All too often there seems to be a disconnect between what procedures are supposed to achieve in terms of safety and the place of paperwork. So it was with a fire aboard BBC Baltic.
Procedures and permits are safety nets. When they become merely a paper exercise bad things happen.
At about 1605 on 26 January 2012, a fire broke out in the number one cargo hold of the general cargo ship BBC Baltic while it was discharging cargo in Port Hedland. At the time, workers from Cervan Marine, a local engineering company, were gas cutting in the cargo hold using an oxy-acetylene torch. The ship’s crew assisted by the local emergency services fought the fire and, by 1625, had extinguished it. There were no injuries as a result of the incident and damage to the ship and its cargo was not serious.
In carrying out the hot work on board BBC Baltic, neither the ship’s crew nor the Cervan Marine workers properly considered and mitigated the risk of fire. All the precautions listed on the ship’s hot work permit were not taken nor was the permit completed properly. Similarly, all the measures listed on Cervan Marine’s job safety analysis were not taken. Furthermore, a tool box meeting was not held to discuss the work and risk, define roles and responsibilities, and the action to take in case of a fire.
As a result of inadequate risk assessments, there was no fire watch, none of the ship’s crew was at the hot work site and Cervan Marine’s workers did not have a clear understanding of the action to take in case of a fire. Consequently, action to fight the cargo hold fire with a fire extinguisher and other fire-fighting equipment was not taken immediately, resulting in a larger fire that took longer to contain.
Read the investigation report here