ship incidenrt lesson learned

1. ABEER 32 EXPLOSION/FIRE ACCIDENT

2. 1) Where and when did it Happened?
Date : 9/10/2006
Time : 2010hrs
Location : Udang “Bravo” Platform Natuna
Operation : Cargo transfer from vessel to
Platform (16 bottles of oxygen in a steel rack)
Weather Condition: At the time of accident, the weather is considered
to be fair and calm. The wind speed is about
5knots and swells about 0.5m. The visibility is not
very good due to the haze but there was no sign
of any rain.
WHERE & WHEN DID IT HAPPENED?
Picture Showing Udang “Bravo” Platform

3. WHERE & WHEN DID IT HAPPENED?
Abeer 32
Air winch
Tugger
Broken Crane
UDANG “B”
PLATFORM Flare
Current to
North – 0,5 knots
Abeer 32
Air winch
Tugger
Broken Crane
UDANG “B”
PLATFORM Flare
Current to
North – 0,5 knots
Wind from
SW – 5 Knots
Picture showing location and direction
N

4. ACCIDENT DESCRIPTION
2) Accident Description
› On Sunday, 8/10/2006 Abeer 32 departed Batam for Udang “Bravo”
Platform Natuna after loading the cargoes and carrying 25 passengers.
› Abeer 32 arrived in Udang “Bravo” Platform on 9/10/2006 at about
1430hrs and started to transfer the 24 passenger using the “monkey
swing” method with vessel going sternward to passenger landing
platform.
› After completed passenger transfer, at about 1600hrs the cargo transfer
to Bravo platform commences. Whilst transferring the last cargo for Bravo
platform containing 16 bottles of oxygen bottles in a steel rack, at about
2010hrs the oxygen bottle steel rack fell directly onto a box containing
some cans of WD40, utensils and miscellaneous stuff located on the
starboard side of the main deck outside the accommodation of Abeer 32
at a height of about 25m.
› The impact of the fallen oxygen bottles causes an explosion and fire to
engulf the main deck accommodation leading to the lower crew
accommodation and partially the wheelhouse.

5. ACCIDENT DESCRIPTION
2) Accident Description (Cont’)
› Mr Hendrik Hasan of PT Pan, at the time of accident was sitting on the
port side outside the accommodation (opposite to the fallen oxygen
bottles) unfortunately did not survive.
› The AB Mr Hasbullah who was standing on the midship stbd main deck
assisting in releasing the mooring line managed to escape to the bow
section.
› The C/O Mr Harry who was in the lower accommodation, the 2/E Mr
Ridwan who was sleeping in the crew quarter and the C/E Mr Sofyan
who was in the engine room manage to run out from the lower deck and
escape to the outside of the accommodation on the forward main deck.
› The AB Mr Tommy managed to jump over to Bravo passenger landing
platform where he immediately contacted the platform personnel for
assistance. With the help of the platform using fire hoses from the top of
platform and passenger landing platform that was activated by AB
Tommy and PT Pan Project Leader Mr Sunaryo, the fire managed to
slow down. At this time, Tommy and Mr Sunaryo tried to enter the engine
room to turn off the main engines but without success due to the heavy
smoke. Thereafter about 15minutes later, a tugboat “Citra” arrived to join
in the fire fighting where in joint effort successfully extinguished the fire.

6. ACCIDENT DESCRIPTION
2) Accident Description (Cont’)
› AB Tommy tried again to enter into the engine room together with one
personnel from Tugboat Citra and eventually managed to turn off the
main engine and shut off the fuel line.
› Immediately after the explosion, the Master mustered the rest of the crew
to the forward section of the vessel, which is considered to be safe at that
time and thereafter Master ordered to lower the rubber boat onboard in
order to evacuate the vessel where he considered to be in a questionable
state that further explosion might occurred.
› The Master made a head count and noted that AB Tommy is already
safely on the passenger landing platform and the AB/Cook Mr Arnoldo
Morong is missing where he immediately reported to the personnel of PT
Pan.

7. MISSING AB/COOK ARNOLDO MORONG
3) Missing AB/Cook Arnoldo Morong
› The AB/Cook Mr Arnoldo Morong is suspected to be standing on the port
side main deck (midship section) where there is an opening for rescue
zone at the time of accident. He could have been thrown overboard due
to the impact of the explosion on the stbd side.
Picture showing the work vest
belonging to AB/Cook Mr
Arnoldo Morong that was found
in the sea
AB/Cook Arnoldo
could be standing
here
Force of explosion

8. RECOVERY
4) Recovery after Accident
› The 5 crew excluding AB Tommy who is already safely on the Bravo
platform and the missing AB/Cook Arnold boarded another Crewboat
from Baruna – “Tempoa” where they were later transferred to Bravo
Platform accommodation.
› After fully extinguished the fire onboard Abeer 32 on the same day
(9/10/2006) at about 2100hrs LT, the Tugboat Citra managed to tow
Abeer 32 to an anchor buoy where she is tied up.
› A Search and Rescue (SAR) operation was activated by PT Pan at about
2100hrs on 9/10/2006 using crewboat “Tempoa”. PT Pan calls off the
SAR on 10/10/2006 at about 0400hrs when the crewboat fails to find the
body of Arnoldo.
› EOT engaged a tugboat “Barlian” from ASL to tow back Abeer 32 –
commence on 17/10/2006, 1245hrs LT.
› After persistent request from EOT, PT Pan managed to conduct a diving
operation on the seabed to search for the body of Mr Arnoldo on
16/10/2006 but still fail to locate him.

9. EXTEND OF DAMAGES
5) EXTEND OF DAMAGES – MAIN DECK

10. EXTEND OF DAMAGES
5) EXTEND OF DAMAGES – PASSENGER AREA

11. EXTEND OF DAMAGES
5) EXTEND OF DAMAGES - GALLEY

12. EXTEND OF DAMAGES
5) EXTEND OF DAMAGES - WHEELHOUSE

13. EXTEND OF DAMAGES
5) EXTEND OF DAMAGES – BELOW MAIN DECK (CREW
QUARTER)

14. INVESTIGATION FINDINGS
5) Investigation Findings
› The source of explosion/fire could be due to the impact of the fallen steel
rack that causes sparks (heat source) in contact with the flammable
gases from the damaged cans of WD40 (rust penetrant) resulting in an
explosion. The fire spread further and larger when it mixes with the rich
leaking oxygen from the damaged cylinder heads enriching the
combustion. The fire in mixture with the rich oxygen causes localized
heat melting through the aluminum plate on the main deck (on two
location as seen in the picture) and spreading the fire across the galley
and alleyway of the crew quarters below main deck.

15. INVESTIGATION FINDINGS
Fire Spreading
thru

16. ROOT CAUSE
ROOT CAUSE
Failure to
follow proper
procedure
Incorrect
Lifting
Methods
Defective
equipment or
materials
Operating
without
adequate
training
Type of Event
(Cause/Agency)
Falling Object

17. ROOT CAUSE
6) ROOT CAUSE – Failure to follow procedure
› The crewboat Abeer 32 was moored to the passenger landing platform of
Udang Bravo during time of cargo transfer, which exposes her to various
dangers. Based on interviews, the Master fully understand this fact but
mentioned that if the vessel is not moored to the platform then cargo
transfer cannot take place due to the offshore crane breakdown and PT
Pan is using a simple air driven winch davit for the cargo transfer.
› Prior to the cargo transfer especially with the heavy cargoes, there had
been no Job Safety Analysis or Work Permit conducted
› The Master having the overriding authority does not have knowledge on
the cargo manifest, weight of cargo and hence there is no way he can
ensure safe transfer of the cargo in protection to shipboard personnel
and Company’s property to his best endeavor

18. ROOT CAUSE
6) ROOT CAUSE – Failure to follow procedure (cont’)
› There is no evidence that proper inspection on the lifting
gears/equipment had been conducted prior to the cargo lift. No proper
identification of the lifting gears were noted to show that it had been
properly tested/inspected to its SWL and proper for use
› The fittings on the 16 bottles of oxygen was not removed during the lift
and there is no proper securing cover on the bottle head
Picture showing the fittings
were not removed during the
lift and there are no protective
covers on the oxygen bottle
head

19. ROOT CAUSE
6) ROOT CAUSE – Incorrect Lifting Methods
› It is our understanding that the air driven winch davit is certified to SWL
of 1ton although there is no evidence of proper certificate to ascertain the
lift and when it was last tested.
› The overall height from the Bravo platform main deck to the sheave block
of the davit is measured at 2.15m and the overall height of the oxygen
bottles steel rack is measured at 2.25m hence it will be difficult for the
operator to hoist in the steel rack to the main deck considering the
weight. Beside the height constraint, there is also obstruction on the
platform main deck further restricting the hoisting in of the steel rack.
From site inspection there is an angle plate protruding about 20mm from
the main deck

20. ROOT CAUSE
6) ROOT CAUSE – Incorrect Lifting Methods (Cont’)
2.25m
Approximately 2.5m outreach
arm
Picture showing angle bar on
the main deck that could
probably further restrict
hoisting in the steel rack
containing the oxygen bottles

21. ROOT CAUSE
6) ROOT CAUSE – Defective Equipment/Material
› There is no evidence that the lifting gears belonging to PT Pan had been
load tested regularly to its proper SWL with proper approved color
identification for use
› There is no evidence of proper planned maintenance system for the
lifting gears and associated equipment carried out by PT Pan
› The lifting wire on the davit is in bad condition
› The lifting hook does not have a safety latch
› It is our understanding that the rack carrying the 16 bottles of oxygen
belongs to a sub contractor in Batam. Although it is stated on the rack
that it’s SWL is 3.6tons but there is no evidence that the welded U bolt on
the top center of the rack is rated to the safe working load of 3.6tons.

22. ROOT CAUSE
6) ROOT CAUSE – Defective Equipment/Material
Picture showing the lifting hook does not have a
safety latch
and
the damage davit lifting wire – breaking off from
the end of the socket

23. ROOT CAUSE
6) ROOT CAUSE – Inadequate Training
› It is our understanding that during the time of accident, the air driven
winch davit is control by a worker and supervised by the Project Leader
on the platform where both are employee of PT Pakarti (Sub-contractor
for PT Pan)
› There is no evidence to show that the person operating the crane is an
approved crane operator or had undergone proper rigger training.

24. LESSON LEARNT
› IF YOU SEE IT YOU OWN IT!
› DO SOMETHING ABOUT IT IF WHAT YOU SEE IS NOT
CORRECT OR IN DOUBT – TELL SOMEBODY! ASK!
› DO NOT ACCEPT SUB-STANDARD SAFETY PERFORMANCE!
› STOP THE WORK IF YOU THINK IT IS NOT RIGHT!
› MASTER MUST EXERCISE HIS OVERRIDING AUTHORITY AND
STOP WORK AUTHORITY
› FOLLOW PROPER PROCEDURE