BRAZILIAN MARITIME AUTHORITY DIRECTORATE OF PORTS …

BRAZILIAN MARITIME AUTHORITYDIRECTORATE OF PORTS AND COASTS

EXPLOSION ABOARD MV “AUK ARROW”, NITERÓI – RJ

02 AUGUST 2010

MARINE SAFETY INVESTIGATION REPORT

Courtesy vesseltracker.com

Reference: IMO Casualty Investigation Code - MSC-MEPC.3/Circ.2 13 June 2008/ Resolution MSC.255(84)

Brazilian Maritime Authority - Directorate of Ports and CoastsSurveys, Naval Inspections and Technical Expertise Management

Maritime Casualty Investigation Department (CIPANAVE) Explosion aboard MV “AUK ARROW”

Marine Safety Investigation Report

GLOSSARY OF ABBREVIATIONS, ACRONYMS AND TERMS

AMB – Brazilian Maritime Authority

BB – Port side

BE – Starboard side

COF - Chemical Carrier Code Certificate of Fitness

CPRJ – Port Captaincy of Rio de Janeiro

DOC – ISM - Document of Compliance ISM Code

DPC – Directorate of Ports and Coasts (Brazilian Maritime Authority Representative)

DPEM - Compulsory Insurance for Personal Injury Caused by Ships or its cargoes

ENAVI – ENAVI Shipyard Ltd

ILO – International Labour Organization

IMO – International Maritime Organization

IOPP - International Oil Pollution Prevention Certificate

ISM – International Safety Managment Code

ISPS - International Ship and Port Facility Security Code Certificate

LPG - Liquefied Petroleum Gas

MV – Merchant Vessel

NLS - International Pollution Prevention Certificate for the Carriage of Noxious Liquid

Substances in Bulk

PPE – Personal protective equipment

SMC – ISM - Safety Management Certificate - The International Management Code for the

Safe Operation of Ships and for Pollution Prevention

STCW - Standards of Training, Certification & Watchkeeping Convention

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I - INTRODUCTION

For the purpose of effecting the collection and analysis of evidence, the identification of the

causal factors and the elaboration of safety recommendations that should be necessary, in order

to prevent that in the future occur similar maritime accidents and/or incidents, the Captaincy of

the Ports of Rio de Janeiro (CPRJ) carried out a Marine Safety Investigation, in compliance

with that laid down in the Casualty Investigation Code of the International Maritime

Organization (IMO), adopted by Resolution MSC. 255(84).

This Final Report is a technical document that reflects the result obtained by CPRJ regarding

the circumstances that contributed or may have contributed to trigger the occurrence, and not

refers to any proving procedures for determination of civil or criminal liability.

Also, one should emphasize the importance of protecting the individuals responsible for

providing information regarding the accident, and the use of information contained in this

report for purposes other than the prevention of future similar accidents could lead to erroneous

interpretations and conclusions.

II – SYNOPSIS

On the third day of the month of August of the year two thousand and ten, in the city of Rio

de Janeiro, the procedures were commenced for examination of the Bahamas flagged Merchant

Vessel “AUK ARROW” on which occurred an explosion aboard at 21.52 hours of the 02

August of 2010, when it was being repaired in the Shipyard ENAVI, in Niteroi-RJ, while

carrying out service of cutting and welding in the ballast tank No.2 on the port side.

As a result of this accident, two workmen died and seven were injured and taken to hospitals

of Niteroi, where afterwards one of them died.

Damage occurred in the internal structure of the ballast tank No.2 on the port side of the

vessel and in the scaffolding installed in the top part of the tank. There was no registry of oil

spill or pollution.

The present procedure was conducted after the notification (Annex A) has been sent to the

Flag State according to the IMO Casualty Investigation Code.

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III – GENERAL INFORMATION

a) Particulars of the vessel :

Vessel: AUK ARROW Flag: Bahamas AB:27.962Area of navigation: Deep Sea Type: MV of General Cargo Propulsion: MotorPort of Registry: Nassau N o IMO 8309397 Length: 281mActivity: Transport of Cargo IRIN: C6KB2 Hull: SteelYear of Building: 1984 Classification Society: Det Norske Veritas (DNV)Owner: GEARBULK SHIPOWNING LIMITEDOperator: KRISTIAN GERHARD JEBSEN SKIPSREDERI A/SCrewmembers: 31 Port of origin: RecifePrevious name HEINA Motor: Sulzer Sumitomo 6RTA58Bow thruster 1200HP Power of motor: 8600HP Maximum draft 12.57m Moulded breadth 16.90mHull: Simple (single) Class:DNV+A1 HC E 1-3-5-7/2-4-6Builder: Sanyoasho Dockyard Place: Mizushina – Japan

Annex B) contains the technical particulars of the ship (Ship Particulars).

Photo 1 – NM “Auk Arrow” (courtesy vesseltracker.com)

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b) Documentation (Certificates):

The statutory Certificates were up to date, as per details below and the Report of Inspection

of Port State Control carried out (Annex C).

CERTIFICATE ISSUED BY VALIDITYSafety of Building DNV 31/05/2014Safety of Equipment DNV 31/05/2014Radio Safety DNV 31/05/2014IOPP DNV 31/05/2014Load Line DNV 31/05/2014DOC – ISM DNV 12/10/2014SMC – ISM DNV 18/12/2013NLS / COF Flag Country UndeterminedSafety Manning Card Flag Country IUndeterminedTonnage measurement DNV 12/06/1991ISPS DNV 04/04/2014Class DNV 31/05/2014

The Obligatory Insurance DPEM is not required as it is a vessel of foreign flag. Are required

to contract this insurance, by Law No. 8374 of 30/12/1991, all owners or operators in general,

of national or foreign vessels subject to registration in the brazilian Captaincies of Ports which

was not case of MV "AUK ARROW". DPEM Insurance is the compulsory insurance that aims

to provide coverage to people, carried or not, including the owners, or conductors and

crewmembers of vessels, and their respective the beneficiaries or dependents.

On the occasion of carrying out the initial inspection of this investigation, the vessel was

berthed alongside the floating dock “ALMIRANTE ALEXANDRINO”, of the ENAVI

Shipyard and presented a regular general aspect due to the effects of the occurred explosion

and due to the fact that it was carrying out various repairs.

Various work fronts were observed, to attend the programmed repairs, whilst on the side of

ballast tank No 2 port side substitution of plating was being carried out (photo 2) The ballast

tanks no 1, no 3 and no 4, all of them on the starboard side, also would be repaired.

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Photo 2 – Change of plating on the ship’s side.

IV – SEQUENCE OF EVENTS

According to information obtained by the experts at the scene, an explosion occurred

aboard when the vessel was berthed alongside the floating dock “Almirante Alexandrino” of

the shipyard ENAVI Naval Repairs Ltd, in Guanabara Bay, Conceição Island, in Niteroi –RJ at

21.52 hours of 02 August 2010, during services of cutting and welding in the ballast tank No.

2 on the port side.

A team of experts of the Captaincy of the Ports of Rio de Janeiro went to the locality for

the necessary steps for initial raising of data, documents and information for the elaboration of

the present investigation. At the same time, various documents were obtained for analysis, in

an attempt to identify the cause of the explosion.

According to the ship's crew the explosion occurred at 21.52 of the 2nd of August of 2010,

in ballast tank No.2 on the port side and after the explosion the general alarm was activated for

the crewmembers to man their positions. Three workmen who fell into the water and were

floating supported by lifebuoys thrown by the crewmembers were quickly recovered by a

motorboat that was close to the area of the accident.

The crew were informed by employees of the s ENAVI shipyard that there were other

people inside the ballast tank. Employees of ENAVI, along with the crew of the MV "AUK

ARROW" went to the ballast tank and rescued five other people. After the removal was

performed recount and found that the crew were all present. After the rescue a recount was

performed and found that the crew were all present.

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As a result of this accident, two workmen died and seven others were injured and taken to

hospitals of Niteroi city, where afterwards one more died.

Damage occurred in the internal structure of the ballast tank No.2 on the port side of the

vessel and in the scaffolding installed in the top part of the tank. There was no registry of

pollution or oil spill.

V – INITIAL INFORMATION

The ship was berthed at the quay of ENAVI shipyard since 25 July 2010 at 09.00 and the

explosion occurred at 21.52 of the 2nd of August of 2010.

The vessel was employed in the transport of general cargo. However according to the last

registries the vessel carried out the transport of forest products (pulp and cellulose), that are not

dangerous goods. The last cargo carried was of bulk malt. There was no sign of spillage of oily

residues in the water after the accident.

The arrangements for the raising of data and information for the accident investigation

started whilst teams of the Fire Brigade and of the Civil Police, of the ship and of the company

itself also acted in the action scene, making impossible a safe isolation of the place to carry out

the survey.

The investigators found that the crew was aware of the services in the ballast tank and,

according to testimony, there is no specific procedures for the Officer on Watch prior carrying

out the work, despite the crew verify if the repair yard was following safety procedures

correctly. At the time of the accident there was no wind and the sky was dark and there were

other cutting and welding services running in the ballast tank No. 4 of starboard. According to

witnesses the accident could have occurred due a leakage of gas that had been accumulated in

the tank, coming to explode.

The investigators also observed by testimony of crew and shipyard workers:

a) that there was no continuous watch service by the crew on the ballast tank, and that

there was a watchman of the ENAVI shipyard there. Usually the surveillance work is carried

out by the workers of the shipyard, and the ship crew used to perform at least three rounds

during the watch;

b) that the ballast tank was empty, without any residue;

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c) that there were eight workmen of the shipyard working aboard when the explosion

occurred;

d) that the witnesses did not observe the existence of alarms and oxigen meters or

explosimeter belonging to the shipyard ;

e) that there were ventilators and exhausters installed at the accident site;

f) that the witnesses were unable to inform if the workers were utilizing Personal

Protective Equipment (PPE) on the day of the accident and at the time of the explosion, as well

as that they didn´t know if the electrical installations in the proximities of the ballast tank were

fitted with anti-explosion components;

g) that the shipyard had safety procedures and they were being followed;

h) that the access to the interior of the ballast tank No.2 had been interdicted by the

Ministry of Labour;

i) that the personnel of the shipyard normally carry out the safety procedures; and

j) that the ship does not identify the workers on their entry and leaving aboard because

they enter and leave frequently.

VI – THE SURVEY

On day 03 August, in the morning a new attempt of inspection was carried out aboard, to

identify the possible causes of the accident. However, the internal area of the ballast tank Nº 2

continued blocked by the police and the Ministry of Labour, with the date of 04 August

scheduled for carrying out of the detailed examination.

In the course of the investigation it was found that on ballast tank No 2 port side the

substitution of plates in the upper part was being made. Before the beginning of the repairs in

tank Nº 2 port side, various double hoses of liquefied petroleum gas (LPG) and of oxygen, for

the services of cutting plates, were placed in the interior of ballast tank no 2 portside through its

vent (Photo 3).

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Photo 3 – Hoses passed through the vent of ballast tank Nº 2 port side

The hoses were connected to two manifolds with various distribution valves (one for

combustible gas and the other for the comburent oxygen) which were installed outside just

above the main deck (Photo 4).

Photo 4 – Manifold of valves for connection of the hoses

The combustible gas utilized to effectuate the cutting of plates was Liquefied Petroleum

Gas (LPG), instead of acetylene. The hoses of oxygen and of LPG were arranged vertically,

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extending in the direction of the lower part of the tank. Each double hose possessed two valves

(photo 5) of manual opening, at their ends.

Photo 5 – Gas opening valves

The tank had a height of 12 metres. One can gather that a little leakage in one of the hoses

of LPG gas or by its discharge valve could cause a slow accumulation of this gas in the lower

part of the tank, as much by the low position of the discharge valves at the end of each hose as

by the tendency of LPG to deposit itself on the lower parts when disseminated in air not

moving, due to its greater specific weight. It is very likely that the simple action of closing the

distribution valves on the LGP manifold, always when the hoses were not in use, could have

avoided the accident.

A Report of the Shipyard was requested by the investigators. The Report describes the

preparation for the repairs and the development of the works. In accordance with the Report,

before start of the work measurements of oxygen and carbon monoxide were made, as well as

the explosiveness was tested and the existence of hydro sulphuric gas. During seven days the

measuring was repeated before work. The certificates of calibration of the equipment used in

the measuring were not presented to the investigators despite had being requested. On 2

August, day of the accident, the measuring was carried out before 07.40 hours and at that hour

work restarted, proceeding until 17.00 hours, when finished the first shift.

The employees of the company D.M.T. were requested to extend this shift until 01.40

hours of 3 August, together with those of the company Engersea but the work was interrupted

from 17.00 hours to 20.00hours and from there up to 21.00 hours for a meal for all the workers

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in a place outside of the ship. Shortly afterwards, at 21.52 hours, the explosion occurred, with

the work fully in progress.

The Report of the Shipyard makes reference to a possible leak of oxygen (O2), comburent

of the explosion, also existing in the air, but certainly should refer to the leakage of LPG fuel of

the explosion, because an excess of oxygen could never alone cause an explosion.

Being a ballast tank, the tank Nº 2 port side does not possess electrical installations inside

it that make possible the risk of explosion. Also there were no residues of oil or of fuel in the

interior of this tank. Salt water was used as ballast.

The three screwed covers, ellipsis-shaped, for access to the tank on the passage deck were

removed and in the openings were installed three small ventilators. These ventilators were

hurled to nearby locations of the openings by a gust of air after the explosion (photo 6).

Photo 6 – Ventilator displaced by the explosion

The ventilators did not have enough force to agitate the air at the bottom of the tank and

remove the accumulated gases but contributed for the formation of an explosive mixture.

Information was received by the investigators that the ventilators, the lights and welding

equipment continued functioning during all of the work period, including during the meals: the

supervisor of the services there affirmed that all the equipments are only switched off at the

end of the work for the day.

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It may be concluded that stronger ventilators could have removed the explosive mixture

and avoided the explosion.

Damages were not verified on the deck and on the side to port resultant from the explosion

because various parts of the upper external plating of the tank had already been taken off and

the tank was exposed to the air, facilitating the decompression of the tank during the explosion.

However, in the inside, it is found that transversal girders separated by plating were bent

upwards, clearly showing that the explosion occurred from below upwards, from the bottom of

the tank to the upper part, after the accumulation of combustible gases mixed with air forming

an explosive mixture.

The installed scaffolds were thrown upwards (photo 7) and a steel plate that was to be

placed on the side fell to the bottom of the tank (photo 8), there being a possibility of this

having hit the workers, provoking injuries.

Photo 7 – Girders destroyed by the explosion

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Photo 8 – Plate fallen to the bottom of the tank

This plate was being stitched in an initial form and there was not sufficient time be fixed,

so that loosened itself with the explosion. Therefore, the stitching of the plate with electric

welding was in progress, which caused the fall of incandescent sparks of metal and electric

welding to the bottom of the tank, where there was an accumulation of an explosive mixture.

This liberation of sparks is normal in all the services of cutting and electric welding. They are

little incandescent pieces of molten solder, not fixed, of little weight, that fall vertically.

VII – CREW

The Captain of the ship had been onboard since 20 July 2010, he is Indian and speaks

English. The Third Officer was the Officer of the Watch at the time of the accident, he had

been onboard since 02 March 2010 he is Indian and speaks English.

The 31 crewmembers of the ship were trained and met the requirements established in the

STCW and in the Safety Manning Card. Annexed is a copy of the Crew list (Annex D).

From the data obtained, there was no direct participation by the crew in performing the

work that was in charge of the Shipyard ENAVI. The Officer of the Watch aboard did a routine

round of the ship, about every two hours, to check if everything was in order. The procedures

of prevention, accompanying and supervision by ship´s crew were not shown to the

investigators, nor the knowledge of the IMO recommendations contained in resolution

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A.864(20), adopted on 27 November 1997, for entry into enclosed spaces aboard ships, which

should be known and adopted by the Owner and by the Captain and its compliance should be

demanded on the occasion of work aboard, when performed by a hired shipyard.

Likewise, there is no record that the recommendations of the International Labour

Organization (ILO) contained in the ILO Code of Practice on Accident Prevention on Board

Ship at Sea and in Port were known, disseminated and put into practice on board the ship.

VIII – NOT CREWMEMBER PERSONNEL

The team of ten workers that worked in ballast tank nº 2 port side belonged to three

subcontractors hired, coordinated and supervised by the ENAVI shipyard. They were skilled

professionals who played for the activities of supervisors, flame cutters, welders and assistants.

In the area of Safety at Work, the shipyard has available an Engineer and competent

Technicians of Safety.

According to the information acquired, including in the interviews with the

professionals of the area of workplace safety and workers themselves of the shipyard, remained

the finding that the doctrine of prevention of accidents was not answered.

Was mentioned the possibility of some worker having left a hose connected or there

being some leakage in the hose or in the valve of the torch . There were not conditions to

define what occurred due the destruction of the components of the system of cutting and

welding by the explosion. There was the knowledge on the basic precautions for the work in

enclosed spaces and the need of the use of Personal Protection Equipment (PPE). Everyone

was aware of the standards and of the risks of the work, but the checking of the atmosphere

inside the tank was only made by the morning of the accident. There was preliminary

assessment of the potential risks and have been taken safety precautions deemed reasonable,

but that proved insufficient to prevent the accident.

The previous evaluation of the risks should appear in Permission to Work (PW). In

accordance with the Report of the Shipyard, the PW had been issued, but it was not presented

to the investigators.

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IX – DATA ON THE PLACE OF THE ACCIDENT

1. Local coordinates 22º52'06"S / 043º07'10"W , Ilha do Viana (Viana Island), Niterói -RJ

(Fotos 9 e 10)

Photo 9 – Viana Island (Fonte: Google Maps)

Photo 10 – Viana Island (Source: ENAVI Shipyard)

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2. Environmental conditions – At the moment of the accident, the sky was dark, calm sea,

mild temperature and without rain.

X – ANALYSIS OF THE DATA GATHERED AND CAUSAL FACTORS

The purpose of the analysis is to determine the contributory causes and circumstances of

the accident as a basis for making recommendations to prevent similar accidents occurring in

the future.

By the analysis of the information and documents gathered, it may be concluded that an

undue accumulation of LPG occurred at the bottom of the ballast tank nº 2 port side, that leaked

from a hose extended vertically in direction of the bottom or from its discharge valve in the

lower part of the tank. The portable ventilators contributed for the mixture of the ambient air with

LPG accumulated, forming the explosive mixture that detonated when the steel plate started to be

stitched in its place, creating the fall of incandescent sparks.

The permanence of the explosive mixture at the bottom of the tank was not detected due

they not having been used the explosimeter before the resumption of work after dinner. The

check for the existence of gases was made only in the morning, before work starts, whilst it

should be made several times during the work day.

The oxygen and LPG hoses should have been coiled right after passing through the vent for

them not to stay hanging in direction of the bottom of the tank.

It may be stated that stronger ventilators could have removed completely the explosive

mixture and prevented the occurrence.

The closing of the valves of the hoses that were not being used on the manifold of

distribution of LPG, could also have prevented the accident.

The following contributing factors were analysed:

a) human factor – there were no indications that the human factor, from the bio-

psychological point of view can have contributed to the accident;

b) material factor – the leakage of LPG from some of the hoses or one of their control

valves contributed to the accident, allowing the accumulation of gas in the bottom of tank nº 2

port side;

c) operational factor – the lack of monitoring with the explosimeter to verify the existence

of explosive mixture in the bottom of the tank contributed to the accident, as well as the use of

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ventilators of small power that did not remove the mass of LPG accumulated in the bottom of

the tank.

So the causal factor to the explosion was the accumulation in the lower part of the tank of

LPG originating from one or more hoses that leaked by the body of the hose or by the control

valve.

XI - PRELIMINARY LESSONS LEARNT AND CONCLUSIONS

Investigations into the circumstances of casualties that have occurred have shown that

accidents on board ships are in most cases caused by an insufficient knowledge of, or disregard

for, the need to take precautions.

The atmosphere in any enclosed space may be deficient in oxygen and/or contain

flammable and/or toxic gases or vapours. Such an unsafe atmosphere could also subsequently

occur in a space previously found to be safe.

From the analysis of the data obtained, it was verified that the causal factor to the

explosion was the accumulation in the lower part of the tank of LPG originating from one or

more hoses that leaked by the body of the hose or by the control valve.

Faced these findings, one can emphasize the learning already widely known that the gas,

being heavier than air is accumulated at the bottom of the tank. It is also evident that the safety

precautions should be observed as for instance the checking of the cutting and welding

equipment to ensure that there are no leakages. The additional precaution of closing the general

valve of the net that supplies the hoses and blowtorches also could have avoided the accident.

The gases were agitated by the three small ventilators installed in the upper part of the tank

and formed a combustible mixture that exploded in contact with sparks of the electric welding,

when commenced the fastening of a steel plate which started to be installed.

Thus we have the teaching that the efficient removal the gas mixture inside the confined

space is a precaution that can not be relegated to the background. In addition to preventing the

occurrence of such accidents, removal of gases provides a healthy atmosphere for the workers

who work on site.

The frequent checking of the concentration of gases in enclosed spaces is also a preventive

measure which should be learnt and put into practice by the workers and crewmembers

involved in the activity.

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During the execution of work in enclosed spaces there is a need for monitoring and

supervision, both by professionals in the department of work safety of the the yard as the crew

of the ship.

The recommendations of the IMO, in resolution A.864(200), adopted on 26 November

1997, for the entry in enclosed spaces aboard ships, should be known and adopted by the

Owner and by the Captain and its compliance should be demanded on the occasion of work

aboard, when performed by a contracted shipyard.

Likewise, the recommendations of the International Labour Organization, included in the

Code of Practices for the Prevention of Accidents onboard ships at sea and in port, should be

known and put in practice in this type of work, as much by the professionals onboard as by

those of the shipyard.

In general the accident showed the existence of failures in the Safety Management System

on board.

XII - RECOMMENDATIONS

In view of the lessons learned and conclusions, are formulated the following

recommendations to the owners, crews and shipyard repair:

a) All services of plate cutting and welding must be constantly monitored by means of

an explosimeter duly certified in order to alert the formation of explosive mixture in the

compartment;

b) The air inside of enclosed spaces should be permanently renewed by adequate

ventilators to not allow the accumulation of explosive gases;

c) The hoses of combustible gas (acetylene or LPG) should remain coiled outside the

tank (enclosed space), when not in use;

d) The valves of the manifolds of distribution of LPG corresponding to the hoses that

are not in use, should remain closed;

e) The Permission to Work should be filled in before the start of the work and verified

daily. The workers should be qualified for the services they are going to do; and

f) The electrical and mechanical equipments existing in the interior of enclosed spaces

should be switched off when they are not in use.

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List of Annexes:

ANNEX A - Notification sent by the Port Captaincy of Rio de JaneiroANNEX B - Ship ParticularsANNEX C - Report of Inspection of Port State Control carried outANNEX D - Crew list

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ANNEX ANotification sent by the Port Captaincy of Rio de Janeiro

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ANNEX BShip Particulars

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ANNEX CReport of Inspection of Port State Control carried out

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ANNEX D

Crew list

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Documents

BRAZILIAN MARITIME AUTHORITY DIRECTORATE OF PORTS …