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