202116 No practice makes no-one perfect

28 Feb 2021 MARS 2021

As edited from TSB (Canada) official report M20A0003

A large shrimp-processing/fishing vessel was engaged in fishing. At approximately 1515, the bosun awoke to the smell of smoke. On leaving his cabin, he saw flames through the window of the closed sauna door and smoke venting from the top of the door. He went to the messroom and alerted the crew members there. One crew member took a fire extinguisher and accompanied the bosun back to the sauna while another crew member went to the bridge. The bosun opened the sauna door and the other crew member emptied the fire extinguisher in the direction of the flames. The door was then closed and the two left for the muster station on deck 03. Meanwhile, the OOW had activated the fire alarm and announced over the PA system that there was a fire on board; this was not a drill. Some crew members mustered with their lifejackets at the muster station and began preparing the vessel’s fire hoses while other crew awaited instructions from the chief mate, who had remained on the bridge. One person was still unaccounted for. The second mate donned breathing apparatus (BA) and went to deck 03 to check the cabins. After confirming that the deck had been evacuated, he returned to the bridge, donned a fire suit,exchanged the air cylinder on his BA and left the bridge for the forward deck. The chief engineer, second engineer, and maintenance man were working in the shrimp-processing factory when the alarm sounded. The chief engineer sent the second engineer and maintenance man to the muster station and then went to the engine control room, where he met the missing person from the muster. He sent the person to the muster station then conferred with the bridge. Approximately 10 minutes after the fire alarm sounded, everyone on board was now accounted for. At the muster station, one person was now dressing in the fire suit but was encountering difficulties. The boots did not fit, the suspenders broke, and the helmet visor was cracked. Once the fire hoses were ready, he proceeded to the forward deck. When he reached the forward deck, neither he nor the other crew members there received direction on how to fight the fire. He took the initiative to enter deck 03 with a fire hose, alone and without a safety line, as the line had broken. Another crew member remained on deck to assist with the fire hose and open the forward hatch. Dense smoke limited visibility as the firefighter descended the ladder and arrived on Deck 03. When he entered the tanning room within which the sauna was located, he stumbled and fell over boxes that were stored there. Recovering, he used the fire hose to spray in and around the sauna, inside the tanning room, and the adjacent changing room. Before returning to the forward deck, he tried to close the sauna door but was unable do so, and left it open. When the second mate arrived on the forward deck, he proceeded down the hatch with a prepared fire hose and a makeshift safety line. He was unable to see through the dense smoke, and inadvertently blocked the way of the firefighter leaving the sauna who was ascending the ladder. The low-pressure alarm was sounding on his BA. The crew on deck now decided to fight the fire with two teams of two, but air in the BAs was low for team one and soon the alarms sounded. They returned to the muster station. As there were no spare air cylinders on board they re-entered Deck 03 with a fire hose, employing dust masks as airway protection. Team one could see another firefighter in front of the tanning room door, but could not progress further because the fire hose was not long enough to reach the sauna door. They sprayed the entrance to the tanning room with water while the other firefighter sprayed the inside of the tanning room and the sauna door. At approximately 1630, the three crew members retreated from the tanning room area and closed up access to deck 03 to contain the fire. Crew members on the forward deck then closed the accommodation fire dampers in the vents to suffocate the fire. By approximately 1745, the heat and smoke from the fire was dissipating. It was considered likely that the fire was contained within the sauna and smouldering. Once the fire was fully extinguished, burned pieces of a wooden footrest were found below the sauna’s electric heater, indicating that the footrest may have been on the heater when it was turned on. With the heater left unattended, the heat likely ignited the footrest, starting the fire.

Burned sauna and heater

Among other things, the investigation found that past fire drills conducted on the vessel had been repetitive, and did not include realistic emergency scenarios. Crew would start the main and emergency fire pumps, inspect and pressurise the fire hoses, and then simulate a fire on deck by spraying the trawl doors with water. The crew did not perform post-drill evaluations.

Lessons learned

  • Regular fire drills, using varied and realistic scenarios, are critical to confirm that firefighting equipment is in working order and to reinforce crew’s knowledge of how to use the equipment and of their assigned emergency duties.
  • Post-drill evaluations in a round-table discussion with all involved are a valuable tool for quality assurance and continued improvement.
  • While hindsight can be said to be 20:20, in this case it remains debatable whether the first intervention of opening the door and emptying a fire extinguisher in the general direction of the fire was effective or only gave the fire more air. Normal procedures would have put boundary cooling in effect, followed by properly dressed and equipped firefighters attacking the fire in an organised manner with a pressurised hose for full effect and safety.
  • It was over an hour after the fire had been discovered and after the attempted  re suppression with hoses before ventilation dampers were closed to starve the fire of oxygen. This is yet another indicator of lack of practice and familiarity with fire suppression procedures.
  • Attacking the fire with dust masks as breathing protection was, to say the least, a dangerous act.