which is IMDG Class 3 dangerous cargo7 , was being carried as deck cargo in IBCs, which is an unsafe practice (Annex 12 refers).
4. Upon receipt of notification of such an incident, SMSA is the Authority mandated to assess and coordinate the response from start to finish. In this case IDC unilaterally took charge of the operation whilst the relevant authorities were reliant on IDC for resources for the operation.
5. No planned search and rescue operation was conducted in line with established search and rescue procedures by the mandated authorities. The surface search operation carried out was being managed by IDC. There was no other or concurrent search and rescue operation carried out by any other authority.
6. First response to the incident was not well-coordinated, nor was it carried out by persons trained in search and rescue operations.
7. The first plane that was dispatched to Coëtivy had a capacity of 14 pax but had only five persons on board, all of which were IDC staff. No persons specialised or trained in search and rescue were on that flight, as would have been expected.
8. During the search operations being carried out there was no means of communication between shore and the vessels conducting the search (prison launches).
9. SCG P/V Topaz reacted with a 6-hour delay from the time of being notified of the incident (from 0200hrs to 0815hrs).
10. SCG vessel “P/V Topaz” left Mahé at approximately 0815hrs on 26th August 2018 and reached Coëtivy at approximately 2200hrs, 14 hours later. Upon arrival of P/V Topaz at Coëtivy, there was no reported search operation conducted immediately after arrival. P/V Topaz remained at Coëtivy anchorage.
11. The search operation that was being conducted by IDC was called off under 48 hours later, as announced by IDC in the media. No other search operation was underway nor was any initiated following the announcement that the search was being called off.
12. The search that was being conducted by the Prison Authority was suspended at 0200hrs, approximately two hours after the incident. Whilst the inmates and personnel of the Prison Authority involved in the search were not trained in search and rescue procedures, they should have been guided by competent persons or authorities trained and mandated to conduct and coordinate such operations.
13. There were several possible sources of ignition on board at the time of the incident. These include the main engine inlet vent fans, electrical extension cable leading from the accommodation to the deep freezer in the container, the two deep freezers stowed in an enclosed container themselves and battery poles connection on the telehandler. Additionally, there were two known smokers on board the vessel, one of whom was on watch at the time of the incident.
14. Volatile fuel on board being carried as deck cargo in flow-bins further fuelled the fire.
15. Strong south easterly winds gusting up to 60 km/hr assisted the rapid propagation of fire from the deck to the crew accommodation and the engine room.
16. The incident occurred just after a rough passage of about thirty-six hours, at a time when the crew was tired, even if the minimum safe manning was respected (refer to minimum safe manning certificate Annex 3).
17. The position of the vessel at time of the incident is calculated to have been 0.628nm (1,163m) from the shore in a depth of 26metres.
18. The vessel had only one anchor forward with 60m (55m effective length) of anchor chain, which is believed to be insufficient for the trade she was plying. Mr. Gappy estimates that he dropped about 30m of anchor chain. The rule of thumb is that the length of chain used should be at least three times the depth.
19. From photographic evidence collected vessel was badly burned, which could have damaged the structure of the vessel.
20. From the engine manifold, the exhaust pipe was made of steel and went down to the bilge where it was joined by a section of flexible pipe and then continued with steel pipe to a strum box, double gate valves before penetrating the hull on the side just after the accommodation/Engine room bulkhead. She was also taking in water through the engine room exhaust as both engine room gate valves were left open.
21. Last known position of vessel was 06º49”S 055º58”E (25.5nm from Coëtivy) at 0725hrs on 27th August 2018 (SAF) (see Annex 9).
22. There were no records of safety drill carried out as per normal practice of the industry.
23. No life-saving appliances (fixed or personal) were used by any member of Sea Horse’s crew during the entire accident.
24. There are no established communication procedures and record-keeping between the vessel and the management company.
25. Everyone interviewed (save for Kumji) stated that that IDC does not normally allow the loading of Mogas in Flow-bins. However, because it was the Prison Authority that had chartered the vessel, the Mogas was loaded. IDC has no laid-down procedures for the carriage and stowage of dangerous goods.
26. There is precedence of dangerous cargo class 3 being carried in IBCs as deck cargo. The Prison Authority has in the past chartered Fishing Vessel St. Andre to transport Class 3 dangerous cargo in IBCs to Coëtivy on at least two previous occasions.
27. Mr. Goldy Dupres, despite being a very experienced seafarer, did not have the proper competency/qualifications to be given the responsibility of the SAR operation on scene.
28. The MAIB recognises that accident happened during adverse weather conditions and as such acknowledges the contribution and effort of the IDC and the Prison Authority, especially the inmates at Coëtivy that we felt, under the circumstances and limited resources at their disposal, assisted greatly in the operation.
29. The outcome of this incident could have been different had there not been delay in mobilisation of resources and response.
30. Had competent personnel/authorities been mobilised in a timely manner, the SAR results could have possibly been more positive.
31. There was no port clearance issued to Sea Horse for this particular voyage. No records exist at SPA for previous voyages since June 2018.
SOURCE:http://www.seymaritimesafety.com/index.php?option=com_content&view=article&id=46&Itemid=179