200875 Fatalities in cargo hold fire
View of fire-damaged tanktop sheathing, spar ceiling and burnt remains of insulation foam.
On a general cargo vessel undergoing repairs at a yard, a shore worker was gas-cutting the deck plating of the upper tween deck. The hold had only one means of access available, consisting of a common access trunk with fixed vertical ladder sections. Eight other labourers were engaged in different tasks in the lower hold. Apart from remnants of wooden sheathing on the tanktop and spar ceiling against the side shell, there was an accumulation of flammable debris, consisting mainly of discarded insulation foam both in the tween decks and at the bottom of the hold.
It is thought that falling sparks and carelessly disposed cigarette butts started a fire in the mid-tween deck and was unnoticed by the workers for a considerable time. Fresh air was passing freely through the openings on the upper tween deck and smoke and hot gases began rising via the access trunk.
By the time the workers detected the fire in the lower hold, it was well established in the mid-tween deck and the flames had spread to the access trunk. The gas cutter operator at the top finally became aware of the fire and ran away to raise the alarm.
Three workers from the lower hold managed to scramble through the fire via the access trunk, sustaining severe burns and injuries, but the remaining five were trapped in the lower hold, which was rapidly filling with smoke and becoming deficient in oxygen.
The shore fire brigade arrived and took charge of the fire-fighting operations. The ship's crew was mustered and found correct, but there appeared to be scanty information about the number of shore workers inside the hold. The fire brigade cut several holes in the deck plating and hull and water was pumped into the hold through fire hoses until the fire was extinguished. Later, search teams waded through the smoke-filled and water-logged lower hold and retrieved the bodies of two dead workers. The last three shore labourers survived and were sent to a shore hospital.
Root cause/contributory factors
The hot work operation was commenced without any risk assessment or issue of hot work permit;
Poor housekeeping resulting in accumulation of flammable debris;
Many of the shore labourers were habitual smokers and prone to dispose of cigarette butts carelessly at the work site;
The cargo hold had only one escape route;
There was no effective deck patrol or fire watch;
The yard had no proper system in place for accounting for their personnel.