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Abeer 32 accident

Ferri Fatra
Ferri Fatra

An explosion and fire occurred on the crewboat Abeer 32 on September 10, 2006 while transferring cargo from the vessel to the Udang Bravo platform in the Natuna area. One crew member was killed in the accident. The root causes identified were the failure to follow proper lifting and cargo transfer procedures, using incorrect lifting methods with potentially defective equipment, and inadequate training. Crews were transferring 16 oxygen bottles when the lifting sling fell, causing an explosion when it impacted other flammable materials on deck. This spread a fire throughout the accommodation areas. An investigation found procedural and equipment issues contributed to the accident.

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ABEER 32 EXPLOSION/FIRE ACCIDENT
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
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
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.
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.
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.
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
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.
EXTEND OF DAMAGES 5) EXTEND OF DAMAGES MAIN DECK
EXTEND OF DAMAGES 5) EXTEND OF DAMAGES PASSENGER AREA
EXTEND OF DAMAGES 5) EXTEND OF DAMAGES - GALLEY
EXTEND OF DAMAGES 5) EXTEND OF DAMAGES - WHEELHOUSE
EXTEND OF DAMAGES 5) EXTEND OF DAMAGES BELOW MAIN DECK (CREW QUARTER)
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.
INVESTIGATION FINDINGS Fire Spreading thru
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
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 Companys property to his best endeavor
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
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
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
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 its 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.
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
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.
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

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Abeer 32 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.
  • 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 Companys 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 its 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