Report of the
Board of Inquiry
into the fire in
HMAS WESTRALIA
on 5 May 1998
VOLUME 1
REPORT/ANNEXES Report of the
Board of Inquiry
into the fire in
HMAS WESTRALIA
on 5 May 1998
VOLUME 1
REPORT/ANNEXES
(Photograph courtesy the West Australian newspaper) © Commonwealth of Australia 1998
This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the Department of Defence.
All Defence information, whether classified or not, is protected from unauthorised disclosure under the Crimes Act 1914. Defence information may only be released in accordance with the Defence Protective Security Manual (SECMAN 4) and/or Defence Instruction (General) OPS 13–4—Release of Classified Defence Information to Other Countries, as appropriate.
Requests for copies of the report should be directed to:
Director of Coordination–Navy R1-4-C070 Russell Offices CANBERRA ACT 2601
(02) 6265 3940
Publisher
Defence Publishing Services Department of Defence CANBERRA ACT 2600
DPUBS: 32871/98 AUTHORISATION
The President and Members of the Board of Inquiry into the fire in HMAS WESTRALIA on 05 May 1998 confirm that we unanimously support the findings, conclusions and recommendations presented in this report.
L. Cuneo C.W. Filor Assistant Chief Officer, Inspector of Marine Accidents, Fire and Rescue Service of WA Commonwealth Department of Workplace Member Relations and Small Business Member
E.G. Walsh R.B. Schedlich Commander, RAN Captain, RAN Member Member
R. Lamacraft Commodore, RAN President
August 1998 OUTLINE
Section 1. Introduction 1
Section 2. Narrative of Events of 5 May 1998 15
Section 3. Actions of the Ship’s Company, their Training and Competence 45
Section 4. Medical Response to the Incident 71
Section 5. Death and Injury of Personnel 86
Section 6. External Assistance 96
Section 7. Firefighting and Safety Equipment 116
Section 8. Materiel State of the Ship 126
Section 9. Causes of Fire 146
Section 10. How Hoses of Inadequate Design came to be Fitted 169
Section 11. RAN Configuration Management 197
Section 12. Quality Assurance 199
Section 13. System Safety Management 204
Section 14. Comcare 211
Section 15. Recognition of Personnel 213
Section 16. Principal Findings 216
Section 17. Conclusions 217
Section 18. Recommendations 231
Section 19. Annexes 239
i TABLE OF CONTENTS
SECTION 1. INTRODUCTION 1
THE BOARD OF INQUIRY 1
ADMINISTRATION OF THE INQUIRY 2
STRUCTURE OF THE REPORT AND ATTACHMENTS 4 The Report 4
REFERENCES THROUGHOUT THE REPORT 7
HMAS WESTRALIA 9 History 9 Activities of the ship prior to 5 May 1998 9 The Main Machinery Space 10
SECTION 2. NARRATIVE OF EVENTS OF 5 MAY 1998 15
EVENTS TO 1030 15 The bridge 15 The MMS and machinery control room 15
THE FUEL LEAK: 1030-1034 16 The bridge 16 The MMS and machinery control room 18 The medical response 20
FIRE INITIATION: 1034 – 1038 20 The MMS and machinery control room 20 Damage control headquarters (HQ1) 25 The bridge 25 The medical response 26
INITIAL RESPONSE: 1038 – 1102 26 Damage control headquarters (HQ1) 26 Aft damage control section base 28 Forward damage control section base 29 The MMS 29 Initial casualty management 30 The bridge 30 External agencies 31
CO2 DRENCH: 1102 – 1126 32 Aft Pump Room 33 Casualties Relocated to the RASCO 33 External Agencies 34
HOSE TEAM OPERATIONS: 1126 – 1232 34 The bridge 37 External agencies 37
FIRE EXTINGUISHED: 1232 ONWARDS 39 Medical activities 39 External agencies 42
ii TABLE OF CONTENTS
SECTION 3. ACTIONS OF THE SHIP’S COMPANY, THEIR TRAINING AND COMPETENCE 45
INCIDENT COMMAND 45 Incident management strategy 45 Decision not to anchor 46 Decision to CO2 drench 50 Emergency organisation with Special Sea Dutymen on watch 51 Use of the Standing Sea Fire Brigade 51 Personnel in Tiller Flat 52 Effective utilisation of female sailors 52
EMERGENCY PROCEDURES AND FIREFIGHTING TECHNIQUES USED 53 Reactions to the fuel leak 53 Charging of hoses laid out in the MMS 54 Escape drills 55 AFFF hand-held extinguishers 55 Containment 56 Ventilation 56 Re-entry 57 Hose teams 57 Sustenance of Hose Teams 58 Breathing Apparatus Control Procedures 58 International Shore Connection 63 Fixed CO2 Fire Protection System – Procedures for use 64 HMAS WESTRALIA Emergency File 65 Ship Knowledge 66
TRAINING 67 Firefighting Training 67 Pre Joining Training 67 Annual Continuation Training 68 Fast Cruise 68 Major Fire/Engine Room Fire at Sea Exercise [DC 101/100] 69 Sea Training Group Covered Training 69 Additional Training Required 69
SECTION 4. MEDICAL RESPONSE TO THE INCIDENT 71
SHIP’S EMERGENCY MEDICAL ORGANISATION 71
INITIAL MEDICAL RESPONSE 72
REPORTING OF MISSING PERSONNEL 73
INITIAL MANAGEMENT AND REPORTING OF THE FATALITIES 74
MEDICAL STAFF SUPPLEMENTATION 75
MANAGEMENT OF THE INJURED AT RASCO 76
MEDICAL EVACUATION OF CASUALTIES 77
FATALITY EXTRICATION 77
MEDICAL INCIDENT MANAGEMENT 78 Medical Incident Management Training 80
COMMUNICATION OF CASUALTY STATE 81
iii TABLE OF CONTENTS
MEDICAL MATERIEL 82 SMET Jackets and Red Cross Brassards 82
MEDICAL TRAINING 83 Clinical Training 83 Ship Board Training 84
SECTION 5. DEATH AND INJURY OF PERSONNEL 86 Medical Screening 86 Personnel in MMS at Outbreak of Fire 87 Fatalities 87 Injured 93
SECTION 6. EXTERNAL ASSISTANCE 96
RAN UNITS 96 RAN Surface Units 96 The Helicopters – Sea King (HMAS SUCCESS) 97 The Helicopters – Seahawk (HMAS ADELAIDE) 99 Air Traffic Control 99
EXTERNAL AGENCIES 100 Fleet Base West and Port Services 100 Fremantle Port Authority (FPA) 101 Fremantle Tug Operators (FTO) 104 Western Australia Police Service and the Coroner 105
CRITICAL INCIDENT STRESS MANAGEMENT 106 CISM Support Provided 106 Acceptance of CISM 107 Possible Contamination of Evidence 108 Preparation for Critical Incidents 109 Peer Support 110
CHAPLAINCY 111
FAMILY LIAISON AND SUPPORT SERVICES 112 Notification of Next of Kin 112 Additional Support 113
EXTERNAL MEDICAL ASSISTANCE 114 HMAS STIRLING 114 St John of God Hospital Murdoch 115
SECTION 7. FIREFIGHTING AND SAFETY EQUIPMENT 116
FIREFIGHTING EQUIPMENT 116 Thermal Imaging Camera (TIC) 116 Waterwall 116
BREATHING APPARATUS RESOURCES 117 Condition and Maintenance of OCCABA 118 Breathing Apparatus Ancillary Equipment 121 Bauer Compressors 121
ANCILLARY FIREFIGHTING EQUIPMENT 122 Communication with hose teams 122 Emergency Fire Pump 123
iv TABLE OF CONTENTS
SAFETY EQUIPMENT 123 Torches 123 Helmets 124 ELSRD 124
SECTION 8. MATERIEL STATE OF THE SHIP 126
DEFECTS 126 Urgent Defects (URDEFS) 126 Fuel leaks 126 Fuel system 127 Main engine controls 129 Ships communications - external 129 Communications - internal 129 Main machinery space gas tight integrity 129 Penetrations into MCR 130 Fixed CO2 firefighting system 131 Ships firemain 132 Exhaust leakage 133 Indicator cocks 133 Future of the injection pump suction and spill pipework 133 Drawings and Technical Documentation 134 Maintenance Funding 134
CLASSIFICATION REQUIREMENTS AND INTERNATIONAL STANDARDS 134 Lloyd’s Certificates 134 SOLAS 135 Surveys 135 International Standard for Emergency Source of Electrical Power 135 International Standard for Means of Escape 136
ENHANCEMENTS 138 Configuration of MMS Ladders 138 Main Machinery Space Communications 140 Replacement/Upgrade of CO2 System 141 Incident Recording Devices 142 System for Opening the Funnel Flaps 142 Fire Detection System 143 MMS Evacuation Siren 144 Emergency Lighting and Reflective Tape 145
SECTION 9. CAUSES OF FIRE 146
ORIGINATION OF FIRE 146 Engine fires in general 146 Ignition point and fuel source 147 Failure of PME supply hose (No. 8 cylinder) and SME return hose (No. 9 cylinder) 148 Secondary bilge fire and areas of fire damage 148 Other expert opinion 149 Fuel specification 150 Ignition source 150 Fuel supply 150
FAILURE OF THE FLEXIBLE FUEL HOSES 151 Description of the hoses 151 Hours of operation of the flexible fuel hoses 151 Metallurgical testing of flexible fuel hoses 151 Failure of flexible fuel hoses due to fatigue 152 Other testing results 153 Spill pulse pressure 154
v TABLE OF CONTENTS
Number of pulses 155 Pielstick, IMO and other information relating to ‘spill pulse’ 156 Outstanding issues between experts 159 Other problems with flexible fuel hoses 162 Design improvements to flexible fuel hose assemblies 167
SECTION 10. HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED 169
MAINTENANCE ARRANGEMENTS 169 WESTRALIA’s maintenance program 169 OAWA 169 ADI RPLSS contract 169
FLEXIBLE FUEL HOSE PROPOSAL 170 Origin 170 1996 Proposal 172 Developments in 1997 173 1998 Proposal 174
ORDERING OF THE HOSES 178 ADI’s initial actions 178 Work Instruction A1161/Specification 180 Selection of subcontractor 182 Allocation of AMP work at pre-AMP meeting 187
MANUFACTURE AND INSTALLATION OF HOSES 188 Production of prototype fuel hoses and use of SST-12 hose 188 Contract Change Proposal 191 Assembly, testing, installation and reinstallation 192
PROCESS DEFICIENCIES AND OTHER FACTORS 194 Introduction 194 NAVY 194 ADI 195 Parker Enzed Technology Organisation 196
SECTION 11. RAN CONFIGURATION MANAGEMENT 197
SECTION 12. QUALITY ASSURANCE 199 Reliance on Certification 199 Navy 199 OAWA 200 ADI 201 Parker Enzed Technology Organisation 202 Defence Accreditation and Auditing Policy 203
SECTION 13. SYSTEM SAFETY MANAGEMENT 204
SECTION 14. COMCARE 211
SECTION 15. RECOGNITION OF PERSONNEL 213 Hose Teams 213 Engine Room Personnel 214 Medical Personnel 215 Other Personnel 215
vi TABLE OF CONTENTS
SECTION 16. PRINCIPAL FINDINGS 216
SECTION 17. CONCLUSIONS 217
SECTION 18. RECOMMENDATIONS 231
SECTION 19. ANNEXES 239 Annex A: Personnel onboard WESTRALIA at 1030H on 05 May 98 Annex B: List of witnesses Annex C: List of exhibits Annex D: Transcript of WESTRALIA Bridge tape (abridged version) Annex E: Timeline of the incident Annex F: Firefighting equipment and techniques Annex G: Biographies of Board members Annex H: Glossary of terms and acronyms
vii ON BEING WISE AFTER THE EVENT
For those who pick over the bones of other people’s disasters, it often seems incredible that these warnings and human failures, seemingly so obvious in retrospect, should have gone unnoticed at the time. Being blessed with both uninvolvement and hindsight, it is a great temptation for retrospective observers to slip into a censorious frame of mind and to wonder at how these people could have been so blind, stupid, arrogant, ignorant or reckless . . .
First, most of the people involved in serious accidents are neither stupid nor reckless, though they may well be blind to the consequences of their actions. Second, we must beware of falling prey to the fundamental attribution error (i.e. blaming people and ignoring the situational factors).
Reason J Human Error Cambridge Uni Press 1991
viii SECTION 1. INTRODUCTION
THE BOARD OF INQUIRY
1.1 A Main Machinery Space (MMS) fire onboard HMAS WESTRALIA on 5 May 1998 resulted in the loss of life of four members of the RAN. The Minister for Defence, the Honourable Mr Ian McLachlan MP, directed that a public inquiry would examine all the circumstances surrounding this tragic incident.
1.2 In response to this direction, the Maritime Commander Australia, Rear Admiral C.A. Ritchie AM RAN, convened a Board of Inquiry pursuant to Regulation 23 of the Defence (Inquiry) Regulations. The Board members1 were:
Commodore Richard Lamacraft, RAN (President)
Christopher William Filor, PSM, Inspector Marine Accidents
Captain Russell Bryan Schedlich, RAN
Assistant Chief Officer Lindsay Cuneo, Fire and Rescue Service of WA
Commander Edward George Walsh, CSC RANR
1.3 The Board was directed by its terms of reference to investigate all the relevant circumstances surrounding the fire in HMAS WESTRALIA on Tuesday 5 May 1998, the death of personnel in that fire and the injury of other members of the ship’s company. The Board was directed that the inquiry should include but not be limited to:
(1) The cause of the fire (9 – 13 of this report) and the manner in which it was fought (see sections 2 and 3);
(2) All the circumstances relevant to the death and injury of personnel (see sections 2, 4 and 5);
(3) The involvement of the ship’s company including their training and competence (see sections 2, 3 and 15);
(4) The materiel state of HMAS WESTRALIA at the time of the fire (see section 7 and 8); and
(5) The involvement of other naval units and external agencies (see sections 2 and 6).
1.4 The President of the Board received a letter from Comcare on 14 May 1998 in which that organisation sought specific information regarding measures taken by the RAN to prevent a recurrence of this type of accident. Comcare’s specific requests have been addressed at section 14 of this report.
1 Short biographies of the Board members are in Annex G.
1 INTRODUCTION
Persons represented before the Board
1.5 In his opening address to the Board, counsel assisting (CAPT P.R. Callaghan SC RANR) indicated that a rupture had been found in one of the ships flexible fuel hoses [T13] and that a number of fuel hoses had been photographed and taken into custody.[T12] He indicated that evidence would be given from an officer of the police arson squad to the effect that the origin of the fire was on the starboard engine, where a fuel leak had developed, spraying a plume of diesel fuel upwards which fell on top of the hot engine and ignited.
1.6 As a result, the Board received three applications, on behalf of parties seeking to be considered as persons who might be affected by the inquiry, for authorisation for appearance and for legal representation during the inquiry. These were ADI Limited, Jetrock Pty Ltd (trading as Enzed Hose Doctor) and Parker Enzed Technology Pty Ltd. All three applications were granted and the term ‘intervening parties’ is used to refer to these parties.
1.7 In the early stages of the hearing, arrangements were made for legal representation for WOMT M.R. Jones and for a senior legal adviser to be available to assist the ship’s company of HMAS WESTRALIA on an as required basis. Towards the conclusion of the hearings, the Board determined that WOMT Jones and LCDR D.R. Crouch, RAN were persons who may be affected by the inquiry and legal representation was authorised.
Urgent safety issues
1.8 As the Board became aware of important safety issues that required immediate attention, these were raised with the Maritime Commander. Four issues were raised, these were:
a. use of flexible fuel hoses in certain circumstances (Telecon Maritime Commander Australia/President BOI of 11 May 98);
b. escape training using ELSRD [E455];
c. firefighting re-entry procedures after CO2 drenching [E456]; and
d. HMAS WESTRALIA compartment escape routes [E454].
ADMINISTRATION OF THE INQUIRY
1.9 The Maritime Commander Australia directed the Board to conduct its proceedings in public and to take evidence on oath or affirmation. The Board convened to commence publicly receiving oral and physical evidence on 11 May 1998. The President opened proceedings with a short statement. Television cameras and sound recording devices were permitted in the hearing room only during that opening session.
1.10 The usual procedure of the Board was for a written statement by the witness to be tendered and adopted by the witness on oath or affirmation. The witness was then questioned by Counsel assisting the Board, followed by Counsel for the intervening parties, and then by Board members. This process was then repeated if necessary. A running transcript of proceedings was kept. The rules of evidence were not applicable.
2 INTRODUCTION
1.11 The Board arranged for expert testing of various engine and system components, and their reports are contained in volume 12 of this report. The intervening parties were offered the opportunity to comment on the protocols for, and to observe the conduct of, that testing. The intervening parties took advantage of that opportunity in relation to most testing. The Photographic Unit in the Submarine Training and Systems Centre, HMAS STIRLING assisted the Board in producing video and photographic records of the state of the ship and its systems, and the conduct of expert testing.
1.12 The ADF does not have a dedicated facility suitable for large hearings in Western Australia. A hearing room, secure storage and offices for the Board, counsel, support staff and transcript recorders were efficiently arranged at short notice by CO STIRLING using the facilities of Naval Training Command Annex – West (NTCA-W). NTCA-W were more than generous with their support and commendably tolerant of the inevitable disruption to their activities during the ten weeks of hearings.
1.13 The Board rose to consider its findings on 17 July 1998, having taken evidence from 93 witnesses resulting in 4477 pages of transcript, as well as receiving in excess of 481 items as exhibits. During the Board’s deliberations, some documents and reports were added as exhibits, notice of that action having been given to the persons represented before the Board.
1.14 During the hearing it became apparent that the Board might make findings adverse to certain persons. Where possible, the substance of that matter involved was put to that person during questioning or in Counsel Assisting’s final address. This allowed the person to respond. Where, during its deliberations, the Board found that they might make an adverse finding which a person may not previously have been given an adequate opportunity to address, that person was given written notice of that possible finding and given the opportunity to make further submissions. The Board has considered these further submissions before arriving at its findings.
1.15 In order to gather and consider the extensive evidence, the Board sought and was granted two extensions to the date for submission of this report. The Board is now confident that it has properly considered the material before it and is in a position to render a comprehensive report on the matters referred to it for inquiry.
1.16 The President and Naval Board of Inquiry members wish to publicly acknowledge the valuable contribution of the two civilian members to the Naval Board of Inquiry. As a result of their extensive expertise and contacts in their respective fields, the civilian Board members have been in a position to access useful technical information and give significant input on suggestions for improvements in RAN equipment and procedures. This is evident in the substance of the report. They have also properly questioned accepted RAN procedures and this has led to a fresh approach and recommendations for improvements.
1.17 The Board is conscious of the considerable support it has received from many agencies and individuals. The Board wishes to acknowledge all those who have assisted this inquiry by way of providing submissions, giving evidence or in any other manner, and providing the day to day support, which has been necessary to enable it to reach its findings and produce this report. The support team has been magnificent and has worked long hours under trying conditions.
1.18 The Board members unanimously present this report. Differences of opinion on issues have arisen at times, but all have been resolved.
3 INTRODUCTION
STRUCTURE OF THE REPORT AND ATTACHMENTS
1.19 The original report to the Maritime Commander Australia includes all the exhibits received by the Board and the transcript of proceedings. The report has also been prepared for wider distribution in 16 volumes. Volume 1 contains the full text of the report and its annexes. Volumes 2 – 11 contain the transcript of proceedings less a small portion of proceedings that were held in confidence. The transcript remains in its original form and contains a number of spelling and transcription errors. There has been no opportunity to correct them. Volumes 12-15 reproduce selected exhibits. Their content is further discussed below. Volume 16 contains medical-in-confidence and staff-in-confidence material and is not intended for public release. It consists of three sections, all of which deal in detail with the discovery, treatment, management and recovery of casualties.
1.20 The Board received in evidence 481 exhibits. All of those exhibits, along with the administrative files and records of the Board, have been passed to Maritime Commander Australia with the original copy of this report. For the convenience of those who will at some point require access to those exhibits, Volumes 12 to 15 reproduce those more likely to be required.
1.21 The exhibits were selected on the basis of whether they were referred to in the report or, were not referred to, but are likely to be of particular interest to elements of the RAN or another government instrumentality. From this list the following classes of material were then removed: any exhibits not capable of convenient publication (e.g. tapes, videos, charts, radiographic images); material duplicated in several exhibits; material published elsewhere (e.g. reports from other bodies and official RAN manuals); classified, commercial-in-confidence and official use only documents.
1.22 Volume 12 reproduces technical expert reports. Volume 13 contains relevant logs and records from WESTRALIA and those who provided assistance to her on 5 May. Volumes 14 and 15 reproduce the documentation relating to the maintenance of WESTRALIA and the fitting of new flexible fuel hoses to the main engines just prior to the fire.
1.23 The first section of Volume 16 is a medical-in-confidence annex covering the clinical details of the casualties and the actions of medical personnel. The annex is summarised in section 5 of this report. The second section contains that portion of the transcript of proceedings not held in public. Those proceedings also related to the discovery and management of casualties. The final section reproduces those exhibits marked by the Board in confidence and relating to the discovery and management of casualties.
The Report
1.24 Volume 1 is divided into 18 sections. The substantive sections of the report, Sections 2 – 18, are discussed below. Section 1 gives the background to the report, how the Board came to be and how it conducted its inquiry. It also gives a general description of the ship and its activities prior to 5 May 1998.
Section 2 - Narrative of Events of 5 May
1.25 Section 2 is a summary of the Board’s findings of fact as to what occurred immediately before, during and after the fire on 5 May 98.
4 INTRODUCTION
Section 3 - Actions of the Ship’s Company and their Training and Competence
1.26 This section examines the actions taken by the ship’s company to deal with the emergency, whether they followed standard operating procedures (SOPs), and whether those SOPs were adequate. It also examines whether the ship’s company had completed all required training and whether that training was adequate to prepare them for this incident.
1.27 This section does not deal with the performance and adequacy of equipment and systems – those issues are dealt with in Sections 7 and 8.
Section 4 – Medical Response to the Incident
1.28 This section examines the adequacy of the medical response to the incident, whether SOPs were followed and whether those procedures were appropriate. It examines the adequacy of medical materiel and training of medical personnel, including Ship’s Medical Emergency Team (SMET) members.
Section 5 – Death and Injury of Personnel
1.29 This section identifies the circumstances in which the casualties were sustained and summarises the Board’s findings in relation to the medical management of the incident. A separate medical-in-confidence annex in Volume 16 describes in detail the discovery, treatment, management and recovery of casualties.
Section 6 – External Assistance
1.30 The purpose of this section is to describe the assistance from external sources provided to: • the ship during and immediately after the incident, • naval personnel during and after the incident, and • the families of personnel during and after the incident. 1.31 It also discusses whether that assistance was appropriate and timely and whether lessons can be learned for future incidents.
Section 7 – Firefighting and Safety Equipment
1.32 The purpose of this section is to examine whether the equipment used to fight the fire worked in the manner intended and if not, why not. It also discusses whether that equipment was adequate to deal with the emergency and identifies any new equipment or changes to equipment required.
1.33 It does not deal with fixed systems that are part of the ship’s configuration e.g. Escape ladders, the CO2 system etc., nor with emergency SOPs. Fixed systems are dealt with in Section 8 and emergency SOPs are dealt with in Section 3.
Section 8 – Materiel State
1.34 The purpose of this section is to examine:
5 INTRODUCTION
• the state of the ship on 5 May (particularly those aspects relevant to the fire); • whether in relevant respects the ship conformed with its class requirements; • whether the fixed equipment and systems used on the day operated correctly and were adequate for their purpose. 1.35 It also discusses whether new equipment and changes to the configuration of the ship are required. Some hazards, which have been identified by the Board but were not a factor in the events of 5 May, are also listed for the information of the ship and responsible RAN personnel.
Section 9 – Causes of the Fire
1.36 Central to this section are the origins of the fire and the failure of the new flexible fuel hoses.
Section 10 – How Hoses of Inadequate Design Came to be Fitted
1.37 This section examines how flexible fuel hoses of inadequate design came to be fitted to the ship, what procedures were in place to prevent this and why those procedures did not work.
Section 11 – RAN Configuration Management
1.38 The RAN has procedures in place to monitor and approve changes to configuration. This section takes a broad look at the subject of configuration management. The application and adequacy of those procedures to the flexible fuel hoses is discussed in Section 10.
Section 12 – Quality Assurance
1.39 The ordering, design, manufacture and installation of the flexible fuel lines were conducted by organisations that had certified quality systems. How those systems failed and some implications for the RAN are discussed.
Section 13 – System Safety Management
1.40 Accidents occur as a result of a complex chain of events and concentration on blame and accountability can lead to oversimplified analysis and a failure to address system errors. This section discusses various system factors that had an impact on 5 May.
Section 14 – Comcare
1.41 Comcare asked the Board to address various issues. Their specific requests are dealt with in this section.
Section 15 – Recognition of Personnel
1.42 All members of the ship’s company contributed to successfully overcoming the Main Machinery Space (MMS) fire, providing good medical care to the casualties and
6 INTRODUCTION returning the ship to Fleet Base West without further incident. This section identifies individuals whose actions are worthy of special recognition by reason of their outstanding contribution in terms of leadership, devotion to duty or bravery.
Section 16 – Principal findings
1.43 This short section encapsulates the thrust of the Board’s major findings.
Section 17-18 – Conclusions and recommendations
1.44 These sections capture the conclusions, findings and recommendations in a tabular form. Each item is identified by a sequential number, its original paragraph number in the body of the report and the page number.
REFERENCES THROUGHOUT THE REPORT
Transcript
1.45 Throughout the report, oral evidence given during the Board’s hearings is referred to by its transcript page number preceded by ‘T’ e.g.[T457]. A number after a decimal point indicates the location within the page on a ten point system so [T569.5] refers to half way down page 569 of the transcript.
Physical evidence
1.46 Documentary and other physical evidence is referred to by its exhibit no. preceded by ‘E’ e.g.[E57] where the evidence has been exhibited. Other material collected by the Board is referred to by its Board Document Register number e.g.[MR021]. Correspondence that has not been exhibited is referred to by its designated internal reference or its folio number in the Board’s correspondence file.
Internal references to this report
1.47 Where it has been necessary to refer to another portion of the text of this report, the reference consists of the paragraph number is preceded by ‘R’ e.g.[R3.91]
Abbreviated names
1.48 In the interests of clarity and brevity, abbreviated titles are used for various people, companies and documents frequently referred to. A short table of those abbreviations follows. A more detailed glossary and list of abbreviations is contained in Annex H. RAN Royal Australian Navy RPLSS contract The contract between the Commonwealth and ADI for the provision of supplies for the Refit Planning and Logistic Support Services for WESTRALIA. ADI ADI Limited – the company holding the RPLSS contract for the maintenance of HMAS WESTRALIA.
7 INTRODUCTION
The Hose Doctor This term covers both Mr Kelvin Old and Jetrock Pty Ltd trading as The Hose Doctor – the subcontractor to ADI who manufactured and fitted flexible fuel hoses to the main engines of WESTRALIA. The Hose Doctor held a franchise from Parker Enzed Technology. Parker Enzed Technology Parker Enzed Technology Pty Limited who granted a franchise to, and distributed the flexible hose used by, the Hose Doctor. Intervening parties ADI, The Hose Doctor and Enzed Technology. Lloyds Lloyd’s Register of Shipping (A Classification Society)
Identification of flexible fuel hoses
1.49 WESTRALIA has two large diesel engines for propulsion, the port main engine (PME) and the starboard main engine (SME). Each engine has 14 cylinders. Each cylinder has two flexible fuel hoses between the fuel rails and the fuel injector – a supply hose and a return hose (see Figure 1). The hoses are referred to by their location e.g.S9R refers to the starboard main engine, cylinder no. 9, return hose. P6S refers to port main engine, cylinder number no. 6, supply hose.
Figure 1. A view of the flexible fuel hoses in place on SME no.5 cylinder. The straight hose in the foreground is the supply hose (S5S), the bent hose in the background is the return hose (S5R) (LSPHOT Lewis)
Time
1.50 Times throughout the report are Time Zone Hotel, that is, the local time in Western Australia where the incident occurred.
8 INTRODUCTION
HMAS WESTRALIA
1.51 HMAS WESTRALIA is an underway replenishment ship. The ship has transfer points for fuel, water and stores and performs a vital role in the replenishment at sea of warships by day or night - she is capable of replenishing two vessels at a time. WESTRALIA can carry over 25,000 tonnes of fuel including several thousand tonnes of aviation fuel for use by RAN helicopters. She is fitted with two S.E.M.T. Pielstick 14 PC2.2V 400 engines. WESTRALIA is the largest ship in the Fleet. She is 171 metres long, 26 metres in beam and displaces 40,870 tonnes fully laden. The ship has a complement of 81, which is normally heavily supplemented by personnel under training. On 5 May 1998 she carried 98 personnel. WESTRALIA is homeported at Fleet Base West (FBW), located near Rockingham in Western Australia.
History
1.52 WESTRALIA was built as a petroleum tanker modified for underway replenishment by Cammell Laird Shipbuilders Ltd at Birkenhead, England. Laid down in 1974 and originally named HUDSON CAVALIER, she was modified in 1979 for service with the UK Royal Fleet Auxiliary. Named APPLELEAF she continued in this role with service in the Falklands in 1982, before being leased by the RAN in 1989 for five years with provision to purchase outright. During her service with the RAN the ship has seen active service in the Gulf War and been involved in Southern Ocean fisheries patrols and the rescue of distressed vessels in the Southern Ocean. She was purchased by the RAN in 1994.
Activities of the ship prior to 5 May 1998
AMP 12
1.53 Prior to the ship sailing from Fleet Base West on 5 May 1998, HMAS WESTRALIA had been undertaking an assisted maintenance period (AMP) for about 6 weeks. During that period certain work was carried out by members of the ship's company of WESTRALIA in conjunction with the Fleet Intermediate Maintenance Authority, FIMA, and the ship's RPLSS contractor, ADI. The ship then ran a series of tests to check the state of equipment after the AMP.
Trials
1.54 Basin trials were conducted with the ship alongside on 22 April 98. The purpose of basin trials is to ensure, amongst other things, that all machinery including main engines is functioning correctly. The ship sailed on 29 April and conducted a series of sea trials, both whilst under way and at anchor. On 1 May 98, she returned to Fleet Base West.
9 INTRODUCTION
The Main Machinery Space
1.55 The MMS in HMAS WESTRALIA is an unusual configuration for a warship. In most warships, bulkheads divide the ship’s machinery into several smaller compartments. In WESTRALIA, the MMS has several levels of walkways and partial decking but it is essentially a cathedral-like open space running from the lowest level of the ship at the bilge to the top of the funnel (see Figure 2 below). The frame numbering also follows the merchant ship convention of numbering from the stern post forward. The MMS extends over 28 frame spaces. At the bottom plates the MMS is 23.6 metres long, measured from the after peak bulkhead at frame 12 forward. (It is 2.6 metres longer at the middle plates because of the stepped pumproom bulkhead.) It measures 34.8 metres from the bottom plates to the top of the funnel and, at 1 deck, has an average width of about 24 metres.
Figure 2. Looking forward from the top plates of MMS down to the rocker covers of the main engines, which are just below the middle plates. Door to the MCR is centre right. The top of the port escape ladder is in the left foreground (LSPHOT Lewis)
10 INTRODUCTION
1.56 The only separate compartment within the MMS is the combined MCR/engineering workshop/main switchboard room, which is an enclosed compartment suspended above the main engines and one level below 1 deck. The entry to the MCR is on the starboard side adjacent to the top of the starboard ladder (see Figure 2). The entry to the workshop is a few metres aft of the top of the port ladder (see Figure 5 below). The main switchboard room does not have direct access to the MMS other than the hatch access to the forward MMS escape ladder.
1.57 The MMS is divided into three levels – the ‘top plates’, ‘middle plates’ and ‘bottom plates’. The top plates are one level below 1 deck; the middle plates are a deck level below that and the bottom plates sit directly above the bilge. The arrangement of the plates can be seen in Figure 3.
Figure 3. Cross sectional view of the MMS (DSTO report)
1.58 There are numerous points of access to the MMS. From 1 deck there are three points of entry: the junior sailors change room (which has ladder access down to the top plates); the after hydraulics room (which gives ladder access through an escape hatch into the main switchboard room); and the fridge flat (which has a door opening onto a landing above the top plates aft of the MCR – see Figure 4).
1.59 Other entry points are from 01 deck through the senior sailors change room, from 05 deck through the funnel door and from the top plate level through the tiller flat.
1.60 All but the hatch from aft hydraulics require personnel to go through the MMS to reach the MCR. Access between the plates and from the fridge flat to the top plates is by long, steep steel ladders (see Figures 4 & 5).
11 INTRODUCTION
Figure 4. Fridge flat entry to MMS and ladder to top plates (WA Police)
Figure 5. Shows entry to workshop at top left and port escape ladder from top to middle plates in the centre. (Mr G. Kelly)
12 INTRODUCTION
Figure 6. The area where the fire started. Shows starboard main engine outboard rocker covers and charged air rail, fire damaged bulkhead and catwalk. (LSPHOT Lewis)
13 INTRODUCTION
Figure 7. Sketch of chart showing WESTRALIA’s position when the fire broke out.
14 SECTION 2. NARRATIVE OF EVENTS OF 5 MAY 1998
EVENTS TO 1030
The bridge
2.1 HMAS WESTRALIA departed Fleet Base West (FBW) at 0900 on Tuesday 5 May 1998. Prior to sailing, a pre-departure brief was held at 0830 and Special Sea Dutymen (SSD) closed up ten minutes later.[T1137, T3146] The ship, with its crew of 98, including two members of HMAS TORRENS’ ship’s company, was scheduled to transfer some of its approximately 20,000 tonnes of F-76 diesel fuel cargo to HMAS SUCCESS at 1300 in the Western Australian Exercise Area and then proceed to northern waters.
2.2 SSD remained closed up as the ship proceeded north from FBW, first through the Parmelia-Success Channel into Gage Roads and then through the Deepwater Channel between the coast and Rottnest Island.[T3146] As was the ship’s usual practice, the Standing Sea Fire Brigade (SSFB) was exercised shortly after sailing.[T3147]
2.3 At 1025 the vessel was approaching the number one buoy in the Deepwater Channel on a course of 005°.[E91] Just before 1030, HMAS WESTRALIA reached the wheel over position for the final leg out of the Deepwater Channel and started to alter course to 325°(see Figure 7). When the vessel reached a heading of 335°, 10° of starboard rudder was applied to check the swing. A few seconds later, just before 1031, the bridge received a request to ‘emergency de-clutch’.[E91] At the time, WESTRALIA was proceeding at half ahead with 70% pitch set for a speed of 14 knots. The chart in use was Aus 112, ‘Approaches to Fremantle’. [E19B]
The MMS and machinery control room
2.4 Earlier that morning both main engines (MEs) were started, tested and then shut down. By 0815 the Deputy Marine Engineering Officer (DMEO), WOMT Bottomley, was able to report to the Marine Engineering Officer (MEO), LCDR Crouch, that the main machinery was ready for sea. SSD closed up in the Main Machinery Space (MMS) at 0840. Between 0840 and about 1030, there were no significant incidents in the MMS.[T23]
Discovery of the port main engine fuel leak
2.5 At sometime before 1030, POMT Hollis entered the MMS from the machinery control room (MCR) via the starboard door for a routine roving check.[T1804] He proceeded aft to the tiller flat, then forward to the starboard ladder outside the MCR door and descended to the middle plates. Arriving on the middle plates he checked each diesel alternator (DA) then went down the starboard side of the middle plates, past the oil purifiers and turned left towards the centre line at the forward end. He did not recall seeing anyone else in the MMS during this time.[T1849]
2.6 Approaching the centre line of the middle plates, he checked the top of MEs and noticed some liquid ‘spewing’ out from the inboard side of the port main engine (PME).[T1804] Initially unsure as to whether this was water or fuel, he descended the
15 NARRATIVE short centre line ladder to the rocker cover catwalk and advanced part of the way between both MEs to about level with number 13 cylinder of the PME. From there, he saw that the liquid was spraying onto the deck between both MEs, apparently coming from the vicinity of the inboard fuel rail. He looked down onto the bottom plates and smelt fuel.[T1864- 1865] When giving evidence, PO Hollis described the quantity of fuel leaking as greater than a stream from a garden hose and that it was spraying downwards at a 45° angle.[T1850] The fuel was also spraying onto the catwalk between the engines, into the bilge and going under the starboard main engine (SME).[T24, T1856] PO Hollis made the discovery close to 1030, as the ship was leaving the number one buoy to port and heading towards the Fairway buoy at the northern end of the Deepwater Channel.[E91]
2.7 At around this time, LSMT Smith was also doing a set of visual rounds in the MMS. He was on the middle plates in the vicinity of the DAs and, on hearing engines (which could have been either the DAs or the MEs) ‘racing’, returned to the MCR to check that everything was running properly. This change in engine speed occurred during an attempted transfer of the electrical load to the shaft driven alternators. He did not notice a fuel leak.[E99]
2.8 Because there were no effective communications between the MMS and the MCR when machinery was running, it was necessary for PO Hollis to return to the MCR to report the fuel leak.[E3, E124, T1622] He went via the starboard middle plates and the starboard ladder to the top plates and entered the MCR for about ten seconds to report the leak to the Engineering Officer of the Watch (EOOW), POMT Herridge.[T25, T1804] He did not see anyone in the MMS on his way back to the MCR.[T1866]
2.9 The following personnel were in the MCR when PO Hollis reported the leak: LCDR Crouch [E188, T2835] MIDN Pelly - under training [E3, T42, T1804, E109, T1458, E115A, T1622] WOMT Bottomley [E3, T28] CPOET Ledlie (I/C switchboard) [E3, T42] POMT Herridge [E3, T28] POMT Smith [E124, T1804] POMT Hollis [E124, T1804] LSMT Meek [E115A, T1622] LSMT Smith [T1804] ABMT Carroll [E109, T1458, E115A, T1622, E390] ABMT Liddell (third hand) [E109, T1458, E115A, T1622] LSET Elliott [T446]
THE FUEL LEAK: 1030-1034
The bridge
2.10 The following personnel were on the bridge for most of the relevant period: CMDR Dietrich Commanding Officer (CO) [T3144-3220] LCDR Triffitt Navigating Officer [T101-185] LEUT Conole Assistant blind pilot safety officer LEUT Humphrey SSD assistant officer of the watch LEUT Read Blind pilot safety officer [T3336-T3342] SBLT Plummer SSD officer of the watch (OOW) [T1135 – T1175]
16 NARRATIVE
CPONPC Walters Coxswain [T790-T815] POSY Chambers Yeoman of signals [T728 – T755] LSSIG Orrell Signalman LSBM Hepple SSD quartermaster (QM) [T1119 – T1135] LSRO Hird Bridge talker [T3469 – T3475] ABET Sheppard Echo sounder operator ABSIG Busby Signalman ABSIG Pietzsch Signalman [E71] SMNSIG Wallace Signalman 2.11 At 1030:55, the EOOW reported a major fuel leak to the bridge and requested an emergency de-clutch of the PME.[E14, E29, E91] After receiving the EOOW’s request, the OOW ordered, ‘emergency de-clutch’ but because of a timely intervention by the Navigating Officer, the order was rescinded and the correct order to ‘stop’ was substituted.[T114-116] Had the Navigating Officer not intervened, the ship would have lost power to both engines for about four minutes while in confined waters.[T114-116]
2.12 The request to stop engines was confirmed by a mismatch of the engine telegraph from the MCR. The MCR pointer was moved to stop. The bridge then matched this by moving the telegraph to stop. In addition, the Navigating Officer spoke with the EOOW using the machinery broadcast to confirm that what was required was not an emergency de-clutch. The Engineer ordered the PME to be shut down and reported to the bridge, 25 seconds after the EOOW had first reported the leak, that he had de-clutched the PME and was shutting it down.[E188, T2835, E3,E115, T1622, E91]
2.13 Fifteen to 20 seconds after the fuel leak on the PME was reported, the OOW ordered the wheel amidships.
2.14 The Navigating Officer stated in his evidence that, ‘we were still in the vicinity of number one buoy and still in the vicinity of dangerous shoals on both sides’ when the PME was shut down.[T116] Steerage way was difficult to maintain with the propeller pitch at zero. This caused an immediate concern to the Navigating Officer as there was a sheep carrier fine on the port bow at about 1,000 yards, effecting a boat transfer and WESTRALIA’s head was falling off to port. With the loss of the propulsion, the ship continued to swing to port until the swing was eventually checked when the telegraph was put to ‘half ahead’ on the SME and the wheel put to starboard.[T114-116, T120, E91]
2.15 The Navigating Officer prompted LCDR Crouch to request that the SSFB be closed up as a precaution.[E91] At 1032, the QM broadcast that the SSFB was to muster in the MCR and the Navigating Officer used the main broadcast to inform the ship’s company of the fuel leak and that the SSFB were closing up in the MCR as a precaution.[E14, E29, E91, T2834]
2.16 The Navigating Officer was also pro-active by talking to the OOW and encouraging her to think about what would happen if the spilled fuel were to ignite and about what precautions should be taken. These anticipated actions included sending the ship to ‘emergency stations’, preparing keys, books and other items for transfer to HQ1 and starting the ‘check-offs’. In addition, the Navigating Officer considered what actions he would take if the SME had to be shut down or became unserviceable.[T122, E91]
17 NARRATIVE
The MMS and machinery control room
Isolating the leak
2.17 WO Bottomley and PO Hollis went to the bottom plates where WO Bottomley saw fuel coming out at a 45° angle into the bilge from somewhere about number eight or number nine cylinders on the PME. He described the situation as a ‘major high pressure fuel leak’. He went on to say that he had seen enough and decided to get help. He headed for the MCR but not before he saw PO Hollis preparing to manually isolate the fuel to the PME. While on the way WO Bottomley noticed a rising, misty vapour cloud above the PME.[T24] He noted in his evidence that the SSFB was needed.
Attempt to fix the leak
2.18 WO Bottomley then returned to the MMS via the port side and headed straight between the MEs to find the leak. The leak had stopped but neither WO Bottomley nor PO Hollis could find where it had come from. POMT Smith was with them. They found a banjo bolt loose on a line that fed into one of the fuel return lines. WO Bottomley went to take out his shifting spanner to remove the banjo bolt but discovered that he had left it behind in the MCR. POMT Smith, who had a spanner commenced taking out the bolt and WO Bottomley headed for the workshop around the SME to get a new banjo bolt. PO Hollis and POMT Smith remained at the site of the leak on the PME.
Preliminary precautions
2.19 ABMT Carroll was directed by the EOOW to go to the middle plates to set up the fire hoses.[T25, T1622, T26] On his return to find the leak, WO Bottomley dragged the trolley mounted, 90 litre AFFF extinguisher behind the fuel boost pumps off the main thoroughfare. AB Carroll came to assist and WO Bottomley took the hose off the extinguisher and put it into AB Carroll’s hands advising him to set it off ‘if there was any problem’ where they were working.[T25]
2.20 In the MCR, the EOOW directed LSMT Smith to assist AB Carroll to run out the hoses on the middle plates.[T1242] LSMT Smith returned to the middle plates through the workshop using the port side ladder, crossed to the starboard side and ran out a fire hose on that side of the middle plates. He returned to the port side to see how AB Carroll was getting on, then proceeded forward along the port side middle plates towards PO Hollis, who at that time was at the forward end of the middle plates.
Movements of other personnel into the MMS
2.21 The EOOW gave evidence that he saw LSMT Meek go from the MCR to the top plates.[T1622] WO Bottomley also saw LS Meek on the middle plates and thought that he may have run out the fire hoses with AB Carroll.[T26]
2.22 POMT Francis was in Damage Control Headquarters (HQ1) and heard the broadcast that the PME had a fuel leak. He reported to the MCR and the EOOW directed him to assist POMT Smith with the leak.[T1455] Entering the MMS via the starboard ladder to the middle plates, PO Francis noticed a fire hose flaked out on the middle plates. He proceeded directly down to the bottom plates via the starboard ladder, then forward outboard of the SME, across the forward end of the SME and between both MEs. He did not notice anyone on his way down to the bottom plates.
18 NARRATIVE
2.23 During SSD, MIDN Pelly appears to have been logging engine orders in the MCR.[T1416] At the time the fuel leak was reported, she was in the MCR but then went into the MMS soon after the PME was shut down.[T23, T42, T1417] WO Bottomley stated that when he was coming up from the bottom plates, he saw her standing near the Diesel Alternators.[E3, T43, E115, T1622, T3453] He was surprised that she was there because she had been informed that ‘during a real incident [she was to] stay out of the way and stay in the MCR’.[T3454]
2.24 SMNMT Robb said that for a couple of days prior to sailing, MIDN Pelly had been assigned to shadow him during his rounds of the MMS. On 4 May, SMN Robb was transferred from the MMS. He thought, therefore, that on 5 May 1998, MIDN Pelly would have shadowed AB Carroll, his replacement in the MMS.[E156]
2.25 On hearing the broadcast that the SSFB was to muster in the MCR for a fuel leak, LEUT Walters went to the MCR and was directed by the EOOW to go to the bottom plates to change the gearbox cooling water.[T582, T583] He entered the MMS via the starboard side ladder to go to the middle plates and noticed MIDN Pelly on the starboard side of the middle plates. He proceeded forward to a position on the middle plates immediately forward of the top of the ladder leading from the rocker cover platform. Whilst standing on the centre line middle plates forward of both MEs, LEUT Walters noticed two other members of the crew on the level of the rocker covers but was unable when giving evidence to identify either of them. He stated that one was between the MEs and the other in front of the PME.
Deployment of the Standing Sea Fire Brigade
2.26 While the technical personnel were investigating the size and location of the leak the SSFB arrived in the MCR.[T2834] The team members were PORS Manderson (I/C) dressed in basic rig, LSBM(FF) Nunn and SMNBM Darwish (attack team 1) dressed in basic rig and equipped with a hand-held extinguisher and LSET Smith and ABMT Munday (attack team 2) dressed in intermediate rig.[T279, T282, T284, T384] Basic rig comprises combat overalls, steel toed boots and anti-flash gloves and hood. Intermediate rig includes basic rig plus an open circuit compressed air breathing apparatus set (OCCABA). The SSFB is intended as a first aid firefighting team only and does not wear the protective Fearnought suits.
2.27 It was SMN Darwish’s first day as a member of the SSFB and LSET Smith had been changed around within the team on the day before.[T282] As a result, LSET Smith arrived at the MCR without an OCCABA set and had to return to the junior sailors’ change room to get one.[T429] This had the effect of delaying the full assembly of the team by one to two minutes but the majority of the team was assembled at approximately 1033.[T438]
2.28 Having gathered in the main switchboard room, the SSFB waited for a direction.[T275] The EOOW told PO Manderson that he wanted the SSFB in the MMS as a precautionary measure but the Engineer countermanded the order. The LCDR Crouch wanted to keep as many people out of the MMS as possible.[E31, T275] He gave evidence that he was worried about ‘slip hazards’ that could be on the decks and ladders as a result of the fuel leak and that the two members of the SSFB in OCCABA would have additional difficulty in descending the ladders in the MMS.[E1888, T2835]
19 NARRATIVE
2.29 Less than 4 minutes after the fuel leak had been reported, the Engineer advised the bridge that the PME had been shut down. He also advised that the cause of the leak was a leaking banjo bolt around numbers 11 or 12 cylinders and there was a lot of fuel over the PME which was still fairly hot. He gave an estimate of the time to repair the leak as about 30 minutes and that he wanted the SSFB to remain closed up in the MCR until the fuel had been cleaned up. Twenty eight seconds later the EOOW reported a fire in the MCR.[E91]
The medical response
2.30 At the time the information about the fuel leak was broadcast, the two medical sailors onboard, POMED Plant and ABMED Moffatt, were in the sick bay.[E97] HMAS WESTRALIA did not carry a medical officer and the medical complement onboard is supplemented by members of the ship’s medical emergency team (SMET) who are medically trained sailors, usually from the supply department. They were in their normal workplaces. On hearing the broadcast, LSSTD Nix and LSWTR Page proceeded to the sick bay.[E161, E97]
FIRE INITIATION: 1034 – 1038
The MMS and machinery control room
Observations of the start of the fire
2.31 As LSMT Smith proceeded forward along the port side middle plates towards PO Hollis, he noticed ‘bubbling liquid’ on the SME exhaust covers around number 9 cylinder.[T1243] When he was almost to the centre line of the forward middle plates a flame about one metre in diameter erupted from the liquid. This was followed by a big fireball which went up and out and covered a major part of the MMS, mostly on the starboard side. LSMT Smith could feel the heat from it.
2.32 PO Hollis was on the middle plates immediately forward of the SME when he noticed a small flash of flame on the outboard side of the SME. This flash passed and was followed a few seconds later by the eruption of a huge flame over the top of the SME rising to a ‘mushroom’ across the underside of the MCR deck.[T1806]
2.33 LEUT Walters was just about to proceed down the ladder to the rocker cover level when he saw a flame come out of the outboard side of the SME, extending to the deck of the MCR. He gave evidence to the Board that the flame resembled that of a blowtorch. In his opinion the fire was clearly being supplied by a high-pressure fuel source, as the flame height was approximately six metres.[T583] He described the fire, at the commencement of the flame, as being narrow with a minimum width at the base gradually increasing in size with the flame becoming slower and smoky at the top.[T583]
2.34 PO Francis found POMT Smith working on the PME between numbers eight and nine cylinders and asked him what he was doing. Almost immediately, PO Francis, who was standing on the bottom plates between the two MEs, noticed fire on the top of the SME near number nine cylinder covering about half the area of the top of the SME with flames about two to three metres high.[T1459]
20 NARRATIVE
2.35 LSMT Smith, PO Francis and PO Hollis gave varying evidence as to the size and nature of the fire that they observed.[T1806, T1242, T1459] Comments from this group detailed how they perceived the fire from its commencement until they evacuated the MMS. In one case, evidence was given that the fire was drawn back into the SME before erupting again, while other comments suggest that the fire burnt with considerable intensity from its commencement.[T1243, T1806]
Location of personnel at the outbreak of the fire
2.36 Based on the evidence available, it would appear that, at the outbreak of the fire at 1034, the following eight personnel were located in the MMS in the following locations:[E28]
a. Bottom plates: PO Francis and POMT Smith were between the MEs attending to the fuel leak.[T25]
b. Forward middle plates: LEUT Walters was about to descend to the rocker cover catwalk and PO Hollis and LSMT Smith were also in the same area.[T582-83, T25, T1243]
c. Aft middle plates: MIDN Pelly was forward of the DAs apparently observing.[T43, T1622]
d. Port middle plates: AB Carroll was apparently tending the trolley mounted, 90 litre AFFF extinguisher.[T25, T583]
e. Middle plates: The exact location and activity of LS Meek are uncertain, but the probability is that he was attending to a fire hose on the starboard side.[T1622]
Immediate effects of the fire
2.37 The flames from the fire on the SME hit a bulkhead adjacent to the engine on the outboard side and extended up to the steel plates that form the deck of the MCR and the main switchboard room (see Figure 6). It appears that on hitting the underside of the deck the flames rolled both forward and aft as well as to the port side.[T1857]
2.38 Various electrical cables directly above the MEs were quickly burnt in the fire severing power supplies for machinery, communications to the bridge and the MMS evacuation siren.[E246,T1625, T2835]
2.39 Smoke and toxic gases being given off by the burning insulation covering the cables added to the quantity of gases being generated in the MMS. Smoke entered the MCR through one or more cable or control penetrations in the MCR deck.[T9, TT2835]
2.40 WO Bottomley observed what was happening in the MMS by opening the starboard MCR door. On seeing the flames and heavy smoke coming up from below, he retreated into the MCR.[T26]
Fire in the MMS
2.41 On seeing the commencement of the fire, LEUT Walters quickly proceeded aft along the port side of the middle plates towards the MCR and yelled to AB Carroll as he
21 NARRATIVE went past to, ‘get out or, lets go’.[T583] He noticed a significant build up in the amount of smoke as he neared the MCR and exited via the port ladder into the workshop. On entering the MCR LEUT Walters advised there that a fire had broken out on the SME.[T583]
2.42 PO Hollis commenced to run aft down the starboard side middle plates and LSMT Smith, ‘only metres’ behind, instinctively followed. They were protected from the flames by a bulkhead. PO Hollis described the fire as ‘like a waterfall.’[T1806, T1858] He dragged the trolley mounted, 90 litre AFFF extinguisher across to the starboard stairwell and attempted to extinguish the fire. The fire hoses which had been run out were not charged and not available for immediate use.
2.43 LSMT Smith continued aft past the DAs looking for an exit. Realising there was no exit that way, he returned forward along the port side of the DAs to the base of the port ladder. By this time there was very thick black smoke in the MMS and visibility was rapidly decreasing.[T1244, E99]
2.44 When the fire started, PO Francis yelled, ‘follow me’ to POMT Smith and ran forward, then to the port side of the PME on the bottom plates level and aft along the outboard side of the PME.[T1459] En route they passed a point where three emergency life saving respiratory devices (ELSRDs) are stored but neither man took one. PO Francis climbed the port side ladder to the middle plates with POMT Smith close behind him. He noticed MIDN Pelly on the middle plates between the two DAs, about three to four metres from the port ladder and PO Hollis on the middle plates spraying AFFF from aft of the SME. PO Francis took a portable, hand-held, fire extinguisher from forward of the port main lube oil filter. AB Carroll came running aft yelling ‘get out’, followed closely behind by someone who may have been LEUT Walters. PO Francis also noticed another person directly forward of the starboard DA close and to the right of PO Hollis, but when giving evidence, was unable to identify the person or what he or she was doing.[T1461]
2.45 On arriving at the base of the port side ladder on the middle plates, LSMT Smith saw LS Meek there, together with PO Francis and AB Carroll. He also noticed several other personnel there, but could not identify them and was unsure of their numbers. He observed that one had a hand-held fire extinguisher, but he could not remember whether it was being used. LS Meek yelled ‘Everyone get out!’ LSMT Smith proceeded up the ladder between the intermittent fireballs that were engulfing the ladder before he reached the safety of the workshop.[T1244] PO Manderson saw LSMT Smith emerge from the MMS trailing smoke and heard him say, ‘It’s gone up. There’s someone behind me’.[T289, T275-276, T319]
2.46 Whilst directing AFFF onto the SME, PO Francis stated in his evidence that he heard one long blast on the MMS siren that meant that the space was to be evacuated immediately. At this point, a massive fireball erupted from on top of the SME and he heard a ‘woof’ sound. He noticed that the air seemed to be on fire, with intense heat; the MMS was filling with thick dense black smoke that reduced visibility to nil.[T1461]
2.47 PO Francis proceeded aft on the middle plates towards the centre line of the ship to look for MIDN Pelly. He felt around the area between both DAs, proceeding to the aft end. Moving forward to the guardrail and across to port, he then went aft down the port side of the port DA and then between the evaporator and the port DA, still searching for MIDN Pelly. At this time, he was gasping for breath and starting to choke. He tried unsuccessfully to find an ELSRD on the port side bulkhead of the middle plates and so headed for the port side ladder to the top plates. PO Francis commenced to climb the
22 NARRATIVE ladder but went back down when a small fireball, apparently from the PME, engulfed the ladder. He then went back up the ladder and initially forward towards the junior sailors’ change room, but was driven back by the heat. As a result, he turned around and felt his way to the workshop door from where he was assisted in to the workshop by WO Bottomley.[T1461-1462]
2.48 Shortly after PO Hollis started to fight the fire, a second fireball erupted in the centre of the SME. By this time thick black smoke was being produced.[E124A] Realising the size of the fire was beyond the capacity of the extinguisher and that it was almost empty, PO Hollis gave up the attempt. He went across the middle plates to the port ladder holding the guardrail to guide him as he was unable to see. He then exited up the port ladder, burning his left hand on the outboard rail that, to his surprise, was hotter than the inboard rail. On arriving at the top of the port ladder, he proceeded towards the workshop door, but was unable to find it. Overcome by fumes, he was found by WO Bottomley who had opened the door to look into the MMS and dragged to safety.[E124A] Visibility at the workshop door at the time was nil.
2.49 At a point immediately after the commencement of the fire, LSMT Bromage entered the MMS from the fridge flat and observed the rapid development of the fire. From his location on the fridge flat level it appears that he observed PO Hollis’ escape into the workshop. Due to the density of the smoke he quickly withdrew from the MMS.
2.50 ABBM Noles entered the MMS from the tiller flat and viewed the fire from the top plates. Having assessed the size of the fire as being very large he quickly withdrew to the fridge flat via the escape ladder from the tiller flat.[T2802] Because the door between the tiller flat and MMS was held open by rope lashings he was unable to close it before escaping.[E178]
2.51 In summary, the five personnel who escaped appeared to do so in the following order and in the manner noted:
a. LEUT Walters – from the port middle plates and the port ladder to the workshop;
b. ABBM Noles – from the tiller flat via the escape ladder to the fridge flat;
c. LSMT Smith – from the starboard middle plates, then aft of the DAs, returning forward to exit via the port ladder to the workshop;
d. POMT Francis - from the port aft middle plates he moved to starboard, searching aft between the DAs for MIDN Pelly, then via the port ladder to the workshop; and
e. POMT Hollis - from the starboard to the port aft middle plates, then via the port ladder to the workshop door being dragged in by WO Bottomley.
2.52 LSMT Smith, PO Francis and PO Hollis, the last three to evacuate, gave evidence of the extensive spread of the flame on bulkheads, the density of the smoke and of the fireballs travelling up the ‘chimney’, all of which inhibited their escape.[T1807, T1455, T1244]
2.53 The four members of the crew who did not escape were last seen in the following positions:
23 NARRATIVE
a. MIDN Pelly - on the middle plates between the DAs;
b. POMT Smith - moving from the bottom plates between the MEs;
c. LSMT Meek - at the base of the port ladder; and,
d. ABMT Carroll - with the trolley mounted, 90 litre AFFF extinguisher on the port middle plates.
Report of fire in the machinery control room
2.54 Not long after WO Bottomley re-entered the MCR a ‘woofing’ sound was heard and some of the occupants noticed smoke coming from behind an urn on the port outboard side.[T26] Personnel within the area immediately reacted, thinking that there was a fire in the MCR.[T275] It was quickly realized that the source of the smoke was from a fire in the MMS and this was confirmed by escaping people entering the MCR from the MMS.[T275] Both LEUT Walters and LSMT Smith reported fire on the SME to those in the MCR.[T275, T583]
2.55 In the MCR, the Engineer activated the MMS evacuation button but did not hear it and thought that it had failed to operate. PO Francis gave evidence, however, that he heard one blast on a siren while in the MMS.[T1461] Thinking that the fire had damaged the cabling LCDR Crouch opened the MCR door to the MMS, stepped out onto the catwalk and yelled for everyone to evacuate the area.[T2835]
2.56 The EOOW reported a fire in the MCR to the bridge at 1035.[E91]
2.57 In the MCR, appropriate actions were taken to shut down the SME and other machinery despite the difficulties caused by the fire damage to cabling. The EOOW attempted to keep an alternator running to ensure that the fire pump operated.[T1626] Isolating all electrical equipment would have meant shutting off power to the fire pump which was then supplying water to the fire main.
2.58 As two members of the SSFB were dressed in OCCABA, the team leader, PO Manderson, asked LCDR Crouch if he wanted them to enter the MMS. The Engineer replied, ‘No’.[T276] PO Manderson reported to HQ1 that the MCR was filling up with smoke.[T276] PO Manderson again told LCDR Crouch that he had people on air and asked whether he wanted them to go into the MMS to search for missing personnel. He was again told no by LCDR Crouch. PO Manderson stated that LCDR Crouch said, ‘Just wait mate.’[E31, T276]
Emergency stations
2.59 At the same time that the EOOW notified the bridge of a fire in the MCR, fire alarms sounded on the bridge.[T2835, E91] The Navigating Officer immediately queried whether the fire was in the MCR or the MMS to which the EOOW responded that the fire was in the MCR.[E91] The fact that the fire was in the MMS became evident when the EOOW requested, 18 seconds after the initial report and the alarm sounding, approval to shut down the SME as it was on fire. A broadcast was made from the bridge 31 seconds after the fire was reported that the ship’s company was to close up at emergency stations.
24 NARRATIVE
Evacuation of the machinery control room
2.60 By 1038 it became necessary for the Engineer to order the evacuation of the MCR.[T2835] The SSFB assisted the casualties to exit the area via the emergency escape in the main switchboard room.[T26]
2.61 As the standard operating procedure required the EOOW to shut down all machinery and be the last to vacate the area, the EOOW put on OCCABA. WO Bottomley assisted the EOOW. Despite their best efforts, they were unable to shut down the starboard DA.[T1626] The last three people to evacuate the MCR were WO Bottomley, the EOOW and CPOET Ledlie.[T2836]
2.62 WO Bottomley took the name pegboard off the wall and gave it to the EOOW and they went to HQ1.[E3, T27] The pegboard was used to indicate the whereabouts of engineering personnel and specifically, those who entered the MMS.
Damage control headquarters (HQ1)
Manning
2.63 Damage control headquarters, HQ1, is a small compartment on 01 deck originally designed as a technical office. It has been adapted as a control centre for directing shipboard emergencies. Its after bulkhead is common to the MMS, about 17m above the bottom plates.
2.64 On hearing the broadcast for the SSFB to muster in the MCR, LEUT Shawcross and POET Edmonds went directly to HQ1.[E126, E157] LEUT Shawcross made the broadcast, ‘HQ1 manned, all reports to HQ1’. Shortly after, a message was received in HQ1 from the I/C of the SSFB that there was a fuel leak on the PME and the SSFB were standing by.[T1901, T290] LEUT Gishubl then arrived and was informed of the shut down of the PME and the precautionary measures which were being taken.[E38, T497]
2.65 Shortly after ‘hands to emergency stations’ was broadcast, LCDR Crouch arrived in HQ1 followed by other personnel. Within four minutes, personnel closed up in or near HQ1 were: LCDR Crouch (action NBCDO) LCDR Jones (rover) LEUT Gishubl (HQ1) LEUT Shawcross (HQ1) LEUT Walters (HQ1) CHAP Gebski (rover) POET Edmond (communications and HQ1 incident log) POMED Plant (I/C Ship’s emergency medical organisation) LSSTD Nix (SMET)
The bridge
2.66 Just after the outbreak of the fire at 1035, the Navigating Officer stated aloud that, ‘we’ve got to decide whether to anchor.’[E91] Three minutes after the fire
25 NARRATIVE commenced, the CO called for the position of the ship and the Navigating Officer recommended a hard turn to starboard to get the way off the ship.[E91]
2.67 Shortly before 1039, the Coxswain reported that the ship had lost steerage way. The priority of the bridge then became the containment of the fire and determining if there were any casualties. The ship’s position continued to be fixed but with initial difficulty as electrical power to the ship’s gyros was lost and power spikes were affecting the power supply to other navigation equipment. Following the outbreak of the fire and the loss of both MEs, HMAS WESTRALIA was ‘not under command’. The ship was disabled and drifting in the Deepwater Channel, on either side of which were shoals. The ship lay beam onto the wind with the head to the east.[T124]
2.68 The CO, in consultation with the Navigating Officer, made a conscious decision to avoid anchoring.[T3154, E91] This decision was based on a lack of power to raise the anchor should the fire situation deteriorate to the point where it became necessary for the ship to be towed clear of the coast or, if the fire was extinguished, for the ship to be towed to FBW.[T3154]
2.69 Within four minutes of the fire alarm being raised, LSSIG Orrell asked whether the ventilation flaps to the MMS should be closed.[E204] The Navigating Officer ordered the Signals Yeoman to ensure that the ventilation flaps were closed. Within a minute this was reported as complete.
The medical response
2.70 When the broadcast was made for the ship’s crew to close up at emergency stations, this was followed shortly afterwards by a second broadcast for the SMET to muster in the MCR. POMED Plant proceeded to HQ1, accompanied by LSSTD Nix.[E97, E383] All the other SMETs made their way towards the aft hydraulics room, having collected their SMET jackets or bags, and two oxy-vivas.[E161, E151, E158, E378, E150, E211, E383, E158]
2.71 On arriving at the aft hydraulics room, LSWTR Page saw the first of the casualties, LSMT Smith, being pushed out of the door, coughing and spluttering and she directed him towards the starboard boat space.[E161] She told ABSTD Osmon and ABSN Hutchinson to go to the MCR, however, both were almost immediately required to leave as it was being evacuated.[E158, T2244, E158]
INITIAL RESPONSE: 1038 – 1102
Damage control headquarters (HQ1)
Initial actions
2.72 Following the broadcast, ‘hands to emergency stations’, the ship’s company, with the exception of those on watch and those who were SSD, closed up at their emergency stations and missing personnel were identified and reported to HQ1.
26 NARRATIVE
Operations
2.73 WO Bottomley and the EOOW arrived from the MCR with the name pegboard. It was not accurate as not all evacuating personnel had ‘pegged out’. While the initial indications were that as many as seven people were missing, when information was combined from the Forward and Aft Section Bases and the SMET, it was determined that MIDN Pelly, POMT Smith, LS Meek and AB Carroll were missing.[T2950] Calls were made over the main broadcast system for the missing crewmembers.[T497]
2.74 The Engineer advised the Aft DC Section Base to prepare a hose team as quickly as possible for an entry into the MMS through the fridge flat.2 The damage control (DC) organisation is such that each of the two DC section bases has a hose team. At about this time, the bridge reported to HQ1 that the MMS ventilation flaps had been closed.[E188]
2.75 The Forward DC Section Base advised that the emergency diesel driven fire pump was running, but as the only fire main pressure gauge was in the MCR, the Engineer asked WO Bottomley to return to the MCR and read the gauge.[E188, T2837] Wearing intermediate rig, WO Bottomley went to the MCR, observed that the fire main pressure was 110 psi and then went to the workshop door. Having found the door ajar, he opened it and stepped out about two feet onto the top plates. He could see nothing and returned to the MCR. Before exiting the MCR, he attempted to shut down the starboard DA (which was running on no load) but was unsuccessful. WO Bottomley returned to HQ1 and reported the fire main pressure and that the paint on the deck of the main switchboard room and the MCR was blistering.[E3, T28]
2.76 In HQ1, LEUT Gishubl directed the Aft DC Section Base to start setting up smoke boundaries and boundary cooling all around the MMS.[E38, T497] HQ1 also directed that a third hose team be established.[E38, T497] At the Forward DC Section Base, POB Body formed the additional hose team from spare hands and it was designated hose team 3.
2.77 On being notified by the Aft DC Section Base that hose team 1 was ready, the Engineer directed them to enter the MMS at 1049.
Command priorities
2.78 The Engineer telephoned the bridge at 1039 and spoke with the CO informing him that there was a major fire in the MMS and that he recommended a CO2 drench although at this stage he thought that there was at least one person still in the MMS. The Engineer believed that the CO2 from the drench would be far more benign than the carbon monoxide and that if anyone was still in the MMS, they would have a far better chance of survival with the drench. He also stated in evidence that he believed that there was a possibility that anyone still in the MMS would get an ELSRD or get to an area that was relatively smoke free such as the bilges.[E188, T2836, T3150, E38, T497] The CO declined to activate the drench and directed that a hose team be sent to search for missing personnel. The CO was concerned about the quality of the telephone communications and went to the Fire control room (FCR) where he spoke to the EOOW to ensure he had received the correct message.[T3150]
2 Descriptions of a hose team and firefighting equipment can be found in Annex F.
27 NARRATIVE
2.79 At some time following his arrival at HQ1, the EOOW proceeded to the Fire Control Room (FCR) in accordance with the standard operating procedures. Once in the FCR he established communications with the bridge by the sound powered telephone and told them that he was standing by to CO2 drench the MMS.[E115, T1628] He also closed the remote fuel shutoff valves.[T1629]
2.80 At about 1056, the CO went to HQ1 to discuss the situation with the Engineer who strongly recommended that the MMS be drenched then with CO2. The Engineer believed that the CO instructed him to continue searching for five minutes and then to activate the CO2 drench.[T1057, E188, E199, T3151, T2839] Confirmation of the intention to drench was passed by HQ1 to CPO Jenkins; he was also directed to withdraw the hose team from the MMS.
2.81 The CO, however, stated in his evidence that the discussion he had with LCDR Crouch did not amount to command approval to CO2 drench after five minutes had expired. Shortly after the CO returned to the bridge he concluded that it would not have been possible for anyone to have survived in the 25 minutes since the fire started given the heat and smoke. After the five minutes had expired LCDR Crouch sought further command approval. The CO then told LCDR Crouch to, ‘Pull [hose team 1] out and execute the CO2 drench.’[T3151]
Aft damage control section base
2.82 The Aft DC Section Base is a sub-unit of HQ1 which is set up outside the junior sailors’ change room.[T543] In addition to the I/C, CPO Jenkins, there are 38 personnel including a 2IC, a communications number with a standby, a five person hose team with a breathing apparatus board operator, four scene leaders, a four person SMET and support parties for hose handling and boundary cooling.[T543, E347]
2.83 Initially, CPO Jenkins and LS Bromage were involved with the removal of firefighting equipment and protective clothing from the junior sailors’ change room to the port hose flat.[T539,E133, T2002] A roll call was undertaken to ascertain if any of the 38 personnel designated to the Aft DC Section Base were missing.[E40] The names of those missing was finalised and PO Sellick handed the list to AB Mortimer who informed HQ1 of those people who had not reported in.[E39, T540, T573, E133, T2003]
2.84 CPO Jenkins directed AB Justice to check that the supply and exhaust ventilation flaps to the MMS were shut. After some early difficulties where she had to seek additional advice from CPO Jenkins, she reported that the flaps were shut.[T4116, T571]
Boundary cooling
2.85 CPO Jenkins instructed personnel to set up boundary cooling inside the superstructure, on the funnel casing and in the aft pump room from about 1049.[T541] Boundary cooling continued intermittently for some time. There is no evidence to conclude precisely when boundary cooling ceased but it may have been as late as 1330.
2.86 The SSFB was given the responsibility to monitor the temperature of the bulkheads in the accommodation on 01 deck. The two members of the SSFB dressed in intermediate rig, commenced boundary cooling in the fridge flat inside the smoke boundary.[E39, T539, T551]
28 NARRATIVE
2.87 SBLT Manders, AB Shingles and LS Quigley commenced boundary cooling in the aft pump room and were relieved some time later by SMN Robb, LS Nixon and PO Sellick.[T3373-3374] During this period there were varying reports as to the temperatures in the aft pump room.
2.88 The first boundary cooling team was dressed in basic rig and they attempted the cooling with hand-held, 9 litre extinguishers.[T3348] Some difficulty was experienced connecting a fire hose to a hydrant and the hose was moved to another area.[T3373] As the casualties were in this immediate area, the hose was not initially used.[T2279]
2.89 The freon cylinders within the fridge flat area were moved at the direction of CPO Jenkins to prevent them overheating. The water spray system on the starboard hose flat was activated to cool acetylene cylinders stored there.[E39,T542]
Forward damage control section base
2.90 Like the Aft DC Section Base, the Forward DC Section Base is a sub-unit of HQ1. The Forward DC Section Base is set up in the replenishment at sea control position (RASCO); PO Body was in charge.
2.91 The first task undertaken by PO Body was to check off names against a list and prepared the RASCO as a base for OCCABA repair and cylinder recharging. Hose team 2 was dressed at the Forward DC Section Base and despatched to the tank deck to standby and then to the Aft DC Section Base.[T382] Personnel were despatched to start the forward fire pump and to de-isolate the fire main to deliver water to the aft part of the ship.[T382]
The MMS
Hose team 1 - preparation
2.92 Hose team 1 was formed at the Aft DC Section Base. Dressed in full firefighting rig, the hose team was made up of the following personnel: [E44, T626] ABBM Smith (No 1 waterwall) ABCK Miskiewicz (No 2 attack nozzle) LSBM Daly (No 3 (I/C)) LEUT Johnson (No 4) ABRO Lindley (No 5) 2.93 When hose team 1 was ready to enter the MMS, HQ1 was advised.[T497] There was some conflicting evidence as to the instructions given to the team prior to entry. Although the Engineer was aware that the CO’s priority was for search and rescue, there is no clear evidence that this direction was actually passed to the team leader.
Hose team 1 - entry
2.94 The team was logged onto an OCCABA control board and made a standard entry into the MMS at 1050 via the fridge flat.[E38, T497, E188, T2837] Shortly after, CPO Jenkins reported that hose team 1 had found nothing, visibility was zero and temperatures were extremely high.[E188, T2837, E38, T498] HQ1 kept the CO informed on the progress of hose team 1.
29 NARRATIVE
Hose team 1 - withdrawal
2.95 After initially setting up an attack from the top platform on the fridge flat ABBM Smith, (waterwall) was able to descend the ladder onto the top plates and momentarily set up his waterwall. As he was trying to pull more hose down the ladder, however, jerking on the hose indicated that he should withdraw.[E206]
2.96 LS Bromage was the scene leader. His Maxon radio set was rendered unserviceable by water from the sprinkler system in the hose flat.[E133, T2004] Having obtained another Maxon radio set he attempted to obtain information from hose team 1 but was not always able to make radio contact. Runners were used to relay messages from the team to LS Bromage at times.[T2003] A Maxon radio was successfully used to inform hose team 1 to exit in preparation for the CO2 drench.[T2004]
2.97 Hose team 1 exited the MMS, taking the two hoses, and closed the door to the fridge flat after them. Almost immediately after, at about 1101, the pipe, ‘drench, drench, drench’ was made and the EOOW released the CO2 from the FCR.[T1629]
2.98 Although hose team 1 had only been in the space for approximately 11 minutes it proceeded to the RASCO to change OCCABA cylinders and prepare for the next entry.[T971] While servicing the OCCABA sets a team member had a problem with an O- ring and another could not release the cylinders.[T971, T990]
Initial casualty management
2.99 The SMET members mustered in the starboard boat space to treat the casualties. In quick succession, PO Hollis and PO Francis exited the aft hydraulics room and were directed to the starboard boat space.[E161] Each SMET member were allocated an individual patient and initial treatment was started.
2.100 In HQ1, PO Plant received notification of the first three casualties and proceeded to 1 Deck.[E97] By the time of his arrival, oxygen therapy had been commenced on all casualties.[E161] PO Plant assessed the condition of the casualties and determined that they were stable.[E158] Additional equipment was obtained from the sick bay.[E97, E161] AB Moffatt inserted an intravenous cannula in PO Francis.[E151]
2.101 On completion of initial treatment, PO Plant provided a situation report to HQ1 advising that all the casualties were stable.[E97] The bridge audio tape3 records him as briefing the CO on the casualty status at 1046 [E91] but neither he nor the CO, subsequently recalled the conversation.
2.102 PO Plant returned to the starboard boat space at 1100. He also administered analgesic medication to PO Hollis after obtaining concurrence from Dr Currie at HMAS STIRLING by mobile telephone.[E365, E57B, E97, T2291] At about the same time he was told by CHAP Gebski that four personnel were unaccounted for.[E97, E388]
The bridge
2.103 Maritime Headquarters Australia West (MHQ West) received the first news of the fire less than 7 minutes after it was first detected. This was via a mobile telephone call
3 An abridged version of the transcript of the bridge tape can be found in Annex D.
30 NARRATIVE from the Navigating Officer who requested tugs, helicopters and other ships.[T127] The second mobile telephone call by the Navigating Officer was to the Port Services Manager (PSM), LCDR Jempson, at FBW. The call included a request for a MO. The Signals Yeoman, PO Chambers, used a mobile telephone to pass seven formal signals to the Naval Communications Area Local Station Fremantle (NAVCALS Fremantle) for onward transmission through the Defence communications network.[T128,E48] Over the next 1½- 2 hours, the Navigating Officer was in regular communications by mobile telephone with the Operations Officer at MHQ WEST or the PSM at FBW. The CO was also in contact with Maritime Headquarters Australia (MHQ) by mobile telephone.[T3155-3156]
2.104 Communications with the Fremantle Port Authority (FPA) were established using a VHF radio and by 1046, the Harbour Master, Captain Atkinson, was aware of HMAS WESTRALIA’s predicament. The message which was passed included the information that the ship had had a major fire in the MMS, both engines were disabled but the situation was under control and the vessel was at anchor between the number one Deepwater Channel and Fairway buoys.
2.105 At 1050 there was a burning smell on the bridge.[E204] The QM located the source, opened a panel and turned the MCR talk-back radio off. He also placed an extinguisher nearby.[T1120]
2.106 Shortly afterwards smoke started entering the bridge to the extent that the Navigating Officer ordered one bridge door be closed and the CO the other.[E91] Between 1057 and 1058, PO Sellick reported ‘thick, black smoke on the port side of 04 deck near the magazine and pyrotechnics locker.’[E91] This smoke, which originated from the port MMS ventilation intake, was then being blown into the bridge.[T1126] The QM used the bridge GX91 meter and measured 120 parts per million of carbon monoxide. The Navigating Officer consequently ordered all unnecessary personnel off the bridge. Those who were required, were only allowed to return to the bridge for short periods.[T1120, T1122]
External agencies
Fremantle Port Authority
2.107 On receipt of the VHF radio advice from HMAS WESTRALIA at about 1046, the Harbour Master immediately placed the port safety and emergency response vessel on standby.[T2452] During a telephone call at 1050 the PSM advised the Harbour Master that the decision was not to anchor the ship. The use of tugs was discussed; this included the possibility of Fremantle Tug Operators (FTO) claiming salvage if WESTRALIA was outside port limits.[T2452-2453] The PSM also requested that the Harbour Master inform the Chairman of the State Marine Oil Pollution Combat Committee of the situation. This was done and all services were placed on standby.[T2452]
Fleet Base West
2.108 As soon as the PSM had finished speaking with the Navigating Officer, he telephoned Defence Maritime Services Pty Ltd (DMS) and requested two tugs be despatched to WESTRALIA. The PSM suggested the Garden Island based tug TAMMAR and a large port tug from Fremantle. The fact that the tugs had been ordered was passed to
31 NARRATIVE
WESTRALIA’s Navigating Officer together with a warning concerning the possibility of a salvage claim.
2.109 Shortly after the first report of the fire, the CO HMAS STIRLING, CMDR Johnson, took charge of the shore support assistance for WESTRALIA.[E387]
2.110 By about 1115 LEUT Stone, a medical officer, and CPOMED Bonner embarked with medical equipment in arigid hull inflatable boat (RHIB). This was the first surface craft to arrive alongside WESTRALIA and did so at 1143.[E91, T1033, T1055, T1076-1077, E387, E91]
RAN Surface Units
2.111 At approximately 1051 a message was received from MHQ West stating that WESTRALIA had a MMS fire and requesting units prepare to offer assistance, if required. At the time, HMAS ADELAIDE was in company with HMA Ships DARWIN, SYDNEY, SUCCESS, with the latter’s Sea King helicopter airborne, engaged in a photographic exercise. The surface units were 26 nautical miles west of Rottnest Island on a course and speed of 240° at 14 knots.
2.112 The CO ADELAIDE was Officer in Tactical Command (OTC) and he conferred with the COs of the ships in company by VHF radio and advised that all units, embarked aircraft and shore agencies would be coordinated by ADELAIDE. He also briefed the ships that he intended to detach units to close WESTRALIA at best speed to provide support. HMAS SYDNEY was detached at 1055 and HMAS DARWIN at 1102.
TAMMAR
2.113 The tug TAMMAR was the first of the FBW units to be despatched to WESTRALIA. The vessel proceeded at full speed after about only 5 minutes notice.[E387]
Fremantle Tug Operators
2.114 DMS telephoned FTO at about 1100 and negotiated an hourly rate towing contract under the company’s hourly hire rates. The tug WAMBIRI, which had been taken out of service the day before for maintenance, was immediately made ready.
CO2 DRENCH: 1102 – 1126
Activation of the drench
2.115 When the five minute period had elapsed, LCDR Crouch sought further confirmation from the CO before ordering the CO2 release.[E199, T1629] The CO confirmed the order at 1101 and the broadcast ‘drench, drench, drench’ was made throughout the ship from HQ1.[E38, E39, T498, T540]
2.116 The EOOW then discharged the CO2 from the FCR; this was reported to HQ1.[E155, T1629-1631] As the EOOW was leaving the FCR, the CO who was then standing outside the FCR asked him whether he had activated the drench and this was confirmed.
32 NARRATIVE
2.117 The EOOW went to the CO2 bottle storage room on 1 deck to check if all the cylinders had discharged. Because of some leaking CO2 there was a thick mist in the room and he was unable to enter to confirm that all the cylinders had been discharged. He went to HQ1 and reported this.
2.118 As a consequence, WO Bottomley went to the CO2 bottle room in OCCABA and found that not all the cylinders had discharged.[T1629-1631] Having checked with the EOOW as to which cylinders supplied the MMS, WO Bottomley concluded that it would be necessary for him to manually activate all the remaining cylinders. Approval was obtained from HQ1 and WO Bottomley activated the undischarged cylinders of CO2 seven minutes after the initial discharge.[T28, E129] Personnel in HQ1 again heard the CO2 discharge through the pipes.[E38, T498]
Decision to re-enter after the drench
2.119 The ship’s company followed the laid down procedure and waited for 15 minutes to elapse after the second release of CO2 before re-entry into the MMS.[T3158] Evidence was given that the re-entry decision was based on the fact that temperatures had not fallen after the introduction of the CO2 drench and in fact, the temperatures seemed to be rising. The first ‘documented’ temperature, however, was taken at 1125 showing a temperature of 50 with a downward arrow.[E128] The second hose team entered at 1126.
2.120 Between 1125 and 1136, seven temperatures were recorded to monitor the MMS boundaries in four different places. Although it was stated in evidence that temperatures other than those recorded were taken there is no evidence to confirm this statement.[T3974]
2.121 Evidence of low levels of oxygen in the MMS was demonstrated by the nature of the smoke from the exhaust of the starboard DA which continued to run for an hour or so after the fire started. The exhaust was described as being like that from ‘Thomas the Tank Engine’ with bursts of smoke puffing out at regular intervals.[T1492]
Aft Pump Room
Fire
2.122 As a result of concerns over what was happening in the aft pump room the XO was asked by LCDR Crouch to take charge of the area. Some of the messages recorded were, ‘nil hot spots aft pump room – 1114, hot aft pump room – 1116, aft pump room blistering –1120 and fire in aft pump room out – 1124’. No evidence has been found to indicate that a fire ever started in the aft pump room.
Casualties Relocated to the RASCO
2.123 Shortly before the CO2 drench, the XO advised PO Plant that the casualties were too close to the scene of boundary cooling efforts and that they should be moved forward to the RASCO.[T1567, T1526] PO Plant directed the SMET to move the casualties, a process which took approximately 10 minutes.[E97, E211, T2291]
2.124 PO Plant then returned to HQ1 where he was informed that two medical officers were in transit to the ship. He also obtained confirmation of the four missing
33 NARRATIVE personnel.[E97] Observation and treatment of the three casualties continued at the RASCO, PO Plant reviewing them again.[E97]
2.125 At about 1145, PO Plant went to the bridge to meet HMAS SUCCESS’s medical officer, LEUT Eggerling, who arrived in the first helicopter, the Sea King from SUCCESS.[E14] He escorted her to the RASCO, briefing her on the casualty state and the four missing personnel.[E97] He almost immediately returned to the port boat space to meet LEUT Stone and CPO Bonner who had arrived from FBW by RHIB at about the same time.[E97, E15, E17A, T135] Both medical teams brought additional equipment, including Thomas packs and oxy-vivas. LEUT Eggerling inserted a cannula in PO Hollis.[E151]
External Agencies
RAN Surface Units
2.126 HMAS ADELAIDE completed a RAS with HMAS SUCCESS and at 1109 both ships commenced passage at best speed to join WESTRALIA which was 38 nautical miles to the east.[E52]
Fleet Base West
2.127 At approximately 1115, the CO STIRLING advised the Harbour Master that there were casualties in WESTRALIA and requested that the Rous Head helipad be readied to receive them. Police assistance was sought to ensure emergency access for ambulances due to the major industrial action which was taking place on the nearby wharves at the time.[T2454]
Fremantle Tug Operators
2.128 By 1125, the tug WAMBIRI left her berth with a crew of six which included two additional hands.[T2437]
HOSE TEAM OPERATIONS: 1126 – 1232
Hose team 2
2.129 Hose team 2 formed at the Forward DC Section Base immediately after ‘emergency stations’ was piped. HQ1 was notified that the team was ready and they were handed over to the Aft DC Section Base. The team was made up of the following personnel: [E45, T663] LSBM Durnan (No. 1 - waterwall) ABBM Noles (No 2 - attack nozzle) LSETW Mitchell (No 3 - I/C) ABET Hunter (No. 4 - hose handler) SMNBM Morris (No. 5 - hose handler) 2.130 CPO Jenkins directed LS Bromage to be the scene leader.[E133, T2005] LSMT Bromage briefed LS Mitchell on the conditions within the MMS and then HQ1 was
34 NARRATIVE informed that the team was ready. They waited for HQ1 approval to enter the MMS.[E133, T2005]
2.131 At 1126 hose team 2 entered the MMS from the fridge flat. The five team members were appropriately dressed and OCCABA procedures were followed. There was zero visibility in the dense smoke and the team reported intense heat.
2.132 Again, there were difficulties with the Maxon radio sets. LS Bromage directed AB Street and AB Richardson to visually confirm that hose team 2 had entered the MMS. The runners confirmed the entry and shortly after, Maxon radio communications were established.[E133, T2005] Radio communications between the hose team and the scene leader remained a continuing problem.
2.133 At 1135, LS Mitchell reported that the thermal imaging camera (TIC) was showing hot spots everywhere and the screen had completely whited out.[T668] Despite the thick smoke and intense heat the team went down the ladder to the top plates.
2.134 The team progressed to the top plates handrail area, cooling oil drums and directing foam over the MEs and onto hot spots identified with the TIC.[E133, T2005] The team also reported that their boots were sticking to the plates and hot water or molten plastic was dripping on them.[E133, T517, T669]
2.135 LS Mitchell noticed that he was running out of air. He pulled his D-ring to activate the reserve air supply and started to leave the MMS with his team. On the way out, he became lost in the smoke but was found by SMN Morris and guided to the ladder.[T670] The team left the hoses on the top plates.[T671] While handing over to LS Cain within the smoke boundary, LS Mitchell ran out of air completely.[T670]
2.136 Hose team 2 proceeded to the RASCO to service the OCCABA and rest. Unfortunately, there was no water for the team to drink, only frozen fruit juice packs.[T671]
Hose team 3
2.137 At the Forward DC Section Base LS Cain volunteered to be the team leader of hose team 3. The team was made up of the following personnel: [T758] LSET Elliott (No.1 waterwall) ABMT Croasdale (No 2 attack nozzle) LSBM Cain (No 3 (I/C)) SMNBM Williams (No. 4) POWTR Mackinnon (No. 5) 2.138 Hose team 3 went aft. Prior to entering the fridge flat at 1151 to replace hose team 2, the scene leader, LS Bromage briefed them as to the conditions and that four people were missing.[T758] The team was correctly dressed in protective clothing and OCCABA and their names were placed on a control board.[T466]
2.139 The change over occurred outside the MMS but LS Cain was still briefed by LS Mitchell.[T759] Hose team 3 followed the hoses onto the top plates, found the nozzles and then started attacking the fire. By using the TIC, LS Cain could see what were apparently flames and directed his team to apply water and foam. He said he could see the water hitting the fire through the TIC.[T760]
35 NARRATIVE
2.140 During hose team 3’s attempt to descend to the middle plates to aid in reaching the seat of the fire, they found LS Meek on the top landing of the port side ladder from the middle plates to the top plates.[T760] LS Cain checked for a pulse, found none and notified the scene leader by Maxon radio of the discovery which was recorded by HQ1 at 1205.[E50, E18] As LS Meek was impeding the progress of the hose team, LS Cain decided to move him to the base of the fridge flat ladder.[T760]
2.141 WO Baker and LS Nunn observed this action from the fridge flat door.[E159, T2400, T1312] WO Baker sent a runner to the Aft DC Section Base to report that he had seen a casualty while LS Nunn descended to the top plates, arriving at the same time as the hose team. As LS Meek was placed on the deck, LS Nunn heard what he thought was a moan.[E101A] LS Nunn checked that LS Meek had no perceptible pulse, and confirmed by other observations that he was dead.
2.142 Observing from the fridge flat landing, WO Baker was uncertain as to whether the casualty was in fact deceased. He tasked LS Bromage to get ELSRDs, one specifically for the casualty.[T2008, E159] A Paraguard stretcher was obtained from the Junior Sailors’ Mess, assembled, and with some difficulty, LS Meek was placed in it.[E172, E101A] At the same time, at 1215, an ELSRD was placed on LS Meek.[E159, E41, E172] At around 1220, all personnel in the vicinity apart from AB Liddell ran out of air and he was left alone to care for LS Meek.[E101A, E390A, E236]
2.143 Hose team 1 continued their attack from the top plates and LS Cain encouraged his team that they were going to beat the fire.[T760] LS Cain received a radio message from the scene leader that foam was about to be dumped through the funnel and that the team was not to panic.[T760-761] They reported that the AFFF which was pumped in through the funnel felt like snow except that it was very hot.[T760-761]
2.144 Hose team 3 was getting low on air when hose team 1 arrived with LS Daly in charge. LS Cain gave a comprehensive handover and then hose team 3 assembled at the base of the ladder on the top plates to ensure that the whole team was present and nobody had been left behind. The area was hazardous and difficult to negotiate due to the number of fire hoses on the deck and the close proximity of the body to the ladder.[T762, T467- 468] LS Cain stayed behind for a short time to assist AB Liddell who was attempting to place LS Meek in a stretcher.[E41, T762]
2.145 On returning with replenished OCCABA, WO Baker descended to the top plates for a second time and confirmed that LS Meek was neither breathing nor had a pulse. He arranged for him to be moved further away from the base of the ladder and for a further situation report to be passed to the Aft DC Section Base by AB Munday.[E159] LS Meek’s ELSRD was changed regularly by a number of personnel until 1255 when PO Plant and LEUT Eggerling arrived in the MMS.[E386, E36A]
2.146 While exiting up the ladder LS Elliott ran out of air and had to pull his D-ring. Within 30 seconds he had completely run out of air and had to remove his mask.[T468] The hose team changeover was recorded by the Aft DC Section Base at 1210. Hose team 3 proceeded to the Aft DC Section Base and then to the RASCO to service the OCCABA and rest.
Hose team 1 re-entry
2.147 Having received their handover, hose team 1, which was made up of the same people who had entered earlier, continued to fight the fire. AB Smith, (waterwall) was
36 NARRATIVE directed to go down to the middle plates via the port ladder. AB Miskiewicz and LS Daly followed shortly after.[T629]
2.148 The team leader, LS Daly, continued to direct the operation and kept the attack hose directed towards the hot spots, although by this time he could see no flame.[T630- 632] As LS Daly was looking around the middle plates he found POMT Smith’s body near the port ladder on the middle plates. He found no pulse. Because his Maxon radio was not working and no-one had come down for a situation report, LS Daly left his hose team and went up to the fridge flat cat walk to make a report.[T630] After his return to the middle plates, he found the bodies of AB Carroll and MIDN Pelly between the DAs.[T631] Neither had a pulse.
2.149 Because LS Daly still had no means of communication, he again went up to make a report, this time that he had discovered two more bodies on the middle plates.[T632] He told LS Durnan whom he believed was from another team and coming to relieve hose team 1 that he had found three casualties and that he believed that the fire was out. He waited on the top plates for the rest of his team which had been relieved and then exited the MMS with them. On the way out with his hose team, LS Daly met LSETW Mitchell and gave him a handover.[T632] He then told WO Baker that he had found three bodies on the middle plates and that while there were hot spots, the fire was out.[T632] At 1232, the Aft DC Section Base recorded that the fire was out.
The bridge
2.150 Between 1108 and 1220, the ship drifted north at a rate of about 0.5 of a knot over a distance of 1350 yards. Once it was known that the tug TAMMAR was on its way, the Navigating Officer continuously calculated its ETA at the ship and the time that HMAS WESTRALIA would drift on to the 8.2 metre shoal. Initially, fixes were taken every three minutes by the OOW and plotted by the Assistant OOW but as the northerly drift towards the 8.2 metre shoal became more apparent, the time interval between fixes was dropped to two minutes.
2.151 The tow by TAMMAR was established at 1220 when the ship’s bridge was less than 200 yards from the shoal patch. Had it been necessary for the vessel to anchor in that position, the length of the ship, the scope of cable and the prevailing wind, would have made grounding almost certain.
External agencies
RAN surface units
2.152 The OTC advised all units to prepare fire teams with a priority on teams comprising ex WESTRALIA sailors and preferably those with an engineering background. At 1142 the OTC informed all units that he was taking command as the On Scene Commander (OSC) in order to co-ordinate support for WESTRALIA. Communications were established between the OSC and WESTRALIA at 1146 and priorities were established as OCCABA, Fearnought suits, Maxon radios, portable pumps and diesel fuel to operate them. HMAS SUCCESS had a suitable pump which was to be transferred to WESTRALIA. At 1206 WESTRALIA repeated that a pump was a priority item to support the fire teams fighting the fire.[E52]
37 NARRATIVE
2.153 At 1210 the OSC executed a screen ‘Cordon’ based on WESTRALIA in order to facilitate the transfer of stores and ‘deconflict’ units.
RAN aircraft
2.154 The first assignment of the Sea King helicopter embarked in HMAS SUCCESS, was to fly a medical officer, LEUT Eggerling, medical equipment, OCCABA sets and Fearnought suits to WESTRALIA and the aircraft launched at 1125. During the flight, radio communications and call signs were ordered to be in plain language.[T849] The flight crew was warned that the vertical replenishment (vertrep) deck would be manned by only a marshaller. To assist the marshaller, the Sea King helicopter aircrewman or the observer were winched down to the vertrep deck on each occasion to assist in controlling it during aviation operations.[T850]
2.155 After LEUT Eggerling was winched to the deck at 1143, the stores were transferred in a Billy Pugh net that is normally used for scooping an injured person out of the water.[E17A, T863]
2.156 The Sea King helicopter then flew to the Helicopter Support Facility (HSF) at FBW and embarked fire crews from HMAS ANZAC and offloaded the fire crews and their equipment on to WESTRALIA by 1228.[T851, E52] There was a minor problem with the winch at that time but this was overcome.[T852]
2.157 The HMAS ADELAIDE Seahawk helicopter was first readied for the transfer of an ADELAIDE fire team at 1137 but was not launched until 1210. Its load included OCCABAs, Fearnought suits, Maxon radio sets and diesel fuel for the fire pumps that were being transferred to WESTRALIA by the Sea King helicopter. The Seahawk helicopter had to hold off until the Sea King cleared from WESTRALIA before it could commence its transfer at 1230.[E52]
Fremantle Tug Operators
2.158 By 1151, DMS had confirmed the order for the provision of tug services by facsimile message to FTO.
2.159 On the bridge of WESTRALIA, however, there was some apprehension that the Master of WAMBIRI had made an open claim for salvage as the tug approached the ship. The Navigating Officer thought that the Master of WAMBIRI used the words:
I reserve the right to negotiate the terms of this charter at a later date.
2.160 The Navigating Officer took this to mean that the Master was leaving a salvage claim open for a later time.[T141] What was read out by the Master of WAMBIRI was in fact a general instruction to all the firm’s tug masters that in local emergency cases within port limits where tugs are called out to assist a ship that has sustained a grounding or collision, tug masters must advise the casualty’s master as follows:
We acknowledge your call and will render assistance immediately. My owners reserve the right to negotiate the terms under which these services are rendered.[E162]
38 NARRATIVE
2.161 It would appear that the message that the tug was under a fixed towing contract was either not passed to WAMBIRI or WESTRALIA, or was passed, but lost in the flow of messages reaching the Naval vessel.
2.162 WAMBIRI is fitted out for ocean rescue work and has a bollard pull of 61 tonnes; she is also fitted with firefighting equipment which includes a water cannon with a capacity of 10,000 litres a minute and about 13 tonnes of foam.
2.163 WAMBIRI arrived at WESTRALIA shortly after TAMMAR commenced the tow.
FIRE EXTINGUISHED: 1232 ONWARDS
Hose Team 2 re-entry
2.164 At 1230 hose team 2 replaced hose team 1 and proceeded to the middle plates to cool hot spots. LS Mitchell could not see any fire or hot spots and also reported that the fire was out.[T672] With their air getting low, hose team 2 exited from the MMS at 1258.
Overhaul and smoke clearance
2.165 Hose team 3 lead by LS Cain received a handover and at 1258 proceeded into the MMS to continue overhauling the fire. The team broke into pairs and continued cooling hot spots until relieved by re-flash sentries who were members of hose team 1. LS Cain reported to the EOOW and CPO Jenkins that there were no hot spots or spot fires.[T764]
2.166 When the hose team 1 re-flash sentries exited the MMS a number of other people were rotated as re-flash sentries. The re-flash sentries were appropriately dressed and wore OCCABA. Smoke clearance continued until just after 1400.
Medical activities
Further casualties
2.167 About 1215 an erroneous report was received in HQ1 that a missing crewmember had been found alive in the MMS. This resulted in the establishment of a casualty reception area on the port side of the tank deck immediately forward of the superstructure, with necessary equipment and a team of personnel including the medical officers, standing by.[E57A, E150] Approximately ten minutes after the resuscitation bay was set up, AB Street became a casualty and was initially taken to the resuscitation bay and then to the RASCO at about 1230. Not long after this, AB Liddell presented as a casualty to RASCO and was also cared for.[E57B, E150, E158 T1033]
2.168 LS Nunn became a further smoke inhalation casualty, reporting to the RASCO at 1350.[E57B, E61] He was treated and returned to duty but required further treatment shortly afterwards.[E57B] Following the second treatment, he again returned to duty. Although no other casualties were formally seen during the day, it became evident during the Board’s hearings that a number of personnel suffered smoke inhalation but who did not report for medical treatment.[T291, T967, T2001, T2961-2962, E173]
39 NARRATIVE
Medical staff supplementation
2.169 WESTRALIA requested additional medical staff from other ships at 1236.[E52, T175] HMAS DARWIN provided an ABMED3 who was transferred at 1240 and HMAS SYDNEY despatched a POMED4 and an ABMED3 who arrived at 1252 along with additional medical equipment.[E17A, E54] These personnel mustered at the resuscitation bay set up in the port boat space. WOMED4 Smith was transferred from HMAS ADELAIDE by Sea King helicopter at 1251 and went to the RASCO.[E17A]
Identification of the deceased
2.170 At the time the fire was reported out the CO formed the view that the situation was coming under control. His priority then became to confirm the fate and identities of the four missing crewmembers, particularly as MHQ was concerned to inform the next of kin. He instructed LCDR Crouch to arrange for the medical teams to recover the bodies to the fridge flat as soon as possible so that he could personally identify them.[T3155, E57A]
2.171 LEUT Eggerling and PO Plant proceeded to HQ1 and were briefed by LCDR Crouch as what to what they might expect when they went into the MMS.[T2967, E97] They entered the MMS at 1250 and identified and certified as deceased, the following casualties:[E41] LSMT Meek at 1255; [E438] POMT Smith at 1308; [E438] ABMT Carroll at 1310; [E438] and, MIDN Pelly at 1315.[E438] 2.172 At 1325, they left the MMS, went to the bridge to brief the CO on their findings and then to HQ1 to brief LCDR Crouch.[E41] The decision was taken to remove the bodies from the MMS to minimise the stress for personnel attending to the aftermath of the fire. Medical teams were arranged for the extrication of the casualties.
Management of the injured at the RASCO
2.173 Care of the casualties at the RASCO continued; they were made more comfortable and additional medication was given by LEUT Stone.[T1033]
2.174 A discussion regarding evacuation ashore took place between the Staff Officer Health Services, LEUT Spehr, and CPOMED Bonner onboard WESTRALIA. The decision was made that the injured should be taken to St John of God Hospital, Murdoch.[E84] At about 1205 the command was requested to arrange a helicopter for a medevac.[E51] At that stage the priority for air assets was the firefighting effort and the casualties were stable. LEUT Stone left the RASCO at about 1240 to assist the resuscitation team aft and CPOMED Bonner left shortly after that. The care of the casualties was left under the supervision of LS Page. Medical evacuation of casualties.
2.175 At sometime after 1250, the CO considered that the situation was under control and that sufficient additional personnel and equipment had been embarked in WESTRALIA.[T3155-3156] The intention to conduct the medevac as the next air tasking was communicated to the OSC at 1301 and the Sea King helicopter was re-tasked a minute later.[E52] Initial information passed to the OSC at 1309 advised that there were three casualties, one of whom required winching in a stretcher, and that they would be ready in
40 NARRATIVE approximately 15 minutes. At 1326, the number of casualties was revised to four and then at 1329, to five.[E52]
2.176 The casualties were taken to 04 deck and positioned just aft of the bridge.[T2293] There was some concern about whether the two casualties with intravenous lines could be safely winched. The vertrep marshaller, LCDR Opie, checked with LEUT Eggerling and WO Smith who confirmed that the procedure would be safe if the intravenous lines were turned off and the bags tucked into their overalls.[E61, E155]
2.177 The medevac commenced at 1340, all casualties being winched in a double-lift strop to the Sea King helicopter.[E17A] No medical escort was sent. By 1406, the medevac of the casualties to St John of God Hospital was successfully completed.[E61, E52]
Casualty extrication
2.178 During the return to FBW, and prior to the extrication teams starting operations two SMET personnel were sent into the MMS at 1416 to cover the bodies with blanket.[E57A, E18, E236]
2.179 The first of the teams entered the MMS at 1515, dressed in intermediate rig.[E18] The four casualties were placed in body bags.[E150, T2512] MIDN Pelly was carried via the port ladder to the middle plates and then aft towards the tiller flat before the team had to exit as they had run out of air.[E57A, E54A] The time that this team departed from the MMS was not recorded.
2.180 The second team, again in intermediate rig, entered the MMS at 1551.[E18] WO Baker arranged to set up a two-fold purchase from the tiller flat into the fridge flat and the bodies of LS Meek and MIDN Pelly were lifted and placed in a refrigerated compartment.[T2512] An attempt was made to lift POMT Smith’s body from the middle plates to the top plates, but this was abandoned as being too difficult. WO Wilson rigged a second handy billy to assist, but by this time, the team’s air had run out and they were forced to leave at 1617.[E60A, E54A, E18]
2.181 On their return to the upper deck following this second entry, the CO discussed the casualty extrication process and the difficulties associated with it with LEUT Eggerling and PO Plant. Given the fatigued condition of the medical teams, he ordered the suspension of recovery operations at around 1642 until it was safe to continue to do so without breathing apparatus.[E18, T3156]
2.182 The third entry of the teams occurred at 1707, OCCABA not being required as the compartment had been declared oxygen safe.[E18]
2.183 Using the previously rigged handy billy, the bodies of POMT Smith and AB Carroll were lifted from the middle plates to the top plates and then via the tiller flat escape ladder to the fridge flat.[E97A, E54A, E84A] Extrication times were recorded as 1721 and 1734 respectively.[E18] The team left the MMS at 1738.[E18]
41 NARRATIVE
External agencies
TAMMAR
2.184 A synthetic rope was used for the towline and the tug, with its 35 tonne bollard pulled WESTRALIA clear of the 8.2 metre shoal. Unfortunately WESTRALIA’s rudder was locked at 30º and in order for the tug to pull the ship on a particular course, it had to position itself about 60º to port of the ship’s head. This placed an additional strain on the towing line, which parted at 1250.[E17A, T142]
Fremantle Tug Operators
2.185 After TAMMAR’s synthetic rope line snapped, WAMBIRI attempted a hook up using its 48-millimetre wire line. There were insufficient numbers of WESTRALIA’s crew on the forecastle at the time and those who were there placed the messenger over a bollard. Eventually the towing wire was brought inboard and secured for towing at 1314.
RAN surface units
2.186 At 1234 the OSC amended the screen ‘Cordon’ to facilitate the transfer of stores by boat which commenced at that time. By 1244 it became evident that sufficient firefighting equipment was either onboard WESTRALIA or en route to the ship. Based on the shift in priorities, a team of Sea Training Group DC specialists was transferred by air to WESTRALIA.[E52]
2.187 Considerable congestion was developing around WESTRALIA while at the same time navigable waters were decreasing. Accordingly, the OSC cleared non-essential units from the area. At 1300 WESTRALIA reported that the fire was extinguished and that the search for casualties had commenced. At 1310, HMAS DARWIN’s boat responded to a request for intravenous fluids. HMA Ships SYDNEY and ADELAIDE supplied water and victuals at 1330 and the ADELAIDE CISM team joined WESTRALIA at 1335.[E52]
2.188 By 1330 the situation had de-escalated to the point where various vessels were ordered to detach. DARWIN and the DTV SHARK were ordered to remain with WESTRALIA, to proceed to FBW when ready and provide ongoing support as necessary.[E52]
RAN aircraft
2.189 Airspace congestion caused by media helicopters reached a point where, at 1332, the OSC requested that Flight Information Services Perth keep civil aircraft out of the immediate vicinity of WESTRALIA. By 1325, Flight Information Services Perth had established an exclusion zone around WESTRALIA and congestion then eased noticeably.[E52]
2.190 At 1308, the Seahawk helicopter winched a fire team from HMAS SUCCESS onboard WESTRALIA. On completion, the aircraft flew to the HSF at FBW to embark a critical incident stress management (CISM) team for WESTRALIA. They were winched onboard by 1414 prior to the aircraft recovering to HMAS ADELAIDE at 1420.[E52]
2.191 The Sea King helicopter’s next sortie was to take 14 members of the Sea Training Group and HMAS ADELAIDE’s fire crews with equipment to WESTRALIA.
42 NARRATIVE
The next assignment was to medevac the casualties. While they were being prepared, the Sea King helicopter flew to ADELAIDE to fuel and return to WESTRALIA.[T854]
2.192 The medevac of the five casualties to St John of God Hospital at Murdoch was without incident. The air traffic control authority assisted greatly and on completion, the aircraft returned to HMAS SUCCESS where it was placed on alert 30.[T855-856]
Fleet Base West
2.193 Subsequent to a request by the Navigating Officer, the PSM arranged for 25 FIMA staff to embark in DTV SHARK to assist WESTRALIA’s crew with their firefighting efforts.[T1742] DTV SHARK also carried spare Fearnought suits, OCCABAs and TICs.[E387] The firefighters and the equipment was offloaded onto WESTRALIA at 1320.
2.194 FBW also provided a CISM team which had been requested by the CO WESTRALIA which was airlifted to the ship by Seahawk helicopter at 1414.[E387]
2.195 In order to relieve the Navigating Officer, the PSM embarked in WESTRALIA at 1456 to act as pilot to bring the ship down the Parmelia-Success Channel to FBW.[T1738 and E387]
2.196 Before WESTRALIA entered the Parmelia-Success Channel, WO Bottomley and 2 members of the STG centred the rudder by hand pump, a task which took about 10 minutes.[T905-906, T910] After the rudder was centred, the tow to FBW was without incident and WAMBIRI and TAMMAR were joined by a second FTO tug, WYONG, at 1515 to assist with the move down the Parmelia-Success Channel. WESTRALIA berthed on Parkes Wharf at FBW at 1811.[E162]
2.197 At the direction of the Minister for Defence, the CO STIRLING held a press conference at 1510 and was otherwise occupied with the media until after the ship berthed.[E387] Other personnel from FBW assisted relatives and friends of the crew of the ship before it arrived. By the time WESTRALIA berthed, hot food and STD telephones were available and accommodation arranged for those who required it.[E387]
2.198 A legal officer, CMDR Vickridge, arranged for the Arson Squad of the Western Australian Police Service (Police) to attend. This assistance was sought in order to conduct formal identification of the deceased, determine their cause of death and the cause and origin of the fire. A mobile Police unit was also established adjacent to the wharf before WESTRALIA berthed. The unit, a Disaster Victim Identification Team comprised an Emergency Operations Unit, a Forensic Division and members of the Arson Squad arrived at 1830. The duty forensic pathologist, Dr Cadden, also formed part of the unit which acted on behalf of the State Coroner.[E452, T78]
2.199 On arrival of WESTRALIA at FBW, Police members embarked and carried out formal identification of the deceased with the assistance of PO Plant.[T1200] The MMS and fridge flat were secured by Police boundary tape and photographed by both still and video photographers. The Arson Squad examined the MMS and, within a relatively brief period, isolated what appeared to them to be the origin of the fire. Evidence was collected and taken into custody by CMDR Vickridge.
2.200 A duty watch from STIRLING was embarked in WESTRALIA so that her ship’s company was able to proceed on leave that night.[E387]
43 NARRATIVE
2.201 The deceased were landed after WESTRALIA’s crew had left the ship and the media had departed. Each of the deceased was piped over the side and marks of respect paid by gangway staff and all personnel in the vicinity. A Naval police vehicle was arranged to escort the hearses to the HMAS STIRLING gangway.
44 SECTION 3. ACTIONS OF THE SHIP’S COMPANY, THEIR TRAINING AND COMPETENCE
3.1 All members of the ship’s company contributed in some way or other in successfully overcoming fire in the MMS. The fire, which was initially intense, was extinguished without further loss of life or loss of the ship; both events which could quite easily have occurred. This was a good effort on the part of HMAS WESTRALIA’s company, due in no small part to the determination of the ship’s firefighting teams to press home their attack on the fire in extremely difficult and hazardous circumstances.
3.2 The purpose of this section is to examine standard RAN procedures for firefighting and determine whether they were adequate to deal with the fire, whether they were followed and if not why not, and finally, if they require amendment or reinforcement. The Australian Book of Reference (ABR) 5476 Vol.1 entitled, ‘RAN Ship Damage Control Manual’, sets out the RAN’s DC policy and recommends standard operating procedures for dealing with, amongst other things, fire and flood at sea. WESTRALIA also has a Ship’s Emergency File which highlights any changes to the RAN’s standard operating procedures (SOP) due to the specific design or equipment matters peculiar to the ship.[E112]
3.3 Set out below is the Board’s analysis of the actions of the ship’s company on 5 May 1998 and comments on training issues. Firefighting equipment and other safety equipment issues are dealt with separately in Section 7 of this Report.
INCIDENT COMMAND
Incident management strategy
3.4 Any ship firefighting strategy requires that the incident commander choose between an offensive or defensive strategy. The strategy adopted must consider the dangers to firefighting personnel and exposures must be weighed against the dangers to the vessel and cargo. Command responsibility lies with the Commanding Officer (CO), CMDR Dietrich, who generally remains on the bridge or where he deems that he can best monitor the incident in order to maintain an overall perspective.[E111,T1544] The Marine Engineering Officer (Engineer), LCDR Crouch, is WESTRALIA’s Action Damage Control Officer (DCO). When the ship goes to emergency stations, LCDR Crouch is responsible for the overall co-ordination of the firefighting and damage control from HQ1. He is also responsible for advising command of the situation and making recommendations. On 5 May 98 there appears to have been some confusion as to the strategy being adopted as the actions being taken included direct attack or search and rescue (hose team entry 1051), indirect attack (1101 CO2 drench) and direct attack again (hose team entry 1126).[E129]
3.5 The length of the communication chain may have compounded the problem of determining the firefighting strategy. For example, the CO requested a hose team enter the MMS to search for people missing prior to the CO2 dump. Yet when hose team 1 entered the MMS the first time, they were intending to fight the fire not to conduct a search.
45 ACTIONS OF THE SHIP’S COMPANY, THEIR TRAINING AND COMPETENCE
3.6 The message to conduct a search came from the CO and was directed to LCDR Crouch, then probably took the following route: the Engineer to LEUT Gishubl, to PO Edmonds, both in HQ1, to Aft DC message receiver to CPO Jenkins, to LS Bromage, and finally to LS Daly who was the hose team leader. Clearly, this lengthy communication process could result in the context of a message being altered slightly each time the message was passed on. In addition, each individual was under considerable pressure and some messages were delivered by sound powered phones which were not operating well.[T2291, T1691] The position of the Executive Officer (XO) as Rover is designed to reduce these communication difficulties.
3.7 At no time during the incident did the command team, namely the CO and his senior officers, assemble to discuss a firefighting strategy, the problems being encountered, determine objectives, and tactics.[T3206, T2982] There was also no evidence that a review process was undertaken to check if the plan was effective and that targets were being achieved.
3.8 Immediately after the CO2 drench, the command team had time to discuss all of these factors and determine the way ahead. Such an approach may have pooled the group’s knowledge of CO2 on how the gas extinguishes fire and the hazards of an early re- entry. This type of discussion may have also uncovered that CO2 had a limited cooling capacity and 15 minutes was insufficient time to notice a significant temperature drop. The hose team may not have been committed to re-enter if an analysis of the temperature readings had been undertaken and identified deficiencies in the recording process.
3.9 What is clear is that a number of personnel had very limited knowledge of CO2 and how it extinguishes fire. As the gas is used as the fixed fire extinguishing agent in WESTRALIA and is relied on to combat major fires in either the ship MMS or after pumproom, the crew should know more about its properties. In addition, there was limited discussion between members of the command team as to the best strategy to employ to combat the fire.
Conclusions
3.10 The command team should have consulted to determine the objectives, strategies and tactics to combat the fire.
3.11 The command team did not meet on a frequent basis during the incident to pool information, evaluate strategies and set appropriate objectives.
3.12 The command communication chain was very long.
Decision not to anchor
3.13 Following the start of the fire in the MMS and the loss of the main engines, HMAS WESTRALIA was ‘not under command’, disabled and drifting. Anchoring the vessel under such circumstances would have removed any risk of grounding; released experienced bridge personnel and those on the forecastle to combat the fire; and removed any immediate requirement to tow the ship. It would also have allowed the ship to lie to the wind so fumes and smoke were directed over the stern. This may have affected helicopter operations but in the event there was little smoke evident after the CO2 drench.
46 ACTIONS OF THE SHIP’S COMPANY, THEIR TRAINING AND COMPETENCE
3.14 The decision not to anchor was based on concerns raised by the CO, CMDR Dietrich, in consultation with the Navigation Officer, LCDR Triffitt.[T137-138, T3154] Their concerns were namely that:
a. in the absence of electrical power, the cable could not be recovered;
b. it could be hazardous to cut the cable;
c. it would be difficult to stop a joining shackle between the winch gypsy and the hawse pipe;
d. breaking a joining shackle could also be hazardous; and
e. it would hamper the ship being towed clear of the coast if the fire situation deteriorated.
3.15 At 1025 the vessel was approaching the number 1 buoy in Deepwater Channel, on a course of 005.[E91] Just before 1030, WESTRALIA reached the wheel over position and started to alter course to port. When the vessel reached a heading of 335 degrees, 10 degrees of starboard rudder was applied to check the swing. A few seconds later, just before 1031, the bridge received the request to shut down the port main engine (PME).
3.16 With the loss of the PME, the ship continued to swing to port until the swing was eventually checked and the ship started to turn to starboard. When power was lost on the starboard main engine (SME) at 1035, WESTRALIA lost way and lay on an easterly heading.
3.17 The drift under the influence of the wind was to the north towards an 8.2m shoal (Australian Tidal Data). The wind was from the south at 15 knots, the predicted high tide at Fremantle was at 1045, with the tide remaining at virtually 0.9 m above the datum until about 1730. There was a one metre swell recorded at South Passage Beacons, about 5 miles south of WESTRALIA.[E165]
3.18 Between 1108 and 1220, the ship drifted at a rate of about 0.5 of a knot over a distance of 1220 metres. The tug TAMMAR established the tow at 1219 when the ship’s bridge was less than 200 metres from the shoal patch.
3.19 The nearest approach to the shoal, based on radar distances from Rous Head, (6.4 miles - Mudrup Rock, 4.63 miles - fairway racon buoy, 1.65 miles respectively) was at 1226 when the vessel was within 130 metres of the shoal.[E17A] At a maximum draught of 9.15 metres and given the existing environmental conditions there was a very real risk of grounding, breaching the hull and the consequent oil pollution.
3.20 The Navigation Officer, when asked about the proximity of the 8.2 metre shoal stated:
I can't remember how far away from it we were at the time but we were being set towards the shoal by the - - or drifting towards the shoal under the influence of the wind. We discussed the use of an anchor to keep us off the shoal. We went into a fair bit of discussion about it and basically decided that the use of the anchor was to be a last resort because we had no power to get the anchor back and even breaking the cable without power to veer or heave so that we could put slips on to take weight off it and things like that, would have been particularly dangerous…[T137]
47 ACTIONS OF THE SHIP’S COMPANY, THEIR TRAINING AND COMPETENCE
3.21 Later the Navigation Officer was asked about the correlation between TAMMAR’s estimate time of arrival (ETA) and the projected time of grounding on the 8.2 metre shoal:
Did you have any, or did you think about any correlation between ‘Tammar’ ETA and I will say the ETA on the 8.2-metre shoal?---I was constantly working on that. I had my offsider on the chart fixing, calculating sets and rates and giving us estimated times to the shoal. When we had radar, when we had emergency power, I was getting ranges to ‘Tammar’ and working out from that her ETA to us and correlating the two to work out who would get there first and fairly soon it became apparent that 4 to 5 minutes before impact on the shoal ‘Tammar’ would be with us.[T141.1]
3.22 SBLT Davey who was in charge of the forecastle head when asked about preparations to anchor the ship and preparing for the tow stated:
Well, it's only from hearsay what I heard but I'd heard anything from 150 yards to 300 yards and from 1 minute to 3 minutes, but that was only afterwards.[T1605]
3.23 LEUT Read, blind safety officer, was asked about monitoring the ship’s position. She was also asked if she could remember how close they came to the shoal:
I didn’t physically. I called out the fix to my assistant. I didn’t actually plot it on the chart, but he did tell me later that we went inside the clearing bearing.[E204,T3341]
3.24 LEUT Humphrey, assistant officer of the watch (AOOW), was plotting WESTRALIA’s position based on the radar distances taken by LEUT Read. He was asked how close the ship was plotted to the shoal and replied:
We got within about 150 yards, sir.[E171, T2490]
3.25 Later LEUT Humphrey was asked whether he was asked to alert the Navigation Officer if the ship came within a certain distance.
No, sir. I don't think so. The Navigator was quite specific in saying, yeah, ‘I need continual updates from the distances to the shoal.’ And he also asked me to provide set and rate, tidal set and rates, figures, and I think I made two or three of them, two or three reports to that degree, telling him we had about, like, 1 knot of tidal stream pushing us in whichever direction.[E171, T2490]
3.26 He was also asked about any discussion on anchoring:
Yes, I do, sir. I only picked up snippets of it, but there was some discussion between the command, you know, the Navigator and the Captain regarding the legalities involved with having the pick go down. Now, I can't recall whether the Navigator wanted to or didn't want to, but my impression was, and it really only is an impression, sir, was that they didn't - - they wanted to leave it unless it was absolutely necessary, otherwise there were legalities to do with salvaging. I am not sure.[E171, T2490]
3.27 The CO stated that he thought the nearest approach to the shoal was about 200 yards.[T3174] When later shown the radar ranges taken from the OOW notebooks he
48 ACTIONS OF THE SHIP’S COMPANY, THEIR TRAINING AND COMPETENCE conceded that WESTRALIA was within the limiting lines drawn on the chart and closer to the shoals than he thought, but:
. . . at the time I was willing to back my judgement that we were going to get connected up and get clear.[T3194]
3.28 The CO when asked about the danger of grounding, stated:
Just getting back to the proximity of the navigational danger and so on. It was always in the back of my mind that the ship was only doing half a knot, quarter of a knot, towards it, and that it - - I guess, you know, even if we had touched, I don't think it was going to incur a lot of damage to the ship, compared to the danger that was from the fire. The fire was a much greater danger than a touch on the bottom at that stage. However, being a professional Naval officer, I didn't want to run aground as well, and would have used the anchor if I thought I was going to.[T3174]
3.29 Although the Navigation Officer carefully calculated the rate of drift against the ETA of the tug TAMMAR, WESTRALIA drifted within the predetermined limiting lines. Whatever the estimated time interval may have been before the ship would have grounded, the reality is that the ship’s radar scanner was 130 metres from the shoal when the tug was secured and started to tow WESTRALIA. Had the tug experienced any difficulty in passing the tow rope or had the rope parted, as later occurred, it would have been too late to anchor. The length of the ship, the scope of cable and the prevailing wind would have made grounding almost certain.
3.30 Given the swell condition at the time, even a low velocity impact would probably have involved some damage to the hull and release of oil. A pollution incident in close proximity to the coast and a major population centre would have compounded the serious problems already being faced by WESTRALIA.
3.31 There was a real risk of the ship grounding and causing a pollution incident. In assessing the risk, more weight should have been given to the consequences of grounding. The fact that the ship did not ground and was towed clear of danger does not mitigate the failure to give insufficient weight to the very real risk that existed.
3.32 Submissions were received from the CO and Navigator in relation to the decision not to anchor. The CO took full responsibility for the decision stating that it was based on his best judgement at the time as previously stated to the Inquiry.
Conclusion
3.33 The Board is not convinced by the reasons offered for the decision not to anchor. If an emergency cable run was rigged between the emergency switchboard and the hydraulics room, the anchor might have been able to be raised. Whilst breaking the cable and slipping an anchor is not an everyday occurrence, such an evolution could have been undertaken with tug assistance if the CO considered it necessary. The Board considers that the decision not to anchor was an error of judgement. Anchoring would have reduced areas of concern to the command team, particularly that of a possible grounding.
3.34 Had the ship gone to anchor this would have released a number of experienced personnel for firefighting, as well as allowing the command to
49 ACTIONS OF THE SHIP’S COMPANY, THEIR TRAINING AND COMPETENCE concentrate totally on the emergency at hand without the nagging worry of running aground.
Decision to CO2 drench
The Engineer’s first recommendation to CO2 drench (1039)
3.35 At 1039 LCDR Crouch telephoned the bridge and spoke with the CO recommending an immediate CO2 drench. The Engineer gave evidence that he based his recommendation on his own observations in the MMS and his belief that a carbon dioxide (CO2) fixed system drench would be more benign than the carbon monoxide from the smoke. The Engineer was of the view that, at this time, there was still the possibility of a trapped person locating an emergency life support respiratory device (ELSRD) or being in a relatively smoke free area such as the bilges.[E188 and T2836] The CO declined to activate the CO2 drench at this point and directed that a hose team be sent into the MMS to search for missing personnel.[E199, T3150] The Engineer explained:
Now, I…said to the commanding officer, recommended the CO2 drench, I knew what his answer was going to be because that’s the answer that I would have given me if I was the CO and someone had rung me up and that to (me), ‘No, go in and search for them,’ but that’s the advice I had to offer him because that’s what I felt at the time. I didn’t believe I had the time or that the commanding officer would be prepared to spare the time to listen to me explain…the reasoning behind my wanting to CO2 drench and I can’t reiterate enough that I honestly believed the commanding officer’s decision was correct in saying, ‘Do not CO2 drench. Search’ [T2947-48]
The Engineer’s second recommendation to CO2 drench (1057)
3.36 The CO left the bridge and went to HQ1 to discuss the status of the fire with LCDR Crouch. There was still a major concern over the missing personnel, but there was a realisation that the personnel in the MMS were unlikely to be alive. Command priority shifted to saving the ship.[E91, T1527] The CO was also aware that hose team 1 was having difficulty making progress past the upper landing adjacent to the fridge flat due to heat and heavy smoke.[E199, T3151] The Engineer strongly recommended to the CO that the MMS be drenched in 5 minutes time. The CO approved the recommendation and directed LCDR Crouch to continue searching the MMS for a further 5 minutes and then to activate the CO2 drench.[E188, T3151] The CO then returned to the bridge.[E199, T3151]
Command approval to activate the CO2 drench (1101)
3.37 The Engineer sought further command approval from the CO immediately prior to ordering the CO2 drench at 1101. In giving evidence, the CO explained that he had concluded that it would have been impossible for anyone to have survived given the heat and smoke and the fact that 25 minutes had elapsed from the start of the fire. He approved LCDR Crouch’s request to CO2 drench.[E199, T3151] The CO2 drench was activated at 1101.[E155, E91]
50 ACTIONS OF THE SHIP’S COMPANY, THEIR TRAINING AND COMPETENCE
Conclusion
3.38 The Board supports the CO’s command decision to CO2 drench and is of the view that the reasoning behind the decision to activate the system at 1101 was appropriate.
Emergency organisation with Special Sea Dutymen on watch
3.39 When a ship is sailing in confined waters with increased risk of navigational dangers, additional and more skilled members of the ship’s crew are required to be closed up to assist with the safe navigation of the ship. These personnel are termed Special Sea Dutymen (SSD). In the event of an emergency when personnel are not at ‘action stations’, personnel not already on watch will be sent to ‘emergency stations’ to provide the best organisation under the prevailing circumstances, to deal with the emergency.
3.40 At the outbreak of the fire in WESTRALIA, many of the ship’s company were at their special sea duty station. When hands were sent to emergency stations, some personnel who would normally be available for firefighting duties, at one of the two Section Bases, were not available. This will always be the case when special sea dutymen are closed up, and as happened on the day, the I/Cs of the section bases will have to improvise and detail other personnel to fill positions required until other personnel can be released from their special sea duty station.
Use of the Standing Sea Fire Brigade
3.41 The SSFB is a five person emergency response firefighting party. If the SSFB is unable to quickly extinguish a fire with the firefighting appliances, then the ship will go to emergency stations.
3.42 The SSFB was piped to the MCR and assembled in the main switchboard room at 1032 [E91] to await further direction.[T275] The EOOW, POMT Herridge, told the I/C SSFB that he wanted the SSFB in the MMS as a precautionary measure. The Engineer countermanded the order as he wanted to keep as many people out of the MMS as possible.[E31, T275] The Engineer gave evidence that he was worried about ‘slip hazards’ due to the fuel that could be on the decks and ladders; further, the two members in OCCABA would have an additional difficulty descending the ladders into the MMS.[E188, T2835]
3.43 Following the commencement of the fire and as 2 members of the SSFB were dressed in breathing apparatus (BA) the team leader, PO Manderson, asked ‘the engineer’ if he wanted them to enter the engine space. The engineer replied, ‘No’.[T276] PO Manderson reported to HQ1 that the MCR was filling up with smoke.[T276] Again PO Manderson told ‘the engineer’ that he had people on air and asked whether he wanted them to go into the MMS to search for the missing personnel. He was told no by the engineer. PO Manderson stated that LCDR Crouch said, ‘Just wait mate’.[E31, T276]
3.44 Both LCDR Crouch and WO Bottomley had opened the starboard MCR door and the port workshop door and looked into the MMS after the fire had started.[T2835, T26] There were two sailors dressed in intermediate rig in the MCR at the time. Evidence was given that the MMS staff routinely accessed the MCR from the lower and middle plates by the port ladder and the MMS workshop. Given that there were four OCCABA stowed in the MCR, it would have been possible to equip two backup personnel and allow
51 ACTIONS OF THE SHIP’S COMPANY, THEIR TRAINING AND COMPETENCE the two SSFB sailors to make a controlled entry to the MCR. Strict conditions could have been imposed to make a quick assessment of the situation as to the feasibility of remaining in the MMS to search close to the port access door for any MMS staff. The Engineer made the difficult decision not to risk further personnel and the SSFB were not used.
Conclusion
3.45 The SSFB should have been properly trained to make a controlled entry into the MMS to:
a. evaluate the situation;
b. conduct a snatch rescue; and
c. guide personnel to safety.
Recommendation
3.46 DC training should emphasise the importance of conducting search and rescue procedures.
Personnel in Tiller Flat
3.47 AB Noles was alone in the aft steering compartment, which is his special sea duty position. The compartment is just aft of the MMS.[E187] He heard the pipe that the ship was going to emergency stations. AB Noles unsuccessfully tried to contact the bridge on his sound-powered headset, then depressed the button to the bridge but got no response. He went into the passageway leading to the MMS where he saw a huge column of flames going straight to the top of the MMS. AB Noles tried to get firefighting equipment from the passageway to the MMS but was beaten back by the heat and smoke. He was unable to close the door between the MMS and the tiller flat as it was held open by rope lashing. Therefore the MMS and tiller flat can be considered to be one space for the purpose of fighting the fire.[E187] AB Noles evacuated through the emergency escape hatch.
3.48 AB Noles stated that he did not contact the bridge straight away to report that he had evacuated the tiller flat as he was intercepted by LS Bromage and CPO Jenkins who directed him to move firefighting gear to the hose flats. He telephoned the bridge immediately afterwards to report that he was out of the tiller flat.[E187]
Conclusion
3.49 AB Noles should not have been on watch alone in the tiller flat.
3.50 AB Noles should have advised CPO Jenkins that he had to report to the bridge before assisting to shift the firefighting gear.
Effective utilisation of female sailors
3.51 LS Page gave evidence that she took offence when she heard on the Maxon radio, ‘We need a hose team to aft DC. WESTRALIA personnel only and no girls’.
52 ACTIONS OF THE SHIP’S COMPANY, THEIR TRAINING AND COMPETENCE
I don't know who made the comment. This comment annoyed me. I could not understand why it was made, when LS Durnan had done such a good job as a member of a hose team. She went in three or four times, and always gave accurate reports [T2424, T2425]
3.52 When questioned on this matter, LCDR Crouch gave evidence that he made statement to that effect in relation to the extrication of casualties. He was questioned in the following terms:
Is there a reason why you stipulated men, not women?---- ‘Yes, sir. It's - - I've got two children in the Navy: one's a son, and a daughter. And I wouldn't like my daughter to go down and have to do that’.
So, you are thinking perhaps that a male would have been more capable? ---- No, not - - well, that the male would be physically stronger, and I - - you know, to be able to manipulate the people; and I believe the psychological make-up of the female would, you know, pretty - - be more scarring to them.[T2938, T2955]
3.53 In today’s times of equality and with female sailors comprising approximately 25 percent of the crew this would appear not to have been an appropriate call to make. There is no evidence to suggest that the women on board suffered from a greater stress reaction than any of the men. There is also no evidence to indicate that female sailors were not capable of performing any duty as competently as their male counterparts.
Conclusion
3.54 The comment made about ‘no girls’ was well intentioned but inappropriate. Female members of the crew performed their duties as competently as their male counterparts.
EMERGENCY PROCEDURES AND FIREFIGHTING TECHNIQUES USED
Reactions to the fuel leak
3.55 Reactions to the major fuel leak on the port engine could have been improved. The Board heard evidence that the size of the leak was such, that it compared in volume to a garden hose in use.[T1850] WO Bottomley acknowledged that the situation which presented itself in the MMS was very dangerous with a risk of fire and explosion.[T255] Fire hoses laid out in the MMS as a precaution against fire were not charged, nor was foam laid in the bilges as a precaution against fire.[T1487, T1888] Consideration might have been given to evacuating non-essential personnel from the MMS at the time.[T255]
3.56 On finding the leak on the port main engine (PME) located on the bottom plates, PO Hollis had to return to the machinery control room (MCR) to make his report as there was no other method of communicating with the MCR. On entering the MCR, he yelled to the PO Herridge, the Engineering Officer of the Watch (EOOW), that there was a major fuel leak on the PME.[T1821] PO Hollis described the leak as big by normal standards and stated, ‘That’s the largest fuel leak I have ever seen’[T1856, T1857] When questioned on how long the fuel could have been leaking he stated, ‘I don't know when the last set of rounds had been done. It could have been 5 minutes before; it could have been 10, 15 minutes before. I don't know’.[T1888]
53 ACTIONS OF THE SHIP’S COMPANY, THEIR TRAINING AND COMPETENCE
3.57 WO Bottomley stated, ‘When I got near the port engine, I could see that there was a major high pressure fuel leak. There was a vapour cloud above the port engine. It was misty. The vapour cloud was above the port main engine, and going up’.[T23-24] In the course of his evidence, WO Bottomley was asked if the situation was very dangerous he replied, ‘I regarded the fuel mist that was above the port main engine dangerous’.[T3453]
3.58 LCDR Crouch, stated, ‘Someone entered the MCR from the MMS. I do not recall who. I asked him what it was like down there. They asked me what I meant and I asked if there was dieso dripping from the upper reaches, or is there a mist or what. Whoever it was told me that there was a mist’.[T2834] In relation to the Standing Sea Fire Brigade (SSFB), he went on to state, ‘The PO in charge started to lead his people out of the MCR and into the MMS. I pulled him up because I was worried about slip hazards due to the fuel that could be on decks and the mist report had alarmed me’.[T2835]
3.59 Clearly, the senior MMS personnel were concerned about the fuel leak and the mist that had been reported. In addition, it was uncertain how long the fuel had been leaking before being noticed.[T1888] The perceived level of risk can be gauged by the urgency with which personnel were dealing with the problem. A number of people were running around setting up equipment, which suggests the situation was dangerous. However, while the crew may have perceived the risk to be high they did not evaluate the information before them and respond with appropriate tactics.
Charging of hoses laid out in the MMS
3.60 Whether or not the fire hoses that were laid out in the MMS should have been charged is a contentious point. The case against charging the lines is the number of electrical hazards. The other point of view is; why bother to run out lines of hose if they are not going to be charged?
3.61 When asked if the hoses were charged, WO Bottomley stated, ‘we don’t charge fire hoses in the MMS because of the amount of electricity we have there’.[T56] While WO Bottomley was concerned about the electrical hazards, he nevertheless assisted AB Carroll position an AFFF extinguisher for use in the event of fire.[T25] If directed onto electrical equipment, the firefighting stream from a foam extinguisher would also conduct electricity.
3.62 The danger of not charging the lines is that once a fire has started, there is a delay in turning on hydrants, charging the lines, preparing foam supplies and directing the nozzles. This does not mean that fires hoses are charged every time there is an event in the MMS. Whether or not fire hoses are charged should depend on the perceived level of risk the incident poses to personnel and the ship. Accordingly, an appropriate evaluation of the situation is required in order to respondent with a safe and effective course of action.
3.63 As most emergencies are invariably different they each require an evaluation to determine the procedures to be implemented. While standard operating procedures are needed, flexibility to adapt to changing circumstances is required.
3.64 In the case of this incident, the safest procedure would have been to evacuate unnecessary people from the MMS, isolate the electrical equipment, ventilate the MMS, charge the fire hoses and apply foam to the fuel spill and the bilge to prevent the escape of flammable vapours. The implementation of such a strategy would have ensured the
54 ACTIONS OF THE SHIP’S COMPANY, THEIR TRAINING AND COMPETENCE minimum number of people were within the MMS. It would have allowed the immediate use of the hoses in the event of the outbreak of fire.
Conclusion
3.65 There was a major fuel leak on the PME.
a. A thorough evaluation of the situation was not undertaken.
b. Unnecessary personnel should have been withdrawn from the MMS.
c. The situation was hazardous enough to warrant the isolation of electrical equipment and the application of foam onto the fuel and into the bilge.
d. If fire hoses laid out for use are not charged and ready, it is highly likely that they will not be used as there will be no time to charge the hoses once a fire has started.
Recommendation
3.66 DC training should emphasise the requirement for personnel to evaluate and assess the risk associated with any type of emergency scenario so that measured departures from the SOP can be initiated to match the risk.
Escape drills
3.67 Initial firefighting operations were conducted under extremely hazardous conditions.[T1488, T1853] Isolations of the machinery were timely, correct and did much to limit the extent of the fire. Regrettably four members of the ship’s company failed to escape from the compartment as smoke quickly engulfed all within the space; escape drills, particularly using Emergency Life Support Respiratory Devices (ELSRD) had not been regularly practiced. Annual continuation training (ACT) outlined in AFTP 4(F) requires this type of training to be conducted two times a year. WESTRALIA conducted escape training (DC Exercise 18) once in 1996, once in 1997, with no serials being conducted up to 5 May 1998. WO Bottomley stated that the ME Department had not conducted escape training recently and he could not recall when it had last been completed.[T253]
Recommendation
3.68 The importance of conducting escape training using ELSRDs should be re- promulgated to the Fleet. (The Board understands that this recommendation has already been implemented.)
AFFF hand-held extinguishers
3.69 Shortly after the commencement of the fire, PO Hollis and PO Francis started fighting the fire with AFFF extinguishers. Not long after, there appears to have been a secondary fireball within the MMS.
55 ACTIONS OF THE SHIP’S COMPANY, THEIR TRAINING AND COMPETENCE
3.70 As a result of the heat generated by the secondary eruption and an increase in the quantity of smoke that was beginning to envelop him, PO Hollis realised the fire was more than he could handle.[T1807] Due to the size of the fire and the deteriorating conditions, PO Francis also assessed the situation could not be controlled with the equipment on hand.[T1461]
3.71 While quick decisive action is required when a fire is detected, the use of extinguishers to attempt to contain a fire of the size described was courageous but likely to fail. Fighting the fire also delayed the departure of people from the MMS and ultimately put their lives at risk.
Conclusion
3.72 The fire was too large to be contained with extinguishers.
Recommendation
3.73 DC training should emphasise the limitations of portable fire extinguishers as well as their use.
Containment
3.74 With any fire onboard a ship, it is vital to keep the fire within the smallest perimeter possible. Where a fire is within any compartment on a ship, containment is primarily achieved by cooling the outside boundaries of the compartment with water or other cooling medium. Effective boundary cooling will limit the spread of the fire by preventing radiant heat igniting combustibles in compartments above, adjacent and below the compartment containing the fire. On 5 May 1998, HQ1 directed after DC repair base to set up smoke boundaries and conduct boundary cooling.[T497] Containment of the fire and major firefighting efforts to combat it were ultimately successful. The requirement for boundary cooling was well understood although containment of the forward boundary of the fire (bulkhead between MMS and after pump space) was slow to be set up.
Ventilation
3.75 Ventilation control was not well understood. The ship had developed a standing operational procedure (SOP) which involved closing both supply and exhaust ventilation to the MMS in the event of an MMS fire. The result of this was to prevent heat and hot gases from escaping from the affected space, increasing the difficulties faced by personnel directed to re-enter from a high entry point to conduct firefighting.
3.76 As outlined in Ships Standing Orders and in the Ship’s Emergency File, WESTRALIA had developed the practice of closing both supply and exhaust ventilation in the event of a MMS fire.[E68, E112] This is contrary to ABR 5476 - RAN Ship Damage Control Manual which directs that in the event of fire, ventilation should be ‘crashed stopped’, supply intakes should be closed whilst exhaust outlets should be left open with selected exhaust fans restarted (WESTRALIA does not have exhaust fans). The Engineer told the Board that he had agreed with the Navigator that if the ship went to emergency stations due to fire in the MMS, the closing of the funnel flaps and ventilation supply flaps would be an SOP.[T2923] The Engineer did not seem aware of the direction in ABR 5476
56 ACTIONS OF THE SHIP’S COMPANY, THEIR TRAINING AND COMPETENCE and agreed that the SOP the ship had developed would restrict the escape of smoke and gases to atmosphere.[T2924, T2925]
3.77 It is probable that even had a conscious decision been made to close the ventilation supply flaps and leave the funnel flaps open, this would have been unsuccessful because the operating levers for closing each of the flaps were not marked or identified in any way.
Conclusion
3.78 The funnel ventilation exhaust flaps should have remained open until Hose Team 1 had exited the MMS.
Recommendation
3.79 The guidance and directions provided in ABR 5476 should be re- emphasised to command teams.
3.80 DC training should emphasise the importance of ventilation for effective firefighting operations.
3.81 The operating levers for ventilation supply flaps and funnel exhaust flaps should be colour coded and marked for ease of identification
Re-entry
3.82 Re-entry procedures to the MMS after the use of the ship’s CO2 system were incorrect. The ship believed that an entry could be made after 15 minutes had elapsed since the space was drenched with CO2. This belief is incorrect and probably arose out of instructions laid down for umpiring DC exercises in AFTP 4(F). Unless there is an overriding priority, a fire scene should not be re-entered after drenching for as long as possible, thus allowing the scene to cool as much as possible in order to prevent a re-flash.
Recommendation
3.83 Fleet units should be made aware of the correct procedures for re-entry to a fire scene after drenching (The Board is aware that this recommendation has already been actioned)
Hose teams
3.84 Two hose teams were formed, one at Aft DC Section Base and one at Forward DC Section Base. HQ1 directed a third hose team be established and this was done at Forward DC Section Base. Firefighting teams from both forward and after repair bases conducted major firefighting competently and with vigour. With only one exception, all members of the ship’s company who gave evidence, commented most favourably on the DC training that they had received both ashore and afloat. LS Daly, who was a hose team leader, when asked if there was anything which he had been tasked to do on the day for which he had not been adequately trained, responded by saying, ‘No, the training that the
57 ACTIONS OF THE SHIP’S COMPANY, THEIR TRAINING AND COMPETENCE
Navy gives us, and the confidence it gives us is very good. They do a good job’.[T645] CPO Jenkins, the OIC of the Aft DC Section Base, when asked if the RAN might improve its firefighting and damage control training replied, ‘No, I think our training was pretty good. On the day it proved that it works’.[T555]
Conclusion
3.85 RAN hose team training is excellent.
Sustenance of Hose Teams
3.86 During the firefighting effort, hose teams replenished their OCCABA and rested at RASCO. In the early stages, limited water was available from a Jerry can provided by the SMET members, and this was provided to Hose Team 1 after their first entry.[E152, T398, T656-7] However, members of Hose Team 2 were limited to frozen fruit juices on their first exit.[E45, E386] Not surprisingly, they reported that the frozen fruit juices were inadequate for rapid rehydration. Later, fluids and ice were available for all the hose teams at RASCO, with drinking water being made widely available.[T485-6, T774, T778] LS Nix noted that all the available water and cordial in the messes had been used up early in the day.[E383]
3.87 PO Mercer started distributing snack food (chocolate bars etc) at about midday, and these were also provided to hose teams after their later MMS entries.[E378] Supplementation of snack food and drinks was requested from the OSC at 1328, and these were provided shortly after by SYDNEY and ADELAIDE.[E52] LS Nixon delivered this to the Repair Bases. The Supply Officer, LCDR Opie, gave evidence that he was involved in organising action snacks, but only after distribution had started.[T2294] LS Nixon observed that no one had time to organise rations, and he had been involved in a variety of firefighting support activities.[E152]
Conclusion
3.88 There was a delay in providing fluids for the refreshment of hose teams after firefighting. Each of the key catering staff had ancillary duties that diverted them from this task.
Breathing Apparatus Control Procedures
3.89 On the day of the fire there were occasions when breathing apparatus (BA) control procedures should have been more closely followed.[T1347] BA control procedures require that an individual will always enter a hazardous area accompanied by at least one other person. BA wearers work as a team to enable one person to come to the assistance of another should someone get into difficulties.
3.90 Shortly after the outbreak of the fire WO Bottomley went to the MCR on his own to check the fire main pressure and while there he entered the MMS to have a quick look around the area.[T26, T57, T260, T261] His location was some distance from any other personnel.
3.91 He also had no partner when he entered the CO2 room to manually discharge some cylinders that had not been activated [T61]. While PO Herridge was outside the door
58 ACTIONS OF THE SHIP’S COMPANY, THEIR TRAINING AND COMPETENCE
to the CO2 room he was not dressed in OCCABA and therefore could not have come to his assistance if needed [T29, T60, T1630, T1631].
3.92 A person dressed in OCCABA operating on their own in areas where there are known to be toxic gases is dangerous practice. An additional concern with WO Bottomley going to the MCR on his own was that there is no evidence to suggest his name was recorded on an entry control board. Although it is not clear from the evidence, it is probable that LCDR Crouch was the only person who knew that WO Bottomley had reentered the MCR. As LCDR Crouch was extremely busy in HQ1 at the time he may not have noticed WO Bottomley was missing if he had failed to return from the MCR. If WO Bottomley had become trapped or overcome in some way, no rescue would then have been mounted because nobody would have known he was missing.
One out all out procedure
3.93 The Board has heard evidence that other control procedures could have been more closely followed. Evidence indicates that in some instances personnel were not dressed in OCCABA when they should have been and that members of the hose teams did not always leave the MMS together.[T3375, T1336] In another case, the after DC thought someone was missing when in fact the person had either bypassed the board marker or the board marker had not cleared the name. The procedure of ‘one out all out’ limits the opportunity for mistakes to occur.[T1336, T2539]
Conclusions
3.94 Breathing apparatus control procedures were not always followed. Of particular concern was the failure, on some occasions, for personnel in OCCABA to work in pairs.
Recommendations
3.95 DC training should reinforce breathing apparatus procedures concerning working in pairs and correct entry control.
Monitoring of time ‘on air’
3.96 The evidence demonstrates that the hose teams did not spend excessive periods of time within the MMS. Evidence suggests that the air supplies were more rapidly consumed than the accepted norm of 40 litres per minute. This could have been due to the conditions and anxiety of personnel or the cylinders were not appropriately charged for an initial entry. There is no evidence of the latter.
3.97 At the height of the emergency a number of individuals ran low on air, had to pull the D ring and exit the MMS.[T670, T227] At different times, two hose teams exiting the MMS had a hose team member run out of air.[T671] In one case, the team member pulled his D-ring but the air supply failed within about 30 seconds.[T467-468] This would indicate the set had malfunctioned in some manner, as after the D-ring is operated approximately 8-10 minutes of air should remain.[ABR 5476]
59 ACTIONS OF THE SHIP’S COMPANY, THEIR TRAINING AND COMPETENCE
BA Control Boards
3.98 Evidence suggests the board markers followed the correct procedures. They appear to have calculated the BA set durations from the endurance table on the control board. The BA control board operators dispatched relief crews as required but in cases where the OCCABA air was used more quickly than anticipated the teams in some cases left the space before another team had entered.[T670]
3.99 The RAN Damage Control Manual (ABR 5476 Vol 1) states ‘personnel wearing beards experience up to 10 percent reduction in the wear time’ and yet when witnesses were questioned they did not seem aware of this fact.[T326, T562] While this matter was not raised with any board markers, it is unlikely that they would have made any calculations to reduce the wearing time of those people who had beards.
Minimum breathing apparatus cylinder pressure
3.100 During questioning, a number of people giving evidence stated that during firefighting operations they did not monitor the OCCABA cylinder air pressure.[T484, T697, T699, T778-779] This is not good practice because consumption can vary depending on the conditions being encountered and the anxiety level of the individuals wearing OCCABA.
3.101 The RAN BA control procedures contained in ABR5476 volume 1 chapter 43 clearly indicate the minimum cylinder pressure of 100 bar cylinder pressure must be in an OCCABA for a re-entry. Evidence suggests that at least one re-entry occurred where the pressure was less than 100 bar. An entry into a large compartment like WESTRALIA’s MMS with the minimal cylinder pressure was poor practice.[T2050]
Conclusions
3.102 Not all personnel wearing OCCABA monitored their pressure gauges.
Recommendation
3.103 DC training should emphasise the issue of varying air consumption rates and the need for personnel in OCCABA to frequently to monitor air pressure.
Breathing Apparatus and Beards
3.104 Breathing apparatus (BA) procedures are instituted to ensure the safety and effective control of personnel at emergencies. However, for procedures to work during emergencies it requires people to willingly comply. The evidence presented to the Board suggests the hose teams were correctly dressed in OCCABA however there were a number of areas where improvement could be made.
3.105 Some sailors with beards used OCCABA on the 5 May 1998. This is despite the warning given in ABR 5476, volume 1, chapter 43 as to the dangers. Chapter 23 of ABR 5476 also makes this comment.
NOTE
60 ACTIONS OF THE SHIP’S COMPANY, THEIR TRAINING AND COMPETENCE
Personnel wearing beards experience up to 10 percent reduction in the wear time because of the reduced efficiency of the face seal. Personnel with beards should not, wherever practicable in peacetime, be allocated to duties, which require them to wear breathing apparatus. In wartime all beards would have to be removed as part of the preparations for war.
3.106 The issue of sailors having beards and wearing OCCABA is relevant here as the Board received evidence the testing of an OCCABA set revealed that its facemask did not maintain a positive pressure.[E429] If the OCCABA is operating correctly and maintaining a positive pressure within the facemask air can leak out around the beard breaking the seal and cause a reduction in the duration of the set. However the failure to achieve a seal can lead to other more serious problems.
3.107 AS/NZS 1715:1994 states, ‘The sealing problem is especially critical when close fitting face pieces are used. The reduction in pressure developed in the breathing zone of these respirators during inhalation may lead to leakage of contaminant into the face piece where there is a poor seal. Therefore, individuals who have stubble (even a few days’ growth will cause excessive leakage of contaminant), a moustache, sideburns, or beard which passes between the skin and the sealing surface must not wear a respirator which requires a facial seal’.
3.108 Australian Standard 1715-1994 – Appendix E deals with the subject of facial hair and respirators in more detail. Part E2 of the standard states; ‘Bearded persons cannot expect to achieve adequate respiratory protection when wearing a full face piece respirator or a half face piece respirator. Accordingly, no one who requires respiratory protection shall attempt to wear either a full or a half face piece respirator over a beard’. Part E5 makes the following comment, ‘Stubble growth depending on its length and stiffness, interferes to some degree with the proper sealing of a face piece and it is necessary that male wearers of respirators shave daily’.
Conclusions
3.109 On the day of the fire bearded members of the ship’s company wore breathing apparatus. Personnel did not have a thorough understanding of how beards could reduce the wearing time of an OCCABA. Accordingly, no allowance was made for personnel with beards when calculating OCCABA duration.
3.110 The practice of allowing bearded personnel to use breathing apparatus does not comply with AS/NZS1715-1994.
Recommendations
3.111 DC training should include instruction on the effect of beards on OCCABA duration and on what adjustments are to made by board markers to compensate for air loss.
3.112 Navy should review its policy regarding personnel with beards wearing OCCABA in light of AS/NZS1715-1994 and occupational health and safety requirements.
61 ACTIONS OF THE SHIP’S COMPANY, THEIR TRAINING AND COMPETENCE
Stage 2 Breathing Apparatus Entry Control Procedures
3.113 During major emergencies such as the fire in WESTRALIA, there can be confusion and the failure of best practice especially in relation to breathing apparatus procedures. With many issues arising simultaneously, those controlling the response to the incident can be overwhelmed with the quantity of information and fail to recognize the dangers. To limit the opportunity of this occurring it is imperative that the span of control is never too great. In relation to breathing apparatus control procedures, this involves the implementation of ‘Stage 2 Entry Control Procedures’ as practiced by civilian fire brigades.
3.114 Stage 2 is an extension of the normal breathing apparatus control procedures and should be implemented when:
a. there is more than entry point to a fire or other emergency;
b. where more than two teams are working simultaneously; and
c. the circumstances require the undivided attention of at least one person whose sole task is to arrange relief crews and cylinders.
3.115 To coordinate these activities and ensure the resources were in place at the right time required the attention of someone to specifically take control of the BA situation.
3.116 A person with the skills and authority must be designated the task of establishing and maintaining an effective stage 2 procedure. This person by undertaking a variety of tasks in relation to organising BA allows the scene leader to concentrate on the operational matters. The stage 2 controller establishes a BA main control point at the most convenient site for easy access and communications with all board markers, scene leaders and the incident commander. His/her responsibilities include:
a. Establishing and recording the availability of OCCABA, associated equipment and personnel resources at the incident.
b. Establishing effective communication with each entry control point (board marker location).
c. Having available adequate numbers of personnel dressed in OCCABA to act as reliefs.
d. Assembling reliefs at each entry control point in sufficient time to enable the entry control officer (board marker) to carry out their responsibilities.
e. Having at least two additional personnel standing by for emergency purposes.
f. Arranging for sufficient fully charged cylinders, or any other requirements necessary to prepare OCCABA for use. This could include operation of Bauer compressors and the repair of faulty OCCABA.
g. Having OCCABA sets ready for personnel to use.
h. Assembling the ship resources.
62 ACTIONS OF THE SHIP’S COMPANY, THEIR TRAINING AND COMPETENCE
3.117 To record this information many fire brigades around the world use a stage 2 Breathing Apparatus Control Board. These boards are more extensive than the normal entry control board and provide capacity to summarise such facts as the number of sets in use at each control point, the reliefs required or sent and details of emergency standby personnel and OCCABA sets.
Conclusion
3.118 Stage 2 BA control procedures would assist with the management and coordination of activities in an emergency.
Recommendation
3.119 Stage 2 BA control procedures should be considered for introduction into the Navy.
International Shore Connection
3.120 As the fire in the MMS had rendered the other fire pumps unserviceable the emergency fire pump was the only source providing the water to the fire main. At different times there were concerns that the pump had insufficient capacity or that it could fail.[T29, T145]
3.121 When the tug WAMBIRI came along side there was discussion between the vessels as to whether the tug’s fire pump could connect into WESTRALIA’s fire main. The idea was rejected by Navy personnel who thought the fire hoses and couplings were different and that WAMBIRI could not connect to WESTRALIA.[T3154]
3.122 When personnel were questioned as to WESTRALIA’s international shore connection there was an obvious lack of knowledge on the subject. As the connection is a fundamental piece of equipment that is required of all ships under Safety of Life at Sea (SOLAS) regulations, this lack of knowledge was a surprise. The ability to use WAMBIRI’s pump would have been vital if the ships emergency pump had failed. That a number of officers and the crew were unaware of the existence of the connection or how it works, suggests that very little training was carried out in this area.[T3154,T2954]
Conclusion
3.123 Ship’s personnel knew little, if anything, about the international shore connection.
Recommendations
3.124 Naval personnel should be trained in the use of the international shore connection.
3.125 DC training should re-emphasise the importance of conducting firefighting training serials which involve civilian fire brigades.
63 ACTIONS OF THE SHIP’S COMPANY, THEIR TRAINING AND COMPETENCE
Fixed CO2 Fire Protection System – Procedures for use
3.126 The fire control team followed the procedures as detailed in the WESTRALIA emergency file. This initially involved the activation of the MMS fixed CO2 fire suppression system and then the re-entry of hose teams into the space to extinguish any remaining fire. The procedure states ‘A minimum of 15 minutes must elapse after the drench before re-entry can be made’.[E112] Hose team 2 entered 18 minutes after the last of the CO2 cylinders were activated.[E129]
3.127 Carbon dioxide is effective as an extinguishing agent primarily because it reduces the oxygen content of the atmosphere so that it can no longer support combustion. Because the CO2 discharges at a low temperature and the gas has a density of one and one- half times that of air it has the ability to replace air above burning surfaces and maintain a smothering atmosphere. The resulting mixture of CO2 and air will be denser than the ambient atmosphere. However the cooling capacity of CO2 is minimal compared to an equal weight of water. These factors were not known by the ship’s company, and as a result they did not make the appropriate operational decisions on when to use the gas, how long to wait after a drench before re-entry and how to clear the space of the gas after the fire.
3.128 The injection of CO2 into a sealed space will extinguish a flammable fuel fire almost immediately but has no cooling effect making, the chances of re-ignition high if oxygen is reintroduced. The sealed space will cool quite slowly after the fire is extinguished.
3.129 Any re-entry into a CO2 saturated atmosphere must be undertaken with caution. Although there are no hard and fast rules concerning re-entry, many factors must be taken into consideration. How hot was the fire? Has the metal cooled sufficiently to prevent re- ignition if oxygen is reintroduced into the space? Are there any over-riding operational reasons to attempt a re-entry – navigational hazard or weather conditions? The decision to re-enter should be a conscious judgment based on the information available and the contingencies of the situation.
3.130 The US Marine Training Advisory Board [E458] recommends that re-entry should not be attempted for at least one hour, to allow the heat to dissipate. Then the re- entry is closely controlled and if excessive heat remains the space should be resealed. Other marine firefighting centres recommend, depending upon the operational situation, a period of at least two hours, or ‘overnight’ where possible, while carefully monitoring the temperature in the space.
3.131 The US Marine Training Advisory Board recommends that any initial entry should be made from the highest point as this limits the disturbance of the CO2 gas which as it is heavier than air settles in the lower parts to the MMS. However a high-level entry forces the hose teams to encounter the highest temperatures and negotiate a number of ladders. It also makes the rescue or removal of casualties difficult.
3.132 WESTRALIA’s emergency file provided LCDR Crouch with no information on the properties of CO2 gas and incorrect information as to the time that should elapse following a drench before hose teams are committed.[E112] In addition, ABR 5476 Vol 1 – the RAN Damage Control Manual - does not provide information to incident managers of the properties and extinguishing characteristics of the gas. As a consequence of lack of knowledge and an incorrect standard operating procedure, the command team did not wait a reasonable period of time for the MMS to cool before the hose teams re-entered.
64 ACTIONS OF THE SHIP’S COMPANY, THEIR TRAINING AND COMPETENCE
3.133 What is clear from the evidence given and the action of the command team is that nobody had a thorough knowledge of the properties of CO2. As a consequence the decision to send hose teams into the space was premature. This lack of knowledge endangered the hose teams and could have made the fire worse.
Conclusions
3.134 ABR 5476 provides insufficient information on the properties and extinguishing characteristics of CO2.
3.135 The command team had limited knowledge of the properties of CO2 and its hazards. As a result the decision to send in the hose teams after the drench to fight the fire, was premature.
Recommendation
3.136 ABR 5476 should be amended to include a section on the properties of CO2 and the hazards when it is used as an extinguishing agent.
HMAS WESTRALIA Emergency File
3.137 WESTRALIAs emergency file contains instructions in the event of a fire and shows hose layouts to be adopted for the various spaces.[E112] One of the purposes of the file was to assist the OOD in an emergency.
3.138 As has been discussed in other parts of this report, the emergency file in WESTRALIA did not always provide the appropriate information for the command team. The file details incorrect advice on when hose teams can enter an area after a CO2 drench and provides the following comment in reference to the emergency fire pump:
A new diesel emergency fire pump has just been installed but very little is known about it at present.[E112]
3.139 Noone appears to have a clear responsibility to write the material, check that standard operating procedures (SOP) actually work and be accountable to keep the file up to date. The Board is concerned that nobody identified there was a problem with the file until after the fire. Whoever is allocated the task to write the emergency file must have significant damage control and firefighting expertise.
3.140 The nominated MMS standard operating procedures for fighting a fire is very one dimensional and alternative approaches are not identified. If the ship has only the one plan to combat a fire and this fails, what do the incident commanders do?
3.141 The SOP was to enter through the fridge flat and that was always the method practiced. There were other alternatives such as entering through the tiller flat. The over reliance on SOPs and the limiting effect it has on lateral thinking is best illustrated by the problems encountered when trying to remove the bodies from the MMS. The SOP and all the training involved bringing the body to the top plate below the fridge flat landing and using the electric winch to remove the body. As there was no electricity to this area after the fire there was a delay in body extrication while feasible alternatives were devised, tried and implemented [T700].
65 ACTIONS OF THE SHIP’S COMPANY, THEIR TRAINING AND COMPETENCE
Sea Training Group
3.142 At regular intervals the RAN Sea Training Group boards the ship to check the performance of the ship’s company in a number of areas. As this group are the RAN experts they should check the emergency file, assess the SOPs and identify any problems.
Conclusions
3.143 The ship’s emergency file provided incomplete and incorrect advice to any incident commander.
3.144 The SOPs were followed without any lateral thinking.
3.145 The Sea Training Group did not identify that the ship’s emergency file was inadequate.
Recommendations
3.146 The WESTRALIA emergency file should be re-written.
3.147 The Sea Training Group should check routinely validity of SOPs in emergency files.
Ship Knowledge
3.148 It became apparent to the Board that many officers and senior sailors did not have an adequate knowledge of their ship and its systems, particularly emergency arrangements.
3.149 The Special Sea Dutymen (SSD) OOW, when asked how much knowledge she had of the CO2 system replied, ‘not a great deal compared to what the engineers would have’.[T1169] When asked if the ship’s emergency power arrangements would provide power to the VHF radio, she responded by saying ‘I’m not sure of that’.[T1169]
3.150 One of the ship’s DC instructors, when presented with a scenario where a SSFB attacking a fire is beaten back by heat and flames, was asked what the SSFB does then replied, ‘I’m not sure’.[T2276] Additionally, when questioned on tugs connecting their salt water service to the ship for firemain boosting, the arrangement of the ships ventilation/funnel flaps and the ships CO2 system, he was unable to demonstrate a competent knowledge of these arrangements.[T2283-2284] Likewise, an engineering officer, when questioned on the ship’s emergency fire pump, was unable to convince the Board that he had a sound knowledge of this equipment.[T1923]
3.151 A Senior Sailor, when questioned about the ship’s emergency pump, emergency generator and the international shore connection, demonstrated little or no knowledge of these equipments.[T2417-2418]
Conclusion
3.152 In general officers and senior sailors displayed a poor knowledge of the ship, particularly of the emergency systems.
66 ACTIONS OF THE SHIP’S COMPANY, THEIR TRAINING AND COMPETENCE
Recommendation
3.153 OOW’s and OOD’s should be trained to ensure competence in ships systems and their emergency arrangements. This competence should be fully demonstrated prior to the award of the appropriate certificate. Where qualified personnel join a ship which has different systems from the ship in which their certificate was obtained, these personnel should understudy current ships staff until competent to undertake duty alone.
TRAINING
Firefighting Training
3.154 Prior to joining a sea-going vessel, it is RAN policy that all crew members are required to have completed firefighting training. Firefighting training is a component of the RAN’s basic Damage Control (DC) course. Firefighting training prepares naval personnel to take appropriate precautions to prevent fire, to raise the alarm on discovery of a fire and to take the appropriate first aid actions to extinguish the fire or to prevent it spreading. Firefighting training also provides every sailor and officer with the knowledge and experience to be a member of a hose team which will be used to combat a major fire. Firefighting training is constantly updated to reflect latest equipment and techniques. If naval personnel have been ashore for more than 3 years, they are required to update their skills and experience by completing a DC requalification course before joining a ship. Advanced firefighting training is also provided to train those naval personnel who will lead the various firefighting teams.
3.155 Ten percent of the ship’s company were not in date for damage control training. Two members had not undertaken the standard DC course whilst others were either out of date for requalification or had not undertaken training commensurate with their rank or billet.[E431]
Pre Joining Training
3.156 Evidence given by WO Bottomley, indicated that not all Marine Engineering (ME) Department personnel had undertaken or completed the appropriate Pre-Joining Training (PJT).[T253] LCDR Triffitt, confirmed that a number of other personnel may also not have completed the appropriate PJT; he further indicated that MHQ was concerned about this matter and had directed all ships to forward a ‘return’ on the number of personnel who had not completed the PJT required.[T160-161] WESTRALIA Minute 72/23/2 dated March 1998 indicates that approximately 25% of the crew had not completed the required billet pre-requisite training.[E233] Of significance, this minute indicates that several officers including: the Executive Officer, the Marine Engineering Officer (Engineer), and the Liquid Cargo Officer (LCO), had not completed the Tanker Safety Course.
Recommendations
3.157 The requirement for personnel to have received the appropriate PJT prior to joining a ship should be further emphasised.
67 ACTIONS OF THE SHIP’S COMPANY, THEIR TRAINING AND COMPETENCE
3.158 Consideration should be given to ship’s raising a Priority 1 URDEF (which would prevent the ship from sailing) if key personnel, or a significant number of the ship’s company, join without the proper qualifications.
Annual Continuation Training
3.159 The ship had progressed Annual Continuation Training (ACT) satisfactorily. The following paragraphs, however, address some deficiencies that became apparent to the Board.
3.160 Damage control exercise 22 (Command Team DC Training) plays an important part in assisting those who have to make command decisions in times of emergency to have a complete understanding of their ship and its equipment, particularly emergency systems. This had not been conducted since June 1997 and the ship had failed to achieve at least 50% of the training requirement for this type of exercise over the previous two years.[E94, E95] In his evidence to the Board, LCDR Crouch could not recall when the ship had last conducted this exercise.[T2922]
3.161 The ship had not exercised dealing with a MMS fire in harbour (damage control exercise 27) since it undertook its Light Off Examination (LOE) in June 1996.[E95]
3.162 WESTRALIA conducted damage control exercise 100 (MMS fire at sea) during a shakedown period on 30 April 1998. From the evidence given to the Board by the ships senior NBCD instructor, WO Baker, it may be inferred that the planning of this exercise and its execution were not as thorough as it could have been.[T2390-T2398] For example, the planned exercise did not encompass casualty management or the operation of CO2 drenching. It is probable that there were insufficient umpires on the day to effectively run the exercise and provide a comprehensive de-brief on completion.
Recommendation
3.163 The NBCD Instructor’s course should be examined to ensure appropriate modules exist, which encompass ACT requirements and exercise planning /execution.
Fast Cruise
3.164 A ‘fast cruise’ is an exercise which is designed to allow a ship to check its organisation and emergency procedures after a lengthy period in harbour. It provides the opportunity for new crew members to familiarise themselves with their ship and its routines as well as highlighting any deficiencies in the ship’s organisation before it proceeds to sea.
3.165 WESTRALIA considered conducting a fast cruise prior to sailing on 29 April 1998 but it was not undertaken.[T161] Currently AFTP 4(F) (Fleet Exercise Instructions) only requires ships to conduct a staff covered fast cruise on completion of a refit period. This is in contrast to AFTP 29 (Submarine Exercise Instructions) which requires submarines to conduct a fast cruise after refit, IMAV and Assisted Maintenance Period (AMP). Noting that it is probable during periods of IMAV and AMP, that a number of personnel will post in/out and that job rotations may well take place, it would seem
68 ACTIONS OF THE SHIP’S COMPANY, THEIR TRAINING AND COMPETENCE sensible for ships to conduct their own fast cruise at the completion of these periods and prior to sailing for the first time.
Recommendation
3.166 RAN ships should be directed to conduct a fast cruise, prior to sailing, after periods of IMAV or AMPs when there has been a change in key personnel or a significant proportion of the crew .
Major Fire/Engine Room Fire at Sea Exercise [DC 101/100]
3.167 The ship has achieved or exceeded its ACT for these types of exercises, however it had not practiced the scenario of receiving outside assistance to help deal with such emergencies.[T171-172] When receiving outside assistance, a ship must have an organisation for receiving, briefing and deploying those resources to meet the commands priorities. To enable the commanding officer to fully utilise these resources, he must be made aware of what resources have joined his ship and the estimated time of arrival of other resources expected. This aspect needs to be reviewed and appropriate instructions compiled and placed in Ships Standing Orders.
Recommendation
3.168 Fleet units should document and practice, receiving assistance from external agencies.
Sea Training Group Covered Training
3.169 The last Sea Training Group (STG) covered training was conducted prior to the ship’s Southern Ocean deployment in October 1997.[T167] Damage control aspects were assessed as standard achieved minus. This training did not appear to include a major fire at sea exercise.
Additional Training Required
Professional Knowledge
3.170 The ‘spill pulse’ phenomenon (discussed later in this report) which led to metal fatigue in the steel braid of the flexible fuel lines was not known to any of the ship’s engineering staff, nor, the Board suspects, was it known to the majority of RAN engineering personnel. This phenomenon was known to other organisations and was described in various literature from time to time.
3.171 Although this is a highly specialised example, the Board believes that the RAN should have the capability to vet professional journals and other literature and where appropriate distribute information contained in such documents to the lowest level deemed warranted. This service should not be confined to engineering but should cover all professional fields.
69 ACTIONS OF THE SHIP’S COMPANY, THEIR TRAINING AND COMPETENCE
Recommendation
3.172 The RAN should investigate the distribution of professional articles, from appropriate journals and literature, to the Naval Community.
Requirements of Lloyds Classification
3.173 Current RAN directives require WESTRALIA to be ‘kept in class’ by Lloyds Register Classification Society. This requirement and what it entails was poorly understood by the ships officers and others associated with the ship. Training in this subject appears to be non-existent. The Board is of the opinion that if some RAN vessels are required to be ‘kept in class’ then training on this requirement should be given to ships officers and staff from the Class Logistics Office.
Recommendation
3.174 Appropriate training should be provided, to enable selected RAN personnel to understand and implement requirements of ‘classification societies’.
70 SECTION 4. MEDICAL RESPONSE TO THE INCIDENT
4.1 The fire in HMAS WESTRALIA resulted in 10 documented casualties- four deaths and six injuries. Three of the injured occurred within the first few minutes of the outbreak of the fire. Within about 20 minutes the four eventual fatalities were listed as missing. In this context, the ship’s Medical Department, was faced with a task beyond their capability to deal with unassisted. On this basis, the incident can be regarded as a mass casualty incident.
4.2 The four personnel who died were all located within the MMS when the fire started. Five other personnel in the MMS at the outbreak of the fire successfully escaped. Three of these suffered from smoke inhalation, two also having minor burns. There were three subsequent casualties amongst those involved in fighting the fire, two with smoke inhalation, (one of whom also suffered an acute stress reaction), and one with an acute stress reaction.
4.3 An indeterminate number of personnel suffered the effects of stress associated with the incident and the loss of shipmates. These personnel were initially managed on board, and the Critical Incident Stress Management (CISM) process was employed to provide support. Details of CISM are included in Section 6.
SHIP’S EMERGENCY MEDICAL ORGANISATION
4.4 A ship’s emergency medical organisation is designed to most effectively utilise the available medical resources during a mass casualty incident. It ensures that the limited resources available are managed in such a way that casualties are afforded the necessary treatment to save life during the early stages of any incident, and are subsequently managed and evacuated with the aim of minimising death and long term morbidity. Important principles involved in achieving this aim include the use of triage to prioritise casualties for care, and effective coordination of resources (importantly personnel and their skills).
4.5 On 5 May 98, HMAS WESTRALIA’s emergency medical organisation consisted of eight personnel - PO Plant, three personnel in the Forward First Aid Post (FAP), and four in the After First Aid Post/Emergency Operating Space.[E347] Six of the seven personnel in the FAPs were Ship’s Medical Emergency Team (SMET) members, the seventh being AB Moffatt, loaned from HMAS STIRLING the day prior to sailing. SMET personnel are non-medical members of the ship’s company, usually drawn from the Supply Department, who are provided advanced first aid and casualty management training to allow them to assist medical staff in the provision of medical care to casualties, including monitoring their condition and identifying clinical deterioration. The ship did not carry a MO, and PO Plant was responsible for managing all aspects of the medical response.
4.6 In the course of the incident, the emergency medical organisation was supplemented with medical staff from STIRLING and ships in company. The expanded team consisted of two medical officers, seven medical sailors, and six SMET personnel. A number of other non-medical personnel also undertook medically related activities. Key personnel involved were: POMED SJ Plant Senior Medical Sailor, WESTRALIA; LEUT AJ Eggerling, RAN Medical Officer, SUCCESS;
71 MEDICAL RESPONSE TO THE INCIDENT
LEUT MJ STONE, RAN Medical Officer, STIRLING; WOMED SA SMITH Fleet Warrant Officer Medical; and LSWTR AA Page I/C Ship’s Medical Emergency Teams, WESTRALIA.
INITIAL MEDICAL RESPONSE
4.7 Medical Department administration and management is governed by Ship’s Standing Orders, Chapter 9.[E468] Detail on responses to ship board emergencies in SSOs is limited. Four Standard Operating Procedures (SOPs) were tendered in evidence governing the actions of the medical organisation in emergencies.[E313-5] These SOPs covered Toxic Hazard and Casualty Incidents as well as Action Stations and Emergency Stations. A Duty SMET of three personnel is maintained each day at sea to attend to such incidents.[T1206, T1211, E313, E418]
4.8 The SOP for Emergency Stations requires that SMET members close up at their designated FAPs – the Junior Sailors’ Café and RASCO. The Casualty SOP requires the Duty SMET and medical sailor to attend the scene for initial evaluation. No SOP for SSFB incidents exists, and PO Plant gave evidence that normal practice is for there to be no medical response unless a casualty occurs. Both he and the SMET members are on standby, listening for further pipes.[T1212] PO Plant gave evidence that in the planning of medical responses to emergencies he was concerned to ensure medical personnel were not placed in danger.[T1216]
4.9 SSFB practice is for the I/C to be positioned so as to be able to coordinate the activities from a position of safety, and it seems reasonable for the Duty SMET to muster in the vicinity of the I/C SSFB. The Duty SMET should consist of two personnel, one from each FAP, and, should casualties occur, they will be in a position to render initial care, and arrange for evacuation further from the scene. Should the ship be sent to Emergency Stations as a consequence of the incident, the FAP that is closest to the scene and therefore likely to deal with casualties will be able to be supplemented by the Duty SMET.
4.10 PO Plant stated that he was concerned by this pipe as SMET personnel should be directed by him.[T1216] In this incident, casualties occurred coincident with the decision to send the ship to emergency stations. The pipe ‘SMET Team muster MCR’ was interpreted as a direction for all SMET members to muster. PO Plant stated that he was concerned by this pipe as SMET activities should be managed by him.
4.11 There would have been an advantage in the Duty SMET mustering in a suitable location in conjunction with SSFB at the time of the initial fuel leak occurring. Two SMET members would have been available to provide necessary assistance and first aid to the casualties. Once the ship went to Emergency Stations, the PO would have been able to direct his SMET resources from HQ1. This might have proved important had casualties evacuated from other entries to the MMS resulting in them being grouped elsewhere.
Conclusion
4.12 The initial medical response proved to be appropriate. Improved flexibility would have been achieved had the Duty SMET been mustered in conjunction with the SSFB from the outset.
72 MEDICAL RESPONSE TO THE INCIDENT
Recommendation
4.13 Medical SOPs should reflect a requirement for the Duty SMET to muster with SSFB on all occasions so as to be in a position to render initial first aid if casualties occur during an incident. If a ship then goes to Emergency Stations, non- Duty SMET members should muster at their designated First Aid Post.
REPORTING OF MISSING PERSONNEL
4.14 LCDR Crouch told the Board that he was not entirely clear how the numbers and names of the missing and injured were collated by HQ1, observing that information on the casualty status (missing and injured) came into HQ1 from a variety of sources.[T2963, T3179]
4.15 On his arrival in HQ1, LCDR Crouch believed that one person (PO Smith) had been trapped in the MMS. He began making pipes for him.[T2836, T2963] A provisional list of personnel missing was made and written on the perspex table top in HQ1.[E127B, E129] The information was compiled, firstly from personnel who had not mustered at their Emergency Stations, and secondly from the MCR Peg Board.[T2317, T2837] There is no evidence of any systematic checking off of names as they were accounted for. This is consistent with PO Edmonds evidence that HQ1 took a ‘mental head count’ of others as they were subsequently reported in from the Bridge and Repair Bases.[T2326]
4.16 LCDR Jones, the Executive Officer, went to find out from the injured whether they had any more information on those left in the MMS.[T1525, T1545, T1565] PO Francis wrote in his notebook the names of those personnel who he believed were in the MMS at the time the fire commenced.[E109, T1491-2] LCDR Jones took the notebook to HQ1 to assist in the confirmation of the names.[T1525, T1565]
4.17 The names and suspected last locations of MIDN Pelly, PO Smith, LS Meek and AB Carroll were entered in the HQ1 narrative prior to the CO2 drench.[T1912, T1913, E18] A number of pipes were made for these personnel, both before and after the first CO2 drench.[T497, T1938, T1939] As a final check, LCDR Crouch instructed WO Bottomley to return to the MCR to read the firemain pressure, but with the implicit direction, understood by both, to check that there were no casualties who had escaped into the MCR.[T2837, T57] He returned to advise he had found no one.[T2837]
4.18 The evidence is unclear as to exactly when and in what order the missing personnel were notified to command. CMDR Dietrich was informed of the first missing person (PO Smith) by LCDR Crouch through the internal telephone system, coincident with the latter’s first recommendation that a CO2 drench be activated.[T3150, T2836] This is consistent with the first message regarding the incident, sent at 1058, which advised of three injured and PO Smith missing.[E48, T3150, T3165]
4.19 There was conflict in the evidence as to when the fourth person was confirmed missing. LEUT Gishubl in HQ1 gave evidence that four personnel were known to be missing before the CO2 drench,[T521] and CMDR Dietrich stated he was also aware sometime between the first SITREP signal being sent (at 1058 [E48]) and the CO2 drench that four personnel were missing, and of their names, stating that MIDN Pelly’s name was the last to be added (although her name was in one of the pipes recorded on the bridge tape).[T3150, T3179, E91] LEUT Shawcross stated that the fact that there was a fourth
73 MEDICAL RESPONSE TO THE INCIDENT missing person was not known until about an hour and a half after the incident occurred.[T1927] LEUT Shawcross’s evidence is consistent with the second message, sent at 1117, which reported the CO2 drench had been activated and only three personnel missing,[E48] and an entry in the OOW Notebook that only three personnel were missing at 1124.[E16A]
4.20 It seems likely that key personnel, including the CO and Engineer, were aware of all four missing personnel at the time of the CO2 drench, however this information was not widely appreciated, and led to at least one inaccurate message being sent to external authorities.
Conclusion
4.21 The initial identification of missing personnel was achieved as quickly as practicable under the circumstances, but was completed in HQ1 in a non-systematic way. The initial notification to external authorities was inaccurate.
INITIAL MANAGEMENT AND REPORTING OF THE FATALITIES
4.22 The first fatality, LS Meek, was found by the second hose team to enter the MMS after the CO2 drench. He was found on the top plates and, after the absence of a pulse was established by the I/C, was moved to the base of the fridge flat ladder.[E50A] He was attended by a number of personnel, who put him in a Paraguard stretcher and placed an ELSRD on him.[T2008, E159, E172, E101A, E41] There appeared to be some initial uncertainty amongst some personnel as to whether he was, in fact, deceased.[E101A, T2415]
4.23 The report of LS Meek’s discovery was recorded in HQ1 (where the location was erroneously noted as middle plates) at 1205.[E18, E129] LEUT Ewington, at Aft DC, stated that the report included the statement that LS Meek did not have a pulse.[E46] Evidence was given by LEUT Gishubl that in HQ1 he heard that the casualty was moving or alive [E38A] and by LEUT Shawcross that he had a pulse.[T1940] Neither officer could recall specifically who the report came from, but LEUT Shawcross stated that it came from Aft DC.[T1940] About 15 minutes later, HQ1 heard by telephone that there was no pulse and the casualty was dead.[E38A, E126, T1914] The source of these reports has not been able to be determined, however it is clear that there was initial uncertainty in HQ1 as to the whether the casualty was alive or dead.
4.24 In response to this uncertainty PO Plant, LEUT Eggerling, and AB Moffatt relocated to port side Tank Deck immediately forward of the superstructure and set up a resuscitation bay. Equipment available included a blanket, Thomas Pack, intravenous fluids [E57A] and defibrillator.[E150]
4.25 The other three fatalities were discovered by Hose Team 1 on the middle plates. On each occasion, the Team I/C, LS Daly, confirmed that there was no pulse, feeling through his antiflash gloves, and on two occasions provided reports personally to personnel at the fridge flat door. These reports were not accurately recorded anywhere. Aft DC recorded ‘casualty middle plates No 2 Hose Team’.[E14, T716-7] The timing of this report is consistent with the discoveries of Hose Team 1, which exited the MMS at 1234. LS Daly made two reports to someone at the fridge flat. His evidence on the latter report is consistent with AB Munday’s evidence that, while she was attending to LS Meek after he had been placed in the Paraguard, someone told her of ‘three casualties in the
74 MEDICAL RESPONSE TO THE INCIDENT middle plates port side’.[T353] It seems likely that the 1229 casualty entry on the Aft DC incident board refers to the latter report of LS Daly. This discovery was not recorded in HQ1 at that time.
4.26 Reports of a further two fatalities being found are recorded (as ‘second’ and ‘third’) in HQ1 at 1240 and 1244, but these times are inconsistent with the known period that hose team 1 was in the MMS.[E129] LEUT Shawcross stated that these reports came from Aft DC.[T1940, E18] Evidence was given that, when Hose Team 2 came to the previously discovered bodies on the middle plates, at least one report was passed to someone in the fridge flat.[E187, E386] The records in HQ1 of the discovery of the second and third fatalities are inaccurate and almost certainly relate to these later reports.
Conclusions
4.27 The source of the inaccurate information that the first casualty found in the MMS may have been alive has not been established. It may have derived from the request for an ELSRD, or the transfer of comments or concerns expressed by those attending to LS Meek. There appears to have been a failure to pass clear casualty information over the normal communications circuits.
4.28 The initial assessment of the casualties by members of the hose teams was appropriate, but was hampered by antiflash gloves, which should have been taken off.
4.29 The placing of LS Meek in a Paraguard stretcher was uneccessary. If extrication was required to allow attempts at resuscitation it should have been done by the quickest available means, and if resuscitation was not to be attempted the evolution was unnecessary.
4.30 The establishment of a casualty reception bay following the receipt of information that one of the casualties in the MMS may have been alive was appropriate. The bay was adequately equipped under the circumstances.
Recommendations
4.31 The importance of clear and concise casualty information being passed over normal communications circuits should be emphasised in damage control training.
4.32 The importance of making the key decision as to whether or not casualties discovered at an incident scene require emergency extrication should be emphasised in damage control training.
4.33 The limitations of stretcher capability should be emphasised in damage control training.
MEDICAL STAFF SUPPLEMENTATION
4.34 The first request for the provision of supplementary medical staff was made within 15 minutes of the outbreak of the fire. WESTRALIA’s emergency medical organisation were solely responsible for providing immediate medical care to the injured
75 MEDICAL RESPONSE TO THE INCIDENT until the arrival at 1145 of the two MOs and CPOMED. Three of the injured (those with smoke inhalation) had the potential to deteriorate.
4.35 Further medical support was requested from ships in company at 1236, and these additional personnel were transferred by boat and helicopter within 20 minutes. It seems likely that this further supplementation was initiated in response to PO Plant’s request of HQ1 for assistance with casualty extrication.
4.36 By 1300, there were a total of nine medical personnel embarked: two MOs, four Skill Grade 4 medical sailors and three Skill Grade 3 medical sailors. The two key personnel, LEUT Eggerling and PO Plant, were in the MMS. WO Smith was at RASCO attending to the injured with the SMETs. The remainder, including the second MO and five medical sailors, were located on the port side tank Deck awaiting the outcome of PO Plant’s and LEUT Eggerling’s inspection of the casualties in the MMS.
4.37 With the number of injured under treatment, the personnel unaccounted for and the ever-present risk of further injury to personnel fighting the fire, the decision to request medical staff supplementation was clearly necessary.
Conclusion
4.38 Medical staff supplementation was appropriately requested and promptly provided.
MANAGEMENT OF THE INJURED AT RASCO
4.39 The overall management and supervision of the injured were in the hands of LS Page for most of the time prior to their medevac. There were a number of interventions by PO Plant in the stages leading up to the arrival of the first medical officer, these being limited to the provision of specific medical procedures and advice. One of the MOs and CPO Bonner were in attendance from about 1150 to 1245, but they were involved principally with individual assessment and treatment, and liaison with FBWHC and command regarding the medevac. WO Smith arrived at 1250 and provided guidance in the ongoing management prior to the medevac. She said in her evidence that LS Page gave her a good handover on each of the casualties and had taken control.[T903]
4.40 Throughout the day, LS Page supervised the monitoring and general care of the injured by the SMET members.[T1219] Her skill at doing this was commended by a number of personnel, both medical staff and casualties. CPO Bonner noted she was well in control and displayed professionalism and concern for her casualties.[T1059] PO Hollis commended her for calming and reassuring him.[E124A] PO Hollis also gave evidence that in the early stages of the incident, she took charge of the SMET members as well as caring for him.[T1875] PO Francis also noted she did a great job leading the SMET members.[E109]
Conclusions
4.41 The provision of continuing medical care of the injured was left to the SMET members and was well carried out.
76 MEDICAL RESPONSE TO THE INCIDENT
MEDICAL EVACUATION OF CASUALTIES
4.42 Neither PO Plant nor the two MOs were involved in the medevac planning process. No medical escort was provided during the flight. LEUT Eggerling agreed that it would have been preferable to have had one, and she would have provided at least a SMET member.[T875] LEUT Stone gave evidence that he left instructions for a medic to accompany the patients, but there is no evidence that this instruction was passed on to LS Page or WO Smith. Dr Mark offered the opinion that the lack of a medical escort during the medevac had no impact on the patients’ care.[T3225, T3231]
4.43 Whilst the lack of positive control over the medevac process by medical staff had no adverse impact on casualty outcome, this was due to the short duration of the flight and the lack of any deterioration in the smoke inhalation casualties. Positive medical control of a medevac is necessary to ensure that all measures are in place to reduce the impact of any unexpected deterioration in the condition of the casualties.
Conclusion
4.44 The decision to implement the medevac was taken by command without consultation with either of the two key medical personnel who were in the MMS at the time. Inadequate consideration was given to the preparation of the injured for medevac or their requirements in flight, and this resulted in no medical escort being despatched, and the management of the intravenous lines being an afterthought. Despite these shortcomings, there was no adverse impact on casualty care.
FATALITY EXTRICATION
4.45 The fatality extrication process took in excess of two hours. There were problems related to the lifting the bodies, both from middle plates to top plates, and then to the fridge flat. These were overcome by the use of two-fold purchases. There were also problems with the quality of the body bags.
4.46 The usual practice of casualty extrication from WESTRALIA’s MMS is in a stretcher using the MMS hoist. In the event that the hoist is unserviceable, casualty extrication is usually undertaken in a Paraguard because the ladders are considered too narrow and steep to carry casualties up. In exercises of this nature, the evolution is time consuming and tiring because of the steep ladder.[T1234, T1356-7] LCDR Crouch stated that stretchers, fire hose lifts, and man carries have been used to get people out of the MMS during exercises [T2957], but the NBCD Training Officer, SBLT Plummer, gave evidence that since she had been on board, the ship had always used the Paraguard stretcher to extricate casualties from the MMS. Fire hose lifts had been considered, but had never been used in the MMS.[T1163-4] WO Baker agreed that fire hose lifts were not exercised in these circumstances because it would place the simulated casualty at risk.[T2412-3]
4.47 The extrication of the casualties was made more difficult by the lack of a suitable stretcher. LS Nunn gave evidence that he asked for a Stokes Litter as it would have been better, but none was carried on board.[E101A] He observed that the Stokes litter replacement, the Ferno Washington would also have been capable of getting a casualty out, but he felt the material was unsuitable as it would be a hazard in the heat.[T1353-4]
77 MEDICAL RESPONSE TO THE INCIDENT
4.48 The body bags were not properly sewn together and the zippers kept breaking. The carry handles were inadequate and the fatalities had to be placed in poleless litters to allow easier carrying.[E378A, T1303]
4.49 The decision to remove the fatalities from the MMS was taken to allow the CO to confirm positive identification and to reduce the possibility of stress on those attending the fire scene. The procedure took a considerable amount of time and a large number of people, and was particularly difficult. Positive identification had been established by PO Plant by 1330, and each of the bodies could have been covered and moved to a discrete and dignified location. When the ship came alongside, people used to handling bodies could have undertaken casualty extrication.
Conclusions
4.50 Although the circumstances that led to the decision to remove the fatalities from the MMS are understandable, a better course may have been to leave them within the MMS, covered and placed in a suitable location.
4.51 The quality of body bags and the lack of a suitable and serviceable stretcher inhibited the fatality extrication process. Extrication was delayed because there was a lack of ready appreciation of mechanisms that could be employed in order to lift casualties in the event the hoist was unserviceable.
4.52 The difficulties encountered in extricating the fatalities highlighted the potential for significant problems had urgent extrication of a live casualty from the MMS been required.
Recommendations
4.53 The quality and suitability of current service issue body bags should be investigated.
4.54 Stretcher requirements for the extrication of casualties should be reviewed.
4.55 Training in the use of all means of casualty extrication from compartments should be regularly conducted, emphasising methods that allow the evolution to be conducted rapidly. Ships should consider the provision of suitable lifting mechanisms to aid the rapid manual extrication of casualties.
MEDICAL INCIDENT MANAGEMENT
4.56 After the initial stabilisation of the injured at RASCO, positive control of the varied medical activities on board seems not to have occurred.
4.57 After the establishment of the resuscitation bay at about 1215, PO Plant spent most of his time attending to the fatalities. In particular, he was in the MMS at the time of the arrangement of the medevac. The second key member of the medical team, LEUT Eggerling, who was the more operationally experienced of the two MOs embarked, was similarly occupied. The other MO joined medical staff on the tank deck shortly before 1300 awaiting the possible recovery of the missing from the MMS, as did all the medical
78 MEDICAL RESPONSE TO THE INCIDENT sailors apart from WO Smith who found only SMETs attending the injured when she arrived at RASCO.[E54A, E55A, E61, E70, E84, E151]
4.58 There were two direct consequences of this situation:
a. the injured were attended to by SMET members, and later WO Smith, with no other MO or medical sailor assistance; and
b. there was no positive coordination of the medevac by medical staff, resulting in a disorganised departure with only passing consideration of the casualties’ needs, and failure to embark a medical escort of any type in the aircraft.
4.59 LCDR Opie who, as the ship’s Supply Officer, has the role of providing help, resources and guidance, whilst leaving the coordination of the medical response to the POMED, stated that he felt that PO Plant coordinated the response, drawing on the knowledge and expertise of the two MOs as necessary.[T2290] PO Plant was clear in his own mind that his role was managing and delegating the resources available to provide the best care to all casualties.[T1225] LEUT Eggerling was also of the view that PO Plant was controlling the situation.[E57] CPO Bonner gave evidence that he left the overall casualty management organisation to PO Plant as it was ‘his ship’, but noted that LEUT Eggerling had a lot of input, mostly in relation to clinical matters.[T1071]
4.60 On the other hand, WO Smith stated that she was not sure who was coordinating the response because she did not know who was on board.[T903] In his evidence, LEUT Stone summed up the situation on board in the following terms:
I guess [there was] some confusion in what role each of us was really playing . . . that stemmed from the confusion that it all happened very quickly. In retrospect, I think the casualty management organisation . . . was quite confused. . . . It seemed to be very much a joint decision-making [process] along the way. PO Plant . . . necessarily took charge of the extraction teams, but the overall [person] in charge was certainly unclear.[T1043-4]
4.61 While this situation did not, in the event, cause any difficulties, had the condition of one of the injured deteriorated significantly, or had another serious injury occurred, the response may have been sub optimal. Better medical incident management would have resulted had HMAS SUCCESS’s MO had prime responsibility handed over to her on her arrival on board, with the POMED acting as the key expert on ship specific matters. Neither should have been involved in activities in the MMS. The second MO, accompanied by another member of WESTRALIA’s ship’s company (not necessarily a member of the medical staff), could have performed the task of identification and certification of the fatalities, and there were sufficient other personnel on board to undertake casualty extrication should it have been deemed necessary.
4.62 Notwithstanding the problems with overall coordination, PO Plant received high praise from many personnel. LEUT Eggerling praised him for his untiring and ceaseless efforts to control the situation and ensure the safety and well-being of all personnel involved in casualty handling.[E57] LS Page stated that his calmness and direction gave her strength to do her job.[E161] LS Nix commented on his calmness when casualty reports were requested when PO Plant was busy.[E383] AB Osmon remarked that he was instrumental in holding the medical personnel together.[E150]
79 MEDICAL RESPONSE TO THE INCIDENT
Medical Incident Management Training
4.63 Inadequacies of the coordination of the medical response appear to have resulted from a lack of training. LEUT Eggerling stated that she had not received any specific training in shipboard mass casualty management. While she had done a number of Navy-specific medical and other courses, and had completed the Early Management of Severe Trauma course (run by the Royal Australian College of Surgeons), none of these specifically covered the issue of management of a ship’s emergency medical organisation, particularly in mass casualty incidents.[T872] LEUT Stone also stated that he had not done any courses where he was provided instruction in the management of mass casualties in a shipboard environment.[T1037]
4.64 PO Plant stated that he had received some training in his Phase 4 Course in mass casualty management, including actual scenarios with up to three casualties in a damage control environment. He stated that he had been given training in the management of the organisation on board in emergencies, but that did not cover in detail the SMET members.[T1226-1227] He completed his Phase 4 Course in December 1996, and WESTRALIA was his first sea posting since then.
4.65 The Leading Seaman Medics Course (authorised in April 1998) includes the subject ‘Manage the Ship’s Medical Emergency Team (in the absence of a Medical Officer)’.[E435] The Board is uncertain to what extent this includes the detail of managing mass casualty scenarios.
Conclusion
4.66 The Board is of the view that the medical incident management could have been achieved more effectively, and that this resulted in inappropriate disposition of medical personnel to meet overall requirements, and inadequate medical control of the medevac. This occurred because the ship’s medical coordinator, and the more experienced of the two medical officers, had their attention diverted towards the identification and confirmation of death of the bodies in the MMS. The Board considers that the more experienced of the two MOs would have been better utilized if she had taken over the role of medical incident management on arrival, utilising the ship’s senior medical sailor as her senior adviser in relation to ship-specific matters. The Board considers that this did not occur because of the inadequate training of MOs in shipboard medical incident management, and the relative inexperience of the senior medical sailor in this role.
Recommendations
4.67 Training of medical officers in shipboard medical incident management should be provided, with a particular emphasis on the need to assume control when embarked in response to a major incident with mass casualties.
4.68 The training of senior medical sailors should be reviewed to ensure that proper emphasis is placed on medical incident management in shipboard mass casualty incidents.
80 MEDICAL RESPONSE TO THE INCIDENT
COMMUNICATION OF CASUALTY STATE
4.69 One of the key factors in effective mass casualty management is a clear understanding by command and the medical incident manager of the numbers and disposition of casualties. This allows for effective deployment of resources, and appropriate command decisions on priorities.
4.70 Most detailed casualty reports provided during the day bypassed the normal communications circuits and consequently were not recorded.[E46] LS Nunn gave evidence that CPO Jenkins told him to pass messages about casualties ‘quietly’ and not to ‘make it well known’, and that this is what CPO Jenkins had been telling everyone.[T1314, T1355] CPO Jenkins stated that he only spoke to LCDR Crouch about casualties.[T3971] LEUT Walters stated that he personally passed much of the information on casualty matters between HQ1 and Aft DC.[E43, T612] Additionally, CMDR Dietrich stated that LCDR Crouch personally updated him by telephone on the casualty state each time it changed.[T3179]
4.71 During all damage control incidents, casualty details should be entered on the DC state boards at HQ1 and Repair Bases as they are reported. These boards were markedly deficient in their recording of casualties.
4.72 In addition to the DC board in HQ1, Emergency Station SOPs require that a casualty state board be maintained in HQ1 by the senior medical sailor.[E312] In the event, PO Plant delegated this task to LS Nix.[E97] The casualty state board as tendered in evidence showed the three personnel initially injured, and the four deceased. Additionally AB Street is recorded as a casualty, but not AB Liddell. Locations of the personnel are recorded, but the only times noted are ‘fridge flat 1536’ against both MIDN Pelly and LS Meek.[E100] This detail is in error: the time recorded was during the first entry of the medical teams for casualty extrication, but the evidence is that MIDN Pelly and LS Meek were only positioned closer to the tiller flat at this time, rather than being lifted into the fridge flat.
4.73 The early information provided to external authorities highlighted the poor recording of the casualty status, with the first two messages reporting only three missing personnel. Signalled updating of the injured to the final total of five only occurred at the time the medevac occurred, which was nearly an hour after the final injured member presented.[E48] Additional detail on the status of the missing and injured was sent by telephone.[E121, E337, E365]
Conclusion
4.74 Casualty status awareness was complicated by the decision to keep casualty information perceived to be sensitive off the normal communications circuits. This resulted in inaccurate information being passed and a failure to keep proper records. Neither the DC state board nor the casualty state board was properly completed.
81 MEDICAL RESPONSE TO THE INCIDENT
Recommendation
4.75 Damage control and medical training should include an emphasis on the need to pass clear information on casualty status through the normal communications circuits to ensure accurate tracking of casualty status throughout an incident so that appropriate management decisions can be made.
MEDICAL MATERIEL
4.76 Quantities of supplementary medical materiel were provided from a number of sources. LEUT Eggerling brought additional equipment with her when she was transferred from SUCCESS [E57A], and the STIRLING RHIB also brought a Thomas Pack and Oxy- viva with the medical team.[E70, E84]
4.77 When WO Smith arrived at RASCO, LS Page advised her that the ship was low on IV fluids, and at 1306 WESTRALIA requested the OSC arrange for some to be transferred. ADELAIDE did so at about 1310.[E61, E52] As the casualties were evacuated within 30 minutes, these items were not ultimately required.
4.78 LS Page commented that about 90 per cent of the medical equipment on board was held in the Sick Bay, and these stores were unable to be readily accessed because the Sick Bay was in the superstructure which was inside the smoke boundary.[E161] Within RASCO, there were two Burns Boxes, but she did not have the key. She did not believe there were any intravenous fluids at RASCO, but there were sufficient available from the aeromedical evacuation kits provided from STIRLING and SUCCESS.[T2447-8]
4.79 There were no significant defects with any specific items of equipment or materiel
Conclusion
4.80 There were adequate quantities of medical materiel available during the incident. Some difficulties were encountered at RASCO because access to the Sick Bay to replenish stocks was inhibited by smoke boundaries.
Recommendation
4.81 Medical materiel should be better distributed between the sickbay and the FAPs rather than concentrated in the sickbay.
SMET Jackets and Red Cross Brassards
4.82 The RAN has recently introduced a SMET jacket, which has several pockets in which medical materiel is carried by the SMET member. The jacket is designed to replace the bag previously used. A standard contents list has been published,[E255] and the jacket includes red crosses to replace the Red Cross brassard. PO Plant indicated that he had modified the contents to include additional items he considered necessary for casualty management, including intravenous fluids and stiff-neck collars.[T1213]
82 MEDICAL RESPONSE TO THE INCIDENT
4.83 PO Plant stated that he does not use a SMET jacket, finding that he can carry in a first aid bag all those items that he requires in the initial management of casualties.[E97] AB Moffatt, having just joined the ship, provided himself with an ad hoc first aid bag.[E151]
4.84 The SMET personnel involved in the incident provided a number of comments in relation to their use around WESTRALIA.
4.85 AB Hutchinson stated she ‘hates’ the SMET jacket, commenting that it is ‘not very good at all’. When filled up it is too bulky, and nothing else can be carried while wearing it.[T2328-9] LS Page gave evidence that the jacket gets stuck on everything when trying to get down hatches and things fall out. She has a bag that contains the same as the jacket, and it is easier to carry.[T2428] AB Gormly noted that the jacket is not ideal, and it is difficult to locate items in the pockets, with some tending to fall out.[E211]
4.86 The alternative view was offered by AB Osmon, who considered the jacket ‘probably better’ than a bag. He had not, and did not on the day, encounter any problems with it.[T2243-4]
4.87 A number of the supplementary medical personnel embarked reported some difficulty identifying who were SMET members when they arrived on board. LEUT Stone was unable to identify them because no one was wearing brassards.[T1044] CPO Bonner recognised the SMET members because of their bags and jackets, but again none had brassards.[T1066] In contrast, AB Hutchinson was able to readily identify WO Smith as a medical sailor as she was wearing a ‘Red Cross thing through [her] epaulettes’.[T2332]
Conclusions
4.88 While there were no specific difficulties associated with the use of the SMET Jacket during the incident, HMAS WESTRALIA’s SMET members find them inconvenient and awkward to use.
4.89 Medical personnel were difficult to identify because they were not wearing Red Cross Brassards.
Recommendations
4.90 The suitability of the SMET jacket should be further investigated.
4.91 All medical personnel, including SMET members, should be required to wear Red Cross Brassards when duty and when at Action or Emergency Stations.
MEDICAL TRAINING
Clinical Training
4.92 Apart from the previously noted lack of training in shipboard medical incident management, both the medical officers had undertaken the military specific courses appropriate to their needs on the day. In particular, they had both undertaken the Rotary Wing Aeromedical Evacuation Course and Early Management of Severe Trauma
83 MEDICAL RESPONSE TO THE INCIDENT
Course.[T871, E70] The two medical sailors likewise had completed appropriate courses, although PO Plant had not done any refresher training in the period immediately preceding him joining the ship.[T1228] LEUT Eggerling stated that in her opinion PO Plant could have capably managed the injured for 24 hours without assistance.[T874]
4.93 All SMET personnel had completed the SMET Course, most within the preceding two years.[E316] The exception was LS Nix who completed his course in 1994, but had been posted to HMAS SWAN in a SMET role up to 1996.
4.94 The training of the SMET members was good. All SMET personnel interviewed stated that they had been trained to undertake all the tasks they were required to perform.[T2328, T2426, T2242] Additionally, none of the medical officers or sailors identified any deficiencies. PO Plant described his SMET members as a ‘good bunch’.[T1207] LEUT Eggerling noted that the SMET members at RASCO were operating very efficiently.[T874] AB Moffatt commented that the SMET personnel performed really well, were reliable and ‘got the job done’.[E151] There were no deficiencies in their skills.[T2261]
Ship Board Training
4.95 PO Plant undertook a program of regular shipboard training, directed particularly towards the provision of first aid skills to ship’s company and SMET members. Additionally, since 01 Jan 98, two toxic hazard exercises, each with two casualties, and two major damage control exercises, the first with two casualties and the second with one, had been conducted.[E98]
4.96 The MMS fire exercise conducted on 30 Apr called for one casualty with a broken leg on the upper deck to occur in the early stages of the incident, with other casualties occurring if firefighting procedures were incorrectly performed. During the exercise, no personnel carried out their drills incorrectly, and only one casualty was simulated.[T1233, T2956-7]
4.97 Evidence was given that most fire exercises conducted in the MMS predominantly involve walking wounded who have been able to get up ladders with minimal assistance. Most casualty exercises in the MMS are toxic hazards where the crane can be used to winch the casualties to the fridge flat from the top plates.[T1164] Concern was expressed over the risks to personnel during exercises when lifting casualties out of the MMS in stretchers or using fire hose lifts.[T1164]
4.98 Little consideration had been given to exercising alternative means of extricating casualties from the MMS in the event that either the winch hoist was unserviceable or rapid evacuation was required. The lack of exercises in which realistic numbers and types of casualties were simulated, other than when Sea Training Group were embarked, exacerbated this.
4.99 PO Plant gave evidence that during most DC exercises he assumes the role of umpire, and therefore did not obtain much practice in medical incident management.[T1205] PO Edmonds also stated that casualty recording procedures during exercises differed from the real situation, in that the DC recorder rather than the POMED did it during exercises.[T2319]
84 MEDICAL RESPONSE TO THE INCIDENT
Conclusions
4.100 The clinical training of medical staff and SMET members was adequate to meet the needs of this incident.
4.101 Shipboard medical training provided to SMET members and ship’s company was adequate.
4.102 The conduct of major damage control exercises did not provide realistic casualty scenarios, either in numbers or types of casualties, and the POMED, because he assumed the role of an umpire, did not obtain sufficient experience in medical incident management.
Recommendation
4.103 Major damage control exercises should include realistic numbers and types of simulated casualties, and should be conducted so that the senior medical sailor receives regular training in medical incident management.
85 SECTION 5. DEATH AND INJURY OF PERSONNEL
5.1 As a consequence of the fire in HMAS WESTRALIA on 05 May 1998, there were a total of 10 casualties sustained:
a. four fatalities;
b. five documented injured; and
c. one injured for whom treatment documentation was not raised.
5.2 All five documented injured were transferred to hospital ashore, and are likely to recover with no long term physical sequelae.
5.3 Additionally, there were a number of personnel who suffered stress reactions that rendered them to a greater or lesser extent ineffective for varying periods of time.
5.4 This Section summarises matters for the public record in relation to the deaths and injuries. Clinical matters that must remain private are included in Volume 16. All conclusions and recommendations relating to the casualties are included in the public section, however in one instance, the detail leading to a conclusion is omitted to protect the privacy of the individual.
Medical Screening
5.5 At the time of the incident, all 10 casualties were fit for sea service, nine being Medical Category ONE (1), and one Medical Category THREE (3).
5.6 Four months before the incident, one of the casualties had been diagnosed with a condition that made him prima facie unfit for sea.[ABR 1991, Vol 1, paras 7-146 to 7- 149 and Chap 7 Annex P] He was accordingly subject to Interim Medical Survey which made him unfit for sea. The stated diagnosis had the potential to be open to differing clinical interpretations.
5.7 Despite one setback, he had sufficiently improved so as to be assessed by FBWHC as fit to return to sea and he was so made on 22 Apr 98. The member was keen to return to sea.
5.8 On the day of the fire, the member became a casualty, was hospitalised and subsequently, on 18 May 98, made, again, unfit for sea. The injury that the member suffered was of a similar nature to the prior condition. However, it cannot be conclusively established whether the prior condition caused or aggravated the injury suffered. Nevertheless, the Board was concerned to clarify the matter of whether this member should have been to sea.
5.9 In a submission to the Board, SMO FBWHC contended that, to the extent that such a determination could be achieved, the member was cured and therefore fit for sea.
5.10 The Board recognises that it is not in a position to establish the exact diagnosis of the prior condition or the member’s clinical state at the time he was made fit for sea. As the Board is unable to determine that his injury on 05 May 98 was related to the prior
86 DEATH AND INJURY OF PERSONNEL condition, and conscious of the fine judgement often called for in the practice of medicine, the Board accepts the decision.
Personnel in MMS at Outbreak of Fire
5.11 The evidence indicates that there were nine personnel in the MMS and tiller flat at the outbreak of the fire; these personnel, their location and final disposition are shown below. Location/Last Seen Escape/Location of Body Outcome LEUT Walters Forward middle plates amidships Escaped via port ladder and Workshop No injuries MIDN Pelly Aft middle plates amidships Port side middle plates at base of between DAs ladder Deceased POMT Francis Bottom plates between BME Escaped via port ladder and Workshop Smoke Inhalation POMT Hollis Forward middle plates starboard Escaped via port ladder and side Workshop Smoke Inhalation POMT Smith Bottom plates between BME Port side middle plates Deceased LSMT Meek Aft middle plates starboard side top plates on port ladder landing Deceased LSMT Smith Forward middle plates starboard Escaped via port ladder and side. Workshop Smoke Inhalation ABMT Carroll Port side middle plates. Port side middle plates at base of ladder Deceased ABBM Noles Tiller Flat Escape ladder to fridge flat No injuries
Fatalities
Cause of Death
5.12 The autopsy reports state that, in each case, death was due to acute smoke inhalation.[E20] The Forensic Pathologist stated in evidence that the key characteristics were the appearance of the body and the high carboxyhaemoglobin (COHb) saturation levels.[T78] The autopsy reports state that, in each case, there was a marked cherry-red colouration to the skin, and there was marked sooting of exposed areas of skin. COHb saturation was in excess of 70% in three of the cases, and 59% in the other. Additional toxicology was negative.
87 DEATH AND INJURY OF PERSONNEL
Time of Death
5.13 Dr Cadden stated that, in his opinion, incapacitation would have occurred in approximately five minutes, and death within five to 10 minutes, after the development of a ‘fierce fire’. He emphasised that all would have been dead well before the CO2 drench was activated.[T79]
Pathophysiological Effects of Carbon Monoxide
5.14 The process to death by carbon monoxide toxicity starts with the inspiration of carbon monoxide into the lung and its absorption through the alveoli into the circulation where it binds to the oxygen-carrying molecule in the blood, haemoglobin, to form a complex called carboxyhaemoglobin (COHb). The carbon monoxide molecule has an affinity to haemoglobin that is approximately 200 times that of oxygen, and once the COHb complex has been formed, the haemoglobin molecule ceases to be an effective transporter of oxygen. Death is caused when the overall oxygen carrying capability of the blood is reduced to a level where insufficient oxygen is delivered to the tissues (in particular the brain and heart) to sustain life.
5.15 The pathophysiological impact of carbon monoxide on an individual is measured by the COHb saturation, which is expressed as a percentage of the haemoglobin in the blood that is bound to carbon monoxide. The fatal saturation level of COHb appears to vary widely, however it is generally agreed that levels of 50% are incompatible with life. The wide variety of post mortem levels recorded in the literature (from below 40% up to 80%) appears to relate principally to the rapidity of build up of carbon monoxide concentration in the atmosphere breathed. Individuals who are exposed to rapidly increasing and extremely high concentrations of carbon monoxide will show very high levels of post mortem COHb since they continue to absorb large quantities between incapacitation and cessation of respiration.[E424]
5.16 The very high levels of COHb saturation in each of the fatalities and the nature of the fire propagation support Dr Cadden’s opinion of the time of death and that the four died of acute carbon monoxide toxicity prior to the activation of the CO2 drench.
Conclusion
5.17 All the deaths resulted from carbon monoxide toxicity prior to the activation of the CO2 drench, and probably within 10 minutes of the outbreak of the fire.
Circumstances of Death
5.18 In each case, death resulted from a failure to escape from the MMS. All personnel who escaped from the MMS survived.
5.19 While some speculation is of necessity involved in an assessment of the circumstances of the death of each member, there are a variety of clues available that assist in coming to reasonable conclusions regarding this matter. Importantly, possible factors that may have contributed to the outcome can be suggested.
5.20 Each body was removed from its place of rest (and the MMS) prior to photographing by the coroner’s staff. However, there is evidence as to the location and
88 DEATH AND INJURY OF PERSONNEL disposition of them prior to being moved. Dr Cadden noted in his evidence that the extrication of the casualties from the MMS did not affect his ability to judge the cause or timing of death.[T80]
Conclusion
5.21 The Board is of the opinion that the assessment of the circumstances of the deaths has not been inhibited by the fact of the bodies being moved prior to examination by Coroner’s staff.
ABMT Carroll
5.22 ABMT Carroll was supervising the refamiliarisation of AB Liddell into his billet of 3rd Hand. He had been despatched into the MMS to lay out fire hoses after the initial fuel leak.
5.23 AB Carroll was tending a 90 l AFFF trolley mounted extinguisher on the port middle plates at the time of the outbreak of the fire. Evidence was given by LEUT Walters [T611] that he went straight to his extinguisher but to what extent he fought the fire is unclear.
5.24 AB Carroll was found on the middle plates slumped between the Port Diesel Alternator (forward end) and the Evaporator. Evidence was given that the body posture gave the appearance that AB Carroll had been protecting MIDN Pelly.[T672] Life was certified extinct by LEUT AJ Eggerling (MO SUCCESS) at 1312.
Conclusions
5.25 The Board finds that Able Seaman Phillip John Carroll S155254 Date of Birth 17 June 1974 died accidentally from acute carbon monoxide poisoning due to smoke inhalation in the MMS of HMAS WESTRALIA off the coast of Western Australia in the vicinity of Perth at approximately 1045 on 5 May 1998.
5.26 AB Carroll was not suffering from any pre-existing condition or intercurrent illnesses that could have affected his escape or survival.
5.27 The Board is of the view that AB Carroll continued to fight the fire for a time after its commencement. The Board believes he would have been aware that MIDN Pelly was in the MMS, both by seeing her and through her attachment to the 3rd Hand. The Board concludes that AB Carroll, having given up firefighting, probably searched for MIDN Pelly and, having found her, attempted to assist her from the MMS before being overcome by fire fumes.
LSMT Meek
5.28 LS Meek was in the MMS apparently laying out fire hoses after the initial fuel leak.
5.29 LS Meek was last positively sighted by WO Bottomley when he exited the MMS before the fire started moving from the port to starboard sides of the aft middle plates, forward of the DAs.[T267] His presence at the base of the port ladder during the escape of personnel was noted by LSMT Smith,[T1244] and POs Francis and Hollis both
89 DEATH AND INJURY OF PERSONNEL believed he was, or could have been, there when they escaped. LSMT Smith stated that he heard LS Meek call out ‘Everyone get out’.[T1244] LSMT was also reported by the I/C SMETs, LS Page, to have said that LS Meek had pushed him up the ladder, and that he would not have got out had LS Meek not done this.[T2422]
5.30 There is some evidence that there may have been a sighting of LS Meek in the MMS shortly after the outbreak of the fire. LS Bromage had just entered the MMS from the fridge flat and gave detailed evidence that he sighted somebody in a sitting posture at the top of the port ladder leading from the middle plates to the top plates as he was standing at the top of the platform just inside the fridge flat door to the MMS. In his statement, LS Bromage identified the person as LS Meek, but in questioning he agreed that that realisation may have come to him later.[E133B, T2024] There were no signs of life, although he admitted he only observed him for a ‘split second’.[E133B, T2025] In questioning, he described the person’s posture, and this description matched that in which LS Meek was found later by Hose Team 3.[T2024, T486-7, T760]
5.31 LS Bromage stated that he passed the information to CPO Jenkins at Aft DC sometime after the ship went to Emergency Stations.[E133B, T2025] CPO Jenkins’ evidence accords with this,[E39A, T3970] although he disagreed with LS Bromage’s account of the actual conversation.[T3971] CPO Jenkins stated that he passed this information discretely to HQ1, possibly around the time of the CO2 drench.[T3971-2] He also stated that the initial entry on the Aft DC Board of 1206 for LS Meek’s discovery was not the first time the discovery of a missing person had been reported to him and emphasised that the earlier report was not recorded at Aft DC, but was passed to HQ1, and ‘HQ1 would have put that in the [DC] board’.[T565]
5.32 PO Edmonds stated that in HQ1 he received a report at 1108 of a casualty on the top plates, and that he believed that this was a report of LS Meek.[E157, T2320] He reiterated in evidence that he believed the time was 1108, as this was on the incident board,[T2320] however it is noteworthy that the incident board records the time as ‘08’ without the hour designator and with the location as middle plates.[E128] The report was not recorded on the perspex table in HQ1.[E129] PO Edmonds’ evidence is consistent with that of LS Bromage and CPO Jenkins, however LCDR Crouch believed that the first report of a fatality came from one of the Hose Teams after the CO2 drench.[T2965] There is no evidence that this report from LS Bromage, if it did indeed arrive in HQ1, was passed to command.
Conclusion
5.33 The Board notes there is some evidence that LS Meek may have been seen at the top of the port ladder in the MMS by LS Bromage, viewing from the fridge flat door, after the fire erupted and before the CO2 drench. This information was not positively passed to HQ1 until after the CO2 drench had occurred. The Board finds it hard to understand how such a sighting could have occurred from a distance in conditions of poor visibility caused by thick smoke and very low light.
5.34 LSMT Meek was discovered on the landing at the top of the port side ladder leading from the middle plates to the top plates. He was in a sitting position, with his back against the inboard/forward ladder rail corner adjacent to the exhaust uptake for the Port Main Engine.[T487] In order to allow effective firefighting to occur, he was moved by the Hose Team to a location adjacent to the bottom of the ladder leading from the fridge flat
90 DEATH AND INJURY OF PERSONNEL landing.[E50A] Life was certified extinct in this location by LEUT A Eggerling (MO SUCCESS) at 1255.
Conclusions
5.35 The Board finds that Leading Seaman Bradley John Meek S147321 Date of Birth 16 July 1972 died accidentally from acute carbon monoxide poisoning due to smoke inhalation in the MMS of HMAS WESTRALIA off the coast of Western Australia in the vicinity of Perth at approximately 1045 on 5 May 1998.
5.36 LS Meek was not suffering from any pre-existing condition or intercurrent illnesses that could have affected his escape or survival.
5.37 The Board is unable to determine exactly where LS Meek was on the outbreak of the fire. It is of the view that, by the time the fire enlarged, he had made his way to the bottom of the port ladder to the top plates and stood there assisting LSMT Smith, and POs Francis and Hollis to make their way up that ladder. At some time after the last of those three exited, he also attempted to make his way up the ladder, probably after realising he was becoming incapacitated, but became overcome by fire fumes at its top, where he collapsed. The Board is of the view that the burns sustained by LS Meek occurred certainly after the onset of unconsciousness and probably after his death.
MIDN Pelly
5.38 MIDN Pelly was a Supply Officer under training, undertaking her first sea posting. She had been tasked to be attached to the 3rd Hand for familiarisation.
5.39 MIDN Pelly was last seen standing on the aft middle plates, forward of and midway between the two DAs.[T267, T1460]. At the time she was standing still observing events, apparently somewhat overwhelmed by them.[T3465]
5.40 MIDN Pelly was discovered on the middle plates slumped between the Port Diesel Alternator (forward end) and the evaporator. Evidence was given that the body postures gave the appearance that ABMT Carroll may have been protecting MIDN Pelly.[T672] Life was certified extinct by LEUT A Eggerling (MO SUCCESS) at 1312.
5.41 The Board has heard of concerns being raised that MIDN Pelly should not have been permitted to enter the MMS at the time of the initial fuel leak, and that when she was seen within the MMS, she should have been ordered out. In considering this issue, the Board has been mindful of the following factors:
a. previous fuel leaks in WESTRALIA had been a common occurrence, and had been handled without incident, and therefore there was some confidence that this incident would be similarly well handled;
b. the initial fuel leak, which was not the source of the fire, had been managed promptly and effectively, with shutting down of PME and isolation of fuel supply;
c. the occurrence of a second fuel leak, which was the source of the fire, within four minutes of the first could not have been foreseen;
91 DEATH AND INJURY OF PERSONNEL
d. the deterioration of the incident to a major fire occurred within seconds, and the attention of all in the MMS was diverted from all else to first aid firefighting;
e. the emergency evacuation alarm in the MMS, which was activated by LCDR Crouch, had become unserviceable as a consequence of the fire; and
f. at the time first aid firefighting was abandoned, others within the space attempted to locate MIDN Pelly.
5.42 Additionally:
a. WO Bottomley gave evidence that he had briefed MIDN Pelly to stay in the MCR if a hazardous situation developed;[T3453-4] and
b. WO Bottomley also gave evidence that she appeared overwhelmed by the activity surrounding her at the time of the initial leak, and offered the opinion that she may have been unaware of the seriousness of the situation that had developed.[T3454]
Conclusions
5.43 The Board finds that Midshipman Megan Anne Pelly L154029 Date of Birth 8 December 1975 died accidentally from acute carbon monoxide poisoning due to smoke inhalation in the MMS of HMAS WESTRALIA off the coast of Western Australia in the vicinity of Perth at approximately 1045 on 5 May 1998.
5.44 MIDN Pelly was not suffering from any pre-existing condition or intercurrent illnesses that could have affected her escape or survival.
5.45 The Board is of the view that MIDN Pelly probably attempted to escape the fire by moving aft between the DAs, this being the logical means of escape for one unfamiliar with the space. Being unable to find an escape ladder (there was none), she may have either made an attempt to return forward or alternatively may simply have stayed aft in the hope that the smoke might not affect her. In either event, the Board is of the view that AB Carroll, who was aware she was in the MMS, found her and led her back towards the port escape ladder before both were overcome by the fire fumes.
5.46 The Board finds that no blame for MIDN Pelly’s presence in the MMS can be attached to anyone. That she was there is of profound regret, however the occurrence of a second fuel leak causing a major fire could not have been foreseen, and the initial leak was being effectively dealt with.
POMT Smith
5.47 POMT Smith was the Assistant Engineering Officer of the Watch (under training).
5.48 PO Smith was located on the bottom plates between BMEs at the outbreak of the fire, working on the fuel leak on PME. He was in the company of PO Francis. Upon the outbreak of the fire, he proceeded forward, to port and then aft along the outboard side
92 DEATH AND INJURY OF PERSONNEL of the PME, slightly behind PO Francis. He was felt by PO Francis to be pushing him up the ladder to middle plates.[T1488]
5.49 POMT Smith was found on the middle plates, port side, slightly forward of the base of the ladder leading to the top plates lying supine, with the head outboard. Life was certified extinct by LEUT A Eggerling (MO SUCCESS) at 1308.
Conclusions
5.50 The Board finds that Petty Officer Shaun Damian Smith S138258 Date of Birth 27 November 1968 died accidentally from acute carbon monoxide poisoning due to smoke inhalation in the MMS of HMAS WESTRALIA off the coast of Western Australia in the vicinity of Perth at approximately 1045 on 5 May 1998.
5.51 PO Smith was not suffering from any pre-existing condition or intercurrent illnesses that could have affected his escape or survival.
5.52 The Board is of the view that PO Smith may have attempted to assist AB Carroll to fight the fire from the port side of the middle plates. Of the three engineering staff who perished, PO Smith was the least familiar with the space, having joined WESTRALIA on 27 Apr 98. It is conceivable that, he became disorientated in his efforts to escape, and so was unable to find the port ladder before being overcome by fire fumes.
Injured
5.53 There were five documented injured. On four of these, appropriate medical documentation (Form PM377, Field Medical Card) was raised on board. There was one casualty for whom no formal contemporaneous record was kept.
5.54 The injured suffered burns to the left hand (two), smoke inhalation (four), and stress reaction (two). All of them demonstrated some degree of emotional distress following hospitalisation.
5.55 Evidence presented to the Board indicated that a number of additional personnel had minor smoke inhalation but did not obtain treatment at any stage.[T291, T967, T2001, E173, T2961-2]
Summary of Treatments Provided
5.56 Treatment of the smoke inhalation cases was uniformly with oxygen by mask. Two of the initial three smoke inhalation casualties had intravenous lines inserted, one with difficulty, and the third case declined to have a cannula inserted. None of the casualties was given any intravenous medication other than analgesia in one case. Apart from the case of smoke inhalation who presented later, none of these cases was given nebulised salbutamol.
5.57 The casualty with the minor burns received no specific treatment for this injury, as it was overshadowed by the severity of his smoke inhalation. Treatment of the more severe burn case was cooling by water followed by the application of a moist dressing.
93 DEATH AND INJURY OF PERSONNEL
5.58 The casualty with significant burns required analgesia in the form of penthrane by inhalation, and parenteral morphine (two doses). He was also given prophylactic prochlorperazine prior to the morphine.
5.59 The two cases of stress reaction were treated by supportive care. One was given oxygen therapy in the initial stages and a single dose of prochlorperazine.
Casualty Management Protocols
5.60 Mass casualty management protocols are contained in the RAN Advanced Clinical Manual (RAN MISCPUB 0157), and are formulated so that, where the numbers of skilled medical personnel are limited, casualties are efficiently provided all modalities of treatment to ensure an optimal outcome. The management of smoke inhalation involves the use of oxygen, and the provision of an intravenous line with dextrose 5% infusion. The administration of intravenous corticosteroids (dexamethasone) and nebulised salbutamol follows.[E474]
5.61 Of the smoke inhalation casualties evacuated ashore, only two had intravenous infusions, and one did not. The fluids used included both Hartman’s and ‘glucose’ (presumably dextrose). None received intravenous steroids or nebulised salbutamol. The smoke inhalation casualty treated on board received oxygen and nebulised salbutamol.
Conclusion
5.62 There were some deficiencies in the provision of specific treatment for the smoke inhalation casualties as compared to laid down protocols. These deficiencies did not in the event adversely affect the clinical outcome, and were contributed to by the relative lack of medical officer or sailor supervision of the casualties at RASCO.
Recommendation
5.63 Training of all medical personnel should be based on casualty management protocols.
Standard of Medical Treatment
5.64 The medical treatment of all casualties was of a high order, considering the circumstances of the number of casualties exceeding the normal ship’s medical staff capability.
5.65 In his evidence, Dr P Mark from SJOGHM complimented the ship on its clinical management of casualties on board. He noted that there were no deficiencies in treatment provided, and that all casualties arrived in a satisfactory condition. He commented particularly on the difficult circumstances in which treatment would have been provided. One of the two intravenous lines was serviceable on completion of the medevac, and Dr Mark also offered the opinion that the lack of a medical escort during the medevac had no substantial impact on the patients’ care.[T3225]
5.66 The three initial casualties commented on their satisfaction with the medical treatment provided on board, and commended the SMET members.[E109, E124A, T1275] LS Nunn also expressed his satisfaction.[T1356] PO Hollis praised the SMET members
94 DEATH AND INJURY OF PERSONNEL and in particular LS Page. They displayed professionalism, and calmed and reassured him.[E124A] PO Francis praised LS Page for they way she looked after the injured.[E109]
95 SECTION 6. EXTERNAL ASSISTANCE
RAN UNITS
RAN Surface Units
6.1 The best overview of the assistance rendered by RAN surface units is to be found in the enclosure to the minute from CAPT LG Cordner, RAN to the Secretary of the Board of Inquiry dated 12 May 1998.[E52] It is summarised in the following paragraphs.
6.2 Upon receipt of the MHQAUST WEST message at 1051, which advised units of WESTRALIA’s fire and requested them to be prepared to offer assistance, the OTC (CAPT Cordner) briefed ships in company that he intended to detach units to close WESTRALIA at best speed to provide support. SYDNEY was detached at 1055 and DARWIN at 1102. At 1109, ADELAIDE and SUCCESS commenced passage at best speed to join WESTRALIA which was 38 nautical miles to the east of ADELAIDE.
6.3 The OTC advised all units to prepare fire teams with a priority on teams comprising ex-WESTRALIA sailors and preferably those with an engineering background. While the individual units were to prepare the teams, the OTC maintained the control of the allocation of assets and timings for transfer.
6.4 The CO SUCCESS (CAPT Flint) realised that expert medical assistance would be urgently required and directed the ship’s doctor, LEUT Eggerling, to embark in the Sea King helicopter with the firefighting equipment prepared by the ship. The Sea King helicopter launched for WESTRALIA at 1125.
6.5 At 1142 the OTC informed all units he was taking command as On Scene Commander (OSC) in order to co-ordinate support for WESTRALIA. Communications were established between the OSC and WESTRALIA at 1146 and damage control priorities were established as OCCABA, Fearnought suits and Maxon radios.
6.6 WESTRALIA later advised that the priority was for portable pumps and diesel fuel to operate them. SUCCESS had a suitable pump which was to be transferred by air to WESTRALIA. At 1206, the CO WESTRALIA repeated his assessment that a P250 pump was a priority item required to support fire teams fighting the fire with foam.
6.7 At 1210 the OSC executed a screen cordon based on WESTRALIA in order to facilitate transfer of stores and ‘deconflict’ supporting units. At 1234, the cordon was amended when sector zero was reduced to 500 yards. This facilitated the transfer of stores by boat, which commenced at that time. By 1224 it became evident that sufficient firefighting equipment was either onboard WESTRALIA or en route to the ship. Based on the shift in priorities, a team of Sea Training Group damage control specialists was transferred by air to WESTRALIA.
6.8 Eventually, there was considerable congestion around WESTRALIA while at the same time, navigable waters were decreasing. Accordingly, the OTC cleared non- essential units from the area. At 1300 WESTRALIA reported that the fire was extinguished. At 1310, DARWIN’s boat responded to a request from WESTRALIA for IV
96 EXTERNAL ASSISTANCE fluids. SYDNEY and ADELAIDE supplied water and victuals at 1330. The CISM team from ADELAIDE joined WESTRALIA at 1335.
6.9 By 1330 the situation had de-escalated to the point where various vessels were ordered to detach. DARWIN and the DTV SHARK were ordered to remain with WESTRALIA, to proceed to FBW when ready and provide ongoing support as necessary.
6.10 The close proximity of 4 major warships to WESTRALIA and the ability of the OTC to control the scene played a significant part in the timely assistance provided to WESTRALIA by these ships.
6.11 After WESTRALIA was berthed at FBW, there was some confusion with the firefighting and other equipment which had been transferred to the ship as not all of it was marked so it could be easily identified as belonging to a particular ship.[T830.1]
Recommendation
6.12 Ships’ damage control and firefighting equipment should be marked for purposes of parent unit identification.
The Helicopters – Sea King (HMAS SUCCESS)
6.13 The Sea King was about to land on ADELAIDE when the crew, under LCDR Moncrieff, received a message from SUCCESS that there was an MMS fire in WESTRALIA. The aircraft disembarked a passenger to ADELAIDE and then hover taxied to SUCCESS where the Sea King embarked LEUT Eggerling, a medical officer, a quantity of medical stores and a number of OCCABAs and Fearnought suits. WESTRALIA was about 30 nm away at the time and took about 15 to 18 minutes to reach. There was some initial difficulty in contacting WESTRALIA by radio but eventually the crew learned that the ship was guarding VHF Channel 69. Initially, radio communications were in cipher but after a couple of minutes, the OTC ordered plain language be used as well as plain language call signs.[T849.9]
6.14 WESTRALIA briefed the Sea King that the vertrep deck would only be manned by a marshaller. Winching operations were, therefore, carried out with only a marshaller. It would appear that the greatest majority of the work on the vertrep deck on 5 May 98 was undertaken by the Supply Officer, LCDR Opie, RAN. The Sea King aircrewman, LSA Llewellyn, was winched down by the observer, LEUT Savage, to assist in controlling the deck during aviation operations.[T850.3]
6.15 After LEUT Eggerling was winched to the deck, the stores were transferred in a Billy Pugh net. This net is a search and rescue device originally intended for use in scooping an injured person out of the water. The net has a rigid frame and a rope net, which can be used for stores transfers up to 1,400 pounds. A limitation on the amount of stores, which may be transferred in any single lift, is the aircraft winch, which is rated at 600 pounds. The net is not carried in the Seahawk as it is too large to safely use within the restricted space available in the Seahawk.[T850.1-T851.7] The time taken in transferring equipment from each of the two aircraft used on the day was noticeable, the Seahawk taking much longer because of the absence of the Billy Pugh net.[T863.8]
97 EXTERNAL ASSISTANCE
Recommendation
6.16 A Billy Pugh type net should be developed for use by Seahawk and Sea Sprite Helicopters.
6.17 The Sea King then flew to the Helicopter Support Facility [HSF] at FBW and embarked fire crews from ANZAC.[T851.4] From FBW, the Sea King transitted to WESTRALIA. Again there was only the marshaller on the vertrep deck and LSA Llewellyn was winched to the deck. The fire crews and their equipment were offloaded and towards the end there was an override in the winch cable. The observer, LEUT Savage made an assessment of the situation that it was safe to continue. The aircraft was then able to land on ADELAIDE where there was a Sea King qualified maintainer who, after running the wire out and re-setting it, considered that the winch was serviceable.[T852.8]
6.18 The Sea King’s next sortie was to take 14 passengers including members of the Sea Training Group, a hose team and equipment to WESTRALIA. On this occasion, the aircraft was found to be 300 pounds overweight. The conditions of the day were examined and the decision to launch was made. At no time did the aircraft approach its power limitations.[T853.6] Again there was only the marshaller on the vertrep deck and LS Llewellyn was winched to the deck. Once again the Billy Pugh net was used to transfer the equipment to the vertrep deck.
6.19 LS Llewellyn remained on the deck on this occasion to prepare casualties for medevac. While this occurred, the aircraft flew to ADELAIDE to hot refuel and then returned to WESTRALIA. LS Llewellyn was recovered so that the crew were able to ascertain the nature of the 5 casualties. LEUT Savage was winched down and brought up each of the casualties in a double lift.[T854.8]
6.20 When tasked to medevac the casualties to St John of God Hospital, the crew did not know its location. They were advised by the Seahawk TACCO and then LEUT Savage who had attended the University immediately adjacent to the Hospital. The air traffic control authorities assisted greatly and the flight was without incident.[T855.4] From St John of God, the Sea King was flown to SUCCESS and placed at alert 30.[T855.9]
6.21 The aircraft flew a total of six hours and six minutes on that day of which about three hours was in support of WESTRALIA. In all, 47 winch transfers were conducted by the Sea King.[T856] Both the pilot and the observer were fulsome in their praise for the part played by ADELAIDE.[T857.2 and T 863.6] LEUT Savage in his statement said:
I would like to say that whoever from ADELAIDE was overseeing the assistance to WESTRALIA did a great job as far as the aircraft co-ordination was concerned. The operation was smooth, the instructions were clear and concise and at most times we knew precisely what we were to do.[T863.6]
Conclusion
6.22 The Board is of the opinion that the Sea King was the ideal aircraft on the day. Apart from the minor difficulty with the overriding winch wire, the aircraft flew without incident.
98 EXTERNAL ASSISTANCE
The Helicopters – Seahawk (HMAS ADELAIDE)
6.23 Statements were not taken from the crew of HMAS ADELAIDE’s Seahawk helicopter due to their overseas deployment.
6.24 The Seahawk was first actioned for the transfer of a ADELAIDE fire team at about 1135. Additional stores in the nature of OCCABAs, Fearnought suits and Maxon radios were carried on the sortie. The aircraft was held on deck while diesel fuel was loaded for a pump which were being transferred to WESTRALIA by the Sea King. The Seahawk eventually launched at 1210 after the load was re-configured. When it arrived at WESTRALIA, the Sea King was transferring its load and the Seahawk held off until it could commence its transfer at 1230.[E52]
6.25 On completion of the transfer of the fire team from ADELAIDE, the Seahawk collected a fire team from SUCCESS and inserted them at 1308. The Seahawk then proceeded to the HSF at FBW and transferred a CISM team to WESTRALIA at 1414 prior to recovering to ADELAIDE at 1420.[E52]
Conclusion
6.26 The Board notes that whilst the Seahawk is not a utility helicopter, the aircraft made a valuable contribution to the timely transfer of necessary resources to WESTRALIA without incident.
Air Traffic Control
6.27 The first helicopter on the scene was from Channel 7 News. WESTRALIA was unable to make radio contact with it.[T134.5] At that time, WESTRALIA’s Navigator was aware that the Sea King from SUCCESS was inbound on its first sortie for WESTRALIA and he was, therefore, concerned about clearance between the two aircraft.[T134.5-T135.3] This concern was passed to MHQ West.[T134.8]
6.28 At 1212 WESTRALIA reported a number of helicopters observed within the near vicinity. At 1223 the ship expressed concern by VHF radio over the number of helicopters operating within the area.
6.29 CAPT Cordner as OTC made the following comments in regard to aircraft in the vicinity of WESTRALIA:
The OTC requested FIS Perth to keep civil aircraft clear of the immediate vicinity – as a number of media helicopters were now circling over WESTRALIA potentially conflicting with Seahawk and Sea King operations. The initial request relayed by FIS Perth to civil aircraft was obeyed, however, within a short time congestion returned. At 1322 the message was repeated on Guard frequency and MHQ WEST discussed with FIS Perth and POLAIR options for clearing the area around WESTRALIA. At 1325 FIS Perth established an Exclusion Zone around WESTRALIA and congestion eased noticeably.[E52]
99 EXTERNAL ASSISTANCE
Recommendation
6.30 Consideration should be given to developing a Standard Operating Procedure, with the appropriate authorities, whereby an Air Exclusion Zone is established around an emergency incident.
EXTERNAL AGENCIES
Fleet Base West and Port Services
6.31 Initially, contact was made by the ship with MHQ West and the Port Services Manager (PSM). This initial contact requested assistance in the form of tugs, helicopters and other ships. In particular, WESTRALIA stated that tugs were urgently required.[T127] At about 1042 the CO STIRLING, CMDR Johnston, took charge of the shore assistance for WESTRALIA using the Port Services office.
6.32 The tug TAMMAR, which is a naval tug operated by Defence Maritime Services Pty Ltd (DMS), was the first of the FBW units to be despatched to WESTRALIA. The vessel slipped after only about 5 minutes notice and proceeded to the ship at full speed.[E387]
6.33 The first surface craft to arrive alongside WESTRALIA was a RHIB from STIRLING. It had departed STIRLING at 1115 and arrived at 1143. Embarked in the craft was a medical officer and a CPOMED from FBW together with some medical equipment.[T1033.1, T1055.6, E387]
6.34 The next unit to depart was the firefighting team from ANZAC which flew from the HSF to WESTRALIA in the Sea King. This team were dressed in full firefighting rig and carried spare OCCABA cylinders.[E387]
6.35 Subsequent to a request by WESTRALIA’s Navigator, the PSM arranged for 25 FIMA staff to embark in the DTV Shark to assist WESTRALIA’s crew in their firefighting efforts.[T1742.2] Embarked with the firefighters were Fearnought suits, OCCABAs, TICs and drums of diesel fuel.[E387]
6.36 FBW also provided a CISM Team requested by the CO WESTRALIA which was airlifted to the ship by Seahawk helicopter.[E387]
6.37 After the fire was extinguished, the PSM embarked in WESTRALIA as pilot at about 1430 to bring the ship down the channels to FBW.[T1738.1 and E387]
6.38 At the direction of the Minister for Defence, the CO STIRLING held a press conference at 1510 and was otherwise occupied with the media until the ship berthed at about 1815.[E387]
6.39 Every effort was made by personnel from STIRLING to assist the relatives and friends of the crew of WESTRALIA before the ship berthed. Hot food was available on the ship’s arrival, accommodation was arranged where considered necessary and telephones for the use of the crew provided.[E387]
100 EXTERNAL ASSISTANCE
6.40 In the best of Naval traditions, the CO STIRLING and members of his ship’s company ensured that all appropriate assistance and comfort was given to assist crew of WESTRALIA.
6.41 As to the response and effort of RAN units, the CO of WESTRALIA summarised his view in the following words:
…support from other ships and FBW was outstanding with a rapid response and I was most impressed with how they anticipated our needs with the minimum of communication. The right personnel support and equipment arrived in the right order and in the right time. Obviously this was not a fluke, but flows from the high standard of training conducted over a long period of time.[T3158.7]
Conclusion
6.42 The Board finds that the support provided by naval units was timely, well coordinated and in the best traditions of the service.
Fremantle Port Authority (FPA)
6.43 The Fremantle Port Authority is responsible for the commercial operation of Fremantle. Its area of responsibility covers the inner and outer harbour, including Cockburn Sound and the dredged Parmelia and Success channels. The integrity of these channels and approaches to Fremantle are vital to the commercial life of the port. To minimise the consequences of an incident within the Port of Fremantle and its approaches, the port has developed the ‘Port of Fremantle Emergency Plan’. This emergency plan forms part of the Western Australia Emergency Plan and whilst the RAN has been involved with the development of this plan, the plan itself does not cover Naval units.
6.44 At the onset of the emergency the WESTRALIA command team were aware that they urgently required outside assistance [T125.3] but did not declare an emergency by way of a internationally recognised prescribed urgency call (PAN call). Consideration was only given to receiving assistance from other naval units rather than to all help which was available.[T171.1] Naval units were over one hour away, however the port of Fremantle was just some seven miles distance and was called 11 minutes after the fire broke out but assistance was not requested.
6.45 The initial advice to the Port of Fremantle Authority’s control centre was made at 1046 on VHF Channel 12, as follows:
This is warship WESTRALIA. I’m in the vicinity of number 1 buoy at the moment. I’ve had a fire - major fire - in my MMS. I’ve lost both my engines. I’m about to go to anchor in this position. STIRLING Port Manager is organising assistance in the form of tugs at the moment.[E91]
6.46 The Board is critical of the fact that no further information was supplied to the FPA. The message itself was misleading in that ‘I’ve had a fire’ can easily be understood to mean that the fire was out and no assistance was required. This may have been reinforced by the reference to STIRLING Port Manager organising assistance.
6.47 The Navigator in a submission to the Board stated that he had established effective communications and did not require radio priority. The Board does not accept
101 EXTERNAL ASSISTANCE this submission which demonstrates an apparent lack of understanding of the purpose of a prescribed urgency call.
Conclusion
6.48 The Board finds that WESTRALIA’s command team made an error of judgment by not making a prescribed urgency call.
6.49 The Harbour Master (Captain Atkinson) received a telephone message, with respect to WESTRALIA’s fire, from the Port Control Centre at about 1046. Following normal FPA procedures, the Port safety and response vessels were immediately placed on standby. These vessels included two pilot launches and a specialised pollution response and firefighting vessel. At about 1050 LCDR Jempson, the Garden Island Port Manager made the first of a number of contacts between the Navy and the port authorities. LCDR Jempson indicated that he was coordinating the support operation from the Port Control Centre, Garden Island.[T2452/2453] The use of tugs was discussed; this included the possibility of Fremantle Tug Operators (FTO) claiming salvage if the ship was outside port limits.[T2452.7-2453.3]
6.50 Neither LCDR Jempson nor the CO of WESTRALIA considered seeking any help from the civilian authorities, other than the provision of Fremantle Tugs. WESTRALIA’s CO was unaware of the emergency plan or of the resources, which had been placed on standby just seven miles away.
6.51 At approximately 1115, the Harbour Master received a telephone call from the CO STIRLING, CMDR Johnson, advising that there were casualties in WESTRALIA. As a result, CMDR Johnson requested that the Rous Head helipad be activated to receive the casualties. Captain Atkinson made the necessary arrangements and requested Police assistance to ensure emergency access for ambulances. At the time, there was considerable industrial action and the road to Rous Head was partially blocked.[T2454.7] Captain Atkinson indicated in evidence that FPA and the Police received complete cooperation from the leaders of the industrial dispute.[T2461] In the event, Rous Head was not required as the decision was made to evacuate the casualties to St John’s.
6.52 A copy of the FPA ‘Emergency Management Plan’ is held by the PSM at FBW.[E168, T2465.3] It would appear that a copy of the document was not held by WESTRALIA.
6.53 One possible flaw in the otherwise close working relationship between the FPA and the RAN at FBW was exposed as a result of the fire in WESTRALIA. There is an apparent conflict of responsibilities in the case of events which have the potential to cause the closure of part of the port to commercial and Naval shipping.[T2456.2] There is no clear understanding or agreed procedures between the parties with regard to the handling of Naval vessels in distress. This could result in conflict between the parties, especially in instances where any action taken by the RAN may have the perceived potential to cause harm to the FPA or its assets.[T2456.2]
6.54 If, for example, WESTRALIA had grounded, either in the main approaches to the Deep Water Channel or on one of the reefs in close proximity, she may have caused a blockage of the approaches to the port or, in the worst case, a major oil pollution incident.[T2456.4]
102 EXTERNAL ASSISTANCE
6.55 In early 1997 representatives of the Port of Fremantle assisted in the development of a plan for the provision of a safe haven for damaged or disabled vessels at sea off the Western Australian coast. This plan is specific to commercial shipping and does not include Naval vessels.[T2456.5] In view of the Government’s two-ocean policy, Captain Atkinson suggests that a further Memorandum of Understanding (MOU) should be developed between the RAN and the Fremantle Port Authority for the handling of Naval vessels in distress.[T2456.9]
6.56 Such an agreement should clearly set out the areas of responsibility of the parties and clearly identify who has the final say and therefore the liability for any such occasions where the parties may not necessarily agree and an incident results in the temporary closure of the port. This agreement could also be linked into the existing plan for the provision of a safe haven for damaged or disabled vessels at sea off the coast of Western Australia.[T2457.2]
Conclusion
6.57 The Board agrees that a MOU should be developed between Navy and the Fremantle Port Authority for handling naval vessels in distress.
6.58 Captain Atkinson went on to suggest that a second channel should be dredged so as to provide a second access to Cockburn Sound.[T2458.2]
6.59 It would appear that on the day, the most suitable vessel to attend to WESTRALIA was the FPA Emergency Response Vessel (MPERV). The vessel is described in the Emergency Management Plan as being equipped to handle a major fire on a vessel at sea or at a berth. The MPERV has 3 main fire monitors capable of producing water at the rate of 20 tonnes per minute. There is a foam capacity AFFF/ATC of 13 tonnes. The vessel has a quick fill capacity for foam and may be replenished within 20 minutes. There is also a self-protection deluge system, producing 10 litres per square metre per minute. Response time varies, but a constant speed in sea state 3 is 22 knots. The Plan goes on to describe the hydrants, fire branches and nozzles, and hoses carried by the MPERV.
6.60 Captain Atkinson did not despatch the vessel because there was no official request for it nor was a ‘PAN’ call made by the ship.[T2467.2] In essence the vessel was not called for because the CO was unaware of the FPA Emergency Management Plan [T3211.5] and, therefore, the existence of the vessel. Captain Atkinson did place the vessel on standby, however, and thought that it was appropriate to send it.[T2467.3]
6.61 At no time did the FPA know how much cargo or the type of fuel WESTRALIA was carrying.[T2475.3]
6.62 During the course of a telephone call between the PSM, LCDR Jempson and the Fremantle Harbour Master at approximately 1050, the former requested Captain Atkinson to inform the Chairman of the State Marine Oil Pollution Combat Committee of the situation immediately and activate the plan. This was done and all services were placed on standby, awaiting further developments.[T2452.6] The Navy is a participant in this plan.[T2469.4]
6.63 In his evidence, Captain Atkinson stated that if he had received a request or advice that there was a pollution incident then the Port Manager would have attended the
103 EXTERNAL ASSISTANCE scene as the on-scene coordinator but no equipment would have been taken to the scene until there was an actual incident.[T2473.9]
6.64 Captain Atkinson and his team were ready and willing to provide assistance to WESTRALIA but a request for their services was not made. The incident has highlighted the need for greater co-operation between the RAN and the FPA. While there is already a mutual professional exchange between the Harbour Master and the PSM, COs of RAN vessels operating/transiting Fremantle Port waters would be better served if they knew of FPA facilities available to them in cases of distress.
Recommendations
6.65 HMA Ships should be made aware of major port facilities that are available to assist in emergencies. The ‘Port Guide’ should contain details of Port Emergency Plans.
6.66 HMA Ships based at Fleet Base West should be issued with a copy of the FPA emergency plan.
6.67 A MOU between the RAN and FPA should be developed for the handling of Naval Vessels in distress which fall within the bounds of the FPA emergency plan.
Fremantle Tug Operators (FTO)
6.68 Fremantle Tug Operators is a civilian tug joint venture responsible for Fremantle inner harbour tugs. The call for assistance to FTO came in at about 1100 from Defence Maritime Services Pty Ltd (DMS) when it was stated that WESTRALIA required urgent assistance in Gage Roads due to an MMS fire. The FTO management made the decision to provide a tug under the basic hourly hire rate from their standard schedule of charges.[E162]
6.69 The tug WAMBIRI sailed at 1125. Five minutes later, DMS incorrectly advised that the ship had anchored and the urgency was downgraded. At no time were FTO administration or tug personnel, ever advised of the full extent of the situation relating to WESTRALIA.[E162] The tug crew only learned of the loss of life onboard the ship when they were in the Parmelia-Success Channel with WESTRALIA under tow.
6.70 There was apprehension on the Bridge of WESTRALIA that the Master of the WAMBIRI made an open claim for salvage as the tug approached the ship. The Navigator thought that the Master of WAMBIRI used the words, ‘I reserve the right to negotiate the terms of this charter at a later date’ which he took to be leaving a salvage claim open.[T141.3] Earlier, LCDR Jempson, on advice from Captain Atkinson, had advised the ship about the possibility of a salvage claim if the ship was outside port limits [T1740.3] and, therefore, the radio transmission caused some angst on the Bridge. This was initially relieved by the fact that TAMMAR commenced the tow before WAMBIRI arrived.[T141.5]
6.71 What was read out was in accordance with a general instruction to tug masters in all Adsteam Marine Operations in Australian ports. That instruction is :
104 EXTERNAL ASSISTANCE
In local emergency cases, that is, within port limits where tugs are called out to assist a ship that has sustained a grounding or collision . . . tug masters must advise the casualty’s master as follows:
We acknowledge your call and will render assistance immediately. My owners reserve the right to negotiate the terms under which these services are rendered.[E162]
6.72 First, there is no doubt that WESTRALIA was within the limits of the Port of Fremantle. As far as the FTO administration was concerned, WESTRALIA was in Gage Roads which is well within the Port of Fremantle limits. Evidence was given that originally, a tug other than WAMBIRI was to be sent out. The master of that tug was aware that the tow was for an hourly rate. The contract for an hourly rate was not passed on to the master of the WAMBIRI. In any event, Defence Maritime Services Pty Ltd, on behalf of the RAN had sent a purchase order by facsimile at 1151 for the services of tugs including a cold move to FBW.[E162]
6.73 In an emergency, FTO can have a tug departing from the berth in the Inner Harbour within 5 to 10 minutes. The decision was made to send WAMBIRI which is fitted out for ocean rescue work and has a bollard pull of 61 tonnes; she is also fitted out with firefighting equipment including a water cannon with a capacity of 10,000 litres a minute and 13 or 14 tonnes of foam and can proceed at 11.5 to 12 knots. The tug arrived at WESTRALIA at 1220 and later attempted a hookup using the 48 millimetre wire towing hawser after the synthetic line used by TAMMAR had snapped. There was insufficient crew on WESTRALIA’s forecastle to handle the hawser without power and initially the messenger was placed over the bollard. Eventually the towing wire was brought inboard and placed on a bollard and the vessel was under tow at 1310.[T2444.6]
6.74 The tow to FBW was without incident and WAMBIRI and TAMMAR were joined by WYONG at 1515 to assist with the move down the Parmelia-Success Channel. WESTRALIA berthed at FBW at about 1830.[E162]
Western Australia Police Service and the Coroner
6.75 A legal officer, CMDR Vickridge, arranged for the Arson Squad and members of the Western Australia Police Service (‘Police’) representing the Coroner to attend at FBW. This assistance was sought in order to conduct formal identification of the deceased, determine their cause of death and the cause and the origin of the fire.
6.76 Prior to WESTRALIA berthing, a mobile Police unit was established adjacent to the wharf. This unit was formed at the invitation of the RAN and acted on behalf of the WA Coroner.[E452] The forensic pathologist, Dr G Cadden, formed part of the unit and also attended.[T78] He later presented his report to the Board shortly after it commenced its hearings.[E20]
6.77 When WESTRALIA arrived at FBW, the Police moved onboard and carried out formal identification of the deceased with the assistance of PO Plant.[T1200.6] All relevant areas were secured by Police boundary tape and photographed by both still and video photography. The Arson Squad examined the MMS and, within a relatively brief period, isolated what appeared to them to be the origin of the fire. Last, the Police organised the hearses to convey the deceased and landed each of them with due reverence being shown at all times. The Police did not secure their team until after midnight.
105 EXTERNAL ASSISTANCE
6.78 Various forensic specialists attended onboard WESTRALIA on the following day.
6.79 The Board acknowledges the assistance provided by the Police which includes the professional advice of the Arson Squad in the provision of the report by Detective Senior Constable W A Hawes [E452], photographic board exhibits [E33], the enhanced bridge tape [E49] and arranging the report from the Chemistry Centre of WA [E184].
CRITICAL INCIDENT STRESS MANAGEMENT
6.80 Critical Incident Stress Management (CISM)is a structured process of debriefing that is initiated in response to an event that has the potential to cause significant emotional stress amongst the personnel who are involved. The debriefing is provided to all personnel involved, and is provided by psychologists, social workers and Peer Support Members (PSM). PSMs are uniformed personnel, chosen because of the possession of particular qualities including maturity, who are provided training that allows them to assist in the conduct of CISM activities. They perform PSM activities ancillary to their normal duties. Navy policy on CISM is covered by DI(N) PERS 5-7.[E88]
CISM Support Provided
6.81 In response to a request by WESTRALIA’s CO, a Critical Incident Stress Management (CISM) response was initiated, in accordance with Navy policy.[E88] As the worst accident in the RAN since CISM was introduced as policy, the response was the largest seen.
On-Scene Support
6.82 Once the fire was out, CO ADELAIDE offered to transfer his CISM team.[T3156, E52] CO WESTRALIA accepted this, having become aware that some personnel were suffering from stress, although he did not see it as a major problem at that stage.[T3183] STIRLING had earlier assembled a team in anticipation of the requirement.[E387] ADELAIDE’s CISM team of two personnel was transferred at about 1335 and STIRLING’s Team of five personnel, headed by Senior Naval Psychologist Mr A. Camac, plus a Chaplain were transferred at 1414.[E52]
6.83 On arrival, ADELAIDE’s Team identified several personnel grieving for shipmates in the vicinity of RASCO. These personnel were moved to a quiet area, support was provided, and they regained their composure and returned to their duties.[E52] At the time the second CISM Team arrived on board, the number of personnel who were suffering stress difficulties had apparently diminished, and only about half a dozen required support.[T1105]
6.84 CISM personnel spent the remainder of the time prior WESTRALIA berthing talking with and observing the ship’s company and others, and assisting with preparations for berthing.[E52, E187]
Informal De-Fusing
6.85 The CO WESTRALIA addressed the ship’s company on WESTRALIA’s arrival at FBW. This took the form of an informal defusing, with an explanation of the
106 EXTERNAL ASSISTANCE day’s events, details of those killed and injured, and advice on the immediate availability of support should it be required.[T1111, E87] Following this, leave was piped to 1000 the following day.
De-Briefing
6.86 Formal de-briefing was preceded by an information session for the whole Ship’s Company the day following the fire. At this time, COs WESTRALIA and STIRLING gave addresses, and a Psychologist (Ms Douglas) outlined the ‘normal’ elements of ‘critical incident’ stress.[E87] Personnel were advised that individual counselling was available on request. On 7 May, formal de-briefing commenced, with a total of 83 personnel being seen in six groups. The groupings were based on commonality of activity during the incident.[E87]
Other Support
6.87 Support was provided for the five personnel hospitalised in SJOGHM on the evening of the incident.[E87, T1090] Further support was provided the following day, but, at the request of the injured, no formal defusing or debriefing took place at the hospital.[E87] The casualty who in hospital on 07 May was also visited.
6.88 The CISM Activity Report submitted by the Senior Psychologist WA (Mr Camac) summarises the first three weeks after the incident as follows:
[Eight] Group Debriefings (total of 103 personnel: 82 from HMAS WESTRALIA and 21 from HMAS STIRLING), [two] dyad Debriefings4 and [eight] individual Debriefing sessions were conducted; a ‘defusing’ was held for 10 personnel from HMAS ANZAC; individual counseling was provided by psychologists for 25 personnel with [four] follow-up sessions . . . conducted; and, Peer Support Members . . . provided general and individual support to a wide range of personnel in a number of environments.[E87]
6.89 CISM activities beyond FBW included follow up of personnel involved in the incident from SUCCESS, ADELAIDE, SYDNEY and TORRENS, and psychologists contacted CERBERUS and ADFA since two of the deceased had recently posted from these establishments.[E87]
On-going Contact
6.90 As of 05 Jun 98, 12 personnel were actively maintaining contact with the CISM process for continued counseling. At 13 Jul 98, three personnel were under psychiatric care for depression and anxiety.[E473]
Acceptance of CISM
6.91 The acceptance of CISM Activities was reported to be high, with management at all levels actively involved in supporting the effort. Personnel were readily released to participate.[E87]
4 A dyad debriefing is one where two personnel are debriefed together [T1098]
107 EXTERNAL ASSISTANCE
6.92 Many witness statements tendered to the Board commented on CISM, and the majority of these were positive. On-scene support was felt to be helpful, making personnel feel better in themselves.[E382, E399, E178A]
6.93 Some witnesses described the CISM debriefings as good and worthwhile.[E38, E42, E63, E89] Although some witnesses felt that it did not do much for them personally, it was generally helpful, allowing personnel to share their experiences and ventilate their feelings.[E63, E89, E175] A number of the witnesses were equivocal, with some being initially reluctant to attend, but feeling positive afterwards, and others feeling they did not need counselling. Some preferred to deal with the situation their own way and some were interested in hearing what other people had been doing on the day.[E152, E161, E206, E211]
6.94 There was some criticism of the CISM debriefing. One witness stated that it upset her, with graphic descriptions of what the bodies looked like and how they were taken out.[E161] A member of the HQ1 team stated that he was grouped with people from the Bridge, but did not feel he had anything in common with them, since they were not directly involved in fighting the fire.[E157] A number of witnesses felt that the debriefing should not be compulsory, as people should not be placed in a position where they publicly break down.[E211, E205]
6.95 There were two personnel from WESTRALIA who did not attend debriefing - one was a refusal, and one stated he was not ready.[T1097] Two personnel from HMAS SYDNEY also rejected the opportunity for referral.[E87]
Conclusion
6.96 A significant CISM intervention was mobilised during and after the incident. It received a high level of acceptance at all levels.
Possible Contamination of Evidence
6.97 The Board was concerned that there appeared to be some potential for contamination of the evidence presented to it as a result of the debriefing process. The Board noticed that on a number of occasions statements tendered by personnel involved in the same or related activities included very similar, if not identical, wording. There were a number of statements also where the comments by others made during debriefings were included (sometimes with attribution). The perceptions of the incident may have been modified by each individual relating his or her involvement in the incident to a group of personnel who had similar roles or experiences in the incident.
6.98 In a submission to the Board, Dr Richard Bryant, Senior Lecturer in Psychology at the University of New South Wales, opined that:
In the context of recounting one’s recollections in the company of others who have been through a similar experience, one risks peoples’ memories of events being influenced by others’ accounts of these events. . . .[and] it is likely that accounts of an incident may be modified somewhat following CISM relative to memories before CISM’s implementation.[E428]
108 EXTERNAL ASSISTANCE
6.99 This issue was put to Mr Camac, and, while admitting the potential for contamination to occur, he stated that similar contamination could occur in general social discussions:
I couldn't deny that that might happen in some instances, but certainly the general observation has been against that being a problematic issue, that the preference has been seen to have psychological debriefings before operational debriefings, making clear the difference between the two, and by people having worked through some of their emotional reactions to incidents, being in a position of being able to provide information for operational briefings in a clearer and less emotive perspective.[T1100]
6.100 Previous Boards of Inquiry have noted the benefit of lowered stress in witnesses giving evidence.[T1110, E478] The Board did observe that, with a number of exceptions, WESTRALIA witnesses seemed comfortable giving their evidence.
6.101 Mr Camac noted in his evidence, that while the optimum time for debriefing is 24 to 72 hours after the incident, on occasions, for various reasons, the process has been extended over a longer period of time.[T1095] He did comment on the potential problems relating to prolonged delay in debriefing:
The risk of leaving it . . .[for] too long a period of time is that you may disrupt the [process of working through their reactions and return to work and taking up their own responsibilities] that people have already started, by introducing some other intervention.[T1095]
Conclusions
6.102 The CISM debriefing process, occurring as it did before the great majority of personnel had made any written record of their recollections of the day, had the potential to contaminate evidence presented to it.
6.103 The Board is of the view that, given the significant resources involved in the provision of CISM, steps should be taken to evaluate the efficacy of the intervention in this incident.
Recommendations
6.104 CISM debriefing should not occur until all personnel involved in an incident have made some written record of their recollections and this record has been secured for future reference in formulating statements. This procedure should be included in the Navy policy on CISM.
6.105 Controlled follow up or other studies should be initiated with a view to contributing to the empirical data available in the scientific literature evaluating the effectiveness of CISM.
Preparation for Critical Incidents
6.106 Navy policy requires CISM awareness sessions be conducted in a variety of Naval courses, including those related to leadership and management. Additionally, all
109 EXTERNAL ASSISTANCE officers, and all sailors in categories with a high likelihood of exposure to critical incidents receive similar sessions.[E88,B]
6.107 Board Member, CMDR WALSH, put to Mr CAMAC that:
we teach people that . . . we’re in a Service which is designed to go out to sea and fight and in doing so, we expect to take damage and deal with that damage, but to make sure you overcome that damage, 90 per cent is done before action. . . . Now, thinking of our people . . . we know today that stress . . . is a natural reaction to pressure . . . it seems to me that part of this CISM work should be done before the incident, and . . . should we not be teaching our people that, ‘Hey, you're in a service that fights. You'll be going out there. You will suffer actual damage. You will see damaged equipment, damaged people, and you will react to this and this is just normal.[T1116-7]
6.108 Mr CAMAC responded:
Well, I have no problems with doing that and . . . allowance for that was encompassed within the DI(N). . . . As a Land Commander once put it, . . . his concern about teaching soldiers about stresses [is] that they all experience it the next day, and so there has been an issue of finding a balance between educating in preparation without generating . . . excess anxiety about it. . . . I'm certainly supportive of the idea in terms of preparing people for this and I think it's important to also prepare managers for this element of the reaction that they may encounter in the incident as well.[T1117]
Conclusion
6.109 The Board considers that more extensive preparation of personnel for critical incidents, including pre-training in stress/trauma management, may have resulted in a reduction in the size of the CISM response required for this incident, including the need for On-Scene Support and individual counselling.
Recommendation
6.110 Navy should examine the appropriateness of introducing more extensive preparation of all personnel for critical incidents, including sailors at the time of entry, and expanding that preparation beyond simple awareness to stress/trauma management, both for the individual and for managers.
Peer Support
6.111 Five personnel (two psychologists and three PSMs) were involved in providing On-Scene Support in WESTRALIA. Only two of these personnel came from ships in company, and none from WESTRALIA.[E87] Two Chaplains provided support additional to CISM one of these being from WESTRALIA.[E87]
6.112 Activities at HMAS STIRLING after the incident involved a total of 14 personnel - eight psychologists and six PSMs. Of these, 10 (five psychologists and five PSMs) were involved in the provision of CISM interventions to those directly involved in the incident. None of these was from WESTRALIA.
110 EXTERNAL ASSISTANCE
6.113 Concern was raised that if this incident had occurred either isolated from shore support or in combat, the availability of personnel to provide the initial support could not be guaranteed. Navy CISM policy does not include a requirement for at least one PSM to be posted to each Major Fleet Unit [T1101-2, T1113] as it does with Alcohol and Drug Program Advisers (ADPA).[DI(N) PERS 31-9] To ensure proper support in the event of an incident, Mr Camac noted that, in a combat scenario, the US Navy, for example, would deploy CISM personnel in its hospital ships.[T1103] The RAN is about to introduce into service 40-bed medical facilities in its LPAs, however the Board understands that accommodation constraints may prevent the deployment forward of CISM resources.
6.114 There would be benefit in having an assurance that some degree of support was available at sea without the need to inhibit operations by deploying CISM personnel to a ship where a critical incident has occurred. A policy of having a PSM posted to each Major Fleet Unit, and the training of all Chaplains as PSMs, would provide an assurance that at least one PSM, and often more, would be available at sea to assist in providing support in some incidents.
Conclusion
6.115 The provision of at least one Peer Support Member on each Major Fleet Unit at all times will assist in providing post trauma management to personnel involved in incidents that occur in combat or isolated operations.
Recommendations
6.116 Navy should introduce a requirement for at least one CISM Peer Support Member to be posted to each Major Fleet Unit.
6.117 All Chaplains should be trained as CISM Peer Support Members.
CHAPLAINCY
6.118 Immediate chaplaincy support was provided by PNF and ANR Chaplains in the Perth area. CHAP Gebski was embarked in WESTRALIA and, in his roving role, provided a wide range of support to personnel on board.[E388]
6.119 CHAP Yesberg heard of the fire in WESTRALIA at the time the initial notification arrived from the ship, he being in MHQ Operations West at the time. He received clarification of the casualty situation from the FBWHC later. At about 1200 he notified the Fleet Chaplain, CHAP Raynor, of the incident.[E389], and also asked two Reserve Chaplains, CHAP Raj and CHAP Stubbs to be on standby to provide family support at about 1230.[E389] Later in the day, CHAP Stubbs went to SJOGHM to meet the casualties evacuated there.[E389]
6.120 Two additional Chaplains were embarked in WESTRALIA during the day. CHAP Graue from HMAS ADELAIDE arrived at 1335 as part of the CISM team, and provided support to personnel in the vicinity of RASCO.[E52, E388] At 1410, CHAP Yesberg arrived with the CISM Team from HMAS STIRLING to lend additional support, but not as a member of the CISM Team.[E17A, E388, E387]
111 EXTERNAL ASSISTANCE
6.121 On the ship’s arrival at STIRLING, CHAP Gebski participated in the Clear Lower Deck conducted by CMDR Dietrich, leading the ship’s company in prayer.[E388] In subsequent days, all Chaplains provided significant support to families and others during the days following the incident.[E388] There is evidence that the availability of chaplains was a source of comfort and support to members of WESTRALIA’s crew.[T702, T959]
Conclusions
6.122 There was a significant chaplaincy effort in support of personnel, family and friends on the day of the incident and subsequent to it.
FAMILY LIAISON AND SUPPORT SERVICES
6.123 The impact of the incident extended greatly beyond the immediacy of those on board. Families and friends suffered the twin burdens of:
a. uncertainty between the time media reports of the accident began and individual outcome (survival, injury or death) was confirmed; and
b. grief in bereavement and/or trauma associated with supporting distressed personnel involved or other family and friends.
6.124 The Personal Services Officer WA (PSO WA - LCDR RJ Smith RAN) coordinated most of the family liaison in Western Australia, with assistance from STIRLING as necessary.
6.125 PSO WA became aware of the incident at approximately 1115 when NAVCALS Fremantle telephoned seeking the CPO Communicator. In the course of the conversation, the incident was mentioned briefly. PSO WA contacted MHQ Ops West and FBW Health Centre and was told of the fire, and that personnel were missing and injured. He stated that the information he received was limited and conflicting, but ‘there was no apparent sense of urgency’.[E391]
6.126 Over the subsequent hour and a half, numerous telephone calls were received from families concerned after hearing media reports of the fire, and LCDR Smith soon became aware that the incident was more serious than first appreciated. He attempted to clarify the situation by telephoning MHQ Ops West and FBW Health Centre but was unable to obtain additional details.[E391]
Notification of Next of Kin
6.127 The major task of family support services on the day was to notify the Next of Kin (NOK) of WESTRALIA personnel of the incident. This was undertaken by the Defence Community Organisation (DCO), through PSOs in the various States, and the Defence Family and Personal Services (DFPS) organisation. The evidence in relation to the notification of NOK was confused, and in some areas conflicting.
6.128 CO HMAS STIRLING contacted PSO WA to advise of the missing personnel, this telephone call being recorded in the Port Services Manager’s narrative at 1300.[E121] At this time LCDR Smith proceeded to contact the NOK to offer support; two families
112 EXTERNAL ASSISTANCE declined this offer, one of which had support already available, and the other had it en route.[E391]
6.129 At 1440, CO STIRLING contacted WESTRALIA by radio requesting the CO call him by mobile telephone as CO STIRLING was about to hold a press conference. During the telephone call, CO WESTRALIA confirmed the four deceased and their names.[E121, E387]
6.130 At 1510, CO STIRLING held a press conference at which the numbers and genders of the four deceased were announced, but no other personal details revealed.[E387]
6.131 PSO WA stated that he received confirmation of the details of the four deceased at 1545, and he was instructed that the families were not to be informed at that time. PSOs in relevant States were notified to place family support on standby. Almost immediately after this, he was advised that a press statement was about to be made, and to be sure that NOK had support in place. The Board is unable to determine with accuracy the timings of these two calls. CO STIRLING in his statement noted that he contacted PSO WA just prior to his press conference at 1510, and this may be one of the calls referred to. One of the press releases issued, DPIO 65/98, which confirmed the deaths, was distributed at 1750K (1550H), and this may be the press statement referred to in the second of the calls. LCDR Smith gave evidence that, because of the times and distances involved, in two cases support could not be put in place before the announcement of the deaths. He gave evidence that one of the families had first heard of the death from media reports.[E391]
6.132 In these days of modern, mobile, communications, with demands from the media for on-the-spot information, the accurate and timely notification of the NOK of personnel before leakage from other sources is a challenge. The use of mobile telephones as a means of disseminating information is difficult to control. Confirmed information regarding the status of personnel who may be casualties should be passed to the DCO as rapidly and clearly as possible. This requires the establishment of simple, formal procedures that emphasise a close working relationship between operational authorities and the DCO. The Board is aware that steps have been taken to ensure this occurs.[E461]
Additional Support
6.133 Prior to WESTRALIA arriving at FBW, STIRLING made arrangements for the provision of accommodation, hot food, STD telephones, transport, press and family liaison. When the ship berthed, the priority was to reunite crew and family.[E387]
6.134 On subsequent days, PSO and DCO staff were involved in finalising travel and accommodation arrangements, other routine administration associated with family support, and providing personal assistance and support to relatives of the deceased and injured. Assistance in arranging funerals was also provided, and also planning and support with respect to the memorial service.[E391]
6.135 STIRLING provided assistance in the arrangements for reception and accommodation of the next of kin of the deceased arriving to attend the memorial service.[E387] A briefing for families of WESTRALIA’s ship’s company was held on 07 May at the Submarine Training and Systems Centre, where advice on support services available to them was provided.[E387]
113 EXTERNAL ASSISTANCE
6.136 Following the memorial service on 08 May, the next of kin of the deceased were escorted through the Engine Room of WESTRALIA.[E387]
6.137 The Board received a number of favourable comments on the family support services provided. MIDN Christie stated that her parents were very impressed that the Navy contacted them to let them know she was all right, even before they heard anything about the fire on the news.[E42] LS Daly reported that his wife had heard from two sources, local and Canberra, that he was safe.[T635]
Conclusions
6.138 The Board considers that family liaison and support services of a very high order were provided throughout the incident and the days that followed.
6.139 The Board is of the view that an inappropriate delay occurred in officially notifying PSO WA of the incident and its scope. The mechanisms that were in place to keep PSO WA updated as the incident unfolded were inadequate.
6.140 The Board considers it likely that at least one of the families of the deceased heard, indirectly, of their loss through media reports. This probably resulted from a deduction based on early notification that the member was missing, followed by public confirmation of the occurrence of fatalities. The Board is of the view that, once NOK had been notified that a family member was missing, no further information on the fate of these personnel should have been released until such time as the NOK had been officially notified.
Recommendations
6.141 Operational authorities should include in their headquarters’ crisis response teams a member solely tasked with coordinating the interface between the operational authority and DCO/PSO authorities.
EXTERNAL MEDICAL ASSISTANCE
HMAS STIRLING
6.142 FBW Health Centre (FBWHC) was notified of the fire in WESTRALIA by telephone from MHQ Ops West at 1050,[E365] with the information being provided that there were four minor casualties with minor burns and smoke inhalation.[E477] At this time, a request was made for a medical officer to be sent out to the ship by RHIB, and LEUT MJ Stone RAN and CPOMED Bonner were despatched at 1100.[E477]
6.143 At 1115, MHQ Ops West advised FBWHC by telephone that there were now four injured and three or four personnel unaccounted for.[E365, E477] At 1135, Staff Officer, Health Services, (SOHS) relocated to MHQ Ops West.[E477] SOHS provided a valuable liaison service between MHQ Ops West, FBWHC, St John of God Hospital Murdoch (SJOGHM) and MHQ medical staff. SMO STIRLING was on site at SJOGHM, and also provided useful liaison services between WESTRALIA’s medical organisation and the Hospital.
114 EXTERNAL ASSISTANCE
6.144 At 1200, CPO Bonner rang FBWHC to advise that WESTRALIA’s intention was to fly the four casualties using SUCCESS’s Sea King helicopter to SJOGHM. He advised that there were still four personnel missing. MHQ Ops West were notified at 1205.[E365] Confirmation of the names of the four injured (not Liddell) was provided in a second call by CPO Bonner at 1245.[E365]
6.145 At about 1230 the Submarine Escape Training Facility recompression chambers at STIRLING were placed on immediate notice for the reception of smoke inhalation casualties. They were stood down at about 1600.[E64]
6.146 FBWHC was advised by SOHS at 1505 to prepare for the reception of minor casualties. This advice was subsequently revised to prepare for the reception of personnel for overnight accommodation. A total of 18 beds were prepared by 1535.[E477] FBWHC staff met the ship on arrival and provided general support. The two ambulances stood by but were not required, neither was the accommodation. FBWHC staff were stood down at 1905.[E477]
St John of God Hospital Murdoch
6.147 St. John of God Hospital, Murdoch, was well placed to received the casualties by air, triage, resuscitate and stabilise them, and, if it had proven necessary, transfer them to more sophisticated treatment facilities in central Perth.
6.148 SJOGHM obtained additional medical staff from Fremantle Hospital.[T3227] The Senior Medical Officer FBWHC, CMDR Robertson, attended the hospital, keeping in touch with MHQ Ops West by mobile telephone to maintain accurate casualty information.[T3224, E384] St. John’s Ambulance provided two ambulances on site to cater for the possible need for transfer to another hospital, which could have been achieved, after stabilisation, within about 15 minutes.[T3223, T3228]
Conclusion
6.149 St John of God Hospital Murdoch is well equipped to receive casualties by helicopter from ships at sea, and transfer them to other hospitals if clinically indicated.
Recommendation
6.150 Agreements should be developed with civilian health authorities and hospitals on the procedures to be followed in the event of casualties being required to be medevacced by air from ships off the Australian coast.
115 SECTION 7. FIREFIGHTING AND SAFETY EQUIPMENT
FIREFIGHTING EQUIPMENT
Thermal Imaging Camera (TIC)
7.1 Thermal Imaging Cameras (TIC) use infrared technology to identify heat sources in poor visibility. TIC can be used to identify hot spots in a fire or to search for personnel.
7.2 The hose teams in WESTRALIA used TICs on 5 May 1998.As there were only three allocated to the ship it was important that this resource was fully operational. Unfortunately there was a problem with one of the TICs which meant that the hose teams had to pass a camera from team to team. LS Mitchell described the TIC failure, saying:
I couldn't see anything through the TIC camera: the screen was black, the lights were still on, but it was not working.[T665, 668]
7.3 The Board also heard evidence that the TICs were of very little benefit at the start of firefighting operations as the camera screens suffered from ‘white out effect’ due to the high ambient temperatures that prevailed in the MMS.[T668.6] Hose team leaders were unable to identify the seat of the fire with any certainty using the TIC until much of the extreme heat in the MMS had dissipated.
7.4 The Board is aware that the Director of Naval Warfare (DNW) is in the process of introducing an improved TIC to the fleet.[DNW Minute D91/3075.1 dated 7 Jul 98] Any new TIC introduced into the naval inventory should be extensively trialled. Depending on the technology available it should be capable of discriminating fire from a background of very high ambient temperatures.
Conclusions
7.5 The TIC currently in service suffers from overload in large fires and was of marginal utility in this case.
Recommendation
7.6 Thermal Imaging Cameras used by firefighting teams should be capable of determining the seat of a fire against very high background temperatures.
Waterwall
7.7 In shipboard firefighting an effective waterwall is an essential element. A waterwall provides a hose team with a shield against the heat from the fire and cools the space around them. The waterwall nozzle should supply a wide cone of water spray.
7.8 A number of personnel who were part of the hose teams have stated that the Elkhart nozzles did not provide a wide enough spray pattern to protect all the hose crew
116 FIREFIGHTING AND SAFETY EQUIPMENT from the high temperatures. The general view of those who came before the Board was that the older English style branch provided a wider protective spray pattern while the new Elkhart branch provided more water but the spray pattern was not as good.[T663, T664, T767, T469, T479]
7.9 The issue here is whether a wider spray pattern would have made any difference on the day. The MMS had been enclosed for some time prior to the entry of the hose teams and was filled with trapped heat and smoke. Firefighting operations would have also produced a significant quantity of steam, which would have made the conditions even more difficult for the teams. In addition the sheer size of the space allows heat to come around behind the hose teams’ protective curtains and impact on personnel. The comments made suggest that the earlier style branches are more effective but testing needs to be carried out to verify if this is in fact the case.[T685, T693] RAN training tends to focus on compartments with low deckheads. The large dimensions of WESTRALIA’s MMS may detract from the utility of the Elkhart branch.
Recommendations
7.10 Although the hose nozzles currently in service in the RAN are appropriate in various fire situations, further evaluation should be undertaken of the most appropriate nozzles, and particularly waterwall nozzles, for use in the whole range of situations which can be foreseen. In particular, compartments with unusual configurations, such as the exceptionally large spaces in WESTRALIA’s MMS, need further study.
BREATHING APPARATUS RESOURCES
7.11 WESTRALIA is equipped with the following OCCABA and spare cylinders:
a. 28 sets in stowage around the ship
b. 2 spare sets in the NBCD store
c. 56 (approx.) spare cylinders [E419]
7.12 The number of OCCABA and spare cylinders is sufficient for one wear of all the sets and a change over of all cylinders once. This theoretically enables operations requiring respiratory protection for 30 personnel to continue for approximately two hours. This is sensible approach considering the likelihood of an emergency arising when there is limited opportunity for the ship to seek external assistance.
7.13 The RAN Damage Control Manual, ABR 5476 Vol 1, details WESTRALIA’s allowance of 30 OCCABA and 30 spare cylinders. This number of spare cylinders is inadequate for a complete change of fitted cylinders. As a result of the conflicting documentation there is some confusion about how many spare cylinders should be carried in the ship.[T1338]
7.14 There was also conflicting evidence as to whether there was an adequate number of OCCABA in WESTRALIA to combat the fire.[T143, T383, T1349, T2839] There were claims that at times there were not enough OCCABA readily available for hose team members to wear.[T383] However it is also clear the WESTRALIA requested
117 FIREFIGHTING AND SAFETY EQUIPMENT additional breathing apparatus sets be sent from the other RAN vessels to supplement the ships resources and these were supplied.[T128, T143]
7.15 The problem of where a ship stores its OCCABA and spare cylinders is a prime consideration. The sets are not located in a common area but are dispersed throughout the ship. This makes it difficult in an emergency to ascertain if all the resources have been gathered and used.[T418]
7.16 During this emergency additional resources were readily on hand but this may not always be the case. To enable the ship to maximise the equipment that is available, the standard operating procedure in a major incident is for all the sets and cylinders to be taken to a central point. From this point a logistics officer, or someone coordinating the entry of hose teams, could monitor the availability of equipment, and allocate resources to the most important area.
Conclusions
7.17 The number of OCCABA carried by the ship was appropriate. The ship carried a greater number of spare cylinders (by a factor of almost two) than the number specified in the RAN Damage Control Manual - ABR 5476 Vol 1.
7.18 In a major incident the utilisation of breathing apparatus should be managed by one person.
Recommendations
7.19 The allocation of spare OCCABA cylinders in a ship should be equal to the number fitted to the breathing apparatus sets.
7.20 ABR 5476 should be updated to reflect the allocation of OCCABA and spare cylinders.
7.21 During any major incident, a coordinator should be designated to gather all OCCABA resources and place them in a central location.
Condition and Maintenance of OCCABA
O rings
7.22 A number of personnel have given evidence that the OCCABA O-rings failed on their set while others reported difficulty in changing cylinders.[T1349, T2524, T2539, T627] It was reported to the Board that the blowing of O-rings was a common occurrence and this happens if the cylinders are turned on too fast.[T980, T984 , T1000, T1349]
7.23 To determine what problems, if any, there are with the OCCABA, the Fire and Emergency Services Authority of Western Australia (FESA) was asked to conduct an independent assessment on a set obtained from HMAS STIRLING. In addition a quantity of O-rings were supplied with the set so that comment could be made on the density of the material used.
7.24 The O-ring test results indicated:
118 FIREFIGHTING AND SAFETY EQUIPMENT
a. In over one hundred operations of the cylinder valves no O-rings failed. However, prior to the test all three O-rings were replaced as they were damaged.
b. The O-rings, BS 111/A90, nitrile (NSN 5330-66-121-8906) as supplied by the Navy store appeared to be correct size and composition.
c. The OCCABA set has three high pressure hand wheels that can vibrate loose in stowage. With a loose connection and the application of high pressure the O-rings can be damaged and cause leakage. A leaking O-ring reduces the maximum duration of the OCCABA.[E429]
Test Bench Interspiro Spirotest 2000 results.
7.25 The OCCABA was placed on a computerised test bench, which was set to the parameters for the non-military version of the unit. The set failed a number of tests, indicating that the complete set was in need of a full service and calibration. The result of most concern was the failure of the set to provide a positive facemask pressure on any of the three breathing rates.[E429] A negative facemask pressure can allow toxic gases to enter the facemask when the wearer inhales. The adverse affect of personnel with beards using breathing apparatus is covered in more detail at Section 3 of this report.
7.26 While this is the test result of only one OCCABA, it was selected at random and may indicate a more general problem with the servicing and maintenance of the equipment throughout the Navy.
7.27 Other matters raised by FESA technicians were:
a. The mass of the apparatus fully charged and ready for use is 19kg. This exceeds the maximum of 18kg for compressed air breathing apparatus in AS/NZS 1716:1994.
b. Breathing apparatus should be serviced as per section 8 of AS/NZS 1715:1994. Point 8.3 of section states ‘In all cases the manufacturer’s instructions should be observed when servicing self-contained breathing apparatus’.
7.28 The details for servicing WESTRALIA OCCABA are outlined in the planned maintenance schedule. This schedule details the weekly, monthly, three monthly, six monthly, twelve monthly and twenty-four monthly requirements. The twenty-four monthly requirements require the complete set to be sent away for servicing and calibration.[E102]
7.29 The manufacturer of the RAN’s OCCABA recommends that the pressure reducer valve should be serviced annually. As the pressure reducer is attached to the backplate this would suggest the complete set should be sent away for servicing annually rather than the 24 months specified in the planned maintenance schedule. No details are available for the servicing of the facemask.[E464]
7.30 A complete set is made up of a number of key components. The major components that are readily separated include the cylinder, backplate (included main valve assembly and pressure reducer) and face mask. In the WESTRALIA the cylinder and backplate are numbered but not the facemask.[T1350] The numbering of these
119 FIREFIGHTING AND SAFETY EQUIPMENT components would enable them to be traced to ensure they meet the requirements of the planned maintenance schedule.
7.31 To ensure all components are serviced at the appropriate intervals the facemask and backplate must be given the same number. This will overcome the problem of facemasks being interchanged onto different backplates. As not all OCCABA are serviced at the same time it is possible, by interchanging facemasks, for facemasks to miss being serviced. This increases the risk of worn or faulty facemasks being attached to a newly serviced backplate, directly affecting the effectiveness of the unit and the safety of the wearer.
7.32 To ensure all OCCABA are maintained in accordance with the planned maintenance schedule, records must be kept of the set numbers and the dates they were last serviced.
Conclusions
7.33 The Board has serious concerns regarding the servicing of OCCABA sets, the unacceptable number of equipment failures and the monitoring of the servicing. The Board also notes that the OCCABA sets exceed the weight recommended by the AS/NZS 1716:1994.
7.34 RAN OCCABA sets have three high-pressure hand wheels. If these are not fully tightened damage to O-rings can result. As there are three high pressure connections rather than the one found on BA generally, there is a three-fold risk of failure.
Recommendations
7.35 The Navy should review its policy on the servicing of OCCABA to ensure it meets the highest standards and meets the manufacturer's instructions.
7.36 A Navy instruction should be distributed outlining the following:
• The type and part number of the O-ring to be fitted to OCCABA.
• Cylinder servicing - outlining care and maintenance procedures for O-rings.
7.37 All facemasks should be numbered and matched to a backplate.
7.38 A system should be implemented in ships to record OCCABA set numbers and dates serviced.
7.39 Standard operating procedures should be reviewed to ensure high- pressure hand wheels are tight before cylinders are opened (part of the donning procedure).
7.40 The Navy should investigate the purchase of new breathing apparatus that has fewer hand wheels and complies with the Australian Standard.
120 FIREFIGHTING AND SAFETY EQUIPMENT
Breathing Apparatus Ancillary Equipment
7.41 The vast majority of professional fire services today fit distress signal units (DSU) on to their breathing apparatus. The DSU is a self-activated detector which emits a loud piercing beep if the BA wearer stops moving. Should a BA wearer be injured or become unconscious the DSU will activate, alert other people to a problem and guide rescuers to the person by listening to where the noise is coming from.
7.42 Attached to the key that activates the DSU is a BA tag that is utilised to record the name of the wearer and cylinder pressure. The BA tag is given to the board marker on entry. Therefore before entry the key is removed with the BA tag and the DSU is activated. The BA tag slips onto the BA control board and is the record of entry for the wearer. The board marker calculates the time due out and includes other details as required. On exiting the scene the tag is taken off the BA board by the maker and given back to the wearer to deactivate the DSU.
7.43 This approach assists the BA board marker keep the entry control records correct. The board maker does not have to try and recognise the name of the wearer on entry and when the person exits they must get the tag from the marker to turn off the DSU. If they do not collect the tag, the DSU normally goes off to remind them they are still logged in on the BA control board. This method of entry control may have alleviated the problem of LS Nunn’s name not being removed from the control board. Had he been missing, as the board marker thought, and was either lost or unconscious within the MMS, the DSU would have assisted the searchers to locate him.[T1336]
Conclusions
7.44 BA control tags are available to assist board markers maintain entry control.
7.45 Distress signal units are an additional safety device that can be fitted to OCCABA.
Recommendations
7.46 The Navy should fit DSUs and BA control tags, if they are acceptable for marine use, to all OCCABA.
Bauer Compressors
7.47 During firefighting operations the crew members of the WESTRALIA were concerned they would run out of fuel for the Bauer and called for additional supplies from other navy ships.[T738, T385] The fuel from the other ships arrived and fuel was taken from one of WESTRALIA’s cargo tanks, which ensured there was no interruption to the process of charging cylinders. However the call for supplies highlights the need to store spare fuel away from the MMS so that the Bauer can be topped up during emergencies.
Conclusion
7.48 The ship had no spare fuel supplies for the forward Bauer compressor.
121 FIREFIGHTING AND SAFETY EQUIPMENT
Recommendation
7.49 Fuel should be stored in a convenient position to re-supply the Bauer compressor.
ANCILLARY FIREFIGHTING EQUIPMENT
Communication with hose teams
7.50 Portable communications equipment (Maxons) although initially serviceable were not reliable or trusted.[T449, T544, T627, T630 T667, T1385, T1531] A significant number of people came before the Board and told of the problems that occurred with the Maxon radios. They got wet during firefighting operations and failed: this may be a result of a failure to use the waterproof bag provided for each unit. They did not work when some hose teams were within the MMS. The wrong buttons can be depressed when trying to transmit messages – compounded by the wearing of anti-flash gloves.[T627, T654 T784] The problems were mainly associated with communications between the hose teams and the scene leader.[T633]
7.51 As the Maxon was the only direct link between the hose teams and Aft DC Section Base and they did not always work, both parties had to rely on the use of runners to relay the information.[T640, T669] With teams working in dangerous situations where there was high risk of injury or the need for assistance, reliable radio communications are an operational necessity.
7.52 To overcome the communications problems often experienced between operational hose teams and command, a number of companies now produce a variety of systems for use with BA. They can come as compact microphone/loudspeaker units designed to be installed in the BA facemask, others fit in the helmet and some are also voice operated for hands free operation.
7.53 In an MMS environment where there may be noise and in situations where team members may not have free hands to operate a radio, these new systems would significantly improve the safety and effectiveness of hose team operations. The Board is aware that the RAN does have some hands free microphones attached to the Maxon for use by hose team leaders. None was used in WESTRALIA during the fire.[T626, T639-640, T771] The usefulness and allocation to ships of currently available systems as well as systems available on the market should be further investigated.
Conclusion
7.54 The Maxon radios did not work effectively on the day and communications with the hose teams failed on occasions.
Recommendation
7.55 The Navy should determine whether more effective and reliable portable radio communication systems than the Maxon are available for use within the ship.
122 FIREFIGHTING AND SAFETY EQUIPMENT
7.56 A voice activated radio communication device should be fitted to a number of OCCABA in each ship.
Emergency Fire Pump
7.57 As the MMS fire pumps were unavailable for use, the forward emergency fire pump was started to charge the fire main for firefighting operations. When WO Bottomley checked the gauge in the MCR a pressure of approximately 110psi was being supplied to the main.[T57] The pump provided an adequate fire main pressure throughout the day to sustain the lines of hose in operation. There was some concern that the pump was going to run out of fuel.[T400]
7.58 WESTRALIA requested incoming personnel from the other ships to bring fuel for the fire pump [T1139]. By the time the fuel arrived on WESTRALIA members of the crew had already used containers tied to ropes and dropped into the cargo tanks to extract fuel for the forward pump [T434]. While this approach was successful, personnel should not have had to rely on such primitive and potentially dangerous methods to keep the pump running.
7.59 The wordings of the Lloyds and SOLAS regulation on fuel supplies are virtually identical. The Lloyds regulation states ‘Any service fuel tank is to contain sufficient fuel to enable the pump to run on full load for at least 3 hours and sufficient reserves of fuel shall be available outside the MMS to enable the pump to be run on full load for an additional 15 hours’. Nobody on board knew of these requirements and the WESTRALIA did not have such an emergency fuel reserve.
Conclusions
7.60 There were no reserve supplies of diesel fuel for the emergency fire pump.
7.61 Current Lloyds and SOLAS regulations state 15 hours reserve fuel must be available outside the MMS.
7.62 Regardless of the Lloyds or SOLAS requirements, the endurance of the fire pump should have been known by the command team and spare fuel should have been kept in an accessible place outside the MMS.
Recommendation
7.63 HMAS WESTRALIA should comply with the Lloyds and SOLAS requirements for emergency fire pump fuel supplies.
SAFETY EQUIPMENT
Torches
7.64 Whilst no personnel came before the Board and complained of lack of torches it appears there were either not a lot available in the ship, or the resources that were available were not fully utilised. Evidence given indicates that personnel were conducting
123 FIREFIGHTING AND SAFETY EQUIPMENT operations within the MMS and the after pump room sharing one torch or with no torch at all [T2279, T659]. As these areas were either very dark or smoke logged, this practice was dangerous and could have caused a serious accident. Comment was also made that the battle lanterns were awkward to use [T768].
Recommendations
7.65 Navy should conduct an evaluation on the battle lanterns to determine their suitability.
7.66 An inventory should be undertaken to determine if there are enough torches on board WESTRALIA.
Helmets
7.67 Some of hose team members made reference to the need for helmets. They described how hot water or dripping plastic fell on their heads and burnt them through their antiflash gear.[T768, T516, T544] Although no serious injury was sustained, the hot material probably added to the stress experienced by the hose teams.
7.68 In any firefighting scenario there is always the chance of a hose team member sustaining a head injury. Modern firefighting helmets produced to the Australian Standard provide head, neck and face protection.
Conclusion
7.69 The hose teams had inadequate head protection.
Recommendation
7.70 Helmets should be introduced for hose team members.
ELSRD
7.71 An Emergency Life Support Respiratory Device (ELSRD) is composed of a fire resistant hood with a clear face piece attached to an air bottle with eight minutes supply of compressed air. They are designed for escape from compartments containing hazards such as toxic gases and smoke.
7.72 Six ELSRDs are located in WESTRALIA’s MMS. They can be used by personnel in need of an emergency air supply to evacuate the area. The ELSRDs are positioned on the bottom plates each side of the catwalk near the ladder leading to the middle plates.
7.73 At the start of the fire there were eight people in the MMS and they were located on different levels. When the fire started the majority of personnel moved rapidly to leave the area or fight the fire. PO Francis and PO Smith ran past the ELSRDs stored on the bottom plates but neither grabbed and put on the device. PO Francis later tried,
124 FIREFIGHTING AND SAFETY EQUIPMENT unsuccessfully, to find an ELSRD.[T1462.1] There is no evidence to suggest that anybody else in the space tried to locate and put on an ELSRD.
Conclusion
7.74 The number of ELSRDs within the MMS was insufficient and confined to the bottom plates.
Recommendation
7.75 The number of ELSRDs in the MMS should be increased from six to at least six on each level and placed on or near the escape routes, clearly identified and readily accessible.
125 SECTION 8. MATERIEL STATE OF THE SHIP
DEFECTS
Urgent Defects (URDEFS)
8.1 On departure on 5 May 98 all but one urgent defect had been rectified [T66, E279] and relatively few other defects remained outstanding [E280]. The one outstanding priority 2 URDEF on the AVCAT cargo system (45/97) was to be rectified at the next Assisted Maintenance Period (AMP). The recent AMP 12 was considered to be one of the best [T19 and T798] although there was some disappointment at the low take on of work. Recovery from the poorly regarded 1996 refit [E370, E285] seemed all but complete.
Fuel leaks
8.2 Fuel leakage had been a perennial problem that caused concern on a number of occasions [E369 and E188A para 27]. In the period between a refit which took place in 1996 and before AMP 10 which was carried out from 24 November - 21 December 1996 [E373], CMDR Ladomirski, then CO WESTRALIA, raised a minute to the Ordering Authority Western Australia (OAWA) attaching a list of defects. The list included numerous fuel leaks.[E137]
8.3 LCDR Crouch joined the ship as the Marine Engineer Officer (MEO) in November 1996. He became aware of the extent of the fuel and oil leaks in January 1997 when WESTRALIA sailed south to participate in the Bullimore rescue [E188 para 18]. In evidence he described the fuel leaks as follows:
…There were a number of lube oil leaks, just coming from joints, flanges, but there were also a number of fuel leaks coming from underneath, or around the injector pumps and from the connecting blocks. In order to get at these leaks in a lot of cases we have to remove injector pumps or connector blocks and it was made extremely difficult by having to manipulate solid lines.[T2844]
8.4 The concern was sufficient for COMFLOT, CDRE Cox, to interview the Engineer, LCDR Crouch in about September 1997 to explore the wisdom of proceeding to sea at that time.[T3445, T2841] The judgement was made that the leaks were no worse than usual and that they would be reduced by routine maintenance. The situation is probably described quite well by POMT Nikiforus (who served in the ship from May 95 to May 96 and January 98 to 4 May 98) in his statement.[T2860]
At times, fuel lines leaked although not seriously as far as I am aware. It was not unusual to have minor diesel fuel leaks. As soon as these leaks were identified, however, every effort was made by the Engineering Department to repair them quickly. I had never seen diesel leaking from the fuel lines become atomised.
8.5 The last engineering sea check was conducted during the period 30 September - 2 October 97 with an assessment given as Standard Achieved Minus. The report of this check [E232] indicated the following points:
126 MATERIEL STATE OF THE SHIP
There were a large number of fuel and oil leaks in the Main Engines and Diesel Alternators [in excess of 100 individual leaks]. Despite this, the main spaces were presented with minimal fuel/oil accumulation and were considered safe to operate, provided that the level of cleanliness achieved was maintained. The report concluded that the ship required time alongside with no external activities to rectify many of the fuel leaks.
8.6 Repairing leaks in the fuel system was often a time consuming task because of the difficulty encountered in removing and refitting the rigid supply and return lines from the fuel rails to the cylinder fuel pumps. The idea of replacing these lines with flexible ones was directed at making rectification of leaks in other parts of the system quicker and easier, rather than replacing an intrinsically poor component. Fuel leaks were recognised as dangerous and wasteful. Ironically it was the attempt to improve safety that led to the fire.[T3353-3554, T2844, T1664, T2229]
8.7 The new flexible fuel hoses are discussed in Section 9 of this report and the conclusion is drawn that they were defective.
Fuel system
8.8 The fuel back pressure system was worked on during AMP 12 by the contractor. The ITT pressure regulating valve on the fuel return line is designed to maintain a back pressure of 5-6 bar. This valve, controlled by air signals, was said to have been overhauled during AMP 12 as work instruction A1167. When the engine was tested after the valve had been refitted, with the fuel flow direction in accordance with the markings on the valve, there was erratic movement of the controller on the valve.[T2734] The valve was removed and turned round. Mr Morland of ADI gave an opinion that ‘. . . one of the controllers was a little bit still erratic, but it actually did the job that it was required to, yes.’[T2735]
8.9 The Board heard evidence of possible over-pressurisation of the fuel return system and some pressure gauges. It was suggested that rapid closing of the ITT pressure regulating valves may have augmented the fuel pulse pressure and contributed to the failure of the flexible fuel hoses.[T4081] The ITT valves were removed for examination and testing in the presence of RAN and ADI representatives.[E480]
8.10 This examination showed that the valve plugs (poppets) had broken away from the valve stems. When aligned correctly this allowed fuel to flow without any back pressure. When the valves were turned round and incorrectly aligned it appears that the valves partially restricted the fuel flow and created sufficient back pressure to allow the engine to operate. In this condition the valves could not close and any effect on the pressures in the fuel system would have been minimal. As Dr Goodwin stated ‘The chosen solution simply hid the problem’.[E481]
8.11 Evidence before the Board suggests that WESTRALIA had difficulty in achieving full power when the shaft generator was on line.[T1620, T1688] As the fuel oil pressure in the return line was low, the injection pump galleries may not fill at each injection stroke. ‘Under these conditions, the engine might fail to run or might fail to achieve full power.’(Goodwin)[E481]
8.12 The examination could not determine with absolute certainty whether or not the valve became detached before or after it had been refitted, although the expert from Western Process Controls considered that the valves had been broken ‘for some
127 MATERIEL STATE OF THE SHIP considerable time’.[E480] Grease and dirt around the spindle suggested that the valve had not in fact been opened up recently.
8.13 The TM200, signed by LCDR Crouch required, amongst other things, for ADI to:
a. inspect stripped units on receipt of opening report;
b. to witness workshop trials.
8.14 The ADI work order (WO976006) to the sub-contractor omitted these requirements.[E145] The required inspections were not completed. Although the work order was signed by Mr Morland, the ship had refused to sign for the work based on the unsatisfactory engine trials.[E480]
Recommendation
8.15 Correct installation and operation of the fuel back pressure system should be confirmed before further use.
8.16 WESTRALIA’s sister ship BAYLEAF had an MMS fire in November 1997 [E21]. The Board obtained an executive summary of the RFA’s report on that fire. That report, which included a copy of Crossley service bulletin 51 issue 2 (first issued in 1978), expressed concern ‘that the fuel isolating cocks fitted to the fuel rails appeared to be of a design not suited to this particular engine’.[E267]
8.17 Service bulletin 51 identifies which of a variety of cocks are suitable for the Pielstick PC2.2V engines dependant on the engine serial number. For WESTRALIA’s engines (serial numbers 18104 and 18105), the originally fitted Auxim cocks should have been replaced by Orseal cocks. The Orseal cocks were prone to leakage and should have then been replaced by a ball valve (PC16677). Although the bulletin is less than clear, it appears that WESTRALIA should now be fitted with modified Auxim cocks (PC 20005) which are identical in appearance and interchangeable with the superceded cock PC 7559. The Bulletin does acknowledge that a Schneider type cock can be fitted to WESTRALIA’s engines and that these cocks have a more positive shut off.
8.18 The BAYLEAF report does not specify which cocks were fitted but alerts to thread incompatibilities if the wrong cock is used. The Board instigated an audit of the actual cocks currently fitted and the results are in Board document MR090.[E472] The audit found that a mixture of cocks are fitted, including those deemed unsuitable by the service bulletin. In addition, many of the cocks had missing or damaged locking plates. Although these cocks had no part to play in this fire, they appear to pose a major danger. The engineering staffs on both BAYLEAF and WESTRALIA were apparently unaware of the existence of Bulletin 51.
Recommendation
8.19 Appropriate fuel isolating cocks should be fitted to the fuel rails.
128 MATERIEL STATE OF THE SHIP
Main engine controls
8.20 The ship has suffered a number of main engine control problems [e.g. T20-21, T62A-63, T1465, T1612, T1656] but none is relevant to the events of 5 May 1998.
Ships communications - external
8.21 When the power was isolated from the main switchboard and the emergency source of electrical power started, normal radio communications were lost. Evidence was given that the emergency power to the radios was through the emergency switchboard and there was no transitory battery supply. After the fire started, power ‘spikes’ made the radio sets in the communications centre inoperative. The communications centre then had to be abandoned because smoke was being drawn in through the air conditioning duct [T3473].
8.22 Notification of the emergency was undertaken by mobile telephone. Other critical messages throughout the emergency were passed in the same way or by means of either hand held VHF radio or the bridge VHF sets on channel 69.
8.23 A portable ‘Raven’ radio was initially set up adjacent to the flight deck but no reception was achieved. The set was moved to the bridge top and communications established.[T3473]
Recommendation
8.24 The emergency power supply to essential radio communications equipment should be reviewed.
Communications - internal
8.25 The ships fitted communications systems performed well given the severity of the fire and the damage to power supplies. Although functional, there were many complaints about the sound quality of the sound powered circuits [T1629, T1599, T1691].
8.26 Hand held radio communications have been discussed in Section 7.
Recommendation
8.27 The ship’s sound powered circuits should be checked for proper operation.
Main machinery space gas tight integrity
8.28 WESTRALIA’s MMS is separated from the accommodation by steel bulkheads and decks rated ‘A60’ for fire resistance. Under SOLAS rules, the bulkheads and decks between the MMS and the accommodation area are required to be suitably stiffened and able to prevent the passage of smoke or fire of a standard fire test for one hour. ‘A60’ bulkheads are insulated with approved non-combustible materials such that the average temperature of the unexposed side will not rise more than 139°C above the
129 MATERIEL STATE OF THE SHIP original temperature, nor will the temperature at any point, including any joint, rise more than 180°C above the original temperature within the 60 minute period.
8.29 The forward bulkhead between the MMS and the pumproom was of steel but was not required to be insulated, and was rated as ‘A0’. There was no time criteria relating to the rise in temperature through this bulkhead.
8.30 To maintain integrity, any doors or penetrations of ‘A’ class bulkheads or deckheads are required to meet the same standards as their respective time ratings. The MCR deck was subjected to very high temperatures from the fire in the MMS. Although there was some evidence that the deck became hot, it did not exceed 165°C and reached a temperature in the range of 130°C to 150°C.[E457] The indications are that the heat transfer through ‘A60’ boundaries was minimal.
8.31 The ‘A60’ bulkheads restricted the passage of heat [T1921, T3004], however the gas tightness of the MMS is poor [T1555]. Access doors do not have sealing strips but rely on metal to metal contact [T526-7, T461, T567]. Ventilation flaps are thin and easily distorted. Other doors forming part of the gas boundary have large gaps generally at the bottom. These deficiencies degraded the effectiveness of the CO2 drench and the containment of smoke. Compliance with SOLAS and Lloyds standards is at best, doubtful. The exhaust and supply flaps for the MMS were well maintained. There is a possibility that one supply flap on the port side did not shut when first activated. If this was the case, then the cause is poor design rather than a lack of maintenance. The door between the MMS and the tiller flat was held open by lashings. It could not be closed during the emergency of 05 May 98, and this further reduced the effectiveness of the isolation of the MMS.
Recommendation
8.32 The gas tight integrity of the MMS should be brought up to the required standards.
Penetrations into MCR
8.33 The flames from the fire on the SME were impinging on a bulkhead adjacent to the engine on the outboard side and the steel plates that form the deck of the MCR and switchboard compartment. There is evidence that upon hitting the starboard bulkhead and the MCR deck the flames rolled forward, aft and to the port side.[T1857-1858]
8.34 There were various electrical cables on the bulkhead directly above the engines that were burnt during the fire [E246 photos P&Q]. Smoke and toxic gases being given off by the burning insulation would have added to the quantity of gases being generated in the MMS. The glands around the electrical cables and pipes passing through the deck did not prevent smoke from entering the MCR [T2835]. The cables were quickly burnt in the fire which then affected the shutting down of machinery, communications to the bridge and the MMS evacuation siren [T1625, T2835].
Conclusions
8.35 The penetrations in the MCR deck for the passage of electrical cables and pipes had not been properly sealed.
130 MATERIEL STATE OF THE SHIP
8.36 The electrical cable runs above the engines are poorly located.
Recommendations
8.37 All cable and pipe penetrations between the MMS and the MCR should be sealed to prevent smoke entry.
8.38 The electrical cables above the engines should be either relocated or covered with a fire resistant material.
Fixed CO2 firefighting system
The system
8.39 SOLAS 74/78 requires that the MMS of a ship be protected, in the event of fire, by a fixed CO2 fire extinguishing system. The required volume of CO2 is calculated on the basis of a MMS volume of 5793 cubic metres, which includes the free air in the main engine air start cylinders.[E116] To reduce the atmosphere in the MMS to one that will not support combustion, the total CO2 release must equal 35 per cent of the total space. This would reduce available O2 to 14 per cent by volume, which is below the level that can support combustion.
8.40 Based on 0.56 kilogram to a cubic metre, the MMS required 81 x 45 kilogram cylinders of CO2 to meet this standard. The ship was in fact equipped with 82 cylinders that are stored in the CO2 bottle store on 1 deck. The requirement is that 85 per cent of the CO2 be released into the MMS within two minutes.
8.41 The FCR, from where the CO2 smothering system can be activated remotely, is situated on the port side aft on 01 deck. The door opens out onto the quarterdeck. Inside the space are the controls for the CO2 release, the forced ventilation shut-offs and the remote closing valves for the ship’s fuel tanks. The space also contained the shore power connection for the ship’s electrical system.
8.42 There are two sets of CO2 discharge valves in separate boxes, one for the MMS and one for the aft pump room. The system is designed so that if either box is opened a siren will sound in the MMS or the aft pump room.
8.43 The CO2 is released by a sequential pulling of levers to prime the control system. The first is to build up pressure to the ‘pilot cylinders’ and automatically activate valves in the CO2 room. The second is to activate the release mechanism for either 82x45 kilogram to be dumped into the MMS or 23x45 kilogram cylinders into the aft pump room. Each space has a separate control box for the release of the CO2.
8.44 Instructions are fixed to the outside of door rather than the inside. The cylinder that should be operated first is labeled ‘2’ and the cylinder that should be operated second is labeled ‘1’.[E256] The EOOW, who activated the system on 5 May and was familiar with its operation, acknowledged that he had one unsuccessful attempt before checking the instructions and trying again [T1723].
8.45 Not all the CO2 cylinders discharged. The evidence is that ‘two banks’ failed to discharge.[T29, T60, T61, T1631] The actual number of cylinders that failed to
131 MATERIEL STATE OF THE SHIP discharge is not known with certainty. Subsequent testing of the system suggests that 53 cylinders probably discharged initially, or 64 per cent of the available CO2.
8.46 The initial release of 53 cylinders of CO2 if it had all discharged to the MMS, would theoretically have reduced the oxygen level to just over 16 per cent. This would be sufficient to support continued combustion, but at a poor rate of burning. The delay in the discharge of the remaining cylinders may have allowed the fire to draw in more air from outside the MMS. The second release of CO2 would also have reduced the oxygen level. CO2 , being heavier than air, would have had a greater effect at the bottom plates.
8.47 Testing of the CO2 release system demonstrated that the system failed to activate correctly because of inadequate tensioning of the actuating wires. In one test the actuation wire to the inboard bank of cylinders jumped off the guide pulley and jammed before the ram reached the full extent of its travel.[E453] In other trials, the operating ram reached the end of its travel before actuation of the cylinders was achieved. Many leaks were also discovered. The mist observed by WO Bottomley and others [T28] was caused by some leaks on the flexible piping system between the cylinders and the rigid steel piping to the MMS and pump room.
Conclusion
8.48 The Board concludes that the CO2 system was not well maintained and failed to operate correctly because of incorrect tensioning of the actuating wires.
Recommendations
8.49 All RAN fixed firefighting systems should be checked to ensure:
• operating instructions can be clearly seen by the person operating the controls
• all valves and levers are clearly labelled and logically numbered
8.50 WESTRALIA’s CO2 system should be thoroughly overhauled before being set to work again.
Ships firemain
8.51 The absence of firemain pressure gauges outside the MCR is a serious shortcoming. Evidence was given that after the fire started the only way of establishing the pressure was for WO Bottomley to re-enter the MCR in OCCABA to read the gauge. Knowledge that the pressure was sufficient was vital before committing hose teams to fight the fire. Direct monitoring of the pressure from HQ1 or the section base may have given the command the confidence to use more hoses and attack the fire on an additional front.[E3]
Recommendation
8.52 Firemain pressure gauges should be fitted in HQ1 and the Damage Control section bases
132 MATERIEL STATE OF THE SHIP
Exhaust leakage
8.53 Leakage from the engine exhausts seems to be another regular problem for the ship [T593, T664, T706]. Besides the health risks the exhaust gases and smoke from new lagging fitted following repairs have repeatedly triggered the fire alarm system.[T3206-7, T390-1, T442] The standard practice has been to isolate the alarms in the MMS zones for a period when proceeding to sea. On occasions, alarms in other zones have been triggered by exhaust gas. Work was completed during AMP 12 to fix exhaust leakage and this may have been successful. Different fire sensors may be better at avoiding false alarms and this should be investigated. This is addressed more fully later in this section.
Indicator cocks
8.54 The indicator cocks and lines in WESTRALIA are unlagged. These fittings are hot, in close proximity to the fuel lines and, being directly connected to the cylinders, reach temperatures close to that of the engine exhaust. Ignition of leaking fuel by a hot indicator cock was observed in the BAYLEAF fire and, as discussed elsewhere in this report, an indicator cock is the likely source of ignition for WESTRALIA’s fire. According to Mr Gillespie of Rolls Royce [E185] the engines were originally fitted with lagging and shielding to reduce the outside surface temperature to less than 220°C. Although he does not specifically mention lagging of the indicator cocks, there is a strong inference that they should be lagged. Further investigation is required.
Recommendation
8.55 Investigations should establish whether the indicator cocks should be lagged and or shielded. If appropriate, insulation and shielding should be fitted.
Future of the injection pump suction and spill pipework
8.56 As discussed in other parts of this report the new flexible hoses were unsuitable. The options for reinstating the system appear to be either to refit the original rigid system with its known problems and dangers or to procure and fit the purpose designed modification from the manufacturer. The new arrangement has apparently not been fitted to any PC 2.2V engines and would be a prototype if fitted to WESTRALIA. The fuel lines can be either flexible or steel. The Board has obtained some basic price and availability information and has passed it to the Class Logistics Office.[E451] As discussed in Section 9, the magnitude of the spill pulse pressures is not known with any certainty, there are doubts about whether any flexible hose is suitable for this application.
Recommendation
8.57 In the absence of information about the actual magnitude of the spill pulse pressures and a lack of clarity about whether any flexible hose can withstand this operating environment, a new piping arrangement, using the rigid steel option, should be procured from the engine manufacturer and fitted.
133 MATERIEL STATE OF THE SHIP
Drawings and Technical Documentation
8.58 The technical documentation available to the ship is generally poor. Although the Board has not researched this issue in any depth, the quality of drawings and information (e.g. The Main Engine fuel system), and the detailed understanding by the crew of their ship has been disappointing. Of particular concern has been the rudimentary knowledge of emergency systems including the CO2 drench. CMDR Stapley’s submission [E355] points to improvements in the ship’s technical documentation since the ship was acquired but suggests that WESTRALIA is not up to the standard of other RAN vessels.
Recommendation
8.59 Although the remaining life of the ship is short and the provision of a satisfactory set of ships drawings and documentation is unlikely to be achievable, priority should be given to providing accurate information on the ships emergency arrangements.
Maintenance Funding
8.60 Claims have been made by some personnel that WESTRALIA maintenance is underfunded and that she is the ‘poor relation’ compared to SUCCESS.[T103, T539, T675, T1382] There is no objective evidence to support such claims. In fact, some observers who know the ship well commented that when she sailed on 5 May 98, she had never been in such good condition [e.g. WO Bottomley T249 and PO Nikiforus E186, T2860]. According to the CO [T3212] ‘the level of funding is as good if not better than most of the other ships’.
8.61 CMDR Coverdale noted in evidence that during AMP 11 the budget of $1 million was overspent by $630 000.[T3284.4]
Conclusion
8.62 The ship’s maintenance history does not support the proposition that there was any policy to reduce or deprive WESTRALIA of funding. In 1996 the ship spent six months undertaking an extensive refit. The ship undertook AMP 10 early in 1997. AMP 11 involved a significant over-spend of the budget allocation.
CLASSIFICATION REQUIREMENTS AND INTERNATIONAL STANDARDS
Lloyd’s Certificates
8.63 WESTRALIA is classed as a ‘tanker under survey’ by Lloyds Register of Shipping. Class certificates are carried covering the provisions of: • the International Load Line Convention 1966; • the Safety of Life at Sea Convention 1974; and • the 1978 Protocol, as it relates to construction and machinery.
134 MATERIEL STATE OF THE SHIP
SOLAS
8.64 The SOLAS Convention sets minimum international standards relating to aspects of ship safety including construction, machinery, electrical installations, fire protection, fire detection and fire extinction for vessels on international voyages. The International Loadline Convention relates to the watertight integrity of ships and the depth to which they may load in safety. The SOLAS convention was extensively amended in 1981 and 1983 and these later amendments do not apply to WESTRALIA. As a minimum standard, the ship is required to meet the provisions of the two conventions, as well as the relevant Lloyds Rules and Regulations for the Classification of Ships.
8.65 SOLAS 74/78 covers extensive safety requirements of the ship’s subdivision and stability, machinery and electrical installations. It also covers fire safety measures for ships carrying Convention certificates.
Surveys
8.66 Under the provisions of SOLAS, merchant ships are subject to a five-year cycle of survey to ensure compliance with various international safety and pollution prevention conventions. The survey cycle consists of an initial ‘Special’ survey, ‘Annual’ surveys (essentially visual inspections to ensure that standards are maintained) and, midway through the cycle, an ‘Intermediate’ survey when a more thorough examination of the ship is conducted. In the case of older ships, particularly tankers, the rigour of examination is increased at 16 years, thereafter every five years such a ship is subject to an ‘Enhanced Special’ survey. In July 1996 WESTRALIA underwent an ‘Enhanced Special Survey’ while in Newcastle. The survey included extensive testing of the hull thickness and condition.
8.67 The items for survey include requirements contained in Chapter II of SOLAS 74, as amended by the 1978 Protocol, for5: • Emergency Source of Electrical Power (Ch.II-1, Reg 26) • Precautions against Shock, Fire and other Hazards of Electrical Origin (Ch.II-1, Reg 27) • Steering Gear (Ch.II-1, Reg 29 as amended by 1978 Protocol) • Fire-Extinguishing Systems and Equipment (Ch.II-2, Reg 52) • Means of Escape (Ch.II-2, Reg 53 & 59) • Special Arrangement in Machinery Spaces (Ch.II-2, Reg 54)
International Standard for Emergency Source of Electrical Power
8.68 The requirement for an emergency source of electrical power is satisfied by the fitting of a generator located above the uppermost continuous deck and outside the machinery casing. Under SOLAS 74/78,
The power available shall be sufficient to supply all those services which are, in the opinion of the Administration, necessary for the safety of all on board in an emergency, . . . The services must include emergency lighting, the general alarm system and navigation lights.
5 International Convention for the Safety of Life at Sea, 1974, London, 1975 (Reprint 1982)
135 MATERIEL STATE OF THE SHIP
8.69 WESTRALIA’s emergency power system exceeded these requirements. In fact they accorded with more stringent Lloyd’s requirements and the 1982/83 amendments, which require, inter alia, the generator to:
a. start automatically in the event of the failure of the main generators;
b. supply power to the navigation equipment;
c. supply power to one of the steering motors.
8.70 When the main switchboard room was isolated at the outbreak of the fire, the emergency generator started automatically and connected to the emergency switchboard. It was reported that this occurred within 15 seconds, well within the maximum time provided by the Convention. Initially there were power ‘spikes’ probably caused by circuits that ran through the MMS shorting out. After a short period, [E16A & E16B], a constant supply was available to the bridge navigation equipment and the emergency lighting.
8.71 Following the fire it was established, on behalf of the Board, that the wiring from emergency switchboard to the navigation equipment on the bridge was in good condition. This was consistent with the maintenance of power to the navigation equipment on 5 May.
8.72 It was also confirmed that the electrical continuity and insulation of the 440 volt supply cables between the emergency switchboard and one of the steering motors was in good condition. This cabling was routed outside the MMS. However, the control circuits to allow change over from main to emergency steering pass through the MMS. Steering from the bridge could have been lost as the 230V control cabling passed through the MMS and was damaged. However, the 440V supply would have provided power to allow the vessel to be steered from the tiller flat.
8.73 The emergency supply apparently did not conform to Lloyds Rules Chapter 6, section 2.3.3 which requires the emergency source of electrical power:
. . . to be such as to ensure that a fire or other casualty in the space containing the main source of electrical power . . . will not interfere with the supply, control and distribution of electrical power.
8.74 The absence of up to date wiring diagrams and drawings made a full analysis of the materiel state of the emergency switchboard and cabling unachievable during the course of the Board of Inquiry.
International Standard for Means of Escape
8.75 For escape from machinery spaces SOLAS 74/78, Regulation 53, requires:
In machinery spaces, two means of escape, one of which may be a watertight door, shall be provided from each engine room, shaft tunnel and boiler room. In machinery spaces, where no watertight door is available, the two sets of steel ladders as widely separated as possible leading to doors in the casing similarly separated and from which access is provided to the embarkation deck.
136 MATERIEL STATE OF THE SHIP
8.76 Escape routes from spaces, including the MMS, are items of survey under Lloyd’s Rules (Pt.6. Ch.4, Section 19.4.3). Lloyd’s provisions, though similar, exceed the SOLAS 74/78 requirements. For ships similar to WESTRALIA:
Two sets of steel ladders as widely separated as possible leading to doors in the upper part of the space similarly separated and from which access is provided to the open deck. In general, one of the ladders is to provide continuous fire shelter from the lower part of the space to a safe position outside of the space. However, the shelter may not be required if, due to the special arrangement or dimensions of the machinery space, a safe route from the lower part of this space is provided. This shelter is to be of steel, insulated where necessary and provided with a self closing steel door at the lower end. If access is provided at other levels each level is to be provided with a steel self closing door.
8.77 In WESTRALIA there are two emergency exits from the MMS. One is the forward bulkhead at the ‘middle’ plates level. This escape is an exposed steel ladder with an access to the main switchboard room and thence to the hydraulics room on 1 deck. At the after end of the MMS, there is a ladder from the bottom plates level on the starboard side, between frames 14 and 15. This ladder extends only to the middle plate level. Any person trying to escape by this route is then forced to move forward to the normal after access ladder leading to the top plates. The route then goes aft to the steering flat, from where there is a vertical steel ladder to the fridge flat.
8.78 The Board is concerned that such an arrangement has been approved by Lloyd’s. Of equal concern is that such an escape route has been accepted by successive crews in WESTRALIA and has not been identified by any audit of the space by other Navy staff.
8.79 Mr Ridland, Area Manager for Australasia of Lloyds Register of Shipping was asked questions relating to the emergency escapes from the MMS. It was pointed out to him that there was no vertical ladder between the bottom plates and the middle plates at the after end of the MMS. He was asked if that conformed to Lloyds Rules or SOLAS [T4062]. Solicitors acting for Lloyd’s provided the following response in a facsimile responding to questions asked of Mr Ridland, which he had taken on notice.
The two means of escape from the engine room are checked at annual survey.[E415]
Conclusion
8.80 The Board notes the failure of Lloyd’s to answer the questions and in the absence of further advice, the Board considers that the arrangements for means of escape from the MMS is not in the spirit of the Convention requirements and is dangerous.
Recommendation
8.81 The Board recommends that enclosed escape arrangements be fitted at both ends of the MMS as a matter of urgency.
137 MATERIEL STATE OF THE SHIP
ENHANCEMENTS
8.82 In the course of the Inquiry, the Board identified a number of ship enhancements that would improve safety. These are discussed in the following paragraphs.
Configuration of MMS Ladders
8.83 The ladder system in the MMS consists of the following: • Port and starboard central ladders from the bottom plates to the top plates, • Forward escape ladder from the middle plates to the electrical switch room, • After escape ladders, bottom to middle and top plate to fridge flat, • Port and starboard ladders from the top plates to the junior and senior change rooms. 8.84 Due to the design of the ship, the central ladders (the main escape route) are the quickest and sometimes only means of egress from the MMS.
8.85 The construction of the ship above the main engines makes it highly likely that, with a large engine fire, flame will impinge on the MCR deck. Evidence given to the Board details the flame and heat hitting the deck of the MCR rolled outwards and rendered the forward escape ladder from the bottom plates to the switch room unusable almost immediately [T1857, 1858].
8.86 The fire modelling analysis that was carried out indicates the temperatures that could be expected around these ladder areas. Figure 8 indicates that one minute after the fire started, the calculated temperature near the forward escape ladder was in excess of 1200°C.
Figure 8. The predicted temperature distribution of the fire incident after 1 minute. The figure shows an aft to forward section through the origin of the fire. The bottom of the picture corresponds to the top of the starboard engine. (Fig 11 of DSTO report)
8.87 The funnel, directly aft of the MCR, created a chimney effect which drew the flame, heat and smoke to this point. The only escape route from the middle plates, other than the forward escape ladder, are those ladders located centrally just aft of the MCR and within the ‘chimney’.
138 MATERIEL STATE OF THE SHIP
8.88 Personnel evacuating the MMS had to proceed from the middle plates to the top plates via the port or starboard central ladder. However the starboard ladder was near where the fire was hitting the bulkhead and was engulfed in flame [T1807]. The flames and heat also rolled aft from under the MCR deck near the port ladder and made egress extremely hazardous.[T1244] Figure 9 indicates the calculated temperature around the top of the port ladder.
Figure 9. Temperatures distribution 1 minute into the event for a cut across the compartment aft of the MCR looking aft. High temperatures of the order of 400°C are predicted to exist at the top of the port ladder (marked with an X). (Fig 12 DSTO report)
8.89 A report of a fire in the RFA BAYLEAF, WESTRALIA’s sister ship, also detailed problems with ladders from the MMS [E21].
8.90 The narrow configuration of the ladders and their location within the MMS made access for the hose teams onto the different levels extremely difficult. During firefighting operations, the number one on the hose teams had to tuck the water wall under his/her arm and descend approximately four metres down a narrow ladder backwards. This activity was undertaken in intense heat with zero visibility and personnel were dressed in OCCABA and protective clothing. The other hose team members also had to descend the ladders in a similar manner and avoid tripping over the hose [T702].
8.91 This procedure, although practiced during training on a regular basis, is difficult, energy sapping and dangerous. On the day of the fire the hose teams were required to undertake this procedure to gain access to the top and then the middle plates. When relieved the hose teams then had to negotiate the ladders again to exit the area. A number of the personnel commented how difficult it was to use the ladders [T702, T762].
8.92 The ladder that created the most difficulty for personnel was the ladder from the fridge flat to the top plate [T627]. To get to the ladder from the fridge flat is not any easy task. On entering the MMS the teams had to veer approximately 90 degrees to the right and then to the left to mount the top of the ladder. This had to be undertaken while trying to bend and twist charged lines of hose [T707, T708].
139 MATERIEL STATE OF THE SHIP
8.93 The ladder concludes in a relatively confined area, which also leads to hoses becoming tangled and getting caught up on objects [T630, T759, T702]. The narrow steep ladder and sharp corners made this route difficult as a way of removing the bodies after the fire was out [T702].
8.94 If a wider and less steep ladder had been fitted to the landing on the fridge flat and went directly from aft to forward (down the centre line of the ship) the majority of the problems would not have arisen. The teams would have had access to the MMS by moving straight ahead and down a ladder that leads to an open space on the top plate.
8.95 The location of the port central ladder between the middle and top plate also caused some difficulties for the hose teams. To get to this ladder the hose team had to progress down a narrow catwalk, turn 180 degrees with fire hoses, and then descend a steep ladder [T629, T760]. In addition, the area where the ladder meets with the top plates, just aft of the MCR, is subject to excessive heat exposure if a fire involves the engines [E457].
8.96 A ladder commencing centrally on the middle plate and finishing on the top plate inline with the workshop door would solve many of the problems that restrict access between the middle and top plates.
Conclusions
8.97 The normal access ladders from the middle plates to the top plates are exposed, and were extremely dangerous to use once the fire had started.
8.98 The ladder from the fridge flat to the top plates and the port ladder between the middle and top plates are difficult for hose teams to use.
Recommendations
8.99 A wide and less steep ladder should be fitted from the fridge flat landing to the top plate running centrally from aft to forward.
8.100 A wide ladder should be installed on the port side between the middle and top plates concluding in line with the workshop door.
8.101 The existing central port ladder and the ladder from the fridge flat to the top plate should be removed.
Main Machinery Space Communications
8.102 WESTRALIA’s MMS is a large cavernous compartment with three distinct levels. The Machinery Control Room (MCR) which controls the operation of the machinery within the MMS, is a self contained compartment at the forward end of the MMS at the ‘top plate’ level. There is not an effective system of communications between the MCR and any part of the MMS. In his evidence PO Hollis, who discovered the fuel leak on the port main engine, notes that he had to ‘race back to the MCR to inform the engineering OOW’.[T1804.4]
140 MATERIEL STATE OF THE SHIP
Conclusion
8.103 The Board is of the view that the lack of MMS to MCR communications is unacceptable.
Recommendation
8.104 A system should be provided to enable personnel working in the MMS to communicate with the MCR. A system similar to the ‘Flight Deck Loop’ communication system would be ideal (combined communications and hearing protection system)
Replacement/Upgrade of CO2 System
8.105 Whilst the ships CO2 fire protection system, when correctly maintained and operated, will provide the appropriate fire protection to the MMS and after pump space. It is considered that new emerging technologies in fire protection systems may provide better options for Navy’s requirements. One such system is ‘Water Mist’. Water Mist systems work on the principle of using a low or high pressure water mist to extinguish, suppress or control the fire by using a combination of methods as follows :
a. Heat extraction from the fire as water is converted into vapour and the fuel is cooled.
b. Reduced oxygen levels as the water vapour displaces oxygen near the fire.
c. Direct impingement wetting and cooling of combustibles
d. Enveloping the protected area to cool gases and adjacent combustibles, as well as to pre-wet the adjacent combustibles while blocking the heat transfer of radiant heat to them.
e. Dilution of flammable vapours by the entrainment of water to such an extent that the resultant mixture of vapours will not burn.
8.106 These systems have the considerable advantage of supporting life.
8.107 The Board is aware that DSTO has been examining water mist and other fire protection systems.
Recommendation
8.108 Whilst WESTRALIA’s CO2 fire protection system might be considered satisfactory, consideration should be given to other fire protection systems such as water mists, which could be fitted in lieu, particularly if these are safer and more adequately meet Navy’s requirements.
141 MATERIEL STATE OF THE SHIP
Incident Recording Devices
8.109 To enable an accurate reconstruction of the events surrounding any incident to be made, it is important that appropriate recording devices are installed in command positions in ships and submarines. WESTRALIA’s bridge had a small commercial portable tape recorder with a single microphone. The tape recording was critical in establishing certain evidence objectively. However, the sound quality of the tape was so poor that the tape required enhancement using sophisticated equipment and even then a great deal of the material was inaudible. The tape also ran for only 30 minutes after the commencement of the incident and, understandably in all the circumstances, it was not replaced when it ran out.
8.110 The aviation industry has been using data recording devices for many years and such devices have been invaluable in enhancing aviation safety. At least two shipping companies, P & O and Silja Line, have adopted recording technology to record critical data from equipment such as the radar, GPS and engine control. There is also provision for recording bridge conversations. The systems are not only used for accident analysis, but also training and planning.
8.111 Apart from emergency incidents, this equipment can record exercises with the results being analysed to provide feedback on the conduct of such exercises. This type of equipment should be of good quality and not a cheap ad hoc arrangement like the bridge tape recorder, used in WESTRALIA.
Conclusion
8.112 Suitable data recorders strategically placed in command positions such as the bridge, MCR and HQ1 can play an important role in enhancing safety at sea.
Recommendation
8.113 Data recording equipment should be fitted in command positions of all HMA ships and submarines.
System for Opening the Funnel Flaps
8.114 The standard operating procedure for a CO2 drench states that the supply air fans and natural ventilation points must be closed [E112]. This procedure is necessary to seal the MMS and prevent oxygen getting to the fire. While sealing the MMS is a relatively simple task the problem arises after the fire is out and the area needs to be cleared of heat, smoke and CO2.
8.115 The funnel door on the starboard side is the highest access point to the MMS. The door could have provided an alternative to the funnel flaps, but in this case, the door was on the windward side, facing a 15 knot breeze. If the ship had been head to wind (at anchor) or drifting, the funnel door may have greatly assisted the ventilation of the MMS – although this cannot be guaranteed.
8.116 Pulling the operating cables on 04 deck retracts the retaining devices and the flaps close under their own weight. To open the exhaust flaps personnel have to enter the funnel, climb a small ladder in darkness and exit through a small trap door at the top and
142 MATERIEL STATE OF THE SHIP then physically lift the heavy covers. During the fire on 5 May such a task would have been virtually impossible. The funnel casing and ladder would have been extremely hot, filled with smoke and there would have been minimal visibility. In addition the personnel would have had to climb a ladder, with BA on, and get through a small trap door. Such an operation could only be considered extremely hazardous and unlikely to succeed during a fire.
Conclusion
8.117 Once shut there is no means of opening the funnel flaps without entering the funnel space.
Recommendations
8.118 A system should be installed that allows the MMS ventilation exhaust flaps to be opened remotely.
Fire Detection System
8.119 The existing fire detection system comprises smoke, heat and flame detectors and manual call points located in service, accommodation and MMS areas connected to a central indicator panel on the Bridge; a sub-indicator panel is located on 02 deck. The detectors are grouped together into zones such that if any detector in a group is activated then the alarm signal for the group is raised on the fire indicator panel. Four alarm zones (Zones 7 to 10) cover the MMS and support area [E430].
8.120 Smoke detectors are used throughout the MMS, with the inclusion of two flame detectors, one over the engines and one adjacent to the generators. The Fire Detection Manual indicates the smoke detectors to be of an ionisation type, while the flame detectors respond to the modulated radiation emitted by flaming hydrocarbon fuel. There is a manual call point in the MCR overlooking the MMS [E430].
8.121 Evidence given suggests that for a period (length not clear, but several hours at least) following the start up of the engines, the MMS detection zones have to be isolated to prevent continual false alarms being generated by haze from the engines [T429, T446, T1186]. Since the flame sensors are on the same alarm zone as the smoke detectors, which cause the false alarms, this has resulted in the flame sensors also being isolated. Were they on a separate zone they could have remained in operation during isolation of the smoke sensors and given a degree of protection – alternatively, heat detectors could have been used for one zone, along with the flame detector, in place of smoke detectors [E430].
8.122 There are number of modern systems which could provide an increased level of protection for the area. These include: • VESDA- (Very Early Smoke Detection Apparatus) This system draws air samples from the area of protection though a network of pipes, filters out the dust and then analyses the sample to see if it is polluted and to what degree. The result can be used for local or remote alerting and if fitted to associated relays can be connected to a system for automatic shut down of the systems to prevent a fire developing. As this system can be fine-
143 MATERIEL STATE OF THE SHIP
tuned to suit the particular need of each individual environment it has been installed in civil and military shipping [E430]. • ALGOREX- (a Grinnel fire detection system) This type of system looks more like a conventional smoke detection system but the sensors each have their own microprocessors to evaluate the data at the source: individual heads can be programmed with parameters suitable for the particular location [E430]. • UNITOR This is an integrated system which will as well as being connected to a system of smoke, heat or other fire detectors, monitors other sensors on equipment which will indicate the likelihood of a fire situation before the production of combustible products [E430]. • CCTV- (Closed Circuit Television) This can be used in conjunction with other systems to provide an additional level of supervision of the protected area and can monitor the environment for optical changes which indicate the development of a fire [E430]. 8.123 The issue of a camera providing pictures of what was occurring inside the MMS at the time of the commencement of the fire has been raised by people giving evidence during the inquiry.[T1424] Had the MCR team had more idea of what was occurring within the MMS at the commencement of the fuel leak and immediately after the fire started, different strategies may have been employed which could have mitigated the tragic consequences of the fire.
Conclusions
8.124 The present system of isolating the MMS detection zones to prevent false alarms is dangerous.
8.125 The fire detection system fitted to the MMS of WESTRALIA is not fit for purpose.
8.126 There are a number of possible systems available to enhance the level of fire protection.
Recommendations
8.127 The fire detection system should be upgraded in the WESTRALIA.
8.128 A CCTV system should be installed in the MMS, MCR and HQ1.
MMS Evacuation Siren
8.129 Immediately following the MCR being alerted that a major fire had broken out within the MMS, LCDR Crouch activated the MMS evacuation siren. Both LCDR Crouch and PO Herridge gave evidence that the siren failed to operate [T1628, T1690, T2835]. However, PO Francis gave evidence that he heard one blast on the siren when in the MMS [T1461]. Thinking the fire had damaged the cabling LCDR Crouch opened the MCR door to the MMS, stepped onto the catwalk and yelled for everyone to evacuate the area [T2835].
144 MATERIEL STATE OF THE SHIP
Recommendation
8.130 Audible warning devices activated by buttons placed on each level of the MMS and in the MCR should be fitted. The cabling should have appropriate fire protection.
Emergency Lighting and Reflective Tape
8.131 PO Hollis exited the MMS via the port ladder shortly after PO Francis. Having made it up to the top plates PO Hollis could not find the door to the MMS due to the darkness and disorientating effects of the smoke [T1807].
8.132 PO Hollis was working his way along the bulkhead looking for the opening when WO Bottomley opened the door, grabbed him and pulled him inside the MCR. By the time PO Hollis evacuated the MMS, the handrail on the port ladder was hot enough to burn his left-hand [T1807].
Conclusion
8.133 There was insufficient lighting or reflective tape at a low level to guide personnel to safety.
Recommendation
8.134 Additional emergency lighting and reflective tape should be placed at a low level on designated escape routes, ladders and doors to assist personnel to evacuate the MMS in smoke or darkness. An arrangement similar to that used to identify escape routes in commercial passenger aircraft would be ideal.
Finding
8.135 When WESTRALIA sailed there were a number of deficiencies in the materiel state of the ship. The two serious deficiencies, the flexible supply and return fuel hoses and the CO2 system were not readily apparent. At that time the flexible fuel hoses gave no sign of any inherent flaw. The condition of the CO2 system, and particularly the tension of the operating wires, would only have been apparent to an expert on close inspection. At 0900 on 5 May 98 there was no obvious materiel deficiency that should have prevented the ship from sailing.
145 SECTION 9. CAUSES OF FIRE
ORIGINATION OF FIRE
Engine fires in general
9.1 The Board examined a number of reports concerning MMS fires.[e.g. E21, E253, E254] Fires in engine rooms are common and a number of flag states issue reports on such incidents. Amongst the material the Board has studied is the International Maritime Organisation (IMO) document FP 42/INF6, entitled ‘Analysis of Fire Casualty Records’, dated 13 October 1997 [E460], introducing and summarising a UK Maritime Safety Authority’s research paper into causes of fire in fuel systems. Australia is a member of IMO, which is an agency of the United Nations established by the Convention on the Intergovernmental Maritime Consultative Organisation 1948. IMO offers technical advice, consults and draft conventions and agreements on matters affecting international trade, maritime safety and marine pollution.
9.2 The environment in which marine engines operate involves vibration and flexing of the ship in a seaway. This predisposes ship’s engines to some leaking of fuel and lubricating oils at joints and connections. In more modern marine diesel engines, problems with leaking fuel are not as great. Fuel pipes are sheathed and components placed in containing cofferdams to control minor leakage. Hot engine surfaces are shielded or lagged to minimize possible ignition sources.
9.3 The presence of fuel oil, air and hot surfaces makes a ship’s MMS a relatively higher risk space for fire compared to other spaces in a ship. An operating engine generates great heat. Exhaust systems and unlagged indicator cocks are a potential source of ignition.
9.4 Taking the propulsion system as a closed system (i.e. excluding an external source of ignition such as an electrical spark lighter or match), the greatest risk of fire is from:
a. a fuel leak from either the low pressure or high pressure fuel lines or lubricating oil systems, spraying on to a hot surface;
b. spontaneous ignition, originating in oil soaked lagging;
c. an overheated bearing in a crankcase igniting the lubricating oil mist and causing a crankcase explosion; and
d. carbon deposits within the scavenge or exhaust systems of the engine igniting.
9.5 Statistics contained in the IMO document show that 50 percent of MMS fires originate from the low pressure fuel system piping and fittings. Other sources of MMS fires originating in the fuel system include:
a. high pressure fuel piping (10 per cent);
146 CAUSES OF FIRE
b. slack, fractured or removed studs/bolts (7 per cent);
c. loose/unscrewed or fractured bleed cocks, screws or valves (7 per cent); and
d. miscellaneous/undetermined fuel leaks (7 per cent).
Ignition point and fuel source
9.6 Detective Senior Constable WA Hawes is a member of the WA Police Arson Squad. He was part of a Disaster Victim Identification Team comprising officers from the Emergency Operation Unit, the Forensic Division and the Arson Squad which attended WESTRALIA at about 1830 on 5 May 1998. The team acted on behalf of the WA State Coroner and at the invitation of the Navy.
9.7 Detective Senior Constable Hawes expressed the opinion in his Preliminary Report dated 14 May 1998:-
The most probable explanation from the fire scene examination, is that diesel fuel has sprayed from the braided fuel line at unit 9, starboard engine onto hot engine parts. The diesel vapour has been heated to ignition temperature by this contact, self igniting and sustaining combustion.[E32]
9.8 He explained in his evidence on 15 May 1998 why he termed his report ‘preliminary’:
With fire scene examination, this examination is one part of it. We develop theories as a result of our examination. These theories we test. A lot of that testing comes from witnesses, on their observations. At this stage, I haven’t been able to speak with all witnesses, so therefore all the information is not available to me.[T305-306]
9.9 Detective Senior Constable Hawes adhered to his original hypothesis when he was recalled to give further evidence on 27 June 1998 and in his final report dated 15 July 1998.[E452] When he gave further evidence he had had the opportunity to review the evidence of the witnesses who saw the start of the fire, namely, PO Hollis, PO Francis, LSMT Smith and LEUT Walters.[T2757] The evidence of the eyewitnesses made it clear that the fire started on the starboard main engine.[T583, T1242-3, T1459, T1806, T2802] That evidence, as well as scientific testing, confirmed Detective Senior Constable Hawes conclusions part of which he stated in his Preliminary Report as follows:
HMAS ‘Westralia’ has suffered a major diesel leak on the inboard side of the port engine. This diesel has sprayed downwards 45 degrees towards the starboard engine, and created a diesel vapour cloud above the engines. Another diesel leak has occurred in the braided fuel line at unit 9 of the starboard engine. This has possibly sprayed upwards and outward due to the inner lining being exposed through the braided outer shell in a cone like shape.[T310] (Figure 10)
147 CAUSES OF FIRE
Figure 10. Hose S9R. The inner teflon tube can be seen protruding through the wire braid in a fan shape. (Fig 48 of Metlabs report)
Failure of PME supply hose (No. 8 cylinder) and SME return hose (No. 9 cylinder)
9.10 Detective Senior Constable Hawes made observations of, and with the assistance of WO Bottomley removed, certain flexible fuel hoses, as described in his report.[E452] The hoses were later more particularly identified and scientifically examined by Mr John Bromley, metallurgist (from AMEC Pty Ltd trading as Metlabs). Evidence before the Board disclosed that on 5 May 1998 two flexible fuel hoses had failed - namely, a supply hose on the PME, number 8 cylinder (P8S), and a return hose on the SME, number 9 cylinder (S9R). The second flexible fuel hose appeared to be the primary cause of the fire as the burst hose provided a source of atomised diesel fuel in the area where the fire was observed to start. A hot engine part nearby, probably an indicator cock, provided the source of ignition.[E452, T308-310; E227, T3419, T3546, T4073-4075, T4180]
Secondary bilge fire and areas of fire damage
9.11 There was evidence of a secondary fire in the bilge. This fire seemed to be confined outboard of the starboard engine, between frames 30 and 31, 7.650 m and 8.500 m aft of the lower bulkhead of the after pump room.[E452] At bottom plates level, there was little damage to the polycarbonate light fittings, other than one immediately outboard and one forward of the apparent seat of the fire. The evidence is that at the bottom plates level, other than the area outboard of no. 9 cylinder, the temperature was relatively low, even during the most intense phase of the fire.
9.12 Above this level, at the middle and top plates, more extensive damage could be seen. Light fittings had melted and heat damage involving the buckling of walkway plates
148 CAUSES OF FIRE and the melting of alloy sheets forming the backs of ladders. This damage indicated temperatures in excess of 600°C. The most extensive area of damage was on the underside of the MCR. All the cabling insulation had been destroyed. Substantial ‘I’ beams for the MMS hoist had been buckled.
Other expert opinion
9.13 Dr G Goodwin, a Senior Research scientist and engineer with the Defence Science and Technology Organisation, Maritime Platforms Division and Mr T P Casey, consulting scientist and engineer, also agreed with Detective Senior Constable Hawes’ hypothesis.[E214 para 38, E228].
9.14 Mr G M Kelly, a fire investigator, was somewhat equivocal: in his opinion there was ignition by an unidentified source of flammable liquid vapour originating from a diesel leak(s) from an unidentified source.[E227]
9.15 Mr P E Burge, a marine engineer, whilst canvassing other possible ways in which the fire may have started, accepted that the most probable cause was that the fire started with the bursting of the starboard no. 9 cylinder return hose (S9R), the spraying of fuel onto a heat source and igniting, as described by Detective Senior Constable Hawes in his Preliminary Report.[E224 para 13.1, T4077-4087]
9.16 Mr Burge ultimately advanced two possible alternative causes of the fire:-
The vapour cloud from the port engine may have been drawn into the turbo charger of the starboard main engine where it ignited and thus internal fire melted the aluminium scavenge ducting. The heat in the duct may have affected the hose immediately beneath it and weakened the hose structure sufficiently to cause a rupture. Fuel under pressure would then have sprayed vertically into the hot parts of the duct and also ignited.[E224 para 13.2]
The oily mist atmosphere within the crankcase may have been ignited from an internal heat source and been released into the engine room. This heat could have ignited any loose fuel or fuel vapour in its vicinity.[E224 para 13.4]
9.17 In his evidence before the Board, as to the first of those possible alternative causes of the fire, Mr Burge accepted this as being no more than a possibility [T4083-4] Mr Bromley conducted a metallurgical assessment of the scavenge ducting (also known as a charge air rail or inlet manifold) and concluded that the source of the fire where the ducting had melted adjacent to starboard 9 cylinder was external.[E398] There was no sign of a fire having occurred internally or of an explosion. Even if an explosive mixture had been drawn into the scavenge ducting there was no material within the scavenge ducting to sustain the fire to raise the aluminium to melting temperature.
9.18 Similarly, Mr Burge did not press the second alternative as anything more than a possibility because of the fact that there was a Gravenor alarm which should have gone off had there been a crankcase explosion, but did not; that there were signs only of a small amount of oil leaving the engine (and these signs may have preceded 5 May 1998); and that there were probably flame traps behind the crankcase doors.[T4086] CMDR Irwin (an engineer) advised the Board:-
149 CAUSES OF FIRE
I even question whether there was an explosion at all but rather a raise in air pressure inside the crankcase caused by the heat.[T3495]
Fuel specification
9.19 Analysis of the fuel oil showed that its closed cup flash point was 71°C and auto ignition temperature was about 310°C.[E311] The fuel was within specification and there was nothing inherent in it which lead to it being a greater hazard than the engine design allowed for.
Ignition source
9.20 A probable source of ignition was the adjacent indicator cock (Figure 11). The ο indicator cock was not lagged or shielded and could reach temperatures in excess of 450 C, well in excess of the 310°C auto ignition temperature established in testing the fuel sample.
Figure 11. A view of the fire damage to the outboard side of the SME showing the indicator cocks at cylinders 8, 9 & 10. (Mr G. Kelly)
Fuel supply
9.21 The fuel to the burst return line on the SME was initially supplied under pressure from the fuel boost pump via the injector pump chambers linking the supply and return ports. The prompt shut down of the engine isolated this source but the design of the system is such that fuel can be supplied under pressure due to gravity from the service tank by means of the return line. The incorrectly fitted and defective back pressure valves would have presented no barrier to the fuel flow.[E480] The service tank was isolated by the EOOW at some time between 1048 and 1053.[E91, p10 & p12] Some fuel may have continued to flow, albeit at a greatly reduced rate, as the fuel lines from the service tank drained. This final phase of the fuel supply to the fire was not tested.
150 CAUSES OF FIRE
9.22 Examination of WESTRALIA’s liquid cargo chits[E80] gives no indication of the fuel oil that may have been consumed by the fire. The dips taken on 14 May 1998 show marginally more fuel onboard than on 5 May 1998, although no fuel oil was later taken onboard in the intervening period.
Conclusion
9.23 The Board accepts the hypothesis of Detective Senior Constable Hawes as to the start of the fire and finds that the fire started as a result of the ignition of atomised fuel from a leak in the new flexible return hose on no. 9 cylinder on the starboard main engine (S9R). The Board finds that the possibility of some other source of the fire is not sustained by the evidence. The source of the ignition was probably the adjacent indicator cock on no. 9 cylinder. It seems that fuel may have continued to supply the fire for at least 15 minutes at a diminishing, and relatively small, rate.
FAILURE OF THE FLEXIBLE FUEL HOSES
Description of the hoses
9.24 The flexible fuel hoses were made from lengths of a hose which comprised a teflon inner tube covered by a stainless steel wire braiding containing seven wires or strands per braid. Fittings were attached at the end of the hoses.
9.25 The supply hoses and return hoses had an exposed hose length of around 140mm and around 160mm respectively. According to a product sheet (which was not given to ADI or Navy) the hose had, amongst others, the following specifications [E197 Tab 4]: Diameter of Bore ¾ inches 19mm Working Pressure 800psi 5.5MPa Minimum Burst Pressure 3500psi 24.1MPa Minimum Bend Radius 9 inches 229mm
Hours of operation of the flexible fuel hoses
9.26 WO Bottomley, stated that he believed that although the flexible fuel hoses were installed on 10 April 1998, the main engines were not operational until 22 April 1998.[E209] The daily TM 136 logs for the period 21 April - 5 May 1998 indicate that the SME had operated for approximately 39.5 hours, and the PME for approximately 36 hours, from the time of hose installation to the time of the fire.[E209, T3418-9]
Metallurgical testing of flexible fuel hoses
9.27 The flexible fuel hoses were all removed from WESTRALIA’s engine for testing in the course of this Inquiry. Mr Bromley, was appointed by the Board to independently conduct an analysis of the integrity of the hoses.[E194A]
151 CAUSES OF FIRE
Failure of flexible fuel hoses due to fatigue
9.28 Mr Bromley confirmed that all the hoses, with the exception of two, showed random, isolated fatigue features of several wires. In particular, he confirmed that:
…the two hoses which failed, the supply hose on port 8 cylinder (P8S) and the return hose on starboard 9 cylinder (S9R), had ruptured as a result of internal pressurisation due to the fact that approximately 50 adjacent wires in 5 to 7 braids had fractured as a result of prior fatigue cracking, leaving the internal teflon tube unsupported and hence unable to support the normal working pressure.[E194A p24]
9.29 Another hose, P12R, was found on examination to have hose characteristics and a wire fracture disposition similar to P8S and S9R.
9.30 Mr Bromley stated in his report that the production of fatigue cracking in the wires in the hose would require prolonged exposure to an alternating stress, which in the hoses would be consistent with a variable pressure induced by the (fuel) injector pump. Further, the damage in the three hoses in which adjacent braids were fractured suggested that these hoses were subjected to more severe fatigue conditions either due to an increase in internal pulsating pressure or an increased stress concentration produced as a result of more radical mechanical damage sustained in prior use.[E194A p25]
Figure 12. The SEM photo of the fracture surface of the wires from the used fuel line, identified as: P5R 491/16, which was burst in testing, showed the fatigue markings present on smooth flat fracture face and the absence of any bulk thinning (scale - 100 microns). (Fig 32 Metlabs report)
152 CAUSES OF FIRE
9.31 Compare figure 12 above, which shows a classic fatigue failure, with the following photograph (Figure 13), which shows a pressurisation rupture, induced by hydro-testing to failure. The wedge shaped fracture surfaces in several wires are associated with tensile failure.
Figure 13. The SEM photo of the fracture surface of the wires from the used fuel line, identified as: P5R 491/16, which was burst in testing, showed a necked, wedge shaped fracture on the wires at the rupture (scale = 100 microns). (Fig 33 Metlabs report)
9.32 The results indicating that the hoses failed due to fatigue are not controverted and are basically accepted by the other experts.[Goodwin E214 para 43; Burge E224 para 16.2; and Casey E228 para 6.5]
Conclusion
9.33 Flexible fuel hoses S9R and P8S failed by reason of fatigue of the stainless steel braiding.
Other testing results
9.34 Selected hoses were pressure-tested to destruction. Only one, P12R (noted above as a hose with characteristics and a wire fracture disposition similar to P8S and S9R) failed at less than the manufacturer’s stipulated burst pressure.[E194 para 11] Mr Bromley also concluded that hoses P8S and S9R would have ruptured at less than expected pressure.[E194 para 24]
153 CAUSES OF FIRE
9.35 On examination, there were signs of mechanical damage to many hoses, particularly permanent sets and internal creases. These were found not to significantly affect the static burst strength.[E194 pp8 and 25]
9.36 In order to test the possibility that damage sustained during installation and/or reinstallation contributed to the failure of the flexible fuel hoses, a sample hose, identified as ‘D’, was gripped using a pair of multigrips and severely twisted and bent in order to produce major damage. Extensive internal and external deformation occurred with the production of scoring and denting but only one obvious fracture of a wire.[E194 para 3.13] Hose D was then pressure tested and failed at just under the minimum specified burst pressure.[E194 para 4.1.3] This testing was video-recorded and shown to the intervening parties.
Figure 14. The recently assembled unused fuel line, identified as D, was extensively twisted and bent, producing permanent distortion, abrasion and a broken strand. (Fig 26 Metlabs report)
Conclusion
9.37 The Board is satisfied that the results of the metallurgical testing indicate that any mishandling, if it occurred during or after initial installation, did not contribute in any significant way to a major reduction in the burst strength of the hoses.
Spill pulse pressure
9.38 What caused the flexible fuel hoses to fatigue? Dr Goodwin is regarded as DSTO’s resident consultant on diesel engine matters. Dr Goodwin was of the opinion that the only likely cause of fatigue failure in the flexible fuel hoses was pressure pulsation originating at the fill and spill ports of the injector pumps.[E214 para 41] Mr Burge was in
154 CAUSES OF FIRE agreement with Dr Goodwin as to the phenomenon of fuel pump ‘feedback’ pressure pulses (as he referred to them) and which he further described in his report as follows:-
In WESTRALIA’s engines, the sharp release of fuel oil under high pressure from the fuel pump plunger through the spill orifice (port) into the annular groove which is machined into the pump body and which forms the common fuel inlet/return gallery, results in pressure shock pulses which are felt in both the fuel supply and return systems.[E224 para 7.1]
9.39 The magnitude of the peak value of these pulses would be at least of an order of magnitude greater than the background pressure of the system but of unknown limits.[T3508-3520, E214D, E401(ER401 para 7.6), T4135-9]. Mr Burge pointed out in his report:-
The British MSA Research Paper 401 in Clause 8.1.5 indicates that the peak pressures of the ‘feedback’ pulses within a fuel reticulation system could range between 41 Bar and 80 Bar and that the pulses are less significant if the light MDO is used rather than HFO. WESTRALIA uses MDO. In this letter dates 20 May 1998 the manufacturers agents, Rolls-Royce, have suggested that the magnitude of the pulses could be as low as 30 Bar (435.1 psi or 3,000kPa) and as high as 70 Bar (7000 kPa or 1015.30 psi). I have not been able to find a definitive industry statement about ‘feedback’ pulses.[E224 para 7.6]
9.40 The magnitude of the pulses would affect the minimum acceptable burst pressure and the frequency of the pulses would need to be considered for its effect on the fatigue life of the pipes and, for example, a letter from Rolls Royce dated 15 May 1998, states at paragraph 3:
The design of all supply pipework and the associated fitting must recognise the above service conditions. The design criteria has to encompass appropriate margins for both the peak pressure and the potential fatigue aspects arising from the high frequency of the applied pressure pulses. The design as originally supplied fulfilled the above requirements.[E181]
9.41 Dr Goodwin was of the opinion that the hoses had been selected with a safe margin over the background pressure, but that the evidence indicated that no consideration had been given to the pressure pulses.
Number of pulses
9.42 According to the expert evidence provided to the Board, 1 million stress reversals or pulses could bring about the fatigue fractures evidenced on the braid of the hoses.[Bromley T3252, Goodwin T3514]
9.43 The two Pielstick PC2.2 engines in WESTRALIA:
a. have 14 cylinders (7 cylinders in each bank);
b. operate at a constant 500 revolutions per minute; and
c. each cylinder fires once every two revolutions.[T3513-5]
155 CAUSES OF FIRE
9.44 By way of illustration, a simplified way to estimate the likely frequency of the pulse for the whole engine, ignoring pulse reflections, can be calculated as follows: Number of cylinders × Revs per second Pulses per sec = Rate of cylinder firing 14 × 8.33 = 2 = 58 pulses/sec [407] 9.45 Although not definitive, this calculation suggests that the flexible fuel hoses were coping with a potential 58 pulses per second. On this basis, WESTRALIA’s engines would have had to operate only for a short amount of time, in the order of 4.76 hours, to reach 1 million pulses.
Conclusion
9.46 Sufficient pressure pulses to cause fatigue failure of the braiding could easily have been generated since installation of the flexible fuel hoses.
Pielstick, IMO and other information relating to ‘spill pulse’
9.47 The Board received evidence that from the early 1970s, the ‘spill pulse’ phenomenon had been known to the manufacturers of Pielstick engines, their licensees and others in the marine diesel industry.[E214D, T4141] Any modification of the fuel delivery system needed to encompass appropriate margins for both peak pressures and potential fatigue aspects arising from the high frequency of the applied pressure pulses.[E181]
Pielstick Service Bulletins
9.48 In Service Bulletins which it issued, Pielstick engine agents, NEI Crossley Engines (now part of Rolls Royce PLC) identified a high spill pulse or pulse spiking as a feature of the Pielstick engines, or more particularly, the jerk injection fuel pump system incorporated with the engine.[E189]
Pielstick Service Bulletin 51 [E189]
9.49 On the subject of fuel pump isolation cocks in PC2.2 and PC2.3 engines, Pielstick Service Bulletin 51 was issued on 2 September 1991. The last paragraph of page one of the bulletin states as follows:
On all these cocks there has been leakage due to incorrect fitting of the ‘O’ rings. It was therefore replaced by a ball valve (PC16677) Fig IV. This valve has been satisfactory in most installations, but with certain fuels the pulsating load [emphasis added] in the fuel main has caused failure of the seats.
9.50 Page 2 of the Bulletin introduced a new cock (PC196818) for use on all engines from serial number18152 onwards and warned:
It is vitally important that the valve is screwed firmly on to the lower set when closed and on to the upper seat when open. In other words, the valve must not be left in an intermediate position, where the high pressure pulses
156 CAUSES OF FIRE
[emphasis added] from the fuel injection pump will damage the seats. In either direction, opening or closing, the valve spindle must be turned until resistance is felt, indicating contact with the seat and must not be backed-off.
9.51 Clearly printed along the side and across the bottom of each page of each Pielstick Service Bulletin (including each page of bulletins 51 and 78) is the phrase, ‘This data is important to service engineers, operators and maintenance staff’.
Pielstick Service Bulletin 78 [E58 Tab 7, E189]
9.52 Pielstick Service Bulletin 78 also dated 2 September 1991 advised that Pielstick had developed a system whereby flexible fuel hoses could be fitted to the engines. However, the flexible fuel hoses were part of a general package of modifications which took into account the spill pulse phenomenon. Pielstick Service Bulletin 78 stated that the engine makers should be contacted for details and advised of the availability of pulsation dampers which ‘reduce the spill pulse to an acceptable level’.[E58 Tab 7]
Criticism of Pielstick Service Bulletins
9.53 Criticism was made of the sufficiency of the references to spill phenomenon in these Bulletins in the closing addresses on behalf of ADI [T4359] and Parker Enzed Technology [T4434] In his evidence, Dr Goodwin conceded that it would have been appropriate for the Bulletins to have included a warning about the phenomenon.[T3538]
9.54 As will be developed in Section 10 of this Report, neither ADI (nor the other intervening parties) nor for that matter, the Navy gave any consideration to the Bulletins, let alone enquired of the engine agents concerning it. The appropriateness of enquiry of the engine agent’s was emphasised by Dr Goodwin:-
…I just wonder if, in your opinion, a professional engineer had been asked to comment on a proposal to change from rigid fuel hoses to flexible fuel hoses in a particular type of engine, he might have actually seriously considered ringing the engine manufacturer to get some advice? …Absolutely. I think the first thing I’d have done is to delve into literature and go for a library search and probably on the second day I’d have thought, ‘Why don’t I ask the manufacturer?’ I think an engineer who was more inclined to be doing this work on a routine basis as modification, I think he’d have run to the manufacturer first.[T3575-3576]
Conclusion
9.55 Regardless of the quality of the information contained in the Pielstick Service Bulletins, information on the subject of spill pulses was available from the Pielstick engine agents, NEI Crossley Engines, at the time of AMP 12. Even a cursory examination of the Bulletins should have alerted a reasonably competent engineer to the existence of the spill pulse phenomenon and should have aroused sufficient curiousity in any technical person to make further enquiry. A reasonably competent engineer would have given the phenomenon due consideration and would have communicated with the engine agents. Indeed, any technical person who was charged with having the flexible fuel hoses manufactured and installed should have communicated with the engine agents.
157 CAUSES OF FIRE
International Maritime Organization (IMO) documentation
9.56 The issue of shipping industry awareness of the effect of spill pulses is also supported by the content of documentation issued by the International Maritime Organization (IMO).
IMO Paper 1994
9.57 IMO Marine Safety Committee Circular (MSC Circ.647) entitled, ‘Guidelines to Minimize Leakages from Flammable Liquid Systems’ was issued on 6 June 1994.[E462] In relation to the design and construction of hose and hose assemblies MSC Circ. 647 states as follows:
Hoses should be constructed to a recognized standard and be approved as suitable for the intended service, taking into account pressure, temperature, fluid compatibility and mechanical loading including impulse (emphasis added) where applicable.[Appendix 2, p 5, para 3]
IMO paper 1997
9.58 The UK MSA research paper of January 1997 referred to in the IMO paper reference FP42/AMF6 dated 13 October 1997 dealt extensively with the phenomenon. Paragraph 8 of the IMO paper stated:-
High pressure pulses lead to vibration and fatigue…The failure of fuel lines and their components will invariably involve fatigue and the initiation of fractures due to tensile stress.[E460]
Conclusion
9.59 The Board is of the view that information concerning the spill pulse phenomena was available and accessible had it been sought. It was not sought.
Awareness of spill pulse by sea-going engineers
9.60 Dr Goodwin attended a meeting on 3 July 1998 held at Wartsila-NSD Australia (Wartsila) in Sydney, where, amongst other things, awareness of spill pulse was discussed.[E401, T4141] Dr Goodwin stated in evidence that at this meeting:-
…there was a general consensus that the industry normally deals with these pulses, and not knowing their magnitude, by simply over-engineering and using much, much stronger pipes than you would need to use for the nominal set pressure. And it became clear to us, I think, that several of the people there thought that everyone ought to be aware of these pulses…[T4141]
9.61 Dr Goodwin gave evidence that on 7 July 1998 he telephoned Mr Eric Clarke, General Manager, Wartsila, with a view to confirming whether their knowledge of spill pulse arose as a result of their marine engineering training or the work experience they had in recent years. Mr Clarke told him that he was trained in England about 24 years ago. He assured Dr Goodwin that a full description of the fuel systems of diesel engines was explained in those courses and that he was made aware of the characteristics of jerk pumps and the sort of signals they produced. Mr Clarke expressed the opinion, that anyone who had completed the kind of course he had, would be similarly aware.[T4141-2] He also
158 CAUSES OF FIRE spoke to Mr Jeff Cleary, Wartsila’s Service Engineer, who had previously spent 9 years teaching marine engineering at Sydney Institute of Technology. According to Dr Goodwin, Mr Clarke told him that in his opinion:-
…anybody who had a Dip. Marine, an advanced Dip. Marine or a first-class marine engineering certificate involving engines – that is the motor part of those qualifications – should be well aware of the effect of spill pulses.[T4142]
9.62 As a result of these discussions, Dr Goodwin stated that:-
Last week I was prepared to say it was clearly well-known in the engine industry, but this evidence seems to me to show it’s well-known amongst sea-going engineers in the merchant navy . . . Navy maintainers, at least now in some arms of the Fleet, are not being trained for heavy maintenance work and they probably would have to have the kind of training that a sea-going chief engineer in the merchant navy would have. Given also that Navy training is also done by senior sailors and engineering officers who’ve come through the Navy training system themselves, I suspect there may be a serious gap in Navy training in this area and that’s why I think the Naval staff may be unaware of things that the merchant marine sea-going engineers should be aware of.[T4143]
9.63 Mr Burge’s evidence was that his inquiries indicated, amongst other things, that the effect of spill pulses was not well known and in particular it was not taught in the marine engineering school at the Marine Centre South Fremantle TAFE College.[T4372]
Conclusion
9.64 Marine engineers with qualifications acceptable to the Merchant Navy would probably have been aware of the nature of pulses caused by jerk pumps, if not the full extent of spill pulse pressure.
9.65 Neither Dr Goodwin nor Mr Burge have relevant expertise on the subject of RAN marine engineering training. The purpose of RAN marine engineering training is not to develop expertise in all aspects of engineering design but is more targeted at machinery operation, accordingly, knowledge of ‘spill pulses’ is not an essential training requirement. Appropriate experts in industry are usually used for deep specialist skills.
Outstanding issues between experts
9.66 The Board has been significantly assisted by the evidence of Dr Goodwin and Mr Burge. By the end of the hearing, Dr Goodwin and Mr Burge were in substantial agreement, with the exception of two issues:
a. the possibility of relevant over pressure in the fuel hoses occurring as the result of some malfunction in the fuel system [E224 paras 14-15]; and
b. the extent of knowledge of the spill or feedback pressure in diesel fuel hoses from high pressure fuel pumps. The second of these issues has already been addressed above.
159 CAUSES OF FIRE
Overpressure occurring due to fuel system malfunction
9.67 ADI suggested that the hose ruptures may have been caused prematurely by a pressure surge operating on degraded hoses. This surge was indicated by defects on three fuel system pressure gauges.[T517, T4385]
9.68 Dr Goodwin viewed the gauges as photographs and gave evidence on the issue.[E135, T3516-3120 and 3567-3570] In commenting on Mr Casey’s report [E228 in E401-ER031], Dr Goodwin stated that he was not convinced that any of these (fuel gauges) related to real overpressures and that one had failed by partial vacuum. Dr Goodwin did not place much credence in the evidence of the gauges. He stated that the MCR repeater was reading an electrical signal from a pressure transmitter near the fire and that this was far more likely to be an artefact of a measuring system in an overheated state. Dr Goodwin concluded that even if there was a real overpressure, it may have been by overheating of a ‘dead leg’ of pipework attached to the gauge during the fire.
9.69 Whilst the failed gauges do not feature as such in Mr Burge’s conclusions, those conclusions in paragraph 16.3 refer to ‘excessive surge pressure’ and include these two paragraphs:
16.4 There is insufficient data to determine the characteristics of the forces which had caused the fatigue failure in the ruptured flexible hoses. A range of engineering analyses and tests needs to be conducted to establish the precise nature and extent of these forces.
16.6 To the extent that aspects of this report are inconclusive, it is because of a lack of data available about the status of elements in WESTRALIA’s engine operating systems.[E224]
9.70 Mr Burge’s attention was drawn to Dr Goodwin’s evidence on the failed gauges during his oral evidence. Mr Burge spoke of gauges ‘wildly fluctuating’ but accepted the possibility of the damage to the gauges occurring after the fire.[T4104-4106]
9.71 In a letter to the Board, from ADI’s solicitors it was submitted:
What is clear from the Metlab’s report is that fatigue damage to 53 fuel supply and return hoses did not render the hoses unfit for their purpose and they continued to function entirely satisfactorily up to the point where the main engines were declutched. Three of the hoses examined showed evidence of degradation which was sufficiently severe as to expose the hoses to the risk of rupture when subjected to abnormal pressure. The degradation was caused either by localised abnormal pulse pressure or mechanical damage. But for the abnormal pulse pressure or the mechanical damage it is highly probable that the hoses would not have failed and would have remained fit for their purpose at all material times.[E214E]
9.72 Dr Goodwin was asked to comment on the ADI assertions.[T3521-3522] He replied as follows:
The first sentence says that the fatigue damage to 53 hoses didn’t render the hoses unfit for purpose. I’m not sure what the meaning of that. There were 56 hoses. If any one of them fails a dangerous situation arises. So there was by reductio ad absurdum; for example, you wouldn’t think an aircraft wing was strong enough if only one of them fell of and that’s sort of - - that’s an analogy. I mean, the fact that 53 survived is not really a terribly important
160 CAUSES OF FIRE
issue. The fact that three failed is the important issue, it seems to me. I think there’s a matter of fact here they can either function up to the point where the main engines were declutched - - that’s true of the 53, that’s right. It’s actually true of 54, I think, because the one that failed under test hadn’t failed at this point. I think where a lack of understanding is really shown here, in this, with respect - - I think there’s a misunderstanding here. When - - the second sentence refers to ‘exposing the hoses to risk of rupture when subjected to abnormal pressure’. I think there’s quite enough evidence before us to show that the large pressure pulses in the fuel lines of these pumps is not abnormal pressure. It may be pressure that’s very much higher than the nominal supply pressure; but the normal pressure for this engine is the nominal supply pressure plus the pulses that come from these pumps. That is the normal working pressure. It includes quite large pulses. Those pulses are part of the normal working pressure, but they don’t show in the nominal supply pressure. I think that’s an important distinction. So, the pulses are not abnormal at all. There’s plenty of evidence, I think, before us now that these pulses are regarded as quite normal in engines of this class. So, the degradation was caused by local pulses, but they weren’t abnormal pulses, in my opinion; and it’s possible that mechanical damage - - some of the hoses may have exacerbated the problem by providing sites for the initiation of fatigue cracks, but there doesn’t appear to be much of that damage, and there appear to be a lot of hoses which had a significant number of broken strands in fatigue where I don’t think there was serious mechanical damage.[T3521- 3523]
9.73 WESTRALIA has two oil fuel boost pumps located at the port side of the MMS on middle plates. They are mounted side by side, and designated ‘outboard’ and ‘inboard’. The inboard pump is fed from the main switchboard via the starboard group starter board located in the MCR. The outboard pump has two sources of power. Its normal source is from the main switchboard via the port group starter board located in the MCR, while its emergency supply is from the emergency switchboard.[E212p1]
9.74 At the request of the Board of Inquiry, the inboard fuel boost pump that was running at the time of the fire was removed from WESTRALIA and placed in a Watmarine Engineering Services (Watmarine) test rig. The fuel discharge pressure from the pumps is controlled by an integral recirculating valve sometimes known as the relief or control valve. The purpose of the testing was firstly, to check the setting of the control valve and hence the likely fuel supply pressure of the time of the fire and secondly, to determine the maximum pressure the pump could produce. This latter test was to see whether the pump was capable of producing the full scale deflection of the defective fuel system pressure gauges.
9.75 Watmarine prepared a pump test certificate dated 29 June 1998 which showed the pumps performance characteristics.[E212 and T3491]
9.76 In his report, CMDR Irwin commented that in the event of a zero flow (i.e. point of maximum output pressure for a positive displacement pump) situation, the pump was shown to relieve internally giving a maximum pressure of 625 kPa. After adjustment, the maximum output pressure the pump was capable of producing with the bypass closed, was measured to be 960 kPa.[E212(folio 333 para 3)] This is well below the full scale deflection of the defective gauges.
161 CAUSES OF FIRE
Conclusion
9.77 The fuel boost pump in use at the time of the fire was set at the correct pressure and was not capable of producing the full scale deflection pressure indicated by the defective fuel system gauges.
9.78 Based on the expert evidence presented to the Board and the results of testing carried out on the fuel boost pump and pressure gauges, the Board prefers Dr Goodwin’s evidence on the subject of fuel gauges. The Board is satisfied that there is no evidence of a mechanism which could have produced an abnormal pressure pulse of sufficient magnitude to cause failure of the flexible fuel hoses.
Other problems with flexible fuel hoses
9.79 Apart from the spill pulse phenomenon, there are a number of other important design issues which were not considered.
Bend radius
9.80 Dr Goodwin gave evidence of a possible explanation for the signs of physical damage to many of the hoses.[R9.35] He advised that the bend radius of some of the return hoses appeared to be too small (ignoring possible additional bending during installation). In accordance with its product sheet, the minimum allowed bend radius for SST12 Astraflex hose is 9 inches.[E197 Tab 4]
9.81 During his oral evidence Dr Goodwin stated that he had reviewed the hose’s bend radius by looking at photographs and taking measurements from a sample hose. Dr Goodwin stated that he was convinced that the bend radius was about 5.8 inches, which is substantially less than the minimum specified radius of nine inches. As a result, Dr Goodwin concluded that the hose was actually bent 25% more tightly in application than the specification allows.[T3502, T4131] While Dr Goodwin did not suggest that this was a cause of the fire, he thought it was an indication of inappropriate engineering design.[T3503] Dr Goodwin concluded that the SST12 hose could not be fitted in this particular location, to join the two connections points together, and meet its own specifications. In other words, it exceeded the allowed tightness of the bend.[T3504]
9.82 In its closing address, ADI submitted that Dr Goodwin’s evidence concerning the alleged failure of the hoses to meet specifications as to the minimum bend radius was not free from doubt, given that the hose was not measured in situ, but measurements were taken from a sample hose and working from photographs, as well as his admission that his measurements were not very precise.[T4370]
Conclusion
9.83 Whilst Dr Goodwin’s measurements are not exact, they provide strong indications that the minimum hose bend radius requirements were ignored by the design.
Fitting flexible hoses in a straight line
9.84 Dr Goodwin gave evidence that hoses should not be installed straight.[T3506] Dr Goodwin based his statement on a text entitled Hose Technology by Colin Evans,
162 CAUSES OF FIRE published in 1974. The substance of Dr Goodwin’s evidence was that rubber or PTFE has a very different coefficient of expansion than that of iron or steel components and there needs to be room for it to move with thermal stress and changes of pressure. Consequently, if a hose is installed straight, it is likely to be under compression or tension.[T3506] Some examples of hose installation guidelines are shown in figures 15-17.
9.85 Measurement of the lengths of the hoses demonstrated some variability. In relation to the impact on the static loading due to different hose lengths, Dr Goodwin and Mr Bromley commented that if a static load, such as tension or compression, is added to a fatigue load then the hose loading situation is worsened.[Metlabs Report E194A pp3-7] Dr Goodwin formed the opinion that a short, straight hose was not a good design solution. Dr Goodwin also agreed with Mr Bromley that the straight arrangement provided no accommodation for different lengths of hose or different gaps to be bridged.[T3506] Mr Burge agreed that a combination of a wide gap and a short hose could put a hose under tension when the end fittings were tightened. Mr Burge further agreed that these conditions would have an impact on the loading of the braid and its susceptibility to fatigue damage.[T4103]
Figure 15. E214C - Fig 34 from Hose Technology by Colin Evans
163 CAUSES OF FIRE
Figure 16. Metallic flexible hose general installation guidelines issued in the Annex to MSC Circ. 647 - Figure 2.1.
164 CAUSES OF FIRE
Figure 17. Non-metallic flexible hose general installation guidelines issued in the Annex to MSC Circ. 647 - Figure 2.2.
165 CAUSES OF FIRE
Lack of means of restraint
9.86 There is evidence that the return hoses were longer than the supply hoses, were curved and all had internal creasing.[T4103, T4131] The supply hoses were the straight hoses and the majority did not have creasing.[E401, T4131] Having explained how the return hoses could have been damaged by excessive bending, Dr Goodwin searched for an explanation of how some of the straight supply hoses could have been damaged resulting in internal creasing. As there is substantial evidence that the crew took care handling the hoses, Dr Goodwin thought it unlikely that mishandling was the cause of the creasing in the supply hoses.[T4132] Dr Goodwin examined the design of the hose coupling.
Figure 18. Diagram by Dr Goodwin explaining potential for hose twisting caused by design of fitting.
9.87 He observed that as one tightens the union nut, it tends to try to twist the hose tail. The friction at point ‘A’ in figure 18 is what stops the hose tail from twisting. Dr Goodwin estimated the torque at ‘A’ to be around 30% higher than the torque at ‘B’, so tightening the nut should not have the effect of twisting the hose.[T4133]
9.88 Dr Goodwin gave evidence that friction analysis only works if both surfaces are in the same condition - here the hose is going into a fuel union. He explained, that if surface ‘A’ is wet with fuel, a type of lubricant, and surface ‘B’ is dry, then it is possible that the torque at ‘B’ exceeds the torque at ‘A’. As the nut is tightened, the hose tail will tend to rotate. Dr Goodwin stated that both ends of the hose would have the same problem and that this is a detail design issue rather than an assembly issue.[T4133, E401-ER032]
166 CAUSES OF FIRE
9.89 Dr Goodwin noted that if it is essential that the hoses are not twisted in assembly, and a twist of 5 degrees may be sufficient to cause damage, there needs to be some means of holding the hoses in correct alignment while the unions are tightened, such as flats on the ferrules so that a second spanner can be used to prevent hose rotation.[E401- ER032] In Dr Goodwin’s opinion, there is no effective way to restrain the hose from twisting.[T4133]
9.90 Dr Goodwin concluded that:
a. there was no provision for preventing a twist of the hose as one tightens the nut; and
b. it was likely that the damaged supply hoses were damaged in twisting rather than bending.[T4133, E401-ER032]
General lack of design
9.91 Dr Goodwin concluded that no design analysis had been carried out in relation to the installation of the flexible fuel hoses. Flexible fuel hoses had simply been used to replace fixed rigid steel lines, without any recognition that this was a design change that required the attention of a design engineer. Dr Goodwin stated that a design engineer would have taken into account the pulsation in the system. The failure to take into account pulsation in the system meant that the flexible fuel hoses were destined to fail eventually due to fatigue, however well made or fitted.[T4232]
9.92 Dr Goodwin concluded in his report that:
There is convincing evidence that the fuel for the fire was supplied by a failure in fatigue of a return hose. These hoses were not fit for purpose because of an aspect of the requirement which was not understood by any of the parties involved. I would expect an examination of this change as an engineering design issue to have led to the consideration of the dynamic nature of the working pressure and therefore to an appreciation of the fatigue requirement.[E214]
Conclusion
9.93 The hose arrangement did not conform with good engineering practice in various respects, as well as the failure to take into account spill pulses.
9.94 The flexible fuel hoses were not properly designed and they were destined to fail.
Design improvements to flexible fuel hose assemblies
9.95 Since the dissemination of MSC Circ.647 in June 1994 [E462], IMO has prepared draft MSC Circ.861 which was approved in May 1998.[E214F] As at 17 June 1998, it had not yet been issued. MSC Circ.861 was reviewed by the Sub-Committee on Ship Design and Equipment in March 1998 and was passed to the MSC unchanged.
9.96 Draft MSC Circ. 861 states that there had been a continuing incidence of MMS fires due to the leakage of oil. Investigation of fire casualties, analysis of casualty statistics and technical research has revealed that leakages from the fuel system are due to the failure
167 CAUSES OF FIRE of worn, incorrectly fitted, slack, over-tightened or unsuitable components. IMO found that the major contributing factors to failure of fuel system components were:
a. the frequent partial dismantling and reassembly of the system for maintenance purposes;
b. the effects of high frequency, short duration pressure pulses which are generated by the action of the fuel injection pumps and which are transmitted back into the fuel supply and spill rails; and
c. vibration.
9.97 In relation to design consideration, draft MSC Circ. 861 states, among others:
3.1 It is essential that the fuel system is designed to accommodate the high pressure pulses which will be generated by the injection pumps. The engine manufacturer and/or the fuel installation manufacturer and the piping installer etc. must be consulted for an explicit statement of the fuel system parameters, including the maximum pressures which will be generated. Many engine manufacturers, aware of the potential risks due to high pressure pulses within the fuel system, now aim to limit the magnitude of the pulses to 16 bar at the engine fuel rail outlets.
3.2 The alternative approaches which may be considered by the designer are:
- design of the fuel system such that it is able to contend with the magnitude of pressure pulses which are generated. Piping systems should be designed and installed to an appropriate classification society or ISO specification;
- installation of pressure damping devices; or
- specification of injection pumps which are designed to eliminate or reduce high pressure pulses.’
Recommendation
9.98 The RAN should adopt the guidelines set out in IMO’s draft MSC Circ. 861 in relation to diesel engine fuel systems.
168 SECTION 10. HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED
MAINTENANCE ARRANGEMENTS
WESTRALIA’s maintenance program
10.1 HMAS WESTRALIA is maintained in accordance with a usage upkeep cycle that includes dedicated maintenance periods and refits. Under the RPLSS contract, HMAS WESTRALIA is programmed for approximately two Assisted Maintenance Periods (AMPs) per year. Refits are programmed on a cycle of approximately 60 months. Refits are normally programmed 18 months in advance and AMPs approximately six months in advance.[E25 Attachment A clause 3.3] As a petroleum tanker modified for underway replenishment, HMAS WESTRALIA is a single ship class within the RAN, and much of its maintenance is contracted.
OAWA
10.2 The Ordering Authority of Western Australia (OAWA) is the Navy organisation responsible for managing the Western Australian Ship Repair Program for ship maintenance activities.[E203 DC2] The aim of ship maintenance in the RAN is to sustain material efficiency, reliability and performance of ships, their systems and equipment, to enable the successful completion of assigned roles and to provide optimum responsiveness for Naval Operations.[ABR 5454 Chapter 1]
10.3 OAWA maintains all documentation and controls the physical and financial aspects of all awarded contracts raised in support of maintenance on both homeported and visiting ships at Fleet Base West (FBW).[E203 para 6, DC2] The RAN’s policy for the logistic support of WESTRALIA is outlined in ABR 5454 Chapters 1 and 30. ABR 5454 sets out in detail the basis for the provision of logistic support to fulfil the Fleet’s operational requirements.[E223 PWB2] CMDR Coverdale became the Officer in Charge (OIC) OAWA on 3 October 1997.[E203 para 5]
10.4 OAWA appoints a Principal Naval Representative (PNR) to provide on-site customer representation to progress Navy contracts.[T3271] At the relevant time, the RAN’s PNR was LCDR Barrett. The PNR is supported by maintenance managers who manage and coordinate all contractor work carried out on difficult classes of ship. Responsibility for management of HMAS WESTRALIA’s maintenance is delegated to the WESTRALIA Management Officer (WMO), namely, WO Jones.[T3271] The WMO is supported by one Chief Petty Officer.[T3271]
ADI RPLSS contract
10.5 On 14 April 1997, the Commonwealth entered into the Refit Planning and Logistic Support Services (RPLSS) contract for the maintenance of HMAS WESTRALIA with ADI. The RPLSS contract provided for ADI to commence work on 15 May 1997 and to continue to do so for a term of five years.[E25 clause 2.1.1] Prior to the RPLSS contract, WESTRALIA was maintained by Dawson Engineering/Brown and Root under a
169 HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED
Logistic Support Contract. No Brown and Root records of work (planned or executed) were formally passed to ADI, although some records and files were passed to the WMO. At a meeting on 19 August 1997, the WMO confirmed that all archive material from Brown and Root had been collected by his office.[E223 para 99]
10.6 The RPLSS contract describes its scope of work in general terms as:
The work performed under this Contract will provide support to HMAS WESTRALIA in three main areas; Logistic Support Services, Refit Planning Services and the Management of certain Maintenance Activities. The nature of the work to be performed covers the spectrum of management, engineering, quality assurance, financial control and logistic support activities necessary to sustain the RAN Auxiliary Oiler replenishment Tanker.[E25 Attachment A Clause 3.1]
10.7 Tasks are to be performed by ADI on either a ‘continual’ basis for the period of the contract, or on a ‘fee for service’ for occasional tasks.[E223 para 14]
10.8 In order to carry out its obligations under the RPLSS contract, ADI set up the RPLSS office at Rockingham. It was initially staffed with a team of four (4) staff who would perform the core RPLSS functions including a project manager/ship’s agent, two technical specialists (hull and electrical), an information document officer and a clerical assistant/librarian.[E216 para 6] The RPLSS contract further provided that six (6) subcontract staff would be engaged by ADI to form the AMP management team.[E25 Attachment A, clauses 3.18-3.20. E223 para 24] The latter provision has recently been varied by arrangement with Navy.[E411]
10.9 The RPLSS office was principally staffed with former senior sailors with tradesman qualifications or equivalent. The senior staff member was Mr Roger Sergeant who was the project manager/ship’s agent WESTRALIA. Mr Sergeant left the RAN as a CPOETC (Chief Petty Officer Electrical Technical - Communications). Mr Alan Morland was employed as a mechanical supervisor or mechanical technical specialist in February 1998 as a result of problems encountered during WESTRALIA’s AMP11 in August 1997,Mr Morland had served in the RAN from 1972 to 1983 and was a POMTPD3 (Petty Officer Marine Technical – Propulsion Diesel) when he left. Before joining ADI he worked, from 1993 to 1997, with Dawsons Engineering, the company that the RAN had contracted with to perform HMAS WESTRALIA’s logistic support. Dawson’s Engineering was later taken over by Brown and Root. Mr Morland was involved with WESTRALIA’s AMPs 9 and 10 while at Brown and Root.[T2554]
FLEXIBLE FUEL HOSE PROPOSAL
Origin
10.10 The history of fuel leaks in WESTRALIA has been discussed in Section 8.[R8.2 – R8.6] The fuel leaks problem had existed since at least September 1991 when WO Jones joined WESTRALIA as Deputy Marine Engineering Officer.[T1967]
10.11 Fixing the leaks was a frequent and time consuming process made worse by difficulty in aligning the rigid fuel lines between the injector pumps and the supply and return fuel rails. The origin of the idea to replace the rigid lines with a flexible version is
170 HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED not clear but the first evidence presented to the Board was in relation to AMP 10 in November 1996.
10.12 WO Bottomley explained:
AMP 10 (November/December 1996) was my first AMP in WESTRALIA. During the AMP Mr Morland and I had a number of discussions concerning the way ahead to cut down the fuel leaks from the fittings and lines connecting the fuel pumps and fuel rails on both main engines. Alan told me that there was a Pielstick service bulletin, which referred to fitting flexible fuel lines, which would allow for more accurate alignment and ease of installation. He informed me that this would alleviate most of our problems relating to fuel leaks.
Mr Morland stated that he had already started documentation to get approval for this configuration change implemented. He told me that Lloyds had already given their approval but it was bogged down with MISD.[E209]
10.13 LCDR Crouch gave evidence that on or about 22 November 1996, just prior to the beginning of AMP 10 and shortly after he joined the ship, he had a general informal discussion with Mr Alan Morland. At the time, Mr Morland was an employee of Brown and Root. LCDR Crouch stated:
…in the course of our conversation, Mr Morland mentioned to me that he had a Pielstick Service Bulletin which referred to fitting flexible fuel hoses to main engines. He told me that he was in the process of getting approval to fit these hoses to the main engines. He handed me a document and said, ‘This is the one we’re looking at, the one that’s circled’. That document had a facsimile imprinted date of 22.11.96 and thus I believe the date of this conversation was either on that date or shortly thereafter. I retained this document and filed it amongst the MEO handover notes.[E188 para12]
10.14 The document referred to by LCDR Crouch was an Aeroquip product brochure. The product reference which is circled is FC234 AQP hose.[E188]
10.15 LCDR Crouch also stated:
…It was the same day or shortly thereafter, that Mr Morland showed me a Pielstick Service Bulletin which related to flexible fuel hoses. I remember looking at the bulletin but did not study it in detail. I was not given a copy of this document.[E188 para18]
10.16 Mr Morland gave evidence on 19 and 22 June 1998. This was before LCDR Crouch’s statement was produced to the Board. On 22 June 1998, Mr Morland became unfit to continue with his evidence. Medical evidence submitted to the Board indicated that Mr Morland would remain unfit to give evidence for the foreseeable future.[E436] As a result, the substance of this evidence by WO Bottomley and LCDR Crouch concerning this conversation has not been put to Mr Morland. Mr Morland did, however, repeatedly give evidence to the effect that he had no recollection of having dealt with the issue of flexible fuel hoses in 1996, or for that matter, prior to early 1998.[T2575-2579, T2581-2585]
10.17 Although LCDR Crouch did not study in detail the Pielstick Service Bulletin, a copy was in fact held onboard WESTRALIA in a ring binder containing Pielstick Service Bulletins. The ring binder was found to be located in HQ1 and was only discovered during the course of this Inquiry. WO Bottomley was, but LCDR Crouch was not, aware of the
171 HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED existence of the Pielstick Service Bulletin binder.[T3420] The binder contained bulletins numbered from one to 94, the last one being issued in 1994.[E189]
1996 Proposal
10.18 When the ship requires external assistance with maintenance, it raises a TM 200 form to request that work be undertaken. The TM200 is used by the ship to rectify defects and deficiencies in order to restore the ship to its approved configuration. If the work required involves a change to the configuration of the ship, then the procedure to be adopted is set out in the RAN Ship Maintenance Administration Manual (ABR 5230 Chapter 4).[E139] The Board has heard a great deal of evidence about what constitutes a configuration change and the way in which changes to the configuration of a ship are achieved.
10.19 A configuration change is initiated by a form TM187. The TM187 process involves a preliminary assessment of the engineering practicability and a user assessment. Following consideration by a configuration control board, the proposal may be authorised for further development. In this instance, Navy’s Manager of In Service Design (MISD) will be involved in the design process or may grant design delegation to the RPLSS contractor. When all engineering documentation is completed and all equipment, stores and material are available, a form TM188 authorising installation is issued.[ABR 5230 Ch 4, E139]
10.20 There are a number of legitimate ways of arranging a configuration change on a temporary basis. A ship could submit an URDEF (Urgent Defect) to obtain permission to effect a temporary design change to regain some lost capability following system or equipment failure. Alternatively, an application to trial material or equipment can be made on a form TT117. A TT117 application must be approved before the trial is commenced or equipment installed. Finally, an ‘Application for Production Permit or Concession’ can be made on Form SG2. The SG2 is used to accept supplies not conforming to contract, where it is known in advance that a specification cannot be met or if there is a need to vary the specification set out in a contract at short notice. The SG2 can also be used by a contractor, as a matter of expediency, to gain interim approval for a configuration change.[E139 para 457] In this case, the normal configuration change process must follow.
10.21 An SG2 application for concession to manufacture 56 flexible fuel hoses and 28 airlines from Aeroquip FC234AQP hose to replace existing rigid fuel lines on WESTRALIA’s main engines was raised by Mr Morland on 27 November 1996.[E58 yellow Tab 5] Annexed to the SG2 was a quote from CHES Engine Reconditioning dated 26 November 1996. It quoted the sum of $12,369.84 for the work and included some diagrams. It did not annex the Pielstick Service Bulletin.[E58 yellow Tab 5]
10.22 Mr Morland gave the SG2 to the WMO - WO Jones.
10.23 WO Jones gave evidence to the effect that he had no recollection of discussions in 1996 concerning the Pielstick Service Bulletin or concerning the general background of the SG2.[T1968, T1978, T2062]
10.24 WO Jones forwarded the SG2 to MISD on 29 November 1996.[E58 yellow Tab 5]; it does not appear on the AMP10 file.[E304] The same day, Mr Morland sent a fax to Lloyds advising that Brown and Root intended fitting Aeroquip FC234 AQP flexible
172 HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED hoses ‘to WESTRALIA main engine timing valves and delivery fuel lines’ and asking whether this would be acceptable to Lloyds.[E103 Tab 1]
10.25 On 4 December 1996, MISD replied that ‘…the proposed changes relate to the integral parts of the Pielstick Main Engines’ and, ‘It is recommended that the SG2 applicant [Brown and Root] seek advice from an authorised Pielstick Agent on these matters. Any records of communication between the applicant and the agent are to be forwarded to MISD for consideration prior to SG2 approval.’ The MISD reply was directed to OAWA and was produced by CMDR Sippel to the Board on 28 May 1998.[E58 yellow Tab 6] CMDR Sippel is Navy’s Afloat Support Amphibious Class Logistics Manager (ASACLM) and is responsible for the logistic support for WESTRALIA.
10.26 WO Jones gave evidence that he thought he would have passed on MISD’s letter to Brown and Root at a weekly meeting.[T1967] A copy of the MISD letter does not appear onneither OAWA’s file or the Brown and Root files passed to OAWA.
10.27 Mr Morland raised a contract change proposal (CCP) 9685 for manufacture of new fuel hoses on 13 December 1996.[E298] No OAWA approval is indicated and CCP 9685 does not appear on the OAWA file. It is possible that it was never submitted, since AMP 10 was scheduled to end on 21 December 1996. As a result of Mr Morland’s ill health and inability to continue to give evidence, his comments on the CCP could not be obtained.
10.28 Work Instruction 3882/03 for manufacture of new flexible fuel hoses for both main engines was raised by Brown and Root on 23 December 1996.[E298] Although it is marked ‘cancelled’, it is not apparent when or in what circumstances it was so marked. This document, too, could not be put to Mr Morland.
10.29 WO Bottomley said:
…It was towards the end of AMP 10 that Alan Mr Morland informed me that he had received approval for the installation of the new flexible fuel lines. I believed that this approval had come from MISD since he had previously told me that they were the ones holding up approval. Funding was not then available nor could the task be achieved in the time frame. If it had been earlier in the AMP I would have pushed for them. I can be very stubborn at times and I wanted them fitted. Because of the budget and time constraints it was decided to put the task off until the next AMP.[E209]
10.30 Again, the substance of this conversation could not be put to Mr Morland.
Developments in 1997
10.31 On 8 January 1997, Lloyds replied by fax (No.F0027/97) to Mr Morland at Brown and Root, firstly, quoting a response received from their London office stating that the Aeroquip hoses were not approved, and secondly, giving general advice about the type of hose that would be necessary, including, that the hose should be:
constructed from synthetic rubber with single or double closely woven integral wire braid reinforcement and external wire braid protection and that the design should have been certified to have been burst tested with the end fittings attached to at least five times the maximum pressure as per Part 5, Chapter 12, Section 6 of the Rules.[E103 Tab 2]
173 HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED
10.32 This fax was produced to the Board by counsel for ADI. It does not appear on the Brown and Root or OAWA files given to the Board.
10.33 Attachment D to the Brown and Root management report to OAWA dated 7 March 1997 contained a list of future work recommendations arising from AMP10. The manufacture of new flexible fuel hoses was not on the list of recommended future work.[E303]
10.34 MISD have indicated to the Board that they received no further correspondence in relation to the SG2.[E445]
10.35 On 7 July 1998, Lloyds produced various documents to the Board. These included a fax dated 16 April 1997 from Lloyds Fremantle to Lloyds London, advising in relation to ‘Flexible Hoses for Main Engine Use’ that ‘Navy has put this project on hold’.[E396] Lloyds have advised that their Mr Wilson-Mitchell believes he received that information by speaking to someone, he cannot remember who, at Brown and Root.
10.36 WESTRALIA’s problem with fuel leaks persisted during 1997. WO Bottomley gave evidence that:
…in the lead up to and during AMP 11 there were several casual conversations between ship’s staff, WO Jones and Roger Sergeant concerning the flexible hoses. I can remember being told that there had been problems locating some of the LSC documentation following the hand over of the maintenance contract from Brown and Root to ADI. Some of this documentation related to the installation of flexible hoses. WO Jones and Mr Sergeant stated that they would locate the documentation for the next maintenance period (AMP 12) which was due to commence in March 1998. I felt angry and frustrated that the flexible lines had been put off yet again. I particularly remember this because WO Jones used to state in jest at the end of most weekly meetings, whether I had any points to raise and then pass the comment, ‘Apart from your lines’, or words to that effect.[E209]
10.37 Since 16 June 1998, WO Jones has also become medically unfit and took sick leave and was unavailable to be recalled to give further evidence.[E437] He was not able to be questioned on WO Bottomley’s evidence, nor on other aspects of evidence given by WO Bottomley and LCDR Crouch.
1998 Proposal
Discussions
10.38 In early 1998, a discussion or discussions concerning flexible fuel hoses took place involving LCDR Crouch, WO Bottomley and WO Jones. WO Jones said in his statement that:
…the issue of replacing the fixed fuel lines with flexible hose lines was raised again with me prior to AMP 12 in early 1998 by the ship’s MEO LCDR Crouch and his Deputy WOMT Bottomley. I do not now recall the precise details of any conversations on that topic nor their dates. However, I do recall some details of our discussion as to the appropriate way of proceeding.[E130A]
174 HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED
10.39 WO Jones’ statement then set out ‘the possible options discussed and their relative advantages and disadvantages’ as follows:
(a) Configuration change: form TM187. On one view, this job involved a change in configuration of ship’s parts and should therefore have been the subject of a TM187 in accordance with ABR 5230 chapter 4. I did not favour this approach as, in my view, this would have been time consuming (as a response, based on past experience, might have taken some months) and perhaps frustrating evolution, although I believe it would ultimately have been approved.
(b) Application for concession: Form SG2. I did not favour this approach either as, in my view, this would have also been a time consuming, (as a response, based on past experience, might have taken some weeks) and perhaps frustrating evolution, although I believe it too would ultimately have been approved.
(c) Material or Equipment Trial Proposal, Form TT117 in accordance with DI(N) Log 82-3. Under this approach, approval for which is often given within 2 days, equipment which has been successfully trialled for 12 months, then feeds into the configuration stream (TM187) process. The equipment could be ordered by way of TM200 and a TT117 would follow. This was my favoured approach as it would have been less time-consuming and would have permitted the material to be purchased and then trialled with little loss of time. I recommended that the ship take the course of raising a TM200 to be followed by a TT117.[E130A]
10.40 When he appeared before the Board, WO Jones was unable to provide any detail of the conversations. He described the discussions as being ‘…just general ones, sir, around the traps.’[T1969] WO Jones also said that whilst in these conversations he had discussed these options, he had not discussed their relative advantages and disadvantages.[T1974]
10.41 LCDR Crouch said that between July 1997 and January 1998 he was in regular contact with WO Jones.[E188] He frequently asked WO Jones when they could get flexible fuel hoses and WO Jones informed him that approval was required. ‘It was always my belief that the Contractor was organising approval for the installation of these hoses’, LCDR Crouch said.[T2826] He gave evidence of another informal conversation that took place in January 1998 on the flight deck. WO Bottomley and Mr Roger Sergeant, ADI RPLSS Supervisor, were present. The conversation was described by LCDR Crouch in his statement:
…I asked WO Jones, ‘When do we get the flexible hoses?’ He replied, ‘Submit a 200.’ Bottomley said, ‘That’s it is it, after all that waiting?’ Jones said, ‘Yes.’ I then instructed WO Bottomley to raise a TM200. I was very pleased when WO Jones told me to raise a 200 because I believed that finally we had the go ahead to install the flexible hoses...[T2826-7]
10.42 LCDR Crouch denied that in the discussions there was any reference to a TM187, SG2 or TT117, indeed to any form other than a TM200.[T2845] He adhered to that view during extensive questioning.[T2875] When asked by Counsel for ADI about the alleged discussion with WO Jones concerning the three methods of obtaining approval for the flexible fuel hose job, LCDR Crouch said:-
175 HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED
Actually that particular statement that WO Jones made dovetails exactly into a conversation we had about LP air compressors…the LP air compressors require changing now and we discussed the best way we could do it and WO Jones raised the subject and we discussed the virtue of 187s, SG2s and 117s.[T2867]
10.43 On the second day of his evidence LCDR Crouch raised a concern. He said that he had been:
…going through questions in my mind and at about 4 o’clock this morning, the picture that popped into my mind of turning to WO Jones and saying ‘Well why not raise a 117, then?’ Now, it was a conversation which took place sometime last year and I don’t remember exactly what the conversation was that led to it…I’ve racked my mind and I just can’t remember…I’ve eliminated everything else. It must have been an association with hoses.[T2996-7]
10.44 WO Bottomley disagreed with WO Jones’ account of the conversation and said:
Around February 1998 I was present during a conversation with WO Jones and LCDR Crouch, which was on the starboard side of the flight deck near the swimming pool. I am not sure but I believe that Mr Sergeant was also present. It was during this conversation that WO Jones told us to raise a TM 200 for the flexible fuel lines to be manufactured so that they could be included in the forthcoming AMP 12 work package. I was over the moon that we were getting the fuel lines but exasperated that all that was required was to submit a 200. I expressed my exasperation to WO Jones in a forceful manner.[E209]
10.45 WO Bottomley explained in greater detail in oral evidence how he ‘expressed (his) exasperation in a forceful manner’:-
Yes. Well, you do describe your surprise to some extent in your statement there but because it’s an important discussion, and it might be some way of triggering people’s memories, what did you say? ---Okay. I had a go at him. I was over the moon at being finally told that it was a TM200 because once it’s a TM200, we set the priorities on high it is in the listing so the engineer’s got some say of where it goes and I was really happy about that, but after all this time and all this battling and head-butting brick walls, that that’s all it required, was a TM200 and to be honest I was - - I swore quite loudly and I think I threatened to probably bash him or something.[T3458]
10.46 WO Bottomley confirmed LCDR Crouch’s association of the TT117 conversation with the air compressors in the following terms:-
Do you recollect any aspect of that conversation being mentioned? ---None whatsoever…the only time conversations of a TT117 were raised was over a general service air compressor.[T3429]
10.47 The evidence of LCDR Crouch and WO Bottomley indicates that they believed that the procedures to implement the change to flexible fuel hoses had been completed.[T2827, T2870, T3422] The history of the flexible fuel hoses proposal set out above provides some justification for that belief but the ship did have the opportunity to, and did not, make enquiries on the due completion of the procedures.[T2878-2879]
176 HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED
Conclusions
10.48 A change to the flexible fuel hoses was clearly a configuration change as defined in RAN documentation and the correct procedure for obtaining approval was not followed.
10.49 The weight of evidence is against WO Jones’ account, which is not accepted, and WO Bottomley’ s account is regarded as the most reliable. The Board is of the opinion that WO Jones told the ship simply to raise a TM200.
10.50 WO Jones’ statements to LCDR Crouch and WO Bottomley concerning the TM200, were such as to mislead them into believing that circumstances had transpired which made a TM200 the appropriate procedure to obtain funding for the work.
10.51 Nonetheless, LCDR Crouch should have made his own enquiries in the absence of any official approval documentation, namely, a TM188.
10.52 The Board has difficulty in understanding why none of the documentation relating to the SG2 remained on an OAWA file. WO Bottomley and LCDR Crouch gave evidence of frequent mention or discussion of the flexible fuel hoses with WO Jones.
10.53 It is remarkable that despite WO Jones’ long association with WESTRALIA’s fuel leak problem, his obvious commitment to the ship, and his ongoing discussions with WO Bottomley during 1997, that WO Jones does not remember any of the circumstances surrounding the SG2 application in late 1996 and that it did not come to mind during his ongoing conversations with WO Bottomley and LCDR Crouch.
TM 200
10.54 A TM 200 was raised by the ship on 1 February 1998 and given to WMO. WO Jones passed the TM200 to ADI and as his statement explained:-
Their normal practice as I understand it, having decided to sub-contract the task, would be to put the work out to tender, evaluate any responses, and submit a quotation for the task.[T1979, E130A para 5.7]
10.55 When giving evidence, WO Jones initially thought that a copy of Pielstick Service Bulletin 78 was attached to the TM 200.[T1978] On checking his records, WO Jones found this was not the case.[T2201]
10.56 The TM 200 specified the work as ‘investigate the manufacture and installment of Lloyd’s approved flexible fuel lines from the fuel rails to fuel pumps and return lines to rail on both M/Es (total 60)’.[E103 Tab 3] Under the heading ‘Task Summary’ were the words ‘Manufacture and install flexible fuel lines on both M/E’s’. The form was drafted by PO Reynolds with changes suggested by WO Bottomley and then LCDR Crouch. LCDR Crouch added the word ‘investigate’ and explained that addition and the requirement for the flexible fuel hoses to be Lloyds approved:-
…It was sometimes my practice when raising these forms to include an instruction to the contractor to ‘investigate’ the particular work order. This was particularly so in situations where the job was beyond my level of
177 HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED
knowledge and expertise. This was such a case. I wanted and expected the contractor to make all the necessary inquiries and investigations concerning the manufacture and fitting of the hoses. Thus I specifically directed the contractor to ensure that the hoses complied with Lloyd’s requirements. If they did, then I knew that the hoses would have been a safe product.[E188 para 33, Bottomley T3419]
ORDERING OF THE HOSES
ADI’s initial actions
Clarity of the TM 200
10.57 The significance of the word ‘investigate’ in the TM200 was canvassed during the hearing. ADI contended [eg.T2114-6] that the word ‘investigate’ was not a word of technical definition, whether in the contract or elsewhere.[E25-section 8.8 of Attachment A; E139] This contention was pressed in the closing address on behalf of ADI with submissions such as ‘It is self-evident that the word ‘investigate’ of itself is inherently ambiguous and imprecise, not containing within itself the measure or extent of investigation required’ and ‘Any investigation envisaged did not extend beyond ascertaining if Lloyd’s had approved hoses that could be used as fuel hoses’.[T4345]
10.58 Counsel assisting the Board, on the other hand, submitted that ‘investigate’ is a word of common usage and meaning and should be read as such and that the Board should not be persuaded that in some way the word was required to be read down or ignored.[T4325]
10.59 Many witnesses were invited to give their impressions of what the word ‘investigate’ might require. The Board has considered all that evidence. In questioning WO Jones, Counsel Assisting drew his attention to, and asked him to accept, the fact that the word ‘investigate’ did not appear in what ADI suggested to be relevant glossaries or lists.[T2187] The evidence then continued:-
…did you have any difficulty in understanding the expression ‘investigate’ when you referred to the maintenance control record? ---No, sir.
Did you feel the need to speak to the ship to seek clarification by what they meant by ‘investigate’? ---No, sir.
Did you feel the need to explain to ADI what…would be involved in the need to investigate? ---No, sir.
Did ADI enquire of you what was meant by ‘investigate’? ---No, sir.[T2187]
10.60 Later in WO Jones’ evidence, this question (on behalf of ADI) and answer appeared:-
Well, this is what I’m trying to ascertain: did you expect them to carry out, and want them to carry out, an engineering analysis of the consequences of the proposed change? ---Assessment or analysis, sir, I believe they’re…both the same term, and ADI, being our prime contractor are there to advise ‘yes, it’s a good idea’, ‘no it’s not a good idea’.[T2207]
178 HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED
10.61 Mr Bruce, the RPLSS Manager from Sydney, ultimately accepted that (if the phrase ‘Lloyd’s Approved’ was taken out of consideration) the word ‘investigate’ would require ‘the consideration and indeed the forming of a judgement as to what was appropriate to go in as flexible fuel lines’.[T3839]
10.62 ADI also contended that a TM200 would not require ADI to make any engineering analysis ‘at its own expense’, ‘without a specific request to do so’ [e.g. T2068] or as it was later formulated, ‘any engineering analysis of the possible operational consequences of the fitting of flexible lines’.[T2123]
10.63 It has also been put on ADI’s behalf that the TM 200 did not set out details of the job requested to the full extent required by ABR5230 para 558.[T802-804] Even though the TM200 is clearly deficient in much of the detail normally expected, the overriding facts however, are that ADI accepted the form without seeking further information and chose to act on it.
Conclusion
10.64 ADI were not specifically requested to do an engineering analysis, certainly not one of the type called for by a TM187. Neverthless, the Board is of the opinion that the ship’s request to ADI to ‘investigate’ cannot be confined in the ways ADI contend. In addition ADI had a general obligation as the engineering contractor to make a proper engineering assessment of the proposal taking all factors into account. The standard of that consideration should have accorded with the engineering expertise [T3096] and ‘world class’ [E405] which ADI claims.
Request for information from Lloyds
10.65 On 11 February 1998, Mr Morland telephoned Lloyds to ask for a list of suitable hoses. He confirmed his oral request by fax. The fax confirmed ADI’s intention to fit flexible fuel hoses to WESTRALIA’s main engines and requested a list of Lloyds approved hoses.[E103 Tab 5] Mr Morland’s fax included the statement, ‘We believe Brown and Root Engineering has made a similar request in the past on Lloyds fax message No F0027/97’ Lloyds replied the same day enclosing a list of Lloyds type approved products.[E103 Tab 6] No one from ADI or the subcontractor had any further communication with Lloyds.
10.66 Mr Ridland, Lloyds Australasian manager, gave evidence that this sort of request was ‘...a general inquiry’ and ‘...was the first part of the chain and ADI should have involved Lloyds in the procedure they were doing’.[T4028, T4029]
Lloyds requirements
10.67 None of WESTRALIA’s engineering staff, the WMO, and ADI RPLSS personnel properly appreciated that the main engines came under the provisions of survey certificates issued by Lloyds. None of them was alert to the fact that any change to the ship’s hull or machinery configuration was required to be submitted to Lloyds for approval, and then during execution to be inspected by Lloyds surveyors. The conditions under which a ship retains its class are clearly stated in the Lloyd’s Rules. In particular, in relation to WESTRALIA, these conditions are stated on the reverse of the Certificate of Class as well as on the reverse of all sheets relating to the Interim Certificate issued in July 1996.[E138] Condition 1.5 reads as follows:
179 HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED
Plans and particulars of any proposed alterations to the approved scantlings and arrangements of hull, equipment, or machinery are to be submitted for approval, and such alternations are to be carried out to the satisfaction of LR’s Surveyors.[E138]
10.68 Condition 6.19 of the RPLSS Contract is in similar terms:-
All repairs to hull, equipment, and machinery which may be required in order that the Vessel retains class, and approved alterations to scantlings and arrangements of hull, equipment or machinery shall be carried out under the inspection of and to the satisfaction of the Lloyd’s Classification Society / AMSA Surveyors as applicable.
10.69 Certain items of hull and machinery also come within the scope of the standards laid down by the Safety of Life at Sea 74/78 (SOLAS). Arrangements for oil fuel, lubricating oil and other flammable oils are items covered by SOLAS 74/78. Chapter II-2, Regulation 33(viii) requires that:
Oil fuel pipes and their valves and fittings shall be of steel or other approved material, provided that use of flexible pipes shall be permissible in positions where the Administration is satisfied that they are necessary. Such flexible pipes and end attachments shall be of approved fire-resisting materials of adequate strength and shall be constructed to the satisfaction of the Administration.
10.70 Despite the requirement in the TM200 that the hoses be ‘Lloyd’s approved’ ADI (and the subcontractor) failed to take any appropriate action to secure such approval.
Conclusion
10.71 Lloyds was not involved by either ADI (or its subcontractor) in approval of plans and particulars of the flexible fuel hoses or in inspection and assessment of their manufacture and installation. ‘Lloyds approved’ hoses were not manufactured and installed.
Work Instruction A1161/Specification
10.72 Mr Morland prepared Work Instruction A1161 describing the job as:
Manufacture 64 new lines to Lloyd’s approved standards. All lines must be protected with outside braiding. There is to be 4 spare delivery lines and 4 spare return lines delivered to ADI Limited Engineer as on board spares for the ship.[E216 Tab RS5]
10.73 That description was deficient in various respects, in that it:
a. omitted the requirement to ‘investigate’;
b. substituted for ‘Lloyd’s approved hoses’, ‘(hoses) to Lloyd’s approved standards’;
c. introduced a requirement for protection by outside braiding;
d. contained no dimensions and no drawing; and
180 HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED
e. contained no specifications for things such as reinforcement, operating parameters or test requirements.
10.74 The Work Instruction was also formally deficient in that the title block was incomplete as to the identification of the ADI Officers who had approved and authorised it and in that it was later stamped ‘Approved for Production’ without any authentication of the affixation of that stamp.
10.75 Deficiencies in the Work Instruction were conceded by both Mr Morland and Mr Bruce.[T2587-2590, T3856]
10.76 WO Jones did not see the Work Instruction.[T1979]
10.77 In his statement dated 10 June 1998 Mr Morland did not mention the 1996 SG2 application relating to flexible fuel hoses [E179]. When he gave evidence on 19 June 1998 he said that he could not remember that documentation (or the matters referred to in it) even when it was produced to him, beyond the fact that it had been shown to him in the previous several days.[T2577-2578, T2584] Neverthless, as has been noted above, the fax which he prepared and sent to Lloyds on 11 February 1998 refers to ‘Lloyd’s fax message No. F0027/97’ (dated 8 January 1997 responding to Mr Morland’s fax of 29 November 1996 from Brown and Root to Lloyds). That fax from Lloyds also referred to part 5, chapter 2, section 7.1 of the Lloyds Rules and that reference was repeated by Mr Morland in his fax of 11 February 1998.[E103 Tab 2] Mr Morland said that he had not been shown the MISD response of 4 December 1996 [E58 Yellow Tab 6] until ‘recent times’.[T2577]
10.78 Mr Morland accepted under further questioning [T2585, T2634] that he must have read the Lloyds fax of 8 January 1997 when he wrote his fax of 11 February 1998, in particular the paragraph:-
However, it would still be expected for the hoses to be constructed from synthetic rubber with single or double closely woven integral wire braid reinforcement and external wire braid protection and that the design should have been certified to have been first tested with the end fittings attached to it at least five times the maximum pressure as per part 5, chapter 12, section 6 of the Rules.[E103 Tab 2]
10.79 The explanation which Mr Morland gave for having added the requirement for external braiding was that he had looked at the Lloyds list of approved hoses and noted that most of the hoses on the list had external braiding.[T2555] However, in the course of his evidence, Mr Morland was unable to identify a significant number of hoses from the Lloyds list which did have the external braiding.[T2746-2747] As noted above, he also accepted that he had failed to specify anything in the Work Instruction in terms of reinforcement and that he should have done so.[T2588]
10.80 Mr Morland gave evidence that he had not been familiar with the concept of high pressure pulses in fuel hoses prior to this Board of Inquiry.[T2627, T2651] Mr Morland confirmed that he had seen the Pielstick Service Bulletin 78 when he was employed by Brown and Root [T2628], but that he did not refer to it when he prepared the Work Instruction.[T2632] Copies of the Pielstick engine operating manual and Pielstick Service Bulletins are held by ADI, and copies held onboard WESTRALIA.[T2628] Mr Morland said that he had a ‘quick look’ at the Manual. He agreed that he looked at no other technical information and made ‘no assessment, engineering or otherwise’ in respect of the flexible fuel hoses.[T2630]
181 HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED
10.81 Mr Sergeant, Mr Morland’s supervisor, said he did not read the body of the TM200.[T3587] He also had not heard of spill pulses until about a week before he gave evidence before the Board of Inquiry.[T3700]
Conclusion
10.82 The Work Instruction prepared by ADI was deficient in that it failed adequately to specify the job which the ship wanted done.
Selection of subcontractor
Preliminary notification
10.83 AMP 12 comprised 86 tasks, 52 of which were to be taken on by ADI, the flexible fuel hoses being one of these. On 12 February 1998, Mr Sergeant sent out a pro forma letter setting out the dates for AMP 12 to all companies which ADI anticipated would be involved as subcontractors.[E216 Tab RS6] The letter did not contain any specifications for the various items of work. It would appear that the purpose of the pro forma letter was to alert prospective tenderers of the upcoming AMP. The pro forma letter advised that work instructions would be relayed on 18 February 1998 to enable the submission of tenders and listed other milestone dates. The letter was not sent to Enzed or the Hose Doctor.
Invitation to quote
10.84 Four ADI employees, Messrs Sergeant, Morland, Singh and Baird-Orr, met on or about 15 February 1998 to decide which subcontractors should be invited to quote. It was decided to ask Mr Old to quote on the flexible fuel hoses, Mr Sergeant said:-
Although ADI had not contracted with Enzed before, I was aware from my own experience that Enzed is a supplier of high performance industrial hoses and held a Quality System Certification to Australian Standard (‘AS’) 3902.[E216 para 37]
10.85 A second pro forma letter, dated 12 February 1998, but in fact despatched on or around 20 February 1998, was sent to subcontractors enclosing the work instructions on which the companies were invited to quote.[E103 Tab 8] Both Mr Morland and Mr Sergeant said that the invitation to quote on the flexible fuel hoses was sent only sent to three subcontractors, namely, CHES Engineering, Rolls Royce and Enzed.[T2555, E216 para 402] The letter enclosed a copy of Work Instruction A1161. In fact, Wartsila NSD Australia Pty Ltd (Wartsila) also received a copy of the letter and work instruction, this having been ascertained by Board of Inquiry staff on or about 3 July 1998.[E402] The fact that ADI sent the invitation to tender to Wartsila was not included in any evidence or documentation produced to the Board by ADI including the matrix which they used to summarise and evaluate the tender process. The omission of any reference to Wartsila is a sign of inattention by ADI to the detail of the tendering process.
The Hose Doctor and Parker Enzed Technology
10.86 Shortly after the letter of 12 February 1998 was sent, Mr Sergeant states he was visited by Mr Kelvin Old at ADI’s Rockingham office. He knew Mr Old to be a
182 HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED competent ex CPOMT as they had both served in the RAN. Mr Old informed Mr Sergeant that he was now an Enzed franchisee at Naval Base, Western Australia. Mr Old gave Mr Sergeant his business card that showed the names Enzed and Parker in prominent positions.[E216 para 36] Mr Old is in fact a director and employee of Jetrock Pty Ltd, a company which trades as an Enzed Hose Doctor. Jetrock Pty Ltd is a franchisee of Parker Enzed Technology.[E343]
10.87 Mr Old, who gave evidence to the Board before Mr Sergeant’s statement was received, was not questioned about his meeting with Mr Sergeant detailed above. Mr Old stated that he knew both Mr Sergeant and Mr Nigel Baird-Orr as a result of his previous service in the RAN. Mr Old said that his first contact with ADI about the job was after he had been sent the invitation to quote. He assumed he received the invitation to quote as a result of his previous connections with the two men.[T3007, T3025-6]
10.88 Mr Old calls himself a Hose Doctor. The Hose Doctor franchise from Parker Enzed Technology Pty Ltd involved agreement with a Enzed network franchisee, Todd Hydraulics Pty Ltd trading as Enzed Fremantle (also trading as Enzed Kwinana).
10.89 According to the franchise documentation (with the Network franchisee being referred to as Franchisee) an Enzed Hose Doctor Franchise means:
…a retail business utilising mobile van units which provide on-site sales and servicing of hydraulic hose fittings and accessories to customers and which operates from the Franchisee’s Enzed Service Centre which supplies the Hose Doctor with inventory, commissions, customer lists, marketing services and other services and information in conjunction with Enzed. The Hose Doctor also will utilise in the operation of its franchised business certain equipment which has been developed and manufactured by Enzed or its affiliates for the preparation of customised hydraulic hose fittings and related products to suit specific requirements of the customers serviced by the Hose Doctor.[E193 Tab 1]
10.90 Under the franchise agreement, the Enzed network franchisee is to provide the Hose Doctor with training. The Enzed network franchisee is also required to provide the Hose Doctor with technical advice and information. Mr Old completed this training in December 1997.[T3024] The franchise agreement provides that Mr Old is to use materials supplied by the network franchisee. Mr Todd sourced products from Parker Enzed Technology and other manufacturers.[T3024]
Provision of Lloyds list of approved hoses
10.91 Both Mr Sergeant and Mr Morland said they believed the Lloyds list of approved flexible hoses was attached to the invitation to quote. However, neither of them was personally involved in the despatch of the pro forma letter and the letter made no mention of that list.[T2605-2506] When questioned, Mr Morland stated he gave Mr Old another copy of the Lloyds list when Mr Old dropped in to the ADI Rockingham office with his quote.[T2638] Mr Old suggested this occurred when he asked for it after he had received the invitation to quote from ADI and had shown Mr Morland the samples, but before he submitted his quote.[T3030]
10.92 Mr Old gave evidence that the Lloyds list was not attached to the invitation to quote [T3026-3028] and it was not with the invitation to quote which Wartsila gave to the
183 HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED
Board. The documentary evidence suggests that the evidence of Mr Old on this issue should be preferred.
Conclusion
10.93 ADI did not send the Lloyds list of approved hoses with the invitation to quote.
Development of quote by the Hose Doctor
10.94 Mr Old said that after receipt of ADI’s invitation to quote, he went to the ADI Rockingham office to get ‘sizes, threads, working pressures, as much information as I could so to help me to prepare a quote’.[T3028] Mr Sergeant introduced him to Mr Morland.[T3008, T3027] Mr Morland told him that the required length was about 200mm, he did not know the threads and gave a ball park figure of around 4½ to 5½ bar working pressure. Mr Morland told Mr Old that the hose had to be tested at 1½ times the working pressure. He could not give Mr Old any indication of the internal diameter of the hose required.[ T3029, T2639]
10.95 Mr Old had several meetings and conversations with Mr Morland. Mr Morland, he said, gave him the Lloyds list at some time in the course of those meetings. Mr Morland at no stage showed Mr Old the TM200, nor the fax of 8 January 1997 from Lloyds and did not tell him of the hose description given in the fax.[T3028-3029, E103 Tab 2] Mr Morland said that (at some unspecified point of time before the quote was submitted):-
I got talking to (Mr Old) about Lloyd’s. It came up in passing. I said to him that everything had to be Lloyd’s approved (mainly talking about hoses). He didn’t respond in detail but simply said okay or something to that effect.[E179 para 18]
10.96 Mr Old asked Mr Brian Todd of Enzed Fremantle which hose he thought would be best. He could not remember whether he showed Mr Todd the Work Instruction and said ‘I basically gave him the same information that I’d received from Mr Alan Morland’.[T3031] Mr Todd suggested Parker 221FR hose, which they later found on the Lloyds list, but which did not have outside braiding.[T3033]
10.97 Sometime before he submitted his quote to ADI, Mr Old stated that he showed Mr Morland a sample of Parker 221FR which does not have an external braid. Mr Morland told him that he wanted a hose with external braiding. Mr Old decided not to fit external braiding to the Parker 221FR as it would be purely cosmetic and too expensive. Mr Old then showed Mr Morland a sample of SST12 hose – a hose with an outer stainless steel braided cover and a teflon liner.[T3009] Mr Morland told him that he should use that type of hose. Mr Morland, for his part, denies ever seeing a sample of hose without external braiding.[T2676-2677]
10.98 At some point, Mr Morland told Mr Old that the ship had used a hose with external braid for its generators. Mr Old contacted Enzed Darwin and found that Parflex 919 hose had been used.[T3033] This gave him some confidence in choosing to quote on Parflex 919. He was probably unaware that the hose had been used for quite a different application on the generator (small bore lubricating oil piping).[T3034, T4183]
184 HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED
10.99 Mr Old gave evidence that he did not understand Mr Morland to be advising him that he must use a hose from the Lloyds list. Mr Old thought the Lloyds list was given to him to help him make a choice. Mr Old did not know what Lloyds was and was not familiar with Lloyds requirements, indeed, he said ‘I was aware that Lloyd’s was to do with insurance and that was about it.’[T3071] Mr Old did not tell Mr Morland that he was not familiar with Lloyds. Mr Old did not make any further enquiries of Lloyds.[T3031- 3032, 3079-3084] Mr Old knew the SST12 hose was not on Lloyds list, but since Mr Morland had said it was OK, he assumed it was Lloyds approved. Mr Old did not ask Mr Morland if the hose was Lloyds approved.[Old T3008-3009]
10.100 Mr Old was not aware of the high pressure pulses which could be present in diesel engine fuel hoses as a result of the action of the injectors. Mr Old did not understand the concept of spill pulse when questioned about it.[T3069-3070]
Conclusions
10.101 The differences between Mr Old’s account and Mr Morland’s account concerning the choice of hose is noted and the Board considers that Mr Old’s evidence is more reliable.
10.102 Mr Old, the Hose Doctor, failed:
a. to supply a hose to Lloyd’s approved standards.
b. to make any, let alone adequate, enquiries of Lloyds.
Submission and acceptance of quote
10.103 Mr Old said he submitted his quote to ADI on 27 February 1998. The ADI document is stamped as having been received on 3 March 1998. The quote was for an SST hose, Parflex TFE919 in the sum of $6,608.89, but included a quote for Parker 221FR in the sum of $6,732.54 with this explanation:
A further quotation utilizing PARKER 221FR hose has also been included for future reference, this hose is listed in the LR Type Approved Products - Part 1 for Marine, Offshore and Industrial Equipment and has been allocated Certificate number DRAFT 97/8. As detailed in the Product Sheet, enclosed, this hose is fire resistant and has been designed for marine applications. The Work Instruction states that the hose to be used must have an external Wire braid, 221FR does not have an external steel braid but a high tensile steel braid is present directly below the fire resistant synthetic rubber cover. It is felt that if the requirement to have an outer cover of steel braid could be waivered 221FR would be a most suitable alternative to PARFLEX 919.[E103 Tab 8]
10.104 The quote was on Enzed letterhead with details printed for the Service Centres at Fremantle and Kwinana. It was signed by Mr Old with the word Enzed typed below his name.[E103 Tab 8] The quote had attached to it product information sheets in respect of the two types of hose. It also covered the hose end fittings.
10.105 The product information sheet for Parker 221FR included a warning: -
!WARNING - FAILURE OR IMPROPER SELECTION OR IMPROPER USE OF THE PRODUCTS AND/OR SYSTEMS DESCRIBED HEREIN
185 HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED
OR RELATED ITEMS CAN CAUSE DEATH, PERSONAL INJURY AND PROPERTY DAMAGE.
This document and other information from Parker Hannifin Corporation, its subsidiaries and authorised distributors, provide product and/or system options for further investigation by users having technical expertise. It is important that you analyze all aspects of your application and review the information concerning the product or system in the current product catalog. Due to the variety of operating conditions and applications for these products or systems, the user, through his own analysis and testing, is solely responsible for making the final selection of the products and systems and assuring that all the performance, safety and warning requirements of the application are met…[E193 tab5]
10.106 There is no evidence that ADI or Mr Old paid any attention to this warning or conducted the recommended analysis and testing.
10.107 At the time he submitted the quote, Mr Old had not seen WESTRALIA’s engines and had received inadequate information from ADI to provide a firm quote. ADI witnesses suggested that this was not unusual. Mr Sergeant stated that:
…it is standard practice for tenderers to submit quotes which may be indicative only and subject to confirmation…The proposed tenderers will generally be given the opportunity to vary their initial quotes after they have inspected the work… [E216 para 31-32]
10.108 Mr Morland gave similar evidence speaking of it as a ‘generic’ quote, one for ‘basically what they thought was going to be costs from the work instruction’, and one which would be ‘reviewed’[T2639] and made the subject of a ‘revised’ quote. This situation may be understandable given that the ship was at sea at the time and these details were unavailable. Nevertheless, no revised quote was ever submitted by Mr Old or Enzed (although Mr Old did eventually submit an account for a revised figure to Mr Sergeant which account Mr Sergeant rejected.
10.109 ADI’s evidence is that the Enzed quote was accepted after a tender evaluation process [Morland T2590, Sergeant E216 para 30, T3698-99] When consideration is given to the uncertainty of the basis of the quote it must be questioned how meaningful any such evaluation could have been. The matrix document used at this tender evaluation meeting noted the Enzed quote in the sum of $6732.54. That figure was for the alternative, ‘non- conforming’ quote from Enzed for Parker 221FR hose.[E216 Tab 12]
10.110 In early March 1998, Mr Morland told Mr Old he had won the tender.[T3009]
10.111 On or about 12 March 1998, ADI sent to Mr Old a purchase order.[E103 Tab 10] The purchase order did not specify which hose type was being ordered but it was also in the amount of $6732.54. Mr Old said he thought a SST (stainless steel teflon) hose was being accepted and Parker was an SST hose.[T3051-3052] ADI intended to accept the quote for Parker 919TFE hose.[Sergeant E216 para 53; Morland T2958-2959]
10.112 A computerised record, a MAXIMO Work Order no, 975991, was raised by ADI on 16 March 1998 with reference to Work Instruction A1161. This, too, referred to the sum of $6,732.54, stipulating it to be for sub-contractor labour. It added to that figure ADI’s on cost of $336.63, making a total price of $7069.17. A print copy of the Work
186 HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED
Order was signed by Mr Sergeant on behalf of ADI and by WO Jones on behalf of OAWA.[E103 Tab 11]
10.113 WMO did not get a copy of the quotation. WO Jones said he was able to sign off on the Work Order because he was ‘relying on ADI’s recommendation’.[T1986] He had no knowledge of the types of hose that had been quoted on or installed.[T1993] WO Jones’ billet description details one of his job functions as ensuring cost effectiveness and efficiencies are being obtained whilst Commonwealth purchasing/contracting policies are being adhered to.[E130A Tab MRJ3]
10.114 In March 1998, after Mr Old had given a quote and it had been accepted, ADI prepared a contract and had this signed by Mr Old.[E103 Tab 20] The contract was evidently a standard form contract used by ADI and its terms were to apply to any work the contractor agreed to perform for ADI. The contractor was expressed to be ‘Enzed (ACN 080 369 268)’. That number is the ACN of Jetrock Pty Ltd, Mr Old’s company. The attestation and description beside Mr Old’s signature on the contract is ‘Signed for and on behalf of Enzed by Kel Old Hose Doctor 25 MAR 98’.[E103 Tab 20]
Conclusions
10.115 ADI paid insufficient attention to the Enzed quote, particularly in relation to the evidence which it contained suggesting that the quote was not for a hose which was ‘to Lloyds approved standards’.
10.116 Approval of the work order was one of the critical checkpoints for the process of fitting the new flexible fuel hoses. WO Jones gave insufficient attention to the documentation supplied by ADI. WO Jones approved the work order for the fuel hoses without having seen an original quote. Had WO Jones seen the original quote, it is possible that he may have been alerted to the fact that the Parflex 919 hose quoted on by Mr Old was not Lloyds approved. WO Jones would then have been aware of the basis for the quote.
10.117 Mr Old presented himself to ADI as a representative of the Parker Enzed Technology organisation and this implied a depth of expertise and knowledge which Mr Old could not, and did not, provide.
Allocation of AMP work at pre-AMP meeting
10.118 A pre AMP meeting was held on 10 March 1998 at STIRLING. At the pre- AMP meeting, key issues regarding the conduct of the AMP including the work package, the schedule and OH&S are discussed.[T3274] There were in attendance various RAN personnel including CMDR Sippel, LCDR Crouch, WO Bottomley and WO Jones (who was the Chairman of the meeting) and ADI personnel including Messrs Bruce and Sergeant. The list of work to be attended to in the AMP was discussed and various jobs approved, in a financial sense. All evidence from those attending the meeting is that the fuel hoses were not discussed except that the title of the TM200 (‘manufacture and install flexible fuel lines on both M/E’s’) was read out and the work approved. During that meeting, CMDR Sippel identified a number of configuration changes from the titles listed on the TM200s. He gave evidence that he pulled them off the work list and insisted that configuration change documentation be raised.[T4188]
187 HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED
10.119 After the pre AMP meeting, CMDR Sippel had a discussion with LCDR Crouch, the substance of which was the reinforcement by CMDR Sippel that TM200s were no longer to be used for configuration changes. The conversation did not mention the flexible fuel hoses or any specific items and CMDR Sippel explained, ‘I was speaking more generically about the process, as opposed to specific items’.[T4195] LCDR Crouch agreed that such a conversation took place, and that the conversation was limited to configuration changes in general and that no mention was made of flexible fuel hoses or other specific items.[T4458]
MANUFACTURE AND INSTALLATION OF HOSES
Production of prototype fuel hoses and use of SST-12 hose
10.120 On 11 March 1998, Mr Old went to the ship to look at the job and receive a safety induction. Mr Morland and Mr Old inspected the engines and Mr Morland gave Mr Old a sample of the rigid fuel line. It became apparent to Mr Old that he had to cope with two details which were different from what was covered in his quote: the end fittings required a thread different from that on the fittings which he had included and the hose diameter was ¾’ which was not a size in which 919TFE hose was produced.
10.121 Having discovered that the threads were different, Mr Old discussed options with Mr Todd. Mr Old decided to have Abonnel Precision Engineering (Abonnel) manufacture some sample tails. The sample tails were delivered on 12 March 1998.[T3010-3011]
10.122 To accommodate the different hose diameter, Mr Old used SST-12, another stainless steel hose supplied by Enzed Fremantle which he assumed was a Parker product. He understood that the SST-12 hose was equivalent in all respects to Parflex 919TFE hose but he referred to no product information sheet on it. He found out only after the fire, that the SST12 hose was manufactured by Astraflex Limited.[T3011-12]
10.123 Mr Brian Watts, the managing director of Parker Hannifin Australasia, explained to the Board that SST is a generic reference used for a variety of manufacturers’ stainless steel teflon hoses stocked in the Parker Enzed Technology range. He explained that they bought SST hoses from several different manufacturers whose products might have slightly different specifications. Parker Enzed Technology accordingly specifies in its catalogue ratings for SST hoses which accommodated the lowest ratings for product they might acquire and market as part of their SST range. SST-12 was the Parker Enzed Technology generic reference for a ¾ inch diameter stainless steel teflon hose.[T3059]
10.124 Information in the form of a product sheet relating to the design of hose assemblies using Astraflex SST-12 should have been made available to Mr Old by Enzed Fremantle. Enzed Fremantle did not provide Mr Old with the Astraflex SST-12 product sheet which contained the following warning:
When selecting Astraflex hose it is very important that the following design considerations are taken into account:
Temperatures and Pressures: Whilst PTFE has a working temperature range between –60°C and 280°C ) dependent upon the grade selected) as with all other types of hose, increased working temperatures require a reduction in maximum rated working or burst pressure. Whenever excessive flexing,
188 HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED
vibration, thermal fluctuations or rapid pressure impulsing [emphasis added] is in evidence, further caution should be exercised in reducing the maximum working pressure. See INFORMATION SHEET 6 - temperature derating curves.[E197]
10.125 This important warning was not available to any of the key personnel involved with the flexible fuel hoses.
10.126 Mr Old did not tell ADI that he would be supplying SST-12 instead of 919TFE.[T3041-3052] ADI did not become aware that SST-12 had been used in the flexible fuel hoses until after the Board of Inquiry commenced.[T2564]
Conclusion
10.127 The Board finds that Parker Enzed Technology:
a. failed to give Mr Old sufficient assistance by way of training and product information to enable him to comply with contractual duties or other duties in respect of the flexible fuel hoses; and
b. failed to give Mr Old adequate product information concerning SST- 12 for use by himself, ADI or Navy.
First and second protoytpe
10.128 Mr Old prepared two prototypes of the flexible fuel hoses and gave these to Mr Morland.[T3011]
10.129 Mr Morland showed the first prototype fuel hose given to him by Mr Old to WO Bottomley in about March 1998.[ T218] The first prototype had the end fittings from the existing fuel pipes in the ship on it.[T2690] WO Bottomley commented that the first prototype was not acceptable because this prototype would mean cutting up the existing fuel pipes and connections so that if the ship needed to reinstall them, it could not.[T219] Mr Morland advised that if the ship wished to retain the fixed fuel pipes with their existing connections, it would be necessary to fabricate new connections and have them connected to the flexible fuel hoses.[T219, T2690]
10.130 On 16 March 1998, Mr Old started removing the rigid fuel lines. Mr Old had previously told Mr Morland he wanted to use the old nuts to fit the hoses. Mr Morland told him that although the ship’s staff liked the hoses, they did not want the rigid fuel lines to be destroyed.[T3012, T219]
10.131 Mr Old undertook to have new end fittings manufactured. He gave a second prototype fuel hose with specially manufactured end fittings, telling Mr Morland that it represented the fuel hoses he proposed installing in the ship.[T2691] This was about 19 March 1998.[T3011]
10.132 Mr Morland left it to Enzed to deal with the issue of Lloyd’s approval. He gave evidence, however, that in March 1998, when they were discussing a prototype of the lines, WO Bottomley asked, ‘Are they Lloyd’s approved?’ and he replied ‘Yes.’ He was questioned about this:-
189 HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED
Yes. And you tell the Board that your understanding, the effect of which you communicated to WO Bottomley, was based on the fact that the instruction required Lloyd’s approval, and the fact also that Enzed had submitted a quote?---That’s correct.
So, you were leaving it to Enzed to ensure the matter of Lloyd’s approval?--- That’s correct.
You knew that the 919 hose was not even referred to in the material from Lloyd’s?---That’s correct.
How did you think that Enzed would have secured Lloyd’s approval?---I would leave that up to them.
Well, had you any idea what would be involved on their part in getting Lloyd’s approval?---Not really; no.
Did you care?---At this stage, no, because I asked for it.[T2602]
10.133 Mr Morland said that he never asked Mr Old specifically if the hoses were Lloyds approved.[T2728] The only question Mr Morland asked of Mr Old was whether the hoses were suitable for fuel.[T2648] Mr Old denied that he was asked even that question.[T3106]
10.134 LCDR Crouch told Mr Morland that he would like to see the prototype before the work went ahead. WO Bottomley was handed a second prototype with end fittings by Mr Morland in Mr Morland’s office.[T219] WO Bottomley took it away.[T2691] WO Bottomley’s evidence was that the new line was also shown to LEUT Walters, the Assistant Marine Engineering Officer in WESTRALIA, before it was given to LCDR Crouch.[T1876, T220, T2831]
10.135 LCDR Crouch stated that he had asked Mr Morland to show him one of the hoses because he wanted ‘to see one to get a feel for the quality of the hose and to see what they looked like’.[T2831] LCDR Crouch says that he asked Mr Morland what pressure the hoses would be tested to. Although he could not recall precisely, LCDR Crouch stated that Mr Morland’s answer, ‘satisfied me that the test pressure was to be far greater than the system would require. I think he mentioned something in the order of one and a half times the system’s normal operating pressure.’[T2831] LCDR Crouch gave evidence that the extent of his responsibility in relation to the flexible fuel hoses was to make general enquiries including asking Mr Morland whether the hoses were to be pressure tested; what they would be pressured tested to; whether they were Lloyds approved and to examine the hose for quality e.g. broken braiding or broken strands; looking down the bore for holes.[T2892-2893]
10.136 When the second prototype was returned to Mr Morland by WO Bottomley [T2849], Mr Morland stated that he was told that the prototype was ‘accepted’.[T2558] In giving evidence, he said that ‘they came back and said they liked it’ [T2689-2690] and that the ‘Navy were happy with it.’[T2692] He made a diary entry, in relation to the flexible fuel hoses, in which he wrote that it was ‘okay to proceed.’[T2733]
10.137 Mr Morland returned the second prototype to Mr Old on or about 23 March 1998 and said that ‘ADI was happy with the prototype fuel line’.[T2692]
190 HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED
10.138 WO Bottomley denies giving approval. In his second supplementary statement WO Bottomley said:-
In paragraph 31 of his statement, Mr Morland asserts that I told him that the prototype was acceptable and that it was okay to go ahead with the installation of the flexible hoses. I do not have the authority to accept the hoses or to give any direction that work commence. I simply told Mr Morland that we were happy with the hose and thought that it looked good and would be a big improvement.[T3417]
10.139 When asked by Counsel for Parker Enzed Technology, who it was at Navy who consented to that second prototype and its suitability, WO Bottomley replied:-
We didn’t get to say. We were only shown it. It wasn’t given to us to approve or not to approve it.[T219]
Conclusion
10.140 Mr Old failed to advise ADI that he had not supplied Parflex 919 hose but another generically described SST hose product.
10.141 The prototype produced by Mr Old, simply involved the substitution of the rigid steel lines with flexible hoses. There is no evidence of any consideration of the different characteristics of the flexible fuel hoses and rigid steel lines or of good engineering practice.
10.142 It is extraordinary that ADI, via its employee Mr Morland, would give the ship an assurance that the flexible fuel hoses were Lloyds approved without carrying out even the most fundamental checks to ascertain whether that assurance was correct.
10.143 The Board finds that Mr Morland’s action in assuring WO Bottomley that the flexible fuel hoses were Lloyds approved when they were not, eliminated a major safety check point. ADI’s failure to ensure the flexible fuel hoses were Lloyds approved was a major contributing factor to the accident.
Contract Change Proposal
10.144 Mr Old obtained a quote from Abonnel for the manufacture of the new end fittings [E193] and faxed an Enzed quote to ADI on 23 March 1998 in the sum of $4,038.52.[E103 Tab 16, T3014]
10.145 Mr Morland prepared a Contract Change Proposal (CCP) [E103 Tab 15] and Work Order 975991/01 [E103 Tab 14] to cover the manufacture and supply of the end fittings. These were for an additional amount of $4,240.45 comprising the Enzed quoted figure together with an ADI on-cost of $201.93. The Abonnel price to Enzed was ultimately $3535.89.[E193 Tab 7, 12 and 17] The Work Order stipulated that it was for materials. It was approved by WMO.[T1952] Mr Morland informed Mr Old that ADI had approved the variation.[T2692] On 24 March 1998, Mr Old ordered the fittings.
10.146 This variation overlooked the fact that the original contract had included an amount of about $3,000 for end fittings and that a credit should have been given by ADI for that amount when the variation was raised.[T3110] This situation was raised during the
191 HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED hearing [T1952] and following that, ADI by letter dated 25 June 1998 gave credit for $3,447.97.[E201] WO Jones said he was ‘not conscious that an overpayment might have been made at the time (he) approved the contract change proposal’.[T1952] The relevance of this situation so far as the Board is concerned is that it further demonstrates inattention to documentation by ADI and WMO. Further relevance was raised by evidence from Mr Old [T3110 and E219] that he had become aware of the need for such a credit, that he delivered to Mr Sergeant an invoice for an amount less than the total prices in the quotes, and that Mr Sergeant rejected the invoice and told him to put in another for the full price, which Mr Old did.[E104 Tab 24] Mr Sergeant conceded this [T3698] This evidence is troubling to the Board.
Conclusion
10.147 The fact that Mr Sergeant directed Mr Old to increase the amount of his invoice seriously detracts from the acceptability of Mr Sergeant’s evidence on the subject of the quotation and evaluation process. Although this is not within its terms of reference, the Board consequently feels concerned about the ADI RPLSS tendering practices.
Assembly, testing, installation and reinstallation
Assembly, installation and testing
10.148 On and between 7 and 10 April 1998, Mr Old assembled and pressured tested the hoses. The pressure testing was at 1000 kPa for 5 minutes. All supply hoses passed the test, but one return hose failed. In accordance with what he said was his ordinary practice, Mr Old destroyed that hose to prevent re-use, and made up a new one. The new hose passed the pressure test. Mr Old then completed the test certificates and tagged the hoses.[T3015,T3016, T3061, T3063]
10.149 The destruction of the hose without fully investigating and documenting the failure, and indeed the failure to inform ADI, suggests poor quality control procedures on the part of Mr Old. LCDR Crouch stated in evidence that if he had known about that one hose failure it would have caused him to question the integrity of all the hoses.[T2832] Mr Old did record the failure of the hose in his closing report. That report was not given to the ship before she sailed on 5 May 1998.[T229]
10.150 Mr Old installed the hoses between 8 and 10 April 1998. He made up and pressure tested the 8 spare hoses on 11 April 1998. Mr Old bagged the spare hoses for storage and gave them to Mr Morland.
Post installation leaks
10.151 Between 17 and 24 April 1998 tests were conducted on the main engines. None of the fuel hoses leaked but there were continuing leaks at fuel pumps and valves.[T2561, E199 para 71] During this period Mr Old attended to various of these leaks, removing blocks and placing or replacing washers.[T22] Mr Old was not present during the test, but Mr Morland told him about it. On 21 or 22 April 1998, Mr Old disconnected and then reconnected seven fuel hoses on the outboard side of the PME to enable the ship’s crew to remove a leaking fuel rail.[T22]
192 HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED
10.152 On 24 April 1998, WO Bottomley accepted the flexible fuel hoses and signed off that the work was complete on behalf of the ship.[T206]
10.153 Continuing leaks were noticed during sea trials which took place 29 April – 1 May 1998. PO Hollis referred to them as ‘a series of minor leaks around the fuel lines’.[T1803]
The opening and closing report
10.154 On 30 April 1998, Mr Old delivered his unsigned opening and closing report to ADI.[E103 tab 22, T3018-19, E219 para 12] ADI did not give that report to the ship before she sailed on 5 May 1998. The report included notes that:
1. It needs to be stressed to all personnel that will be required to install/remove the new hoses that they will not tolerate:
a. twisting, or
b. excessive bending.
2. When removing or installing the assembly, care should be taken to ensure that it is not subjected to any of the above.
Leak rectification on 4 May 1998 by the Ship’s Crew
10.155 On 4 May 1998, in accordance with instructions from WO Bottomley [T22], PO Hollis tasked LSMT Smith, LSMT Meek, AB Croasdale and AB Justice to attend to the leaks by replacing about 18-20 steel washers on both main engine fuel pump connection blocks.[T1803] He told them ‘not to bend the lines’. He explained:-
From my experience, I knew that flexible lines should not be bent or twisted. Nobody from ADI, Enzed or the ship’s staff told me about this. I checked on them twice that morning and everything appeared to be going well.[T1803]
10.156 Each of the sailors who worked on the lines was questioned on how they handled the hoses. While giving evidence, LSMT Smith and AB Croasdale recalled having difficulty tightening the block on no. 10 cylinder PME and having to ask PO Hollis to assist. LSMT Smith cannot now find the list of which blocks were leaking. AB Justice remembers working on STBD 8 and 9 cylinders. The sailors seem to have been generally aware of the dangers of excessive bending or twisting of the hoses and to have acted accordingly.[PO Hollis T1811, 1815, 1818, 1827, 1846; LSMT Smith T1248-1250, 1254- 1260; AB Croasdale T1390-1396, 1398-1400; AB Justice T4124-4126] AB Justice pointed out how difficult it was to get at the flexible hoses to see what was happening to them:-
…it’s above my head and so it’s really difficult because you’re bent back and so I couldn’t put it in because I couldn’t see to line it up.[T4125]
10.157 ADI contends that damage was done to the hoses on 4 May 1998 reducing their resistance to fatigue.[T4374] Dr Goodwin has pointed out despite careful handling, installation was impossible without excessive bending, and twisting was a significant risk as a result of poor design.[T3500-T3506] He said that damage during installation may have reduced hoses’ resistance to fatigue.[E214, T4232] Mr Bromley has expressed the
193 HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED opinion in any event, that mechanical damage to hoses, particularly permanent sets and internal creases were not found to significantly affect the static burst strength.[E194 pp8, 25] Further, Mr Bromley’s testing of sample hose ‘D’ particularly suggests that abuse in itself would not result in hose failure.[E194 para 3.13 and 4.1.3]
Conclusion
10.158 Because of design deficiencies, the hoses could not be installed without damage to them. Whether any damage done to hoses on 4 May 1998 was more significant than any damage done to hoses by when they were installed or otherwise handled before 4 May 1998, is impossible to say. Testing has, however, established that such damage was not relevant to the leaks in the hoses which occurred on 5 May 1998. In any event, susceptibility to damage under these circumstances would have demonstrated their unfitness for purpose.
PROCESS DEFICIENCIES AND OTHER FACTORS
Introduction
10.159 There were numerous process deficiencies and other factors which led to the installation of the defective flexible fuel hoses. The following paragraphs draw together, on an organisational basis the more significant process deficiencies and other factors. Matters directly relating to Quality Assurance are dealt with in Section 12.
NAVY
HMAS WESTRALIA
10.160 As noted in R10.50 and R10.51, notwithstanding that LCDR Crouch was led into error by oral advice from WO Jones, he should have himself instigated checks as to just what had occurred in relation to securing appropriate approval for the installation of the flexible fuel hoses.
OAWA
10.161 WO Jones misled LCDR Crouch and WO Bottomley into believing that circumstances had transpired which made the use of a TM200 the appropriate next step to be taken in relation to the flexible fuel hoses, as noted in R10.50.
10.162 At the stage of approval of the MAXIMO Work Order, WO Jones failed to view essential documentation, particularly the Enzed quotation.[R10.116] His inattention to documentation was in evidence again when he approved the Work Order for the variation in respect of the new end fittings, as set out in R10.144-10.146.
10.163 Against these deficiencies, however, the Board acknowledges that WMO has not been trained in contract administration and has only completed a 2-3 day financial training course and a basic ‘purchasing’ course.[T2154] Despite his extensive naval marine engineering background and knowledge of WESTRALIA, the WMO has not been trained to manage a complex maintenance contract such as RPLSS.
194 HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED
10.164 No one within the OAWA, let alone WMO, has received any training in matters pertaining to Lloyds Classification and the need to ensure that WESTRALIA remains as required, ‘in class’.[T3324]
Conclusions
10.165 The Board finds that the WMO was not adequately trained for his role within the OAWA.
10.166 WMO failed to give attention to the documentation, to confirm that the job on the flexible fuel hoses was being done as requested by the ship.
10.167 WO Jones did explain that:
AMP 12 was a busy period for me, as my CPO was unavailable for one week due to his training commitments prior to transferring to the business office within OAWA at the completion of AMP12 activities. [T1946]
Recommendation
10.168 The WMO billet should be filled by a person who has, amongst other requirements, received appropriate training in contract administration, financial management and Lloyds Classification Society requirements.
ADI
10.169 Deficiencies in process on the part of ADI might be summarised as follows, and there is included at the end of each summary item a list of relevant conclusions expressed above:-
a. ADI failed to give any adequate engineering consideration to the flexible fuel hoses.[R 9.93-4, R10.64, R10.71 and R10.143]
b. ADI failed to adequately to specify or otherwise design the flexible fuel hoses.[R9.93-4, R10.64, R10.82, R10.143]
c. ADI failed to supply flexible fuel hoses which were Lloyd’s approved [R10.71, R10.141] and ADI assured WO Bottomley that the hoses were Lloyds approved when they were not.[R10.143]
d. ADI failed to take adequate steps to ensure compliance by their subcontractor of compliance with the TM200.[R10.82, R10.115]
e. ADI supplied flexible fuel hoses which were not fit for their intended purpose.[R9.94]
Occupational Health and Safety Legislation
10.170 In addition to those deficiencies, matters pertaining to ADI’s obligations pursuant to the Occupational Health and Safety (Commonwealth Employment) Act 1991 (the ‘Act’) have been considered by the Board. Whilst the RPLSS contract does not
195 HOW HOSES OF INADEQUATE DESIGN CAME TO BE FITTED explicitly refer to obligations under to the Act, that omission does not relieve ADI of its responsibilities under the legislation. Current RAN policy, as outlined in ABR 6303 (RAN Safety Management Manual) is that any contract entered into by the RAN should include responsibilities placed on the RAN and the Contractor under the relevant occupational health and safety legislation.
10.171 ADI, as a supplier of goods, had an obligation under the Act to ensure that such goods at the time of supply were safe for use and without risk to the health of those who use the goods; additionally, the Act required ADI to carry out, or cause to be carried out, the research, testing and examination necessary in order to discover, and to eliminate or minimise, any risk associated with the goods being supplied.
Recommendations
10.172 Consideration should be given by an appropriate authority as to whether ADI failed to comply with the Act.
10.173 Care should be taken to ensure that all RAN contracts include explicit reference to occupational health and safety legislation as stipulated in ABR 6303 Chapter 4.
Parker Enzed Technology Organisation
10.174 The Board has concluded above that Mr Old failed to supply a hose “to Lloyd’s approved standards” (as it was referred to in the Work Instruction), failed to make any adequate enquiries of Lloyd’s Register [R10.102], and failed to alert ADI to his change to SST-12.[R10.140] It has also concluded that Mr Old presented himself to ADI as part of the Parker Enzed Technology organisation and this implied a depth of expertise and knowledge which Mr Old, could not, and did not, provide.[R10.117] In paragraph R10.127 the Board has further concluded to the effect that Parker Enzed Technology gave inadequate support to Mr Old in the obligations which he undertook as part of their organisation. The Board wishes to add a further conclusion, based on the whole of the evidence canvassed above.
Conclusion
10.175 The Parker Enzed Technology organisation apparently allowed Mr Old to present himself to ADI as representing the Parker Enzed Technology organisation thereby giving rise to an unwarranted expectation of the level expertise and knowledge he could provide.
196 SECTION 11. RAN CONFIGURATION MANAGEMENT
11.1 There have been some allegations in evidence notably from CMDR Sippel [T4199], CMDR Stapley [E355] and Mr Bruce, the Contract Administrator for ADI [T3854-3855], that there is a lack of discipline in configuration management in the RAN. They suggest that some configuration changes have been inappropriately accomplished by means of the TM200 repair process. These allegations may well be true. The Board suspects that the prime motivation for using the TM 200 process to implement change is a strong desire to quickly implement safety and other improvements (e.g. reducing fuel leaks). Unfortunately, use of this repair process bypasses a number of checks which may expose more fundamental safety issues.
11.2 While it is tempting to suggest that change process should be expedited to alleviate the frustration and allow modifications to be made quickly, the nature of investigations necessary before changes are approved is often unavoidably protracted. Resource constraints limit the staff available to process proposals and restrict the funding for investigations of the feasibility and safety of proposed changes. Detailed work is often required to develop a proposal to the point where management can make an informed decision on the desirability and priority of the change. The lead times are compounded by the time required to put in place suitable contractual arrangements for the investigation and ultimately the work to make the change. Some streamlining of the process may be possible but is unlikely to be of the order that personnel at the coal face would like to see.
11.3 No unequivocal evidence has been produced to substantiate widespread malpractice but there seems little doubt that the practice exists to a degree. One of the difficulties is in determining exactly what is a configuration change. LCDR Crouch gave an example in evidence of his attempts to replace a rusting steel 44 gallon drum, used to store firefighting foam for the flight deck foam cannon, with a more durable stainless steel container.[T4460] Although he initially planned to accomplish this change by TM 200 action, someone pointed out to him that it was a configuration change and a TM187 approach was more appropriate. Technically, this advice was correct but the ship still had an unsatisfactory arrangement. To be on the safe side, all changes to ships should be subjected to a rigorous change process, but this approach ignores the imperatives of schedule, common sense and initiative.
11.4 The key to the right approach is good professional engineering judgement. Ideally, this would be exercised in the first instance by the initiator of the potential change but a professional engineering authority should validate it before work is set in train. The Board has not explored whether the RAN has the right resources close to or at the waterfront to exercise this role. The staffing of OAWA is certainly inadequate in terms of qualifications and capacity to assume this responsibility. In the light of resource limitations, there may be no choice but to persist with current unsatisfactory arrangements for configuration change.
11.5 In the case of the flexible fuel hose change, no competent authority either within the RAN or ADI critically examined the wisdom of the intended course of action. The innocuous title of the job (‘manufacture and install flexible fuel lines M/E’s’) hid it from possible critical scrutiny at the pre AMP meeting [T4187]. There was at least one other configuration change planned as a TM 200 which was identified and stopped by CMDR Sippel at that meeting [T4188]. These instances [T4194] in WESTRALIA may be
197 RAN CONFIGURATION MANAGEMENT symptomatic of a poor understanding of the implications of configuration change on a RAN wide basis.
Conclusions
11.6 The formal RAN configuration change process is circumvented at times, generally by well intentioned personnel, and this can have a severe impact on safety.
Recommendations
11.7 An urgent review of the configuration management training provided in MEO and CO Desig courses together with a review of other pre joining and career courses should be conducted.
11.8 A firm reminder of the importance of a disciplined approach to configuration management to the RAN community should be issued and reinforced on a regular basis. The Board notes the direction given by the Maritime Commander [MHQAUST message 210733Z JUL 98] to initiate audits and to manage the safety implications resulting from the unauthorised configuration changes and inappropriate use of procedural workarounds.
11.9 A technical review of work packages by a competent professional engineering authority should be introduced as part of the procedure for authorising work.
11.10 A review of the RAN configuration management process in the light of the shortcomings revealed to this Inquiry and the recent organisational changes such as Class Logistic Offices and Refit Planning Logistic Support Services (RPLSS) contractors, should be conducted. The review should include an assessment of the level of engineering expertise available in the RPLSS offices.
198 SECTION 12. QUALITY ASSURANCE
12.1 The processes of design, manufacture and installation of the flexible fuel hoses was conducted by organisations which had certified quality systems: OAWA ISO 9002 [E345] ADI ISO 9001 [E471] Parker Enzed Technology AS 3902 [E193 KMO4] and ISO 9002 [E216 RS7] 12.2 Quality systems (also called quality management systems or QMS) are ‘aimed primarily at achieving customer satisfaction by preventing non-conformity at all stages from design (production: ISO 9002) through to servicing’ [Scope, ISO 9001:1994]. The flexible fuel lines installed did not conform to the specified standard of Lloyds approval or to the necessary standard of fitness for purpose.[T2602] How could organisations with certified quality systems allow this to occur?
Reliance on Certification
12.3 During the hearing, WO Jones was asked ‘…is there any scrutiny or check made on behalf of Navy, or the Commonwealth, of RPLSS performance of that sort of obligation?’(supplied products meeting specified requirements) [T1958], to which he replied, ‘No’. WO Jones later explained [T1958-1960] that when goods arrive, the invoice is checked, ‘… and if companies have been suppliers to ADI and have the logo of the five ticks, quality accredited, … (I am) heavily reliant on those sort of things, sir.’ Mr Sergeant explained his decision to invite Enzed to quote in these terms:
Although ADI had not contracted with ENZED before, I was aware from my own experience that ENZED is a specialist supplier of high performance industrial hoses and held a Quality System Certification to Australian Standard 3902.[E217 para 7]
12.4 The assumption that a certified QMS guarantees quality of product is not appropriate. Certification is gained by having documented procedures for design control, inspection and testing, control of non-conforming product, internal quality audits and so forth. Unless the documented procedures are well written, reflect customer requirements and are rigorously implemented, certification is meaningless to the customer.
12.5 Internal quality audits are conducted regularly in order to ensure conformance and applicability, and maintain certification. If these audits are not conducted correctly, inappropriate procedures can continue unchecked, appropriate procedures can be ignored, and non-conforming product can continue to be provided to the customer.
Navy
12.6 With the introduction of RPLSS type contracts, the contractor drafts the work instruction, and thus the type and number of QA inspections and hold points. Under this system, the Navy must ensure that QA requirements are adequately explained in the TM200. Contract managers and ships’ staff must then ensure that the Work Instruction raised by the contractor reflects these requirements.
199 QUALITY ASSURANCE
12.7 As the QA involvement was previously set by the Ordering Authority in consultation with the ship, guidelines may be required to assist ship’s crews in determining the appropriate type and frequency of inspections, based on risk, type of job, and experience of personnel.
Recommendations
12.8 RAN contract managers and ships’ staff should thoroughly check work instructions to ensure that all requirements are accurately specified and the appropriate level of QA checks are included.
12.9 Work should not be accepted until all QA requirements have been met, including the provision of the appropriate documentation.
OAWA
12.10 OAWA’s Quality Plan and Standard Operating Procedures were out of date, CMDR Coverdale stating ‘I am painfully aware the quality management system does need updating’. [T3292] The SOP for WESTRALIA contract management [E296 SOP 200] is only 9 pages long, of which 5 pages are examples. The SOP refers to the previous contract for logistic support for WESTRALIA. When read in context with the rest of OAWA’s procedures the SOP does not provide adequate guidance on:
a. Handling TM200s
b. Validating Work Instructions raised by the contractor
c. Processing SG2s
d. Procedure for CCPs
e. Planning a maintenance period (for WESTRALIA)
f. Managing a maintenance period
12.11 Indeed, the only existing SOP for assessing the technical merit of TM200s [E302], was discarded when the responsibilities of FIMA Perth and OAWA changed in late 1997:
… OAWA has endeavoured to provide an uncompromised, customer oriented approach towards the ship and support craft it is tasked to support. In particular, this has included … the removal of previous procedures for the rejection of forms TM200 ...[E345]
12.12 The absence of any technical assessment of the TM200 and the work instruction in relation to the flexible fuel hoses was central to the problem which occurred. OAWA SOPs did not address in any way how these important assessments were to occur under the RPLSS contract.
200 QUALITY ASSURANCE
Conclusion
12.13 The quality management system of OAWA is inadequate, particularly in relation to the management of maintenance for WESTRALIA.
Recommendations
12.14 OAWA’s SOPs should be updated to reflect the WESTRALIA RPLSS contract.
12.15 SOPs for all RAN contract managers should address each type of maintenance process in which the contractor is involved, clearly defining the responsibilities of both parties.
12.16 RAN contract managers should insist on receiving all appropriate quality documentation (including test certificates and opening/closing reports) and check them for accuracy and completeness prior to approving payment.
ADI
12.17 The ADI Project Quality Plan [E131] refers to a set of standard procedures, including a procedure for service design control (SP 04.01 Issue 2.2 [E469], superceded by LSP 04.01 Issue 1[E470]). This procedure applies to all sub-contractors, and includes the ‘development of proposals to fully meet a customer’s requirements’. This procedure includes raising a set of instructions that will:
a. Meet the design input specification,
b. Contain or reference acceptance criteria,
c. Conform to appropriate regulatory requirements whether or not these have been stated in the input information, and
d. Identify those characteristics of the design that are crucial to the safe and proper functioning of the service (service being defined as work carried out by the company). [E469 para 4.6]
12.18 The procedure states that a record of service design or validation will be maintained, and an example form is provided (F S0401 Issue 2.2 [E469]). In the documentation provided by ADI [E103] there was no S0401 for the flexible fuel hose work.
12.19 Coincidentally, an internal QA audit (LSP04.01 – Design Control) was conducted for the flexible fuel hose task after the fire.[E221 SS4] The audit assessed conformance to the procedure as satisfactory.
12.20 The internal audits were conducted by following the given questionnaire. [T3775] The questionnaire for design control [E221 SS4 0000085] addresses the numbering of documents, rather than the content. This means that the audit can not determine if responsibilities are being fulfilled. Indeed, ADI’s Internal Auditor Mr Singh stated that he very rarely looks at the content of documents.[T3778] In the case of the
201 QUALITY ASSURANCE flexible fuel hoses documentation, this meant that the auditor assessed the work instruction as satisfactory, even though it had various formal defects, none of which he noted.[T3779]
12.21 An external audit of ADI Rockingham was conducted after the incident, including a review of Mr Singh’s audit of the flexible fuel hose documentation.[E221 SS5] This audit included review of the flexible fuel hose work and was surprisingly positive in the light of the deficiencies demonstrated to the Board [T3779-3781]. The summary of the audit noted in part that:
….the system was found to be well documented and effectively implemented in accordance with the standard. All personnel involved are to be complimented.
12.22 Despite the contractual requirement to maintain suitable quality records to be able to demonstrate the achievement of the required quality [T3784], Mr Singh conceded that that no-one in ADI considered the adequacy of the documentation for the flexible hose job. He also admitted that the positive findings by the external auditors were extraordinary [T3786] and that ADI’s quality responsibilities had not been duly discharged [T3787].
12.23 Of particular concern in a quality assurance sense, is the absence of objective evidence to warrant satisfactory findings by two ADI audits of management responsibility [T3797-3800]. In response to the question ‘Has the responsibility, authority and inter- relationship of all personnel who manage, perform and verify work affecting quality been defined?’ Mr Singh agreed that other than the generalities of the ADI RPLSS Project Quality Plan [E131], there was no documentation of the specific responsibilities of his office.
Conclusion
12.24 The internal and external quality audits of the ADI quality management system failed to identify significant deficiencies in the implementation of that system
12.25 The ADI SOP for Service Design Control was suitable to ensure an adequate product. That procedure was not followed, however, and internal and external audits failed to detect this situation.
Parker Enzed Technology Organisation
12.26 Mr Old was unsure of whether he was working in a quality certified organisation, and what the implications were. For example, he was unable to answer the question ‘Are you quality accredited?’ [T3129]. His business card displays a quality accreditation that appears to be by association with the Parker Enzed Technology organisation. Mr Old believed that he was required to provide certain documents for quality checks as part of his franchise agreement.
12.27 In any event, procedures that are normally expected as part of a quality system were not carried out. For example:
a. No test certificate or entry into the test register was made of the hose that failed the pressure test [T3061]. The only documentation recording the failure was the open and closing statement, which the ship had not
202 QUALITY ASSURANCE
received at the time of the incident. (ISO 9002 Inspection and Test Records Criteria)
b. Mr Old did not keep the length of hose that failed, or inform anyone that a failure had occurred, or investigate the cause of the failure himself.[T3063] (ISO 9002 Corrective Action Criteria)
Conclusion
12.28 Mr Old was unaware of his quality assurance responsibilities and had not been adequately trained in relation to them.
Defence Accreditation and Auditing Policy
12.29 Part of the problem for Navy may be the reliance on third party accrediting organisations that are hired by the company being audited. There seems to be little incentive for the accrediting organisation to be particularly rigorous when their future depends on satisfied customers (the hirer). A different attitude might occur if the third party organisations were contracted by Defence.
Recommendation
12.30 Defence should re-examine the policy of quality accreditation for companies engaged in Defence work with a view to contracting the accrediting organisations to work on Defence’s behalf. A price reduction resulting from the transfer of responsibility for the work should be vigorously pursued.
203 SECTION 13. SYSTEM SAFETY MANAGEMENT
13.1 Sections 9 and 10 of this report discuss in detail the evidence relating to the fitting and subsequent failure of the flexible fuel hoses. The Board has concluded that the hoses were manifestly unfit for purpose. This conclusion is clear but it does not address the underlying situation that led to the fire and tragic deaths of four Naval personnel.
13.2 Inquiries seem to deal in blame and accountability and to concentrate on these issues can lead to an oversimplified analysis of any accident and a failure to address the system errors. In so doing, organisations are in danger of retaining systems with inherent faults or ‘pathogens’. These inherent faults can all too easily lead to other accidents, which on close analysis, have similar underlying organisational causes.
13.3 Accidents occur as a result of a complex chain of events, including malign factors (which in themselves are not causative) coming together in a moment when the system is vulnerable. Few, if any, accidents are caused by one single factor but typically by a substantial number of factors including human errors, slips, lapses, violations and mistakes. These occur at all levels of the organisation, not just at the operator level.
13.4 Researchers into accidents have emphasized the extreme difficulty of those involved to foresee any possible adverse conjunction between what seemed to them to be unconnected and, in many instances, not especially unusual or dangerous happenings or decisions (Wageneer & Groeneweg, 1988, p.42):
Accidents appear to be the result of highly complex coincidences which could rarely be foreseen by the people involved. The unpredictability is caused by the large number of causes and the spread of the information over the participants. . . . Accidents do not occur because people gamble and lose, they occur because people do not believe that the accident that is about to occur is at all possible.
13.5 Reason (1991) cautioned against rushing to judgement and seeking scapegoats:
First, most of the people involved in serious accidents are neither stupid nor reckless, though they may well be blind to the consequences of their actions. Second, we must beware of falling prey to the fundamental attribution error (i.e. blaming people and ignoring the situational factors). (Reason, Human Error, 1991. P 216).
13.6 A tragic irony of the fire and fatalities aboard WESTRALIA is that all those immediately concerned in the fitting of the flexible hoses (LCDR Crouch, WO Bottomley, WO Jones, Mr Morland, Mr Sergeant and Mr Old) genuinely cared about the ship and saw the fitting of the flexible hoses as a means of enhancing WESTRALIA’s operational effectiveness and safety.
13.7 Given the totality of the evidence before the Board, the accident highlights latent weaknesses within the Navy and ADI. These weaknesses involve long term management strategies, line management deficiencies, individual training, perceptions and knowledge, and inadequate defences against breakdowns in the system.
13.8 The evidence before the Board demonstrated, that the ship’s company of WESTRALIA and those ex-service personnel employed by ADI:
204 SYSTEM SAFETY MANAGEMENT
a. did not sufficiently understand the ship safety regime under which WESTRALIA operated;
b. had not been sufficiently alerted to a safety regime foreign to the majority of Naval ships;
c. had not received any instruction or training in the classification of ships;
d. had not received any clear direction on the need to consult the classification society in line with the conditions of class;
e. did not have the level of training in, or theoretical knowledge of, diesel engines to alert them to the possible dangers.
13.9 The responsibility for ensuring that WESTRALIA’s engineers, OAWA, and RPLSS staff had the appropriate base knowledge rested with their respective organisations, Navy and ADI.
RAN
13.10 LCDR Crouch was asked if he received any specific instructions relating to his responsibilities when he was appointed to WESTRALIA. He answered ‘no’ (T2969). He was also asked if any part of any Naval training covered keeping a ship in class:
No. I do have a general - - well, a hazy understanding of the requirements to keep a ship in class, mainly from the minesweeping project where we were involved in commercially built craft. That was AMSA requirements, and I believe Lloyds requirements are similar - - -[T2909]
13.11 When asked to explain his understanding of the way classification societies work he stated:
The vessel would be classified in accordance with its intended use and its capabilities and the - - well, basically, that’s it. Its intended use and its capabilities. That is - - it goes down to as far as what expected sea states it can survive and how many people it can carry onboard.[T2970]
13.12 The answer demonstrated, at best, a superficial knowledge of the role of classification societies.
13.13 It could be argued that there is some initial information provided to Naval personnel in the RAN Logistic Support Policy Manual (ABR 5454) at paragraph 3003 [E58]. However there is no detail on the relationship between the ship and the classification society, or the need to conform to the conditions of the certificate of class.
13.14 WO Jones understood that Lloyd’s carried out surveys on the ship’s structure and machinery [T1956]. However, he considered the issues of Class were a matter for ADI [T1958]. He was questioned about the terms and conditions appearing on the back of the Lloyd’s Certificate of Class [E138] by Counsel Assisting.
You will see the opening paragraph, paragraph 1, of that recitation of the terms and conditions that:
205 SYSTEM SAFETY MANAGEMENT
‘Continuance of class is subject to compliance with the requirements of Lloyds Register of Shipping’s Rules and Regulations for the Classifications of Ships’
And attention is drawn in particular to the following extracts from rules, part 1 chapter 2, and one of the extracts is paragraph 1.5, which, without reading the full paragraph but reading it in terms of its presently relevant words:
‘Plans and particulars of any proposed alterations to machinery are to be submitted for approval, and such alterations are to be carried out to the satisfaction of Lloyds Register’s surveyors.’
Does that represent your understanding of what should be done in relation to a proposed alteration to machinery on board HMAS ‘Westralia’ so far as Lloyds are concerned?---Yes, sir.
And this change from rigid, or fixed, fuel lines to flexible fuel lines would have involved a relevant alteration to machinery, would it not?---Yes, sir.[T2064]
13.15 He was referred to general condition 6.19 of the contract [E25]:
‘Approved alterations to machinery shall be carried out under the inspection of and to the satisfaction of the Lloyds Classification Society/AMSA surveyors as applicable.’
Was any consideration given by you to the contractual obligation or the Lloyds requirement for their involvement in this alteration to the fuel lines on HMAS ‘Westralia’?---As per the 200 submitted by the ship, sir.
Yes. Nothing beyond that?---No, sir.[T2064]
13.16 Although the CO was not directly involved in the procedures for the fitting of the flexible fuel hoses, his evidence as to the understanding of the role of class is indicative of the overall knowledge by Naval staff.
13.17 CMDR Dietrich was asked about his knowledge of the classification of ships [T3208]:
Do you know much about classification societies? ---Not a lot. I have been learning on the job on ‘Westralia’.
13.18 When asked what he had learnt of the role of Lloyd’s he stated:
That there are - - that Lloyds conducts regular checks of certain aspects of the ship’s engineering configuration, I guess mostly on the engineering side and hull structure side and that the ship is required to meet routine survey requirements of Lloyds and that’s factored into our planned maintenance arrangements.[T3208-3209]
So it’s factored into your planned maintenance but, I mean, does the Navy provide you with an idiot’s guide to what Lloyds require? It would seem sensible to me that at least something is outlined to you - -?---No. The Navy does not provide that. I think to some extent we rely on the contractor.[T3209]
206 SYSTEM SAFETY MANAGEMENT
13.19 The Cargo Ship Safety Construction Certificate is issued in accordance with SOLAS 74/78. When asked if he knew anything about the Convention he stated:
--I’m aware of it.
Again, there is no education process or briefing process that goes on from anybody exactly what is covered in that? Nothing like that is provided to you? ---Not before joining the ship.[T3209]
13.20 The final sentence of para 3003 of the Logistic Support Policy Manual (ABR 5454): ‘Standards therefore, should not vary from commercial to military unless an essential need is demonstrated’ [E58 tab1], probably had little meaning to those to whom it was directed.
13.21 The Board accepts that issues such as maintaining a ship in Class and the provisions of conventions related to commercial ships on international trade are totally foreign to naval staff. It is outside their experience.
ADI staff
13.22 All the ADI personnel were ex RAN and were selected for their engineering experience, knowledge of Naval maintenance procedures in general and their familiarity with WESTRALIA. Such a selection policy can either be seen as to narrowly focussed or as wholly logical, employing like minded and similarly trained individuals, steeped in the way ‘the Navy does business’.[T3862]
13.23 The danger of such a policy is that inherent practices and attitudes become entrenched and introverted. There was certainly limited appreciation of the implications of retaining a ship in class. In the case of WESTRALIA, there was a requirement that the safety provisions and standards ‘should not vary from commercial to military unless an essential need is demonstrated’.[E58 Tab 1]
13.24 Mr Morland knew that the ship was required to remain in class with Lloyd’s [2580]. Although he was indisposed before questions could be put to him on his detailed knowledge of classification requirements, the totality of his evidence showed that he had no greater understanding than other ADI or RAN witnesses of what was involved in retaining a vessel in Class.
13.25 Mr Morland’s role of technical specialist was specifically related to WESTRALIA, and there was an ADI requirement for him to have a ‘Knowledge of naval fleet maintenance systems’. However, the ADI description relating to his position contained no reference to Lloyd’s or SOLAS74/78 despite the fact that WESTRALIA was to be maintained to commercial standards.
13.26 The only position description of the four man RPLSS management team that mentioned the class society was that of the Quality Coordinator, Mr Shingara Singh.
13.27 Mr Sergeant gave evidence of a meeting with Lloyd’s [T3656]:
when the contract first was undertaken, we arranged a meeting with myself and also Mr Singh, went up to Fremantle, talked through quite a few bits and pieces. There were a couple of surveys that were due at that particular time and you are quite right, we had no idea on what was physically required. We certainly didn’t have the Lloyds books and as a result of that opening
207 SYSTEM SAFETY MANAGEMENT
discussion 14 months ago, or thereabouts, we certainly learnt quite a few bits and pieces, but we have an ongoing discussion with Lloyds.
13.28 It is evident that whatever discussions had been held with Lloyd’s, the ADI staff did not understand either that:
a. modifications to the hull or machinery of a ship in class require a full approval process by the relevant classification society; or
b. what such an approval process involved.
System failure
13.29 As major accidents are made up of a complex web of factors, it is unlikely that the exact circumstances of the fire aboard WESTRALIA will be replicated in another incident. However accidents are more likely to occur where the system is fundamentally weak. The very complexity of the RAN ordering system and the low level at which important technical decisions are made are fundamental weaknesses.
13.30 There was a failure on the part of both Navy and ADI to provide staff that understood the somewhat unusual situation of operating a ‘warship’ while requiring that the safety provisions and standards ‘should not vary from commercial to military unless an essential need is demonstrated’. The differing, and sometimes parallel, standards and procedures of the RAN and Lloyd’s seem to have caused confusion. This, coupled with the limited experience of both the RAN and ADI staff, were elements in a system that failed at a critical time.
13.31 Looking at a system that has failed, in the first instance six basic safety questions should be asked:
a. Were the risk factors identified or identifiable?
b. Was the equipment in use fit for purpose?
c. Were the systems and procedures on board effective to maintain safe operation?
d. Were the individuals involved qualified, competent and effective?
e. Were emergency procedures and defences effective?
f. Was there a management system to monitor performance?
13.32 When considering the factors surrounding the fitting of the flexible fuel hoses in WESTRALIA, on all counts the answers to the above questions must be ‘no’.
Other System Weaknesses
13.33 The issues of potential ‘system’ failure or system weakness are not confined to selecting and fitting flexible fuel hoses. Issues raised in this report demonstrate underlying organisational and management issues that contributed to the fire on 5 May 98 and which could lead to other serious breaches of safe practice. Taking each aspect individually, the
208 SYSTEM SAFETY MANAGEMENT issues raised may seem inconsequential or trivial. Taken as a group they point to a wider malaise.
13.34 The requirements for pre-joining training are apparently being systematically disregarded [R3.156]. As the onus is on the releasing billet to provide the requisite training, the releasing billet has no direct stake in ensuring the procedures are followed.
13.35 When LCDR Crouch took over as the Engineer in October/November 1996, [T2970] he did so in the rank of LEUT from a LEUT Jones [E304]. The RAN Marine Engineering Manual (ABR 5225) states in a note on the supersession procedure at para 191:
In ships in which the Marine Engineer Officer is below the rank of Commander, as much of this detailed examination as is practicable should be carried out in conjunction with the Marine Enginee Officer on the staff of the Administrative Authority.
13.36 Practical or not, this procedure was not followed although both Officers were LEUTs.
13.37 WESTRALIA had not completed its required number of escape training exercises from the MMS since June 1996 [R3.67]. Although pro-forma returns on training were submitted to Maritime Headquarters this shortfall in training was not identified.
13.38 Allegations of an increasing use of the TM200 format to achieve configuration change were made to the Board [R11.1]. Authorisation to fit flexible fuel hoses in WESTRALIA was a case in point.
13.39 The WESTRALIA Damage Control Log, recording damage control exercises in port shows that the minimum standard achieved at any time was SA- (standard achieved, minus). Since 1 January 1998, over 50 exercises and instructional sessions have been recorded in the log.[E92] Given the evidence before the Board of the general level of knowledge of the ship and its safety systems, it is hard to accept that standards recorded fairly reflect the ship’s overall proficiency in damage control.
13.40 On the question of safety audits it is worth considering the lessons from other safety investigations. An assessor to the Piper Alpha Inquiry, Brian Appleton, an ICI Executive and qualified engineer, commenting on an audit of a safety system which contained no criticism whatsoever said:
In my experience there is always news about safety – some of it bad – continuous good news you worry.
13.41 As has been stated earlier, the Board was particularly concerned at the general lack of knowledge and ignorance of officers of their ship, particularly of the safety equipment.
13.42 Of major concern is the low level of knowledge of the ship’s company in the safety systems and equipment and the lack of external identification of this deficiency by Sea Training Group. The primary example of this was the knowledge of the primary firefighting system protecting the space with the highest fire hazard – the CO2 system protecting the MMS.[R3.135]
209 SYSTEM SAFETY MANAGEMENT
13.43 The lack of knowledge of the ship was not confined to individuals, or limited groups of individuals, but appears to apply to the ship’s company as a whole. This is indicative of a wider system deficiency in the safety management of WESTRALIA.
13.44 The Board notes that Navy issued the RAN Safety Management Manual (ABR 6303) on 13 February 1998. As such a recent publication, it has not yet had sufficient time to affect the existing safety culture of individuals, ships or organisations within the RAN.
13.45 Numerous specific recommendations have been made elsewhere in this report covering matters referred to above. A more general conclusion follows.
Conclusion
13.46 There are systemic defects within RAN and ADI safety management.
Recommendation
13.47 Training in the RAN Safety Program, specified in ABR 6303, should be given priority.
210 SECTION 14. COMCARE
14.1 On 8 May 1998, Comcare (Mr Mark McCabe, General Manager Occupational Health and Safety Legislation General Division) wrote to the Board that it was conducting an investigation under the Occupational Health and Safety (Commonwealth Employment) Act 1991 following the fire onboard WESTRALIA and requested that the Board consider certain matters. Ms Meryl Stanton (Chief Executive Officer Comcare) wrote to Head Defence Personnel Executive on 11 May 1998, with a copy for the President of the Board, seeking assurance that the occupational health and safety issues identified by Comcare would be addressed.
14.2 The occupational health and safety matters raised by Comcare were considered by the Board, and outcomes of those considerations are reflected throughout this report. General questions have been raised by Comcare and while the answers are correspondingly general, they should be considered in the context of this report’s coverage of the fire in WESTRALIA, in particular the ‘system’ weaknesses identified in Section 13 of the report.
14.3 What steps had the Australian Defence Force (in particular the Royal Australian Navy) and the Department of Defence taken to provide and maintain plant that was safe and without risk to employees health and safety?
14.4 The RAN requires that all plant supplied to it, meets or exceeds the relevant national or international standards where they exist. Where such standards do not exist safety aspects are called for in contract documentation as well as the requirements for maintenance aspects and training courses for operators of plant where none is in existence. The RAN has directed all managers who procure plant and machinery for the Navy to reference the requirements for safe supply and installation of such plant and machinery under the Occupational Health and Safety (Commonwealth Employment ) Act 1991.
14.5 What steps had the Australian Defence Force (in particular the Royal Australian Navy) and the Department of Defence taken to provide and maintain a system of work that was safe for employees and without risk to their health?
14.6 The Royal Australian Navy’s safety program (NAVSAFE) provides the framework for the management of safety, at all levels, throughout the RAN. It describes that a sound maintenance program, frequent inspections and above all, the education of all personnel must be recognised as prerequisites to safety. NAVSAFE states that it is the responsibility of all persons regardless of rank or profession to observe and obey safety regulations and procedures but in particular, it is the responsibility of supervisors to ensure that every precaution is taken to minimise hazardous situations. NAVSAFE directs that each ship and establishment within the RAN is to have a safety team (OHS committee) which is to ensure:
a. working environments are safe;
b. the correct operating methods are specified, precautions and hazards are highlighted;
c. only approved and properly maintained equipment and appliances are used;
d. the responsibilities of supervisors and workers are known;
211 COMCARE
e. all accidents and incidents are investigated and reported; and,
f. a continuous program of safety publicity and education is maintained.
14.7 WESTRALIA has an active occupational health and safety organisation under the leadership of WO Baker.[T2389-2390]
14.8 As the Navy’s safety manager, the Chief of Navy requires each member of the RAN to contribute to the achievement of a safe system of work and from time to time, issues appropriate instructions to achieve this.
14.9 What steps had the Australian Defence Force (in particular the Royal Australian Navy) and the Department of Defence taken to ensure the health and, safety of employees and absence of risks at work in connection with the use of plant?
14.10 Appropriate instruction, in the form of a defence instruction (Occupational Health and Safety – Management of Risks Associated with Plant: DI(G) PERS 19-11), has been promulgated to the Defence Forces and the Department of Defence. This instruction provides guidance to managers and supervisors on their responsibilities with respect to the ‘plant regulations’. In particular, the RAN requires documented operating and maintenance procedures for all items of plant. Other documentation in the form of Australian Books of Reference and Ships Standing Orders provide detailed guidance for operating and maintaining plant safely. Within the RAN these aspects are audited, both ashore and afloat, at approximately 18 month intervals however, the redirection of effort and reduced resources which form part of the Defence Reform Program will, regrettably, detract from the number and quality of such audits in the future. Ironically, in response to its last audit, it was an attempt to improve the safety associated with operating the main machinery onboard WESTRALIA, which led to the fire.[E232]
14.11 What steps had the Australian Defence Force (in particular the Royal Australian Navy) and the Department of Defence taken to provide information, instruction, training and supervision necessary for employees to enable them to perform their work in a manner that was safe and without risk to their health?
14.12 The RAN provides significant resources to the training of its personnel. Approximately one third of its members are engaged in training at any one time. Much emphasis is placed on safety procedures in all professional courses undertaken by officers and sailors. In addition, all officers and sailors are required to undertake formal occupational health and safety training on entry to the Navy and prior to becoming supervisors and managers; such training will identify lessons learnt as a result of past accidents and incidents.
14.13 What steps had the Australian Defence Force (in particular the Royal Australian Navy) and the Department of Defence taken to monitor the conditions of the workplace?
14.14 RAN ship safety teams are directed to conduct safety inspections of the workplace every three months; the aim of these inspections is to detect hazards and unsafe acts. Additionally, audits by senior personnel are conducted at regular intervals. The RAN has introduced a system of openly reporting incorrect maintenance procedures, drill errors, hazards, near misses and mistakes arising out of activities conducted in the workplace.
212 SECTION 15. RECOGNITION OF PERSONNEL THIS SECTION INTENTIONALLY BLANK - NOT FOR RELEASE
Hose Teams
6
6
213 RECOGNITION OF PERSONNEL
Engine Room Personnel
214 RECOGNITION OF PERSONNEL
Medical Personnel
Other Personnel
215 RECOGNITION OF PERSONNEL
SECTION 16. PRINCIPAL FINDINGS
16.1 The fire in HMAS WESTRALIA on 5 May 1998 was caused by diesel fuel from a burst flexible hose spraying onto a hot engine component and then igniting. The hose was one of a number of new flexible hoses supplied by the ship’s support contractor, ADI Limited, to replace the original rigid pipes. In the Board’s view, the hoses were not properly designed and were unfit for the intended purpose.
16.2 A change of this type should have been processed through the RAN configuration change process as well as being approved by the ship’s classification society, Lloyds Register. Both processes were bypassed, largely as a result of ignorance and incompetence. Key personnel within the RAN, and more particularly ADI Limited, were not adequately trained or qualified for the responsibilities placed on them. Regardless of the scrutiny that was avoided by bypassing these approval processes, ADI Limited should have taken steps to ensure that a safe, properly engineered product was supplied for a demanding application; it demonstrably failed to do so.
16.3 The four personnel who died in the fire did so as a result of acute carbon monoxide toxicity consequent upon inhalation of fire fumes. From the rapid increase in the magnitude of the fire and consequent production of smoke and fumes, the Board is able to conclude that incapacitation occurred within five minutes and death within 10 minutes of the outbreak of the conflagration and well before the CO2 drench.
16.4 The dangerous and difficult fire in the main machinery space of WESTRALIA was fought heroically and effectively by the ship’s crew. There were many acts of bravery and exceptional performances on the day. The Board has identified a number of personnel in the recommendations whom it believes should be singled out for special recognition. The choice has been difficult.
16.5 WESTRALIA received excellent support from a wide variety of sources and it was most welcome but not used to its full potential. The ship’s crew can take great pride in the fact that they saved their ship. Tragically, nothing further could have been done by them to save their shipmates.
16.6 The Board’s many recommendations have been drafted with the clear aim of preventing a re-occurrence and making life at sea safer. Unfortunately, there can be no guarantees that fire can be totally avoided in what is inherently a dangerous environment.
216 SECTION 17. CONCLUSIONS
17.1 This section reproduces all the conclusions and findings made in the report. The first number in the list is a conclusion number included for convenient reference. The second is the paragraph number of the reference in the body of the report. The page number at which the conclusion is found follows the conclusion.
Rec Para Conclusion Page no. no. no.
Section 3 – Actions of the Ship’s Company and their Training and Competence 1. 3.10 The command team should have consulted to determine the objectives, strategies and tactics to combat the fire. 46 2. 3.11 The command team did not meet on a frequent basis during the incident to pool information, evaluate strategies and set appropriate objectives. 46 3. 3.12 The command communication chain was very long. 46 4. 3.33 The Board is not convinced by the reasons offered for the decision not to anchor. If an emergency cable run was rigged between the emergency switchboard and the hydraulics room, the anchor might have been able to be raised. Whilst breaking the cable and slipping an anchor is not an everyday occurrence, such an evolution could have been undertaken with tug assistance if the CO considered it necessary. The Board considers that the decision not to anchor was an error of judgement. Anchoring would have reduced areas of concern to the command team, particularly that of a possible grounding. 49 5. 3.34 Had the ship gone to anchor this would have released a number of experienced personnel for firefighting, as well as allowing the command to 49 6. 3.34 concentrate totally on the emergency at hand without the nagging worry of running aground. 50
7. 3.38 The Board supports the CO’s command decision to CO2 drench and is of the view that the reasoning behind the decision to activate the system at 1101 was appropriate. 51 8. 3.45 The SSFB should have been properly trained to make a controlled entry into the MMS to: 52 a. evaluate the situation; 52 b. conduct a snatch rescue; and 52 c. guide personnel to safety. 52 9. 3.49 AB Noles should not have been on watch alone in the tiller flat. 52 10. 3.50 AB Noles should have advised CPO Jenkins that he had to report to the bridge before assisting to shift the firefighting gear. 52
217 CONCLUSIONS
11. 3.54 The comment made about ‘no girls’ was well intentioned but inappropriate. Female members of the crew performed their duties as competently as their male counterparts. 53 12. 3.65 There was a major fuel leak on the PME. 55 a. A thorough evaluation of the situation was not undertaken. 55 b. Unnecessary personnel should have been withdrawn from the MMS. 55 c. The situation was hazardous enough to warrant the isolation of electrical equipment and the application of foam onto the fuel and into the bilge. 55 d. If fire hoses laid out for use are not charged and ready, it is highly likely that they will not be used as there will be no time to charge the hoses once a fire has started. 55 13. 3.72 The fire was too large to be contained with extinguishers. 56 14. 3.78 The funnel ventilation exhaust flaps should have remained open until Hose Team 1 had exited the MMS. 57 15. 3.85 RAN hose team training is excellent. 58 16. 3.88 There was a delay in providing fluids for the refreshment of hose teams after firefighting. Each of the key catering staff had ancillary duties that diverted them from this task. 58 17. 3.94 Breathing apparatus control procedures were not always followed. Of particular concern was the failure, on some occasions, for personnel in OCCABA to work in pairs. 59 18. 3.102 Not all personnel wearing OCCABA monitored their pressure gauges. 60 19. 3.109 On the day of the fire bearded members of the ship’s company wore breathing apparatus. Personnel did not have a thorough understanding of how beards could reduce the wearing time of an OCCABA. Accordingly, no allowance was made for personnel with beards when calculating OCCABA duration. 61 20. 3.110 The practice of allowing bearded personnel to use breathing apparatus does not comply with AS/NZS1715-1994. 61 21. 3.118 Stage 2 BA control procedures would assist with the management and coordination of activities in an emergency. 63 22. 3.123 Ship’s personnel knew little, if anything, about the international shore connection. 63 23. 3.134 ABR 5476 provides insufficient information on the properties and extinguishing characteristics of CO2.65 24. 3.135 The command team had limited knowledge of the properties of CO2 and its hazards. As a result the decision to send in the hose teams after the drench to fight the fire, was premature. 65 25. 3.143 The ship’s emergency file provided incomplete and incorrect advice to any incident commander. 66 26. 3.144 The SOPs were followed without any lateral thinking. 66 27. 3.145 The Sea Training Group did not identify that the ship’s emergency file was inadequate. 66
218 CONCLUSIONS
28. 3.152 In general officers and senior sailors displayed a poor knowledge of the ship, particularly of the emergency systems. 66
Section 4 - Medical Response to the Incident 29. 4.12 The initial medical response proved to be appropriate. Improved flexibility would have been achieved had the Duty SMET been mustered in conjunction with the SSFB from the outset. 72 30. 4.21 The initial identification of missing personnel was achieved as quickly as practicable under the circumstances, but was completed in HQ1 in a non-systematic way. The initial notification to external authorities was inaccurate. 74 31. 4.27 The source of the inaccurate information that the first casualty found in the MMS may have been alive has not been established. It may have derived from the request for an ELSRD, or the transfer of comments or concerns expressed by those attending to LS Meek. There appears to have been a failure to pass clear casualty information over the normal communications circuits. 75 32. 4.28 The initial assessment of the casualties by members of the hose teams was appropriate, but was hampered by antiflash gloves, which should have been taken off. 75 33. 4.29 The placing of LS Meek in a Paraguard stretcher was uneccessary. If extrication was required to allow attempts at resuscitation it should have been done by the quickest available means, and if resuscitation was not to be attempted the evolution was unnecessary. 75 34. 4.30 The establishment of a casualty reception bay following the receipt of information that one of the casualties in the MMS may have been alive was appropriate. The bay was adequately equipped under the circumstances. 75 35. 4.38 Medical staff supplementation was appropriately requested and promptly provided. 76 36. 4.41 The provision of continuing medical care of the injured was left to the SMET members and was well carried out. 76 37. 4.44 The decision to implement the medevac was taken by command without consultation with either of the two key medical personnel who were in the MMS at the time. Inadequate consideration was given to the preparation of the injured for medevac or their requirements in flight, and this resulted in no medical escort being despatched, and the management of the intravenous lines being an afterthought. Despite these shortcomings, there was no adverse impact on casualty care. 77 38. 4.50 Although the circumstances that led to the decision to remove the fatalities from the MMS are understandable, a better course may have been to leave them within the MMS, covered and placed in a suitable location. 78
219 CONCLUSIONS
39. 4.51 The quality of body bags and the lack of a suitable and serviceable stretcher inhibited the fatality extrication process. Extrication was delayed because there was a lack of ready appreciation of mechanisms that could be employed in order to lift casualties in the event the hoist was unserviceable. 78 40. 4.52 The difficulties encountered in extricating the fatalities highlighted the potential for significant problems had urgent extrication of a live casualty from the MMS been required. 78 41. 4.66 The Board is of the view that the medical incident management could have been achieved more effectively, and that this resulted in inappropriate disposition of medical personnel to meet overall requirements, and inadequate medical control of the medevac. This occurred because the ship’s medical coordinator, and the more experienced of the two medical officers, had their attention diverted towards the identification and confirmation of death of the bodies in the MMS. The Board considers that the more experienced of the two MOs would have been better utilized if she had taken over the role of medical incident management on arrival, utilising the ship’s senior medical sailor as her senior adviser in relation to ship-specific matters. The Board considers that this did not occur because of the inadequate training of MOs in shipboard medical incident management, and the relative inexperience of the senior medical sailor in this role. 80 42. 4.74 Casualty status awareness was complicated by the decision to keep casualty information perceived to be sensitive off the normal communications circuits. This resulted in inaccurate information being passed and a failure to keep proper records. Neither the DC state board nor the casualty state board was properly completed. 81 43. 4.80 There were adequate quantities of medical materiel available during the incident. Some difficulties were encountered at RASCO because access to the Sick Bay to replenish stocks was inhibited by smoke boundaries. 82 44. 4.88 While there were no specific difficulties associated with the use of the SMET Jacket during the incident, HMAS WESTRALIA’s SMET members find them inconvenient and awkward to use. 83 45. 4.89 Medical personnel were difficult to identify because they were not wearing Red Cross Brassards. 83 46. 4.100 The clinical training of medical staff and SMET members was adequate to meet the needs of this incident. 85 47. 4.101 Shipboard medical training provided to SMET members and ship’s company was adequate. 85 48. 4.102 The conduct of major damage control exercises did not provide realistic casualty scenarios, either in numbers or types of casualties, and the POMED, because he assumed the role of an umpire, did not obtain sufficient experience in medical incident management. 85
220 CONCLUSIONS
Section 5 - Death and Injury of Personnel 49. 5.17 All the deaths resulted from carbon monoxide toxicity prior to the activation of the CO2 drench, and probably within 10 minutes of the outbreak of the fire. 88 50. 5.21 The Board is of the opinion that the assessment of the circumstances of the deaths has not been inhibited by the fact of the bodies being moved prior to examination by Coroner’s staff. 89 51. 5.25 The Board finds that Able Seaman Phillip John Carroll S155254 Date of Birth 17 June 1974 died accidentally from acute carbon monoxide poisoning due to smoke inhalation in the MMS of HMAS WESTRALIA off the coast of Western Australia in the vicinity of Perth at approximately 1045 on 5 May 1998. 89 52. 5.26 AB Carroll was not suffering from any pre-existing condition or intercurrent illnesses that could have affected his escape or survival. 89 53. 5.27 The Board is of the view that AB Carroll continued to fight the fire for a time after its commencement. The Board believes he would have been aware that MIDN Pelly was in the MMS, both by seeing her and through her attachment to the 3rd Hand. The Board concludes that AB Carroll, having given up firefighting, probably searched for MIDN Pelly and, having found her, attempted to assist her from the MMS before being overcome by fire fumes. 89 54. 5.33 The Board notes there is some evidence that LS Meek may have been seen at the top of the port ladder in the MMS by LS Bromage, viewing from the fridge flat door, after the fire erupted and before the CO2 drench. This information was not positively passed to HQ1 until after the CO2 drench had occurred. The Board finds it hard to understand how such a sighting could have occurred from a distance in conditions of poor visibility caused by thick smoke and very low light. 90 55. 5.35 The Board finds that Leading Seaman Bradley John Meek S147321 Date of Birth 16 July 1972 died accidentally from acute carbon monoxide poisoning due to smoke inhalation in the MMS of HMAS WESTRALIA off the coast of Western Australia in the vicinity of Perth at approximately 1045 on 5 May 1998. 91 56. 5.36 LS Meek was not suffering from any pre-existing condition or intercurrent illnesses that could have affected his escape or survival. 91 57. 5.37 The Board is unable to determine exactly where LS Meek was on the outbreak of the fire. It is of the view that, by the time the fire enlarged, he had made his way to the bottom of the port ladder to the top plates and stood there assisting LSMT Smith, and POs Francis and Hollis to make their way up that ladder. At some time after the last of those three exited, he also attempted to make his way up the ladder, probably after realising he was becoming incapacitated, but became overcome by fire fumes at its top, where he collapsed. The Board is of the view that the
221 CONCLUSIONS
burns sustained by LS Meek occurred certainly after the onset of unconsciousness and probably after his death. 91 58. 5.43 The Board finds that Midshipman Megan Anne Pelly L154029 Date of Birth 8 December 1975 died accidentally from acute carbon monoxide poisoning due to smoke inhalation in the MMS of HMAS WESTRALIA off the coast of Western Australia in the vicinity of Perth at approximately 1045 on 5 May 1998. 92 59. 5.44 MIDN Pelly was not suffering from any pre-existing condition or intercurrent illnesses that could have affected her escape or survival. 92 60. 5.45 The Board is of the view that MIDN Pelly probably attempted to escape the fire by moving aft between the DAs, this being the logical means of escape for one unfamiliar with the space. Being unable to find an escape ladder (there was none), she may have either made an attempt to return forward or alternatively may simply have stayed aft in the hope that the smoke might not affect her. In either event, the Board is of the view that AB Carroll, who was aware she was in the MMS, found her and led her back towards the port escape ladder before both were overcome by the fire fumes. 92 61. 5.46 The Board finds that no blame for MIDN Pelly’s presence in the MMS can be attached to anyone. That she was there is of profound regret, however the occurrence of a second fuel leak causing a major fire could not have been foreseen, and the initial leak was being effectively dealt with. 92 62. 5.50 The Board finds that Petty Officer Shaun Damian Smith S138258 Date of Birth 27 November 1968 died accidentally from acute carbon monoxide poisoning due to smoke inhalation in the MMS of HMAS WESTRALIA off the coast of Western Australia in the vicinity of Perth at approximately 1045 on 5 May 1998. 93 63. 5.51 PO Smith was not suffering from any pre-existing condition or intercurrent illnesses that could have affected his escape or survival. 93 64. 5.52 The Board is of the view that PO Smith may have attempted to assist AB Carroll to fight the fire from the port side of the middle plates. Of the three engineering staff who perished, PO Smith was the least familiar with the space, having joined WESTRALIA on 27 Apr 98. It is conceivable that, he became disorientated in his efforts to escape, and so was unable to find the port ladder before being overcome by fire fumes. 93 65. 5.62 There were some deficiencies in the provision of specific treatment for the smoke inhalation casualties as compared to laid down protocols. These deficiencies did not in the event adversely affect the clinical outcome, and were contributed to by the relative lack of medical officer or sailor supervision of the casualties at RASCO. 94
222 CONCLUSIONS
Section 6 - External Assistance 66. 6.22 The Board is of the opinion that the Sea King was the ideal aircraft on the day. Apart from the minor difficulty with the overriding winch wire, the aircraft flew without incident. 98 67. 6.26 The Board notes that whilst the Seahawk is not a utility helicopter, the aircraft made a valuable contribution to the timely transfer of necessary resources to WESTRALIA without incident. 99 68. 6.42 The Board finds that the support provided by naval units was timely, well coordinated and in the best traditions of the service. 101 69. 6.48 The Board finds that WESTRALIA’s command team made an error of judgment by not making a prescribed urgency call. 102 70. 6.57 The Board agrees that a MOU should be developed between Navy and the Fremantle Port Authority for handling naval vessels in distress. 103 71. 6.96 A significant CISM intervention was mobilised during and after the incident. It received a high level of acceptance at all levels. 108 72. 6.102 The CISM debriefing process, occurring as it did before the great majority of personnel had made any written record of their recollections of the day, had the potential to contaminate evidence presented to it. 109 73. 6.103 The Board is of the view that, given the significant resources involved in the provision of CISM, steps should be taken to evaluate the efficacy of the intervention in this incident. 109 74. 6.109 The Board considers that more extensive preparation of personnel for critical incidents, including pre-training in stress/trauma management, may have resulted in a reduction in the size of the CISM response required for this incident, including the need for On-Scene Support and individual counselling. 110 75. 6.115 The provision of at least one Peer Support Member on each Major Fleet Unit at all times will assist in providing post trauma management to personnel involved in incidents that occur in combat or isolated operations. 111 76. 6.122 There was a significant chaplaincy effort in support of personnel, family and friends on the day of the incident and subsequent to it. 112 77. 6.138 The Board considers that family liaison and support services of a very high order were provided throughout the incident and the days that followed. 114 78. 6.139 The Board is of the view that an inappropriate delay occurred in officially notifying PSO WA of the incident and its scope. The mechanisms that were in place to keep PSO WA updated as the incident unfolded were inadequate. 114 79. 6.140 The Board considers it likely that at least one of the families of the deceased heard, indirectly, of their loss through media reports. This probably resulted from a deduction based on early notification that the member was missing, followed by public
223 CONCLUSIONS
confirmation of the occurrence of fatalities. The Board is of the view that, once NOK had been notified that a family member was missing, no further information on the fate of these personnel should have been released until such time as the NOK had been officially notified. 114 80. 6.149 St John of God Hospital Murdoch is well equipped to receive casualties by helicopter from ships at sea, and transfer them to other hospitals if clinically indicated. 115
Section 7 - Firefighting and Safety Equipment 81. 7.5 The TIC currently in service suffers from overload in large fires and was of marginal utility in this case. 116 82. 7.17 The number of OCCABA carried by the ship was appropriate. The ship carried a greater number of spare cylinders (by a factor of almost two) than the number specified in the RAN Damage Control Manual - ABR 5476 Vol 1. 118 83. 7.18 In a major incident the utilisation of breathing apparatus should be managed by one person. 118 84. 7.33 The Board has serious concerns regarding the servicing of OCCABA sets, the unacceptable number of equipment failures and the monitoring of the servicing. The Board also notes that the OCCABA sets exceed the weight recommended by the AS/NZS 1716:1994. 120 85. 7.34 RAN OCCABA sets have three high-pressure hand wheels. If these are not fully tightened damage to O-rings can result. As there are three high pressure connections rather than the one found on BA generally, there is a three-fold risk of failure. 120 86. 7.44 BA control tags are available to assist board markers maintain entry control. 121 87. 7.45 Distress signal units are an additional safety device that can be fitted to OCCABA. 121 88. 7.48 The ship had no spare fuel supplies for the forward Bauer compressor. 121 89. 7.54 The Maxon radios did not work effectively on the day and communications with the hose teams failed on occasions. 122 90. 7.60 There were no reserve supplies of diesel fuel for the emergency fire pump. 123 91. 7.61 Current Lloyds and SOLAS regulations state 15 hours reserve fuel must be available outside the MMS. 123 92. 7.62 Regardless of the Lloyds or SOLAS requirements, the endurance of the fire pump should have been known by the command team and spare fuel should have been kept in an accessible place outside the MMS. 123 93. 7.69 The hose teams had inadequate head protection. 124 94. 7.74 The number of ELSRDs within the MMS was insufficient and confined to the bottom plates. 125
224 CONCLUSIONS
Section 8 - Materiel State 95. 8.35 The penetrations in the MCR deck for the passage of electrical cables and pipes had not been properly sealed. 130 96. 8.36 The electrical cable runs above the engines are poorly located. 131
97. 8.48 The Board concludes that the CO2 system was not well maintained and failed to operate correctly because of incorrect tensioning of the actuating wires. 132 98. 8.62 The ship’s maintenance history does not support the proposition that there was any policy to reduce or deprive WESTRALIA of funding. In 1996 the ship spent six months undertaking an extensive refit. The ship undertook AMP 10 early in 1997. AMP 11 involved a significant over-spend of the budget allocation. 134 99. 8.80 The Board notes the failure of Lloyd’s to answer the questions and in the absence of further advice, the Board considers that the arrangements for means of escape from the MMS is not in the spirit of the Convention requirements and is dangerous. 137 100. 8.97 The normal access ladders from the middle plates to the top plates are exposed, and were extremely dangerous to use once the fire had started. 140 101. 8.98 The ladder from the fridge flat to the top plates and the port ladder between the middle and top plates are difficult for hose teams to use. 140 102. 8.103 The Board is of the view that the lack of MMS to MCR communications is unacceptable. 141 103. 8.112 Suitable data recorders strategically placed in command positions such as the bridge, MCR and HQ1 can play an important role in enhancing safety at sea. 142 104. 8.117 Once shut there is no means of opening the funnel flaps without entering the funnel space. 143 105. 8.124 The present system of isolating the MMS detection zones to prevent false alarms is dangerous. 144 106. 8.125 The fire detection system fitted to the MMS of WESTRALIA is not fit for purpose. 144 107. 8.126 There are a number of possible systems available to enhance the level of fire protection. 144 108. 8.133 There was insufficient lighting or reflective tape at a low level to guide personnel to safety. 145 109. 8.135 When WESTRALIA sailed there were a number of deficiencies in the materiel state of the ship. The two serious deficiencies, the flexible supply and return fuel hoses and the CO2 system were not readily apparent. At that time the flexible fuel hoses gave no sign of any inherent flaw. The condition of the CO2 system, and particularly the tension of the operating wires, would only have been apparent to an expert on close inspection. At 0900 on 5 May 98 there was no obvious materiel deficiency that should have prevented the ship from sailing. 145
225 CONCLUSIONS
Section 9 - Causes of the Fire 110. 9.23 The Board accepts the hypothesis of Detective Senior Constable Hawes as to the start of the fire and finds that the fire started as a result of the ignition of atomised fuel from a leak in the new flexible return hose on no. 9 cylinder on the starboard main engine (S9R). The Board finds that the possibility of some other source of the fire is not sustained by the evidence. The source of the ignition was probably the adjacent indicator cock on no. 9 cylinder. It seems that fuel may have continued to supply the fire for at least 15 minutes at a diminishing, and relatively small, rate. 151 111. 9.33 Flexible fuel hoses S9R and P8S failed by reason of fatigue of the stainless steel braiding. 153 112. 9.37 The Board is satisfied that the results of the metallurgical testing indicate that any mishandling, if it occurred during or after initial installation, did not contribute in any significant way to a major reduction in the burst strength of the hoses. 154 113. 9.46 Sufficient pressure pulses to cause fatigue failure of the braiding could easily have been generated since installation of the flexible fuel hoses. 156 114. 9.55 Regardless of the quality of the information contained in the Pielstick Service Bulletins, information on the subject of spill pulses was available from the Pielstick engine agents, NEI Crossley Engines, at the time of AMP 12. Even a cursory examination of the Bulletins should have alerted a reasonably competent engineer to the existence of the spill pulse phenomenon and should have aroused sufficient curiousity in any technical person to make further enquiry. A reasonably competent engineer would have given the phenomenon due consideration and would have communicated with the engine agents. Indeed, any technical person who was charged with having the flexible fuel hoses manufactured and installed should have communicated with the engine agents. 157 115. 9.59 The Board is of the view that information concerning the spill pulse phenomena was available and accessible had it been sought. It was not sought. 158 116. 9.64 Marine engineers with qualifications acceptable to the Merchant Navy would probably have been aware of the nature of pulses caused by jerk pumps, if not the full extent of spill pulse pressure. 159 117. 9.65 Neither Dr Goodwin nor Mr Burge have relevant expertise on the subject of RAN marine engineering training. The purpose of RAN marine engineering training is not to develop expertise in all aspects of engineering design but is more targeted at machinery operation, accordingly, knowledge of ‘spill pulses’ is not an essential training requirement. Appropriate experts in industry are usually used for deep specialist skills. 159 118. 9.77 The fuel boost pump in use at the time of the fire was set at the correct pressure and was not capable of producing the full scale
226 CONCLUSIONS
deflection pressure indicated by the defective fuel system gauges. 162 119. 9.78 Based on the expert evidence presented to the Board and the results of testing carried out on the fuel boost pump and pressure gauges, the Board prefers Dr Goodwin’s evidence on the subject of fuel gauges. The Board is satisfied that there is no evidence of a mechanism which could have produced an abnormal pressure pulse of sufficient magnitude to cause failure of the flexible fuel hoses. 162 120. 9.83 Whilst Dr Goodwin’s measurements are not exact, they provide strong indications that the minimum hose bend radius requirements were ignored by the design. 162 121. 9.93 The hose arrangement did not conform with good engineering practice in various respects, as well as the failure to take into account spill pulses. 167 122. 9.94 The flexible fuel hoses were not properly designed and they were destined to fail. 167
Section 10 - How Hoses of Inadequate Design Came to be Fitted 123. 10.48 A change to the flexible fuel hoses was clearly a configuration change as defined in RAN documentation and the correct procedure for obtaining approval was not followed. 177 124. 10.49 The weight of evidence is against WO Jones’ account, which is not accepted, and WO Bottomley’ s account is regarded as the most reliable. The Board is of the opinion that WO Jones told the ship simply to raise a TM200. 177 125. 10.50 WO Jones’ statements to LCDR Crouch and WO Bottomley concerning the TM200, were such as to mislead them into believing that circumstances had transpired which made a TM200 the appropriate procedure to obtain funding for the work. 177 126. 10.51 Nonetheless, LCDR Crouch should have made his own enquiries in the absence of any official approval documentation, namely, a TM188. 177 127. 10.52 The Board has difficulty in understanding why none of the documentation relating to the SG2 remained on an OAWA file. WO Bottomley and LCDR Crouch gave evidence of frequent mention or discussion of the flexible fuel hoses with WO Jones. 177 128. 10.53 It is remarkable that despite WO Jones’ long association with WESTRALIA’s fuel leak problem, his obvious commitment to the ship, and his ongoing discussions with WO Bottomley during 1997, that WO Jones does not remember any of the circumstances surrounding the SG2 application in late 1996 and that it did not come to mind during his ongoing conversations with WO Bottomley and LCDR Crouch. 177 129. 10.64 ADI were not specifically requested to do an engineering analysis, certainly not one of the type called for by a TM187. Neverthless, the Board is of the opinion that the ship’s request to
227 CONCLUSIONS
ADI to ‘investigate’ cannot be confined in the ways ADI contend. In addition ADI had a general obligation as the engineering contractor to make a proper engineering assessment of the proposal taking all factors into account. The standard of that consideration should have accorded with the engineering expertise [T3096] and ‘world class’ [E405] which ADI claims. 179 130. 10.71 Lloyds was not involved by either ADI (or its subcontractor) in approval of plans and particulars of the flexible fuel hoses or in inspection and assessment of their manufacture and installation. ‘Lloyds approved’ hoses were not manufactured and installed. 180 131. 10.82 The Work Instruction prepared by ADI was deficient in that it failed adequately to specify the job which the ship wanted done. 182 132. 10.93 ADI did not send the Lloyds list of approved hoses with the invitation to quote. 184 133. 10.101 The differences between Mr Old’s account and Mr Morland’s account concerning the choice of hose is noted and the Board considers that Mr Old’s evidence is more reliable. 185 134. 10.102 Mr Old, the Hose Doctor, failed: 185 a. to supply a hose to Lloyd’s approved standards. 185 b. to make any, let alone adequate, enquiries of Lloyds. 185 135. 10.115 ADI paid insufficient attention to the Enzed quote, particularly in relation to the evidence which it contained suggesting that the quote was not for a hose which was ‘to Lloyds approved standards’. 187 136. 10.116 Approval of the work order was one of the critical checkpoints for the process of fitting the new flexible fuel hoses. WO Jones gave insufficient attention to the documentation supplied by ADI. WO Jones approved the work order for the fuel hoses without having seen an original quote. Had WO Jones seen the original quote, it is possible that he may have been alerted to the fact that the Parflex 919 hose quoted on by Mr Old was not Lloyds approved. WO Jones would then have been aware of the basis for the quote. 187 137. 10.117 Mr Old presented himself to ADI as a representative of the Parker Enzed Technology organisation and this implied a depth of expertise and knowledge which Mr Old could not, and did not, provide. 187 138. 10.127 The Board finds that Parker Enzed Technology: 189 a. failed to give Mr Old sufficient assistance by way of training and product information to enable him to comply with contractual duties or other duties in respect of the flexible fuel hoses; and 189 b. failed to give Mr Old adequate product information concerning SST-12 for use by himself, ADI or Navy. 189 139. 10.140 Mr Old failed to advise ADI that he had not supplied Parflex 919 hose but another generically described SST hose product. 191 140. 10.141 The prototype produced by Mr Old, simply involved the substitution of the rigid steel lines with flexible hoses. There is
228 CONCLUSIONS
no evidence of any consideration of the different characteristics of the flexible fuel hoses and rigid steel lines or of good engineering practice. 191 141. 10.142 It is extraordinary that ADI, via its employee Mr Morland, would give the ship an assurance that the flexible fuel hoses were Lloyds approved without carrying out even the most fundamental checks to ascertain whether that assurance was correct. 191 142. 10.143 The Board finds that Mr Morland’s action in assuring WO Bottomley that the flexible fuel hoses were Lloyds approved when they were not, eliminated a major safety check point. ADI’s failure to ensure the flexible fuel hoses were Lloyds approved was a major contributing factor to the accident. 191 143. 10.147 The fact that Mr Sergeant directed Mr Old to increase the amount of his invoice seriously detracts from the acceptability of Mr Sergeant’s evidence on the subject of the quotation and evaluation process. Although this is not within its terms of reference, the Board consequently feels concerned about the ADI RPLSS tendering practices. 192 144. 10.158 Because of design deficiencies, the hoses could not be installed without damage to them. Whether any damage done to hoses on 4 May 1998 was more significant than any damage done to hoses by when they were installed or otherwise handled before 4 May 1998, is impossible to say. Testing has, however, established that such damage was not relevant to the leaks in the hoses which occurred on 5 May 1998. In any event, susceptibility to damage under these circumstances would have demonstrated their unfitness for purpose. 194 145. 10.165 The Board finds that the WMO was not adequately trained for his role within the OAWA. 195 146. 10.166 WMO failed to give attention to the documentation, to confirm that the job on the flexible fuel hoses was being done as requested by the ship. 195 147. 10.175 The Parker Enzed Technology organisation apparently allowed Mr Old to present himself to ADI as representing the Parker Enzed Technology organisation thereby giving rise to an unwarranted expectation of the level expertise and knowledge he could provide. 196
Section 11 - RAN Configuration Management 148. 11.6 The formal RAN configuration change process is circumvented at times, generally by well intentioned personnel, and this can have a severe impact on safety. 198
Section 12 - Quality Assurance 149. 12.13 The quality management system of OAWA is inadequate, particularly in relation to the management of maintenance for WESTRALIA. 201
229 CONCLUSIONS
150. 12.24 The internal and external quality audits of the ADI quality management system failed to identify significant deficiencies in the implementation of that system 202 151. 12.25 The ADI SOP for Service Design Control was suitable to ensure an adequate product. That procedure was not followed, however, and internal and external audits failed to detect this situation. 202 152. 12.28 Mr Old was unaware of his quality assurance responsibilities and had not been adequately trained in relation to them. 203
Section 13 - System Safety Management 153. 13.46 There are systemic defects within RAN and ADI safety management. 210
Section 15 - Recognition of Personnel THIS SECTION INTENTIONALLY BLANK - NOT FOR RELEASE 154...... 213 155. 15.5 ...... 214 156. 15.7 ...... 214 157. 15.9 ...... 214 158. 15.12 ...... 215 159. 15.14 ...... 215 160. 15.16 ...... 215 161. 15.19 ...... 215
230 SECTION 18. RECOMMENDATIONS
18.1 This section reproduces all the recommendations made in the report. The first number in the list is a recommendation number included for convenient reference. The second is the paragraph number of the reference in the body of the report. The page number at which the recommendation is found follows the recommendation.
Rec Para Recommendation Page no. no. no.
Section 3 – Actions of the Ship’s Company and their Training and Competence 1. 3.46 DC training should emphasise the importance of conducting search and rescue procedures. 52 2. 3.66 DC training should emphasise the requirement for personnel to evaluate and assess the risk associated with any type of emergency scenario so that measured departures from the SOP can be initiated to match the risk. 55 3. 3.68 The importance of conducting escape training using ELSRDs should be re-promulgated to the Fleet. (The Board understands that this recommendation has already been implemented.) 55 4. 3.73 DC training should emphasise the limitations of portable fire extinguishers as well as their use. 56 5. 3.79 The guidance and directions provided in ABR 5476 should be re-emphasised to command teams. 57 6. 3.80 DC training should emphasise the importance of ventilation for effective firefighting operations. 57 7. 3.81 The operating levers for ventilation supply flaps and funnel exhaust flaps should be colour coded and marked for ease of identification 57 8. 3.83 Fleet units should be made aware of the correct procedures for re-entry to a fire scene after drenching (The Board is aware that this recommendation has already been actioned) 57 9. 3.95 DC training should reinforce breathing apparatus procedures concerning working in pairs and correct entry control. 59 10. 3.103 DC training should emphasise the issue of varying air consumption rates and the need for personnel in OCCABA to frequently to monitor air pressure. 60 11. 3.111 DC training should include instruction on the effect of beards on OCCABA duration and on what adjustments are to made by board markers to compensate for air loss. 61 12. 3.112 Navy should review its policy regarding personnel with beards wearing OCCABA in light of AS/NZS1715-1994 and occupational health and safety requirements. 61 13. 3.119 Stage 2 BA control procedures should be considered for introduction into the Navy. 63
231 RECOMMENDATIONS
14. 3.124 Naval personnel should be trained in the use of the international shore connection. 63 15. 3.125 DC training should re-emphasise the importance of conducting firefighting training serials which involve civilian fire brigades. 63 16. 3.136 ABR 5476 should be amended to include a section on the properties of CO2 and the hazards when it is used as an extinguishing agent. 65 17. 3.146 The WESTRALIA emergency file should be re-written. 66 18. 3.147 The Sea Training Group should check routinely validity of SOPs in emergency files. 66 19. 3.153 OOW’s and OOD’s should be trained to ensure competence in ships systems and their emergency arrangements. This competence should be fully demonstrated prior to the award of the appropriate certificate. Where qualified personnel join a ship which has different systems from the ship in which their certificate was obtained, these personnel should understudy current ships staff until competent to undertake duty alone. 67 20. 3.157 The requirement for personnel to have received the appropriate PJT prior to joining a ship should be further emphasised. 67 21. 3.158 Consideration should be given to ship’s raising a Priority 1 URDEF (which would prevent the ship from sailing) if key personnel, or a significant number of the ship’s company, join without the proper qualifications. 68 22. 3.163 The NBCD Instructor’s course should be examined to ensure appropriate modules exist, which encompass ACT requirements and exercise planning /execution. 68 23. 3.166 RAN ships should be directed to conduct a fast cruise, prior to sailing, after periods of IMAV or AMPs when there has been a change in key personnel or a significant proportion of the crew . 69 24. 3.168 Fleet units should document and practice, receiving assistance from external agencies. 69 25. 3.172 The RAN should investigate the distribution of professional articles, from appropriate journals and literature, to the Naval Community. 70 26. 3.174 Appropriate training should be provided, to enable selected RAN personnel to understand and implement requirements of ‘classification societies’. 70
Section 4 - Medical Response to the Incident 27. 4.13 Medical SOPs should reflect a requirement for the Duty SMET to muster with SSFB on all occasions so as to be in a position to render initial first aid if casualties occur during an incident. If a ship then goes to Emergency Stations, non-Duty SMET members should muster at their designated First Aid Post. 73 28. 4.31 The importance of clear and concise casualty information being passed over normal communications circuits should be emphasised in damage control training. 75
232 RECOMMENDATIONS
29. 4.32 The importance of making the key decision as to whether or not casualties discovered at an incident scene require emergency extrication should be emphasised in damage control training. 75 30. 4.33 The limitations of stretcher capability should be emphasised in damage control training. 75 31. 4.53 The quality and suitability of current service issue body bags should be investigated. 78 32. 4.54 Stretcher requirements for the extrication of casualties should be reviewed. 78 33. 4.55 Training in the use of all means of casualty extrication from compartments should be regularly conducted, emphasising methods that allow the evolution to be conducted rapidly. Ships should consider the provision of suitable lifting mechanisms to aid the rapid manual extrication of casualties. 78 34. 4.67 Training of medical officers in shipboard medical incident management should be provided, with a particular emphasis on the need to assume control when embarked in response to a major incident with mass casualties. 80 35. 4.68 The training of senior medical sailors should be reviewed to ensure that proper emphasis is placed on medical incident management in shipboard mass casualty incidents. 80 36. 4.75 Damage control and medical training should include an emphasis on the need to pass clear information on casualty status through the normal communications circuits to ensure accurate tracking of casualty status throughout an incident so that appropriate management decisions can be made. 82 37. 4.81 Medical materiel should be better distributed between the sickbay and the FAPs rather than concentrated in the sickbay. 82 38. 4.90 The suitability of the SMET jacket should be further investigated. 83 39. 4.91 All medical personnel, including SMET members, should be required to wear Red Cross Brassards when duty and when at Action or Emergency Stations. 83 40. 4.103 Major damage control exercises should include realistic numbers and types of simulated casualties, and should be conducted so that the senior medical sailor receives regular training in medical incident management. 85
Section 5 - Death and Injury of Personnel 41. 5.63 Training of all medical personnel should be based on casualty management protocols. 94
Section 6 - External Assistance 42. 6.12 Ships’ damage control and firefighting equipment should be marked for purposes of parent unit identification. 97 43. 6.16 A Billy Pugh type net should be developed for use by Seahawk and Sea Sprite Helicopters. 98
233 RECOMMENDATIONS
44. 6.30 Consideration should be given to developing a Standard Operating Procedure, with the appropriate authorities, whereby an Air Exclusion Zone is established around an emergency incident. 100 45. 6.65 HMA Ships should be made aware of major port facilities that are available to assist in emergencies. The ‘Port Guide’ should contain details of Port Emergency Plans. 104 46. 6.66 HMA Ships based at Fleet Base West should be issued with a copy of the FPA emergency plan. 104 47. 6.67 A MOU between the RAN and FPA should be developed for the handling of Naval Vessels in distress which fall within the bounds of the FPA emergency plan. 104 48. 6.104 CISM debriefing should not occur until all personnel involved in an incident have made some written record of their recollections and this record has been secured for future reference in formulating statements. This procedure should be included in the Navy policy on CISM. 109 49. 6.105 Controlled follow up or other studies should be initiated with a view to contributing to the empirical data available in the scientific literature evaluating the effectiveness of CISM. 109 50. 6.110 Navy should examine the appropriateness of introducing more extensive preparation of all personnel for critical incidents, including sailors at the time of entry, and expanding that preparation beyond simple awareness to stress/trauma management, both for the individual and for managers. 110 51. 6.116 Navy should introduce a requirement for at least one CISM Peer Support Member to be posted to each Major Fleet Unit. 111 52. 6.117 All Chaplains should be trained as CISM Peer Support Members. 111 53. 6.141 Operational authorities should include in their headquarters’ crisis response teams a member solely tasked with coordinating the interface between the operational authority and DCO/PSO authorities. 114 54. 6.150 Agreements should be developed with civilian health authorities and hospitals on the procedures to be followed in the event of casualties being required to be medevacced by air from ships off the Australian coast. 115
Section 7 - Firefighting and Safety Equipment 55. 7.6 Thermal Imaging Cameras used by firefighting teams should be capable of determining the seat of a fire against very high background temperatures. 116 56. 7.10 Although the hose nozzles currently in service in the RAN are appropriate in various fire situations, further evaluation should be undertaken of the most appropriate nozzles, and particularly waterwall nozzles, for use in the whole range of situations which can be foreseen. In particular, compartments with unusual
234 RECOMMENDATIONS
configurations, such as the exceptionally large spaces in WESTRALIA’s MMS, need further study. 117 57. 7.19 The allocation of spare OCCABA cylinders in a ship should be equal to the number fitted to the breathing apparatus sets. 118 58. 7.20 ABR 5476 should be updated to reflect the allocation of OCCABA and spare cylinders. 118 59. 7.21 During any major incident, a coordinator should be designated to gather all OCCABA resources and place them in a central location. 118 60. 7.35 The Navy should review its policy on the servicing of OCCABA to ensure it meets the highest standards and meets the manufacturer's instructions. 120 61. 7.36 A Navy instruction should be distributed outlining the following: 120 • The type and part number of the O-ring to be fitted to OCCABA. 120 • Cylinder servicing - outlining care and maintenance procedures for O-rings. 120 62. 7.37 All facemasks should be numbered and matched to a backplate. 120 63. 7.38 A system should be implemented in ships to record OCCABA set numbers and dates serviced. 120 64. 7.39 Standard operating procedures should be reviewed to ensure high-pressure hand wheels are tight before cylinders are opened (part of the donning procedure). 120 65. 7.40 The Navy should investigate the purchase of new breathing apparatus that has fewer hand wheels and complies with the Australian Standard. 120 66. 7.46 The Navy should fit DSUs and BA control tags, if they are acceptable for marine use, to all OCCABA. 121 67. 7.49 Fuel should be stored in a convenient position to re-supply the Bauer compressor. 122 68. 7.55 The Navy should determine whether more effective and reliable portable radio communication systems than the Maxon are available for use within the ship. 122 69. 7.56 A voice activated radio communication device should be fitted to a number of OCCABA in each ship. 123 70. 7.63 HMAS WESTRALIA should comply with the Lloyds and SOLAS requirements for emergency fire pump fuel supplies. 123 71. 7.65 Navy should conduct an evaluation on the battle lanterns to determine their suitability. 124 72. 7.66 An inventory should be undertaken to determine if there are enough torches on board WESTRALIA. 124 73. 7.70 Helmets should be introduced for hose team members. 124 74. 7.75 The number of ELSRDs in the MMS should be increased from six to at least six on each level and placed on or near the escape routes, clearly identified and readily accessible. 125
235 RECOMMENDATIONS
Section 8 - Materiel State 75. 8.15 Correct installation and operation of the fuel back pressure system should be confirmed before further use. 128 76. 8.19 Appropriate fuel isolating cocks should be fitted to the fuel rails. 128 77. 8.24 The emergency power supply to essential radio communications equipment should be reviewed. 129 78. 8.27 The ship’s sound powered circuits should be checked for proper operation. 129 79. 8.32 The gas tight integrity of the MMS should be brought up to the required standards. 130 80. 8.37 All cable and pipe penetrations between the MMS and the MCR should be sealed to prevent smoke entry. 131 81. 8.38 The electrical cables above the engines should be either relocated or covered with a fire resistant material. 131 82. 8.49 All RAN fixed firefighting systems should be checked to ensure: 132 • operating instructions can be clearly seen by the person operating the controls 132 • all valves and levers are clearly labelled and logically numbered 132
83. 8.50 WESTRALIA’s CO2 system should be thoroughly overhauled before being set to work again. 132 84. 8.52 Firemain pressure gauges should be fitted in HQ1 and the Damage Control section bases 132 85. 8.55 Investigations should establish whether the indicator cocks should be lagged and or shielded. If appropriate, insulation and shielding should be fitted. 133 86. 8.57 In the absence of information about the actual magnitude of the spill pulse pressures and a lack of clarity about whether any flexible hose can withstand this operating environment, a new piping arrangement, using the rigid steel option, should be procured from the engine manufacturer and fitted. 133 87. 8.59 Although the remaining life of the ship is short and the provision of a satisfactory set of ships drawings and documentation is unlikely to be achievable, priority should be given to providing accurate information on the ships emergency arrangements. 134 88. 8.81 The Board recommends that enclosed escape arrangements be fitted at both ends of the MMS as a matter of urgency. 137 89. 8.99 A wide and less steep ladder should be fitted from the fridge flat landing to the top plate running centrally from aft to forward. 140 90. 8.100 A wide ladder should be installed on the port side between the middle and top plates concluding in line with the workshop door. 140 91. 8.101 The existing central port ladder and the ladder from the fridge flat to the top plate should be removed. 140 92. 8.104 A system should be provided to enable personnel working in the MMS to communicate with the MCR. A system similar to the
236 RECOMMENDATIONS
‘Flight Deck Loop’ communication system would be ideal (combined communications and hearing protection system) 141
93. 8.108 Whilst WESTRALIA’s CO2 fire protection system might be considered satisfactory, consideration should be given to other fire protection systems such as water mists, which could be fitted in lieu, particularly if these are safer and more adequately meet Navy’s requirements. 141 94. 8.113 Data recording equipment should be fitted in command positions of all HMA ships and submarines. 142 95. 8.118 A system should be installed that allows the MMS ventilation exhaust flaps to be opened remotely. 143 96. 8.127 The fire detection system should be upgraded in the WESTRALIA. 144 97. 8.128 A CCTV system should be installed in the MMS, MCR and HQ1. 144 98. 8.130 Audible warning devices activated by buttons placed on each level of the MMS and in the MCR should be fitted. The cabling should have appropriate fire protection. 145 99. 8.134 Additional emergency lighting and reflective tape should be placed at a low level on designated escape routes, ladders and doors to assist personnel to evacuate the MMS in smoke or darkness. An arrangement similar to that used to identify escape routes in commercial passenger aircraft would be ideal. 145
Section 9 - Causes of the Fire 100. 9.98 The RAN should adopt the guidelines set out in IMO’s draft MSC Circ. 861 in relation to diesel engine fuel systems. 168
Section 10 - How Hoses of Inadequate Design Came to be Fitted 101. 10.168 The WMO billet should be filled by a person who has, amongst other requirements, received appropriate training in contract administration, financial management and Lloyds Classification Society requirements. 195 102. 10.172 Consideration should be given by an appropriate authority as to whether ADI failed to comply with the Act. 196 103. 10.173 Care should be taken to ensure that all RAN contracts include explicit reference to occupational health and safety legislation as stipulated in ABR 6303 Chapter 4. 196
Section 11 - RAN Configuration Management 104. 11.7 An urgent review of the configuration management training provided in MEO and CO Desig courses together with a review of other pre joining and career courses should be conducted. 198 105. 11.8 A firm reminder of the importance of a disciplined approach to configuration management to the RAN community should be issued and reinforced on a regular basis. The Board notes the direction given by the Maritime Commander [MHQAUST
237 RECOMMENDATIONS
message 210733Z JUL 98] to initiate audits and to manage the safety implications resulting from the unauthorised configuration changes and inappropriate use of procedural workarounds. 198 106. 11.9 A technical review of work packages by a competent professional engineering authority should be introduced as part of the procedure for authorising work. 198 107. 11.10 A review of the RAN configuration management process in the light of the shortcomings revealed to this Inquiry and the recent organisational changes such as Class Logistic Offices and Refit Planning Logistic Support Services (RPLSS) contractors, should be conducted. The review should include an assessment of the level of engineering expertise available in the RPLSS offices. 198
Section 12 - Quality Assurance 108. 12.8 RAN contract managers and ships’ staff should thoroughly check work instructions to ensure that all requirements are accurately specified and the appropriate level of QA checks are included. 200 109. 12.9 Work should not be accepted until all QA requirements have been met, including the provision of the appropriate documentation. 200 110. 12.14 OAWA’s SOPs should be updated to reflect the WESTRALIA RPLSS contract. 201 111. 12.15 SOPs for all RAN contract managers should address each type of maintenance process in which the contractor is involved, clearly defining the responsibilities of both parties. 201 112. 12.16 RAN contract managers should insist on receiving all appropriate quality documentation (including test certificates and opening/closing reports) and check them for accuracy and completeness prior to approving payment. 201 113. 12.30 Defence should re-examine the policy of quality accreditation for companies engaged in Defence work with a view to contracting the accrediting organisations to work on Defence’s behalf. A price reduction resulting from the transfer of responsibility for the work should be vigorously pursued. 203
Section 13 - System Safety Management 114. 13.47 Training in the RAN Safety Program, specified in ABR 6303, should be given priority. 210
238 SECTION 19. ANNEXES
Annex A: Personnel onboard HMAS WESTRALIA at 1030H on 05 May 98
Annex B: List of witnesses
Annex C: List of exhibits
Annex D: Transcript of HMAS WESTRALIA Bridge tape (abridged version)
Annex E: Timeline of the incident
Annex F: Firefighting equipment and techniques
Annex G: Biographies of Board members
Annex H: Glossary of terms and acronyms
239 ANNEX A TO BOI REPORT: HMAS WESTRALIA FIRE ON 05 MAY 98
PERSONNEL ONBOARD HMAS WESTRALIA AT 1030H ON 05 MAY 98
Baker DT - WOB Body GV - POB Bottomley C – WOMT
Bromage DB – LSMT Bull SN – ABMT Busby SA - SMNSIG
Cain JA - LSBM Carroll PJ – ABMT Chambers MC – POSY
Christie SM – MIDN Conole BA – LEUT Croasdale CE – ABMT
Crouch DR – LCDR Daly JD - LSBM Darwish Z – SMNBM
Davy NJ - SBLT Dietrich ESD – CMDR Duguid DE – ABRO
Durnan CL – LSBM(SE) Easterling NA – SBLT Edmonds SJ – POET
Elliott CE - LSMT Emmerton LJ – ABRO Ewington FJ – LEUT
Francis RC – POMT Gebski K – CHAP Gishubl RM – LEUT
Gormly NJ – ABSTD Haley RD – ABCK Hepple JC – LSBM
Herridge KD – POMT Hind JD – LSRO Hollis GW – POMT
Humphrey SR – LEUT Hunter DR – ABET Hutchinson BM - ABSN
Jenkins GW – CPOMT Johnson SM – LEUT Jones GW – LCDR
Justice PK – ABMT Kelly MC – LSBM Kidman GR – ABRO
Knox BW – ABBM Lambeth JA – ABSTD Ledlie GM – CPOMT
Liddell MJ – ABMT SM Lillimagi TM – ABSTD Lindley JS – ABRO
A-1 Mackinnon C – POWTR Manders BS – SBLT Manderson JA – PORS
Mason S - LSMT Meek BJ – LSMT Mercer BS – POCK
Merivale BA – ABMT Miskiewicz LA – ABCK Mitchell TJ – LSET
Moffatt JMG – ABMED Morgan SJS – LSNPC Morris C – SMNBM
Mortimer DK – ABRO Munday MA – ABMT Nix VE – LSSTD
Nixon CA – LSCK Noles WH – ABBM Nunn JE - LSBM(FF)
Opie CA – LCDR Orrell RJ – LSSIG Osmon BG – ABSTD
Page AA – LSWTR Pelly MA – MIDN Pietzsch RL – ABSIG
Plant SJ – POMED Plummer JP – SBLT Quigley MT – LSET
Read NM – LEUT Richardson CK – ABBM (NY) Robb KM – SMNMT
Roberts MJ – ABRO Roberts NVB - ABCSO Sellick BA - POB
Shawcross RB – LEUT Sheppard DJ – ABET Shingles NJ – ABCK
Smith LA – LSMT Smith LM - LSET Smith MJ – ABBM
Smith SD – POMT Spanswick KT – ABBM Street NJ – ABSIG
Surjan P – SMNBM Triffitt WJ – LCDR Turville DW – POSN
Wallace LS – SMNSIG Walters DJ – LEUT Walters GL – CPONPC
Williams NC – SMNBM Wilson MA - SMNBM
A-2 ANNEX B TO BOI REPORT: HMAS WESTRALIA FIRE ON 05 MAY 98
LIST OF WITNESSES
Name Transcript Exhibit(s) Atkinson EJ - CAPT 2451-2485 163 Baker DT - WOB 2387-2420 159 Barker M - MR QC 4387-4415 CLOSING ADDRESS Barrett AD - LCDR 3389-3410 207 Body GV - POB 379-427 35 Bolitho TM - LEUT 847-862 53 Bonner GP - CPOMED 1053-1074 84 & 84A Bottomley C - WOMT 18-75 3 186-272 3411-3468 209 4179-4184 407 Bromage DB - LSMT 2000-2058 133A Bromley JF - MR 3234-3268 194 A - D Bruce PW - MR 3808-3949 223 Burge PE - MR 4076-4109 224 4177-4178 406 Cadden GA - DR 77-82 80 Cain JA - LSBM 757-789 50 & 50A Callaghan PR - CAPT 4213-4341 CLOSING ADDRESS 4467-4476 REPLY Camac A - MR 1086-1118 86 Chambers MC - POSY 728-755 47 Conole BA - LEUT 2264-2274 153
B-1 Name Transcript Exhibit(s) Coverdale D - CMDR 3268-3335 203 Croasdale CE - ABMT 1381-1414 107 Crouch DR - LCDR 2821-3005 188 & 188A 4454-4461 449 Cuder R - CPOMT 1074-1084 85 Daly JD - LSBM 624-662 44 & 44A Davy NJ - LEUT 1591-1607 114 Dietrich ESD - CMDR 3144-3220 199 Dillon N - MR 4416-4438 CLOSING ADDRESS Edmonds SJ - POET 2308-2326 157 Eggerling AJ - LEUT 865-875 57 & 57A Elliott CE - LSET 463-493 37 Ewington FJ - LEUT 711-727 46 Fitzgerald MR - LEUT 827-835 53 Francis RC - MR 2436-2445 163 Francis RC - POMT 1456-1519 109 & 109A Gishubl RM - LEUT 495-534 38 & 38A Goodwin G - DR 3500-3582 214 4129-4177 Gormly NJ - ABSTD 3476-3479 211 & 211A Hawes WA DET S/C 305-313 32 2750-2801 Hepple JC - LSBM 1119-1135 89 Herridge KD - POMT 1609-1736 115A-D Hind JD – LSRO 3469-3475 210 Hollis GW - POMT 1800-1889 124A & 124B Hoyle TR - CMDR 4461-4467 CLOSING ADDRESS Humphrey SR - LEUT 2485-2499 171
B-2 Name Transcript Exhibit(s) Hutchinson BM - ABSN 2326-2334 158 Irwin GJ - CMDR 3490-3500 212 Jempson ID - LCDR 1737-1766 120 Jenkins GW - CPOMT 535-576 39 & 39A 3967-3976 Johnson SM - LEUT 965-1019 67 & 67A Jones GW - LCDR 1520-1579 111 Jones MR - WOMT 1944-1998 130A & 130B 2062-2236 Jones TN - CMDR 905-922 62 Justice PK - ABMT 4111-4128 399 Kelly GM - MR 4072-4076 227 Kelly MC - LSBM 1020-1030 69 Kirkham A - MR QC 4343-4386 CLOSING ADDRESS Ledlie GM - CPOMT 1415-1453 108 Mackinnon C - POWTR 1768-1777 123 Manders BS - SBLT 2274-2285 154 Manderson JA - PORS 274-304 31 313-343 Mark PD - DR 3221-3232 202 Mason S - LSMT 1579-1591 113 Miskiewicz L - ABCK 940-965 65 Mitchell TJ - LSET 663-711 45 & 45A Moffatt JM - ABMED 2251-2261 151 & 151A Morland AJ - MR 2553-2749 179 Morris CR - SMNBM 925-936 60 & 60A Munday MA - ABMT 346-378 34 Nunn JE - LSBM(FF) 1306-1369 101 &101A-B
B-3 Name Transcript Exhibit(s) Old K - MR 3006-3143 193 Opie CA - LCDR 2286-2296 155 Osmon BG - ABSTD 2239-2250 150 & 150A Page AA - LSWTR 2420-2435 161 2446-2450 Plant SJ - POMED 1195-1238 97 & 97A 1284-1304 Plummer JP - SBLT 1135-1194 90 Read NM - LEUT 3336-3342 204 Ridland S - MR 4011-4071 395 & 396 Robb KM - SMNMT 2297-2308 156 Savage AJ - LEUT 864-865 53 Sellick BA - POB 3342-3354 205 & 205A Sergeant R - MR 3583-3764 216 & 217 Shawcross RB - LEUT 1893-1935 126 Singh S - MR 3767-3808 221 Sippel DP - CMDR 877-896 4185-4200 411 Smith LA - LSMT 1239-1283 99 Smith LM - LSET 428-461 36 & 36A Smith MJ - ABBM 3354-3363 206 & 206A Smith S - WOMED 898-904 61 & 61A Stone MJ - LEUT 1031-1048 70 7 70A Street NJ - ABSIG 2499-2501 172 & 172A Triffitt WJ - LCDR 101-185 Walters DJ - LEUT 581-622 43 & 43A Walters GL - CPONPC 790-815 51
B-4 ANNEX C TO BOI REPORT: HMAS WESTRALIA FIRE ON 05 MAY 98
LIST OF EXHIBITS
Entries in bold indicate that the exhibit was dealt with as an Inquiry-in-Confidence exhibit.
Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
001 Deacons Graham & James to Counsel Assisting BOI : Faxed letter re: representation as an SUB018 affected party, dated 09 May 98 (BOI folio 24, Part 1)
002 WESTRALIA: Safety Equipment Plan DCM029
003 WOMT C Bottomley statement
004 WESTRALIA: Colour Diagrams of Main Machinery Space: Layout of Top, Middle and MAN018 Bottom Plates
005 Short Description of WESTRALIA from ‘Royal Australian Navy Today’ PUB005
006 Police Photographs: Fuel lines in situ and removed from main engines: EP009 A1-A6: PME No 9 1 B7-B9: SME No 9, and C1-C4: PME No 10. 2 007 WESTRALIA: Flexible fuel hose (SME No 9 Return) EP001
008 WESTRALIA: Flexible fuel hose (PME No 9 Supply) 3 EP003
009 WESTRALIA: Flexible fuel hose (PME No 10 Return) 4 (Control) EP002
010 WESTRALIA: Flexible fuel hoses (Two spares) EP004
011 WESTRALIA: Flexible fuel hose connection block EP005
012 WESTRALIA: Diagram of fuel supply system for main engines & diesel generators MAN 017
013 Photographs of fire control room (FCR), machinery control room (MCR), 90L AFFF DCL020 extinguishers, fridge flat, MMS and starboard main engine (SME): A-D: FCR E-H: MCR I-K: 90L AFFF extinguishers L-N: Fridge Flat O-R: MMS S-AA: SME and components 014 Incident time line 5 May 98 (created using times from Ship’s Log [E15], OOW Notebook LEG002 Blind #1[E16B], OOW Notebook Actual #1 [E16A], HQ1 Incident Log [E18])
1 Recorded as PME No. 9, actually PME No. 8 [T4179-4182] 2 Recorded as PME No. 10, actually PME No. 9 [T4179-4182] 3 Incorrect label - see footnote 1 4 Incorrect label - see footnote 2
C-1 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
015 WESTRALIA: Ship’s Log, May 1998 BR001
016A WESTRALIA: OOW notebook number 1, Blind 5 BR002A
016B WESTRALIA: OOW notebook number 1, Blind BR002B
017A WESTRALIA: OOW notebook number 1 6 BR003A
017B WESTRALIA: OOW notebook number 2 7 BR003B
018 WESTRALIA: HQ1 incident log DCL021
019 Charts AUS 111, AUS 112 & AUS 117 (Blank) BR016
020 Post Mortem Reports: (IN CONFIDENCE) ABMT PJ Carroll MED006 LSMT BJ Meek MED005 MIDN MA Pelly MED004 POMT SD Smith MED003 021 RFA BAYLEAF-Main Engine Room Fire-27 Nov 97 Executive Summary, and Pielstick ER005 Service Bulletin 51 Issue 3 (Fuel pump isolation cocks), with covering fax and covering letter from Commodore, RFA Flotilla
022 Phillips Fox to the Secretary of the BOI : Faxed letter re: representation as an affected party, SUB019 dated 12 May 98 (BOI Folio 27 Part 1)
023 Corrs Chambers Westgarth to the Secretary of the BOI: Faxed letter re: representation as an SUB020 affected party, dated 12 May 98
024 Not used
025 Contract {CAPO No. MACS (WA)0044}between the Commonwealth of Australia & ADI MR001 Limited – Technology Group for the provision of refit planning and logistic support services for WESTRALIA (Commercial-in-Confidence sections removed, now E371 IN- CONFIDENCE)
026 Not used
027 WESTRALIA: Charts AUS 111, AUS 112 & AUS 117 BR015
028 WESTRALIA: Two bridge audio tapes 05 May 98 BR009
029 Transcript of bridge audio tape (superceded by transcript of enhanced bridge tape E91]) BR007
030 WESTRALIA: Forms TSM136 (Record of working of machinery & systems – MCR Log 05 EL007 May 98)
031 PORS JA Manderson statement
032 Preliminary Fire Scene Examination Report. Superceded by E452 ER003
033 Police Photographs of MMS, Main Engines and Fuel Hoses: ER004 Labelled as referred to in preliminary fire scene report [E32], and Fire Scene Examination Report [E452] as: Board 1: 1.1-1.11, Board 2: 2.1-2.12, Board 3: 3.1-3.10, and Board 4: 4.1-4.8
5 Labelled ‘number one’ and ‘blind’, actually OOW notebook number 1 [T1177] 6 Labelled OOW notebook number 1, actually OOW notebook number 2 [T1177] 7 Labelled OOW notebook number 2, actually OOW notebook number 3 [T1177]
C-2 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
034 ABMT MA Munday statement
035 POB GV Body statement
036 LSET LM Smith:statement
036A LSET LM Smith statement (IN CONFIDENCE)
037 LSET CE Elliott statement
038 LEUT RM Gishubl statement
038A LEUT RM Gishubl statement (IN CONFIDENCE)
039 CPOMT GW Jenkins statement
039A CPOMT GW Jenkins statement (IN CONFIDENCE)
040 WESTRALIA: Aft Repair Base (AFT DC, or AFT DC Section Base) ‘tick off board’ as at DCL016 04 May 98 – Action Stations, Emergency Stations
041 WESTRALIA: Transcript of aft repair base (AFT DC, or AFT DC Section Base) stateboard DCL018
042 MIDN SF Christie statement
043 LEUT DJ Walters statement
043A LEUT DJ Walters statement (IN CONFIDENCE)
044 LSBM JD Daly statement
044A LSBM JD Daly statement (IN CONFIDENCE)
045 LSET TJ Mitchell statement
045A LSET TJ Mitchell statement (IN CONFIDENCE)
046 LEUT FJ Ewington statement
047 POSY MC Chambers statement
048 Ten sitrep (situation reports) signals sent by NAVCALS Fremantle on behalf of OT014 WESTRALIA
049 WESTRALIA: Enhanced bridge audio tape BR013A
050 LSBM JA Cain statement
050A LSBM JA Cain statement (IN CONFIDENCE)
051 CPONPC GL Walters statement WESTRALIA: Bridge narrative 05 May 98 BR006
052 HMAS ADELAIDE statements: AB C Leviston, CHAP RL Graue, CAPT LG Cordner OT009 CO HMAS ADELAIDE to Secretary WESTRALIA Board of Inquiry: Minute Report by CAPT Cordner on Events of 05 May 98, dated 12 May 98 Statements (contd.): CPO R Patton, LSEWL P Fletcher, LEUT EL Bryce, LSCSO EP Skinner, LSBM(FF) MR Jones
053 HMAS SUCCESS statements: ABMT MF Mulder, LSA PN Llewellyn, ABMT CW Blease, POMT A Campbell, SMNMT S Brodie, LS Walker, LSMT SM Whyte, CAPT AW Flint (CO HMAS SUCCESS), LEUT AJ Savage, LEUT MR Fitzgerald
C-3 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
054 HMAS SYDNEY statements: CMDR JVP Goldrick LSCD DL Skerman, and LSNPC M Walker
054A HMAS SYDNEY statement: ABMED SM Targett (IN CONFIDENCE)
055 HMAS DARWIN statements: ABBM TS Whitworth, LSBM MP Yeardley, and LSBM EW Tielens
055A HMAS DARWIN statement: ABMEDU MA Dickinson (IN CONFIDENCE)
056 HMAS ANZAC statements: ABCK AJ Hampton, SMNET MS Hawkins, SMNCSO NL Botica, SMNCSO FJ McDonald, SMNCSO RA Mongan, SMNET RN Lankford, POMT GA Pope, SBLT JP Wilson, LSMT BD Lowry, SMNCSO AF Verlin, and ABRO CLM Hillis
056A HMAS ANZAC statements: SMNCSO AF Verlin & ABRO CLM Hillis (IN CONFIDENCE)
057 LEUT AJ Eggerling statement
057A LEUT AJ Eggerling two statements (IN CONFIDENCE)
057B Field/Transport medical reports: LSMT L Smith, ABSIG N Street, POMT RC Francis MED16 (Two) & POMT G Hollis (Two) (IN CONFIDENCE), LSBM (FF) Nunn) A-D & MED021
058 Briefing pack (on WESTRALIA), from ASACLM: MR031 1. Logistic Support Policy for WESTRALIA 2. Refit Planning Logistic Support Services (RPLSS) Contract Structure 3. Flexible Fuel Lines Task 975991 4. Lloyds Rules and Regulations Extracts – Fuel Hoses 5. Application for Concession (SG2) Nov 96 6. Design Approval Authority (DAA) – MISD Fax Relating to SG2 7. Rolls Royce Fax – Service Bulletin 78 8. Design Authority (DA) Services – RPLSS Contract 9. Quality Assurance (QA) Services – RPLSS Contract 10. Director of QA Standard Operating Procedure SG 2 059 CAPT MD Adams (DCLM) to ASACLM, OAWA & Supportability Manager - ASACLO: MR023 minute DCLM 090/09 re: Rectification of Urgent Defect 30/98 dated 15 May 98
060 Sea Training Group statements: WOMT JN Walker, WONPC JP Wilson, WOB JM Hill, CMDR BM Dowsing, WOMT GR Rogers, LCDR RV Mannion & CPOB GW Strawbridge
060A Sea Training Group statement: WONPC JP Wilson (IN CONFIDENCE)
061 WOMED SA Smith statement
061A WOMED SA Smith statement (IN CONFIDENCE)
062 CMDR TN Jones statement
063 SMNBM CR Morris statement
063A SMNBM CR Morris statement (IN CONFIDENCE)
064 CPOMED NM Perrin statement
064A CPOMED NM Perrin statement (IN CONFIDENCE)
065 ABCK L Miskiewicz statement
066 WESTRALIA: Joining Book and Joining Questionnaire DCL031
067 LEUT SM Johnson statement
C-4 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
067A LEUT SM Johnson statement (IN CONFIDENCE)
068 WESTRALIA: Copy of chapter 2 of Ship’s Standing Orders - NBCD BR005A
069 LSBM MC Kelly statement
070 LEUT MJ Stone statement
070A LEUT MJ Stone statement (IN CONFIDENCE)
071 ABSIG RL Pietzsch statement
072 WESTRALIA: Forms TSM 136 (Record of working of machinery & systems) from 22 Apr EL006 98 - 4 May 98
073 WESTRALIA: TSM 110-A (West) Main machinery log PME 5 May 98 EL012
074 WESTRALIA: TSM 110-A (West) Main machinery log SME 5 May 98 EL011
075 WESTRALIA: TSM 110-A (West) Main machinery log PME 29 Apr 98 - 1 May 98 EL004
076 WESTRALIA: TSM 110-A (West) Main machinery log SME 29 Apr 98 - 1 May 98 EL005
077 WESTRALIA: TSM 110 (West) Diesel alternator log 5 May 98 EL013
078 WESTRALIA: Supplementary Rough Engine Room Register 29 Oct 97 – 5 May 98 EL001
079 WESTRALIA: Engineering Night Order Book EL009
080 WESTRALIA: Liquid cargo chits for 1, 5 & 14 May 98 EL002 EL003 EL008
081 WESTRALIA: TI 19 diesel engine life history log PME EL010A
082 WESTRALIA: TI 19 diesel engine life history log SME EL010B
083 WESTRALIA: Copy of chapter 6 of Ship’s Standing Orders – Engine Room & Engine BR005B Room Matters
084 CPOMED GP Bonner statement
084A CPOMED GP Bonner statement (IN CONFIDENCE)
085 CPOMT R Cuder statement
086 Mr A Camac statement
087 Mr A Camac, Senior Psychologist HMAS STIRLING to CO WESTRALIA, CO HMAS OT024 STIRLING, Senior Psychologist HMAS PENGUIN, and DPSYCH-N dated 25 May 98: Report on CISM Activity Following Fire in WESTRALIA 5 May 1998
088 DI(N) PERS 5-7: Critical Incident Stress Management PUB004
089 LSBM JC Hepple statement
090 SBLT JP Plummer statement
091 WESTRALIA: Transcript of enhanced bridge audio tape (E49) LEG017
092 WESTRALIA: Damage Control Log DCL001
093 Three aerial photographs of WESTRALIA taken on 5 May 98 (Copyright The West EL015 Australian)
094 WESTRALIA: Damage Control Progress Log DCL003
C-5 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
095 WESTRALIA: Damage Control Training – Summary of ACT Progress DCL002
096 WESTRALIA: Joining Questionnaire – MIDN MA Pelly (IN CONFIDENCE) DCL019
097 POMED SJ Plant statement
097A POMED SJ Plant statement (IN CONFIDENCE)
098 WESTRALIA: SMET training and whole ship medical training – 1 Jan – 5 May 98 MED012
099 LSMT LA Smith statement
100 WESTRALIA: Casualty state board for all incidents (from HQ1) DCL032
101 LSBM(FF) JE Nunn statement
101A LSBM(FF) JE Nunn statement (IN CONFIDENCE)
101B LSBM JE Nunn supplementary statement Data Sheet on FF/DC equipment types, locations and numbers DCM021 OCCABA locations, serial numbers and replacement dates DCM034 Location and numbers of spare OCCABA cylinders A Handwritten information on fearnought suits DCM020 DCM013 101C WESTRALIA: Damage control board legend - RESTRICTED (IN CONFIDENCE) DCM018
102 WESTRALIA: Damage control and fire fighting planned maintenance schedules DCL034
103 Documents provided by ADI: MR021 01 Brown & Root Engineering Pty Ltd to Lloyd’s Register of Shipping: Fax dated 29 Nov 96 02 Lloyd’s Register to Brown & Root Engineering Pty Ltd: Fax dated 8 Jan 97 03 RAN work order number 975991 dated 1 Feb 98 04 ADI Ltd work instruction number A1161 dated 11 Feb 98 05 ADI Ltd to Lloyd’s Register: letter dated 11 Feb 98 06 Lloyd’s Register to ADI Ltd: Fax dated 11 Feb 98 07 ADI Ltd to contractors: pro forma letter dated 12 Feb 98 08 ENZED quotation to ADI Ltd to carry out work detailed in work instruction A1161 dated 27 Feb 98 09 CHES Engine Reconditioning: quote dated 3 Mar 98 10 ADI Ltd purchase order number 3598 dated 9 Mar 98 11 ADI Ltd work instruction number A1161 dated 16 Mar 98 12 Rolls-Royce Industrial Power (Pacific) to ADI Ltd: Fax dated 18 Mar 98 13 WESTRALIA Management/Ordering Authority to DI Ltd RPLSS – approval of MAXIMO work order dated 19 Mar 98 Shaded documents moved to E371 (IN-CONFIDENCE) 14 ADI Ltd work order number 9759991/01 – manufacture & instal flexible fuel hoses on main engines WESTRALIA 15 ADI Ltd Contract Change Proposal (CCP) to ENZED dated 23 Mar 98 16 ENZED Kwinana quotation to ADI Ltd to supply end fittings to WESTRALIA main engine fuel lines 17 ADI Ltd to ENZED: letter dated 25 Mar 98 18 WESTRALIA Management/Ordering Authority to ADI Ltd: Fax dated 25 Mar 98
C-6 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
19 ENZED Test Certificates FRE 471, 477-533 & 536-539 dated 25 Mar 98 to 11 Apr 98 20 ADI Ltd & ENZED: contract dated 27 Mar 98 21 ENZED Kwinana to ADI Ltd: Fax enclosing Les Cooke Instrument Co Pty Ltd test report on pressure gauge dated 7 Apr 98 22 Opening & Closing Report WESTRALIA Main Engines Fuel Supply and Return Lines Work Instruction A1161 dated 29 Apr 98 23 Mr A Morland diary: three extracts 24 AMP 12 Work list & Base Line Schedule Contractors 104 Bundle of Documents from Enzed (Phillips Fox): MR022 01 ENZED pressure test log extracts dated 12 Dec 97 & 29 Apr 98 02 ENZED test certificates for hydrostatic pressure testing on fuel lines FRE 477-539 dated 7 Apr 98 to 11 Apr 98 03 Les Cooke Instrument Co Pty Ltd test report on pressure gauge dated 27 May 96 (Test conducted 24 May 96) 04 Martin Bright Steels heat certificate number 049569-01 dated 28 Nov 97 to Assab Steels Pty Ltd 05 ADI Ltd work instruction number A1161 dated 11 Feb 98, with ‘approved for production’ stamp dated 13 Mar 98 06 Lloyd’s Register to ADI Ltd: Fax F203/98 dated 11 Feb 98 enclosing 13 pages of Lloyd’s Register Type Approved Products – Part 1 for Marine, Offshore & Industrial Equipment 07 Martin Bright Steels heat certificate number 041616-08 (03?) dated 15 Feb 96 to Assab Steels Pty Ltd 08 Martin Bright Steels heat certificate number 050207-01 dated 17 Feb 98 to Assab Steels Pty Ltd 09 ENZED to ADI Ltd: letter dated 27 Feb 98 enclosing quotation to carry out work instruction number A1161. Enclosed: Quote using Parker 919 TFE Hode, Quote using Parker 221FR Hose 10 ADI Ltd purchase order number 3598 dated 9 Mar 98 11 ADI Ltd to ENZED: Fax dated 12 Mar 98 enclosing purchase order 12 Martin Bright Steels heat certificate number 043943-02 dated 16 Mar 96 to Assab Steels Pty Ltd 13 Abonnel Precision Engineering invoice 24042 (for tails 22 dia x 70 long 4 off) dated 17 Mar 98 to ENZED 14 Abonnel Precision Engineering to ENZED: Fax dated 23 Mar 98 enclosing quotation to manufacture tails & nuts (Enclosure not discovered) 15 ENZED to ADI Ltd: Fax dated 23 Mar 98 re: quote for end nuts and tails 16 Abonnel Precision Engineering invoice 24061 (for tails: nuts hex) dated 25 Mar 98 to ENZED 17 ENZED purchase order number 12092KWN (for tails and nuts) addressed to Abonnel PrecisionEngineering dated 24 Mar 98. Attached quote from Abonnel Precision Engineering Q4269 re: tails and nuts 18 ADI Ltd to ENZED: Fax dated 25 Mar 98 Re: Approval for Contract Change Proposal Number 007 19 Assab Steels Pty Ltd invoice number 250311 dated 26 Mar 98 to Abonnel Precision Engineering 20 ADI Ltd & ENZED: contract dated 27 Mar 98 21 Martin Bright Steels heat certificate dated 16 Mar 98 to Assab Steels Pty Ltd (Attached
C-7 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
to item 12) 22 ENZED Kwinana to ADI Ltd: Fax dated 7 Apr 98 enclosing Les Cooke Instrument Co Pty Ltd test report on pressure gauge dated 27 May 96. (Test conducted 24 May 96) 23 Abonnel Precision Engineering invoice 24176 dated 14 Apr 98 to ENZED re: tails long and short, nut m/s 24 ENZED to ADI Ltd: invoice number F96202 dated 23 Apr 98 re: Work Instruction A1161, Hoses and Tails, 2 pages 25 Opening & Closing Report WESTRALIA Main Engines Fuel Supply and Return Lines Work Instruction A1161 dated 29 Apr 98 26 Abonnel Precision Engineer in to ENZED: Fax dated 11 May 98 re:material certificate for fittings supplied on APE job number 13794 (Enclosures not discovered) 105 Parker Hannifin (Aust) Prt Ltd (Wodonga) to Astraflex: purchase order number 41264 - 000 MR019 dated 8 Aug 96 re: S/less Steel-Teflon Hose MR020 Astraflex Ltd to Parker Hannifin (Aus) Pty Ltd: sales invoice number 16390 dated 17 Sep 96 re: customer’s order no. 6/41264 Astraflex teflon PTFE hose data sheet number 1: General Purpose Imperial Range Series
106 Astraflex Ltd to Parker Hannafin (Aus) Pty Ltd: sales invoice number 16390 dated 17 Sep 96 re: customer’s order no. 6/41264 Order No. 394264 from Enzed Fremantle to Parker Enzed Technology – request for parts, including 30m SST-12, dated 21 Nov 96 Parker Enzed Technology Invoice 394264 – 001 to Enzed Femantle. Line No. 56 Re: S/Less Steel Teflon Hose, dated 26 Nov 96 Enzed Kwinana order AB2211/KWN (?) dated 22 Nov 96 requesting SST-12 Enzed Invoice No. 394118-000 dated 22 Nov 96 re:Line no 1. S/less Steel Teflon Hose Enzed SST technical data sheet (Top left hand side - 208 Hydraulic Hose)
107 ABMT CE Croasdale statement
108 CPOMT GM Ledlie statement
109 POMT RC Francis statement
109A POMT RC Francis statement (IN CONFIDENCE)
110A WESTRALIA: Engineering casualty control drill (ECCD) reports – 29 Apr 98 (four) EL017
110B WESTRALIA: Engineering department weekly training reports for periods: 08 Feb – 08 Mar EL018 98, 26 Apr- 03 May 98
110C WESTRALIA: Engineering ECCD training plan 1998 updated 04 May 98 EL019
110D WESTRALIA: Technical department competency log progression chart Updated 03 Jun 98 EL020
111 LCDR GW Jones statement
112 WESTRALIA: Emergency File extract: Fixed Fire Fighting Systems, Main Machinery DCM001 Space Fire – Points to note, Fire-Fighting Check-Off Cards for MMS Top, Middle and A Bottom Plates
113 LSMT S Mason statement
114 LEUT NJ Davy statement
115A POMT K Herridge statement
C-8 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
115B POMT K Herridge supplementary statement number 2
115C POMT K Herridge supplementary statement number 1 (IN CONFIDENCE)
115D POMT K Herridge recommendations dated 10 Jun 98 SUB022
116 WESTRALIA: Technical Drawing of General arrangement of Ginge CO2 fire extinguishing DCM004 system for protection of engine room & of the aft pump room dated 24 Jan 74
117 WESTRALIA: Ginge CO2 system instruction manual DCM005
118 Twenty seven photographs of the CO2 system in WESTRALIA taken on 9 May 98 DCL014
119 WESTRALIA: CO2 instruction sign DCM007 120 LCDR ID Jempson statement
121 Narrative of WESTRALIA incident Tuesday 5 May 1998 taken at Port Services Tower by OT026 LEUT Stone
122 LEUT AG Stone statement
123 POWTR Mackinnon statement
124A POMT GW Hollis statement
124B POMT GW Hollis: A3 size Colour diagrams of MMS: MAN021 MAN021A: Top Plates Layout MAN021B: Middle Plates and exposed equipment MAN021C: Bottom Plates 125 Extract from the Opening & Closing Report WESTRALIA Main Engines Fuel Supply and Return Lines Work Instruction A1161 dated 29 Apr 98
126 LEUT RB Shawcross statement
127 WESTRALIA: Nine photographs of HQ1 in WESTRALIA taken on 9 May 98 DCL011
128 WESTRALIA: Transcript of HQ1 DC Board DCL023
129 WESTRALIA: Transcript of perspex desk cover from HQ1 DCL025
130A WOMT MR Jones statement
130B WOMT MR Jones supplementary statement
131 ADI Ltd project quality plan for contract acceptance and purchase order Nos. MR028 N260171, N260201, MACS(WA)0044 & N260250 (WESTRALIA, HMAS SUCCESS, STS Young Endeavour and FFGs) Copy No 13 issue 2 Commercial – in - Confidence
132 LEUT JP Booker report of analysis and testing of flexible fuel hoses dated 14 Jun 98. ER009
133A LSMT DB Bromage statement
133B LSMT DB Bromage statement (IN CONFIDENCE)
134 Mr C Ollier, Det Norske Veritas surveyor –Report on removal of flexible fuel hoses from ER006 WESTRALIA on 21/22 May 98. Covering letter dated 9 Jun 98.
135 Six photographs of pressure gauges in WESTRALIA taken after 5 May 98 EP039
136 LEUT JP Booker Minute re: Fuel system audit dated 10 Jun 98 LEG020
137 CO WESTRALIA to CSO(E) Minute 16/3/20 re: Post 1996 Refit Defects dated 23 Sep 96 MR010A
C-9 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
138 Lloyd’s Register certificate of class, LR Number 7342017 “WESTRALIA” MR037A
139 ABR 5230: Chapter 4, including Annexes A, B, C, D & I: Configuration Changes – Policy PUB007 and Procedures A Annex I to Chapter 5: RAN Specification for Maintenance Documentation Standard Terms Paras 549 – 599: Maintenance Control Record – Form TM 200 (FOR OFFICIAL USE ONLY)
DI(N) LOG 82-3, including Annexes A&B: Equipment/Material Trial and Evaluation and PUB013 Use of Form TT117 – Material or Equipment Trial Proposal, ABR 5225 Chapter 4: Upkeep (Ship maintenance policy, documentation and inspection of the marine engineering department), Military Standard 973 (MIL-STD-973): Standard Military Definitions pages 8 – 9 (alphabetically from ‘computer software documentation’ to ‘configuration management’), ADI Minutes of pre-AMP 12 meeting held at HMAS STIRLING Building 73 Conference Room 10 March 1998 at 1300
140 WMO document listing report: Brown and Root Archived Files, RF96 – 1996 refit, 15 pages MR041
141 WMO document listing report: Brown and Root Archived files, printed Jun 97, 83 Pages MR040
142 List of archived WMO technical files for WESTRALIA MR039
143 Ordering Authority Western Australia: 1996-1997 business plan MR042
144 Ordering Authority Western Australia: Standing Orders and Standard Operating Procedures MR043 part 1 (SOSOP1)– Quality Manual
145 Ordering Authority Western Australia: TM200 task list tabled at pre AMP12 meeting MR029A 1
146 Ordering Authority Western Australia: AMP 12 Work List (Annex A) given to OAWA MR029A by ADI Commercial-in-Confidence (IN CONFIDENCE) 2
147 WMO file 97S(5?)991: AMP 12 – MANF AND INSTALL FLEXIBLE FUEL LINS BME MR038 (P983D0023) (sic)
148 Video film of WESTRALIA taken by Channel 7 photographer on 5 May 98 OT025
149 Video taken in WESTRALIA by Western Australia Police Service on 5-6 May 98 ER002
150 ABSTD BG Osmon statement
150A ABSTD BG Osmon statement (IN CONFIDENCE)
151 ABMED JM Moffatt statement
151A ABMED JM Moffatt statement (IN CONFIDENCE)
152 LSCK CA Nixon statement
153 LEUT BA Conole statement
154 SBLT BS Manders statement
155 LCDR CA Opie statement
156 SMNMT KM Robb statement
157 POET SJ Edmonds statement
C-10 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
158 ABSN BM Hutchinson statement
159 WOB DT Baker statement
160 WESTRALIA: Minutes of Ship’s Safety Team meeting on 8 Apr 98, 26 Nov 97, 18 Aug 97, MED014 and 11 Jul 97
161 LSWTR AA Page statement
162 Fremantle Tug Operators report of WESTRALIA incident on 5 May 98 OT030
163 Captain Eric Atkinson statement, Fremantle Port Authority: Fremantle Port Authority SUB011 Harbour Master’s Report
164 Fremantle Port Authority: Chart AUS112
165 Fremantle Port Authority: Swell diagram – Fremantle Port Authority (FPA) South Passage May 98
166 Fremantle Port Authority: Audio tapes of 5 May 98 OT001A OT001B OT001C
167 Fremantle Port Authority: Meteorological records – history dated 5-6 May 98 OT032A - peak wind dated 5-6 May 98 OT032B - peak wind 5 May 98 OT032C 168 Fremantle Port Authority: FPA Emergency Management Plan PUB014
169 Fremantle Port Authority: Extract from FPA Emergency Management Plan PUB011 A
170 Fremantle Port Authority: FPA log dated 5 Apr [sic] 98 OT006
171 LEUT SR Humphrey statement
172 ABSIG NJ Street statement
172A ABSIG NJ Street (IN CONFIDENCE)
173 SMNBM Z Darwish statement
173A SMNBM Z Darwish statement (IN CONFIDENCE)
174 ABRO SJ Lindley statement
174A ABRO SJ Lindley statement (IN CONFIDENCE)
175 ABMT BA Merivale statement
176 POCSS MW Palmer statement
177 CPOCD TJ Smith statement
178 SMNBM NC Williams statement
178A SMNBM NC Williams statement (IN CONFIDENCE)
179 Mr A Morland statement SUB026
180 ADI Ltd Transmittal Note No. 0799 to Activity A1161 dated 30 Apr 98, forwarding reports on A1161. CHES Diesel & Marine Services to Brown & Root: Fax dated 28 Nov 96 enclosing Aeroquip FC234 AQP hose data sheet & Bureau Veritas Non-metallic flexible pipes/hoses
C-11 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
approved product list ADI Ltd tendering matrix
181 Rolls-Royce to Australian Naval Liaison Office: Fax re: Spill Pulse Pressure dated 15 May 98
182 Video film of flexible fuel hoses being tested on 8-9 Jun 98 ER012
183 WA Police Service: Draft Computer generated impression of Bottom Plates - View of Main MAN024 Engine space looking aft
184 Chemistry Centre to WA Police Service Arson Squad: letter 97F3305 re: Report on Diesel ER014 fuel samples from WESTRALIA, dated 4 Jun 98
185 WA Police Service to Rolls-Royce: Fax re: Operating Temperature of Pielstick 14 PC2V MAN025 Engines dated 21 May 98 A Rolls-Royce UK to Rolls Royce Australia: Fax re: Operating Temperatures, dated 27 May 98 MAN025 Rolls Royce Australia to WA Police Service: Fax forwarding MAN025B B Rolls Royce Australia to WA Police Service: Fax advising that MAN025A has been forwarded to Rolls Royce UK. MAN025 C MAN025 D
186 POMT JP Nikiforos statement
187 ABBM WH Noles statement
188 LCDR DR Crouch statement
188A LCDR DR Crouch statement (IN CONFIDENCE)
189 WESTRALIA: Rolls Royce Industrial Power Group, Service Bulletin, Crossley Engines. MAN027 Index and Service Bulletins. Numbered: 1, 2, 6, 8, 13-16, 19-30, 32, 33, 35-44, 46-48, 51-67: Issue 2; 68A: Issue 3; 69- 79: Issue 2; SB79; 80, 81: Issue 2; 83-86; 87, 88: Issue 2; 89-94.
190 The International Convention for the Safety of Life at Sea (IMO, 1986): Extracts: PUB015 p1: General obligations pp 93-99: Emergency source of electrical power in cargo ships, Starting arrangements for emergency generating sets, Precautions against shock, fire and other hazards of electrical origin pp110-112: Application, basic principles, definitions p119: Fuel tank capacity p125: Carbon dioxide systems p145: Oil fuel pipes and valves p188-192: Means of escape, Restricted use of combustible materials p 207-209: Fire integrity of bulkheads and decks
C-12 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
191 Lloyd’s Register Cargo Ship Safety Construction Survey Certificate, IMO number 7342017, MR037B “WESTRALIA”, dated 7 Mar 97 Interim Certificate No. NSW 600006, “WESTRALIA” (11 sheets), dated 27 Jun 96 Interim Certificate No. NSW 600006, “WESTRALIA” (Sheets 1 and 12), dated 12 Aug 96 192 ABR 5225 Chapter 4: Upkeep (Ship maintenance policy, documentation, inspection of the marine engineering department)
193 Mr K Old statement SUB025
194A Metlabs: Metallurgical Examination and Testing of Flexible Fuel Hoses Report No. ER016 8H24/M1
194B Appendices to E194A: Pressure Test Report Challenge Pipeline Services Pty Ltd ER016A Appendix 1: Test Results and Charts Appendix 2: Calibration Certificates Appendix 3: Test Supervisors Daily Report 194C Additional Records of Testing as discussed in E194: Radiographic Inspection Report ER016B
194D Mr JF Bromley: Resume ER018
195 Mr K Old’s Business Card
196 Australian Security Commision Records of Various Parker/Enzed companies: ER008 Parker Enzed Technology Pty Ltd Jetrock Pty Ltd Parker Hannifin (Australia) Pty Ltd Todd Hydraulic Pty Ltd The Hose Doctor: SA, TAS, QLD, ACT, NT, NSW, VIC 197 Mr NS Graef statement - Statement of Parker Enzed Technology Pty Ltd SUB030
198 WOMT KM Old: RAN historical record (personal details removed) SR013A
199 CMDR ESD Dietrich statement
200 OAWA Documents re: Work Order 976006 – M/E Fuel Return System MR054 Work order number 976006 ADI Ltd to OAWA(WMO): invoice number RPLSS 78423 dated 1 May 98: Progress claim WESTRALIA AMP 12 WMO to ADI RPLSS: Fax WMO 537/98, re: Approval of Work Order 976006, dated 1 May 98 ADI Ltd revised quotation for work order number 976006 dated 17 Apr 98 ADI Ltd to WMO: Fax RPLSS-357/98 re: Work Order 976006, dated 20Apr98 KD Instruments to ADI Ltd: Fax re: prices for CCPs, dated 16 Apr 98 WMO to ADI Ltd: Fax WMO 276/98, re: Approval of Maximo Orders (listed at Annex), dated 19 Mar 98 ADI Ltd Maximo Work Order No 976006, dated 12 Mar 98 Maintenance Control Record Serial No P983D0030: Overhaul and reset M/E Fuel Regulating Valves, dated 29 Jan 98 201 ADI Ltd to WMO: letter RPLSS8-494/98 re: Credit for Fuel Line task, dated 25 Jun 98 MR055
202 Dr PD Mark statement
203 CMDR D Coverdale statement
C-13 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
204 LEUT NM Read statement
205 POB BA Sellick statement
205A POB BA Sellick statement (IN CONFIDENCE)
206 ABBM MJ Smith statement
206A ABBM MJ Smith statement (IN CONFIDENCE)
207 LCDR AD Barrett statement
208 OAWA to WOMTP M. Jones, minute OAWA GEN/68/97 re: Delegation to the Naval SR017 representative, dated 25 Aug 97
209 WOMT C Bottomley supplementary statement
210 LSRO JD Hind statement
211 ABSTD NJ Gormly statement
211A ABSTD NJ Gormly statement (IN CONFIDENCE)
212 CMDR GJ Irwin dot-point brief re: Answers to specific questions on equipment running, DCM022 location etc, dated 21 May 98 CMDR GJ Irwin to Board of Inquiry: minute IRW 003/98 Requests for information update, dated 27 Jun 98 CMDR GJ Irwin to Board of Inquiry: minute IRW 004/98 Requests for information update, dated 30 Jun 98
213 Pump Test Certificate for Fuel Boost Pump Serial No. 34546-10, Watmarine Engineering ER019 Service of 29 Jun 98 Industrial Gauge Pressure Test Certificate Report No 13463 A for Dobbie Gauge WG 012, KD Instruments, dated 7 Jan 98 Calibration Certificate No. 12853/E(?)M 4011, Counter CUB 5, dated 14 Oct 97
214 Dr G Goodwin statement
214A Overhead transparency of flexible steel hose (marked R A)
214B Overhead transparency of flexible steel hose (marked Section H.H.)
214C Overhead transparency of flexible steel hose (marked Fig.34)
214D Australian Naval Liaison Office to President, Board of Inquiry: Fax dated 26 Jun 98, Folio 307 enclosing Rolls-Royce to ANLO-UK: Fax re Spill pulse pressure, dated 26 Jun 98
214E Deacon Graham & James to CMDR G Vickridge: Extract of Fax 30 Jun 98 (page 4 para 8.2)
214F Australian Maritime Safety Authority International Relations to Mr T Arrowsmith, dated 17 KIRK 1 Jun 98, enclosing draft MSC circular: guidelines on engine fuel systems prepared by the Fire Protection sub-committee of IMO (approved as MSC/Circ. 861)
214G Marine Engineering Review June 1998 on Engine Room Fires: Why IMO is issuing fuel PUB017 system guidelines
214H MSC Circular 647 Appendix 2: Flexible Hose and Flexible Hose Assemblies
215 Dr G Goodwin resume ER017
216 Mr R Sergeant statement SUB034
C-14 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
217 CPOETC R Sergeant RAN historical record – personal details removed SR015A
218A Deacons Graham & James to BOI: letter DP:ATM:988864:dp re: job descriptions and SUB037 resumes of ADI staff, dated 1 Jul 98 covering: A Position Description: Technical Specialist, Approved 20 Apr 98, signed 21 Apr 98 Position Description: Project Manager – WESTRALIA RPLSS Position Description: Technical Specialist 1 ADI to Shingara Singh: Internal memorandum RPLSS1-2552/97 re: Appointment as Quality Coordinator, dated 27 Sep 97 Position Description: Technical Specialist, approved 11 Mar 98, signed 12 Mar 98 218B Resumes of ADI personnel: AJ Morland, R Sergeant, S Singh & N Baird-Orr (In SUB037 Confidence) B
219 Mr K Old supplementary statement
220 Lloyds Register’s Published Rules and Regulation for the Classification of Ships Part 5 Main MR065A Auxiliary Machinery Chapter 12 Piping Design Requirements: Section 7 Flexible Hoses; Section 8 Hydraulic Tests on Pipes and Fittings, & Section 9 Appendix – guidance notes on metal pipes for water services 221 Mr S Singh statement SUB035
222 CPOMT S Singh RAN historical record – personal details removed SR018A
223 Mr PW Bruce statement – many attachments have privacy markings
224 Mr PE Burge statement – Marine Engineering Consultant ER024
225 Deacons Graham & James to the Board of Inquiry: Annexure to Fax re: Hypothesis, dated 2 Jul 97
226 Annex A to FIMA PERTH minute 18/98 of 3 Jul 98 Diesel Injector Tests: SME 8,9, and 10 ER022
227 Mr G Kelly – Fire, Factual and Forensic Investigations: Report on WESTRALIA fire, dated ER025 4 Jul 98
228 Mr TP Casey – Forensic Services Australia: Report on Vessel Fire: HMAS ‘Westralia’, ER021 dated 3 Jul 98
228A Mr TP Casey resume SUB039
229 WESTRALIA: Daily Orders 28,29 & 30 Apr 98 BR017
230 WESTRALIA: Organisation Diagrams: A – Admin, B – Action/Emergency Stations, C – BR020 Cruising/Defence Watches
231 WESTRALIA: Polaroid Photographs of Damage Control Stateboards in HQ1, FWD and DCL004 AFT DC Section Bases
232 Engineering Sea Check 01 Oct 97 (Declassified version) including: DCL005 Overall Assessment A Engineering Casualty Control Drills Material State Report Notes on WESTRALIA Material Sea Check 30 Sep – 02 Oct 97 233 WESTRALIA: CO WESTRALIA to MHQ: Minute 72/23/2 re: Report of Lack of Billet Pre- DCL007 requisite Training and Permanent Posting Directives for WESTRALIA crew members, dated Mar 98
C-15 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
234 Sea Training Group assessment of Damage Control and Fire Fighting 01 Oct 97, including: DCL012 Sea Training Group Report on Damage Control and Fire Fighting Exercise Report – SSFB Fire Exercise Report – SSFB Toxic Gas Exercise Report – Flood WESTRALIA NBCD deficiencies/recommendations 30 Sep 97 235 WESTRALIA: Photographs of Funnel Flaps and Air Intake Vents and Valves DCL013
236 WESTRALIA: Transcript of FWD DC Section Base stateboard DCL015
237 WESTRALIA: Transcript from FWD DC Section Base perspex DCL024
238 WESTRALIA: Recording Sheet for gas levels DCL026
239 MHQ to WESTRALIA: Minute AF 35/1/100 NBCD Audit on WESTRALIA 23 Oct 96, DCL029 dated 14 Mar 97 (Declassified version) A Audit Report (declassified version) WESTRALIA Engineering Department, 26/27 Mar 97 Communications Department Audit 1 Mar 97, dated 31 Mar 97 240 WESTRALIA: Forward Section Base - Emergency Stations/Action Stations Personnel and DCL036 Duty List
241 WESTRALIA: Notes on fire couplings held in WESTRALIA DCL039
242 WESTRALIA: Internal Safety Audit - Engineering 19 Jan 98 DCL040
243 WESTRALIA: Assorted Documents from beneath perspex cover in HQ1 DCL041
244 WESTRALIA: Bundle of photographs of stateboard and perspex cover from DCL042 HQ1/AFT/FWD DC
245 WESTRALIA: Minute re: Safety Inspections Seaman/Communications Department 19/20 DCL043 Jan 98, dated 22 Jan 98
246 WESTRALIA: Photographs of Fire Damage to Engine Room, taken on 06 May 98, labelled DCL045 A-Q with description
247 Closing report and attachments – Job Number 705/237/0000 Survey and Overhaul Water DCM006 Drench Discharge V/V, (CO2 System including cylinder tests), dated 17 Jun 96 248 WESTRALIA: DC Training Plans and Assessments DCM008
249 WESTRALIA: Procedure for Main Machinery Space Fire - Extract from Ship’s Emergency DCM010 File
250 WESTRALIA: hand Drawn Diagram of CO2 Drench System, dated 14 Nov 93 DCM012 251 Test Reports on Wool/Aramid Fabric Colan XF1077-Thermal Protection Fabric DCM014
252 Syllabus A for Standard and Advanced NBCD Courses DCM017
253 Engine Room Fire - Guide to Fire Prevention (ClassNK Nippon Kaiji Kyokai, 1994 DCM023
254 Report on Investigation into the Engine-Room Fire aboard the New Zealand Flag Ro-Ro DCM027 Vessel UNION ROTOMA on 3 Dec 97 (Dept of Tpt Draft, dated 13 May 98)
255 Description of SMET Jacket with Standard Contents DCM028
256 WESTRALIA: Notes on Operation of CO2 Drench System, Copied from Fire Control Room DCM030 CO2 Cabinet Doors 257 Video - Hi-Fog Marine Fire Protection System DCM033
C-16 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
258 Technical Data Sheet for Parflex TFE 919 Hose with Stainless Steel Wire Braid MAN002
259 WESTRALIA: Servicing Instructions for Crossley-Pielstick Turbocharged Four Cycle MAN003 Marine Engine Type 14PC2V MK2 Engine, Engine Numbers 18104 and 18105
260 WESTRALIA: WESTRALIA PMS O-195 - Fire Extinguishing Systems - Maintenance Plan MAN007 - 555
261 WESTRALIA: Engine Room Auxiliary Systems Section 6 (includes Oil Booster Pump MAN008 Schematic Diagram)
262 IMO Conventions and Conferences, International Convention for the Safety of Life at Sea MAN009 (SOLAS) as Amended, Regulation 11-2 Construction – Fire Protection, Fire Detection and Fire Extinction, Regulation 11-2/A, 15.2: Oil Fuel Arrangements Lloyds Registers Published Rules and Regulations, Pt 5 Main and Auxiliary Machinery, Ch 12 Piping Design Requirements, Section 7 Flexible Hoses, 1997 IMO Assembly Resolutions, MSC and MEPC Resolutions and Circulars, MSC/Circular.647 (adopted on 6 June 1994)-Guidelines to Minimize Leakages from Flammable Liquid Systems Appendix 2 Flexible Hose and Flexible Hose Assemblies: Scope, Application, Design and Construction, Installation, Inspection and Maintenance Wartsila Technical Bulletin Issue 02, Document No. 3217T011GB(?) Page 7(7) Special Recommendations Concerning Power Plants: flexible hoses Diagram labelled Figure 2.1 Metallic Flexible Hose General Installation Guidelines, Source Unknown Diagram labelled Figure 2.2 Non-Metallic Flexible Hose General Installation Guidelines, Source Unknown
263 WESTRALIA: Hand drawn diagram of WESTRALIA fuel system (SBLT Forgie) MAN011
264 Diagram of Oil Fuel System for Ships No 1363 and 5 (Cammel Laird Shipbuilders) MAN012
265 Marine Information Note 25 (M+F): Research Project 401:Failures of Engine Low Pressure MAN015 Fuel Systems (Expires 31 Jan 99, MSA)
266 Marine Incident Investigation Unit to BOI: Fax re: Standards for flexible fuel lines, dated 26 MAN019 May 98
267 Pielstick Engine Service Bulletin 51 Issue 2, reviewed and approved 2/9/91 re: Fuel Pump MAN022 Isolation Cocks PC2.2, and PC2.3 Engines
268 High Pressure Fuel Pumps for Diesel Engines – Pulsation in Fuel Lines – Summary Brief, Dr MAN028 G. Goodwin, undated
269 Large Colour Diagram of S.E.M.T Pielstick PC2-5V 400 Engine MAN033
270 Navy Headquarters to All Ships and Shore Establishments: Signal 020115Z Mar 98 re MAN034 Contractor Safety RESTRICTED CO WESTRALIA to CMDR Walsh: e-mail re above signal, dated 04 Mar 98 (IN CONFIDENCE)
271 Lloyd’s Register Type Approval Certificate Extension (For certificate No. 97/00021) for MAN035 Parker Hannifin Corporation Wire Braided Rubber Hose Assemblies 221FR, covering the sizes ¼” to 7/8”, with series 20, 22 and 26 fittings, dated 09 Oct 97
272 WESTRALIA: URDEF Log, RESTRICTED (IN CONFIDENCE) EL022
273 Photographs of Fuel Boost Pumps EP011
C-17 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
274 Photographs of Flexible Fuel Lines - in situ on main engines, and removed EP038
275 WMO documents relating to installation of flexible fuel lines: MR002 WMO to ADI RPLSS: Fax WMO 317/98 re Approval of Maximo Work Order 975991/01, dated 25 Mar 98 ADI Contract Change Proposal 01 for Work Order 975991 dated 25 Mar 98 Maximo Quote for CCP 007 for Work Order 975991 dated 24 Mar 98 Enzed Contract Change Proposal 007 for Work Order 975991 dated 24 Mar 98 Enzed Kwinana to ADI: Fax re: Quote to supply end fittings for fuel lines, dated 23 Mar 98 TM 200 Maintenance Control Record Serial No. P983D0023 (Flexible Fuel Lines), dated 01 Feb 98 WMO to ADI RPLSS: Fax WMO 276/98 re: Approval for Maximo work orders listed at annex (AMP 12 Work List), dated 19 Mar 98 Maximo Work Order 975991, (No CCP No), dated 16 Mar 98 276 FIMA-P work package for AMP12 MR003
277 ADI work package for AMP12 MR004
278 WESTRALIA’s proposed work vide TM200’s list for AMP12 MR005
279 WESTRALIA: Outstanding URDEF’s as at 4 May 98 MR006
280 WESTRALIA: WESTRALIA 1998 Defect register - Certified copy MR007
281 ADI Documents collated by WOMTP Jones on 6 May 98: MR008 Maintenance Control Record for Work Instruction A1161- Manufacture and install flexible fuel lines on both M/Es Work Instruction No: A1161 Install Flexible Oil Fuel Lines to M/Es Black and White Photocopies of colour diagrams of Top, Middle and Bottom Plates layout – WESTRALIA Schematic Diagram of Fuel Supply System for M/Es and D/Gs Rolls-Royce (Australia) to ADI: Fax 980241 re: Quote for PC08013 Nut (Qty 56) for WESTRALIA, dated 18 Mar 98 Maximo Work Order 975991 (No CCP No.), dated 16 Mar 98 Pielstick Engine Service Bulletin Number 78 Issue 2 (second front page showing full top of page) Enzed (Mr Old) to ADI: Quote for work detailed in Work Instruction A1161, dated 27 Feb 98, with Attached quote using Parker 919 TFE Hose with Stainless Steel Braid Enzed Kwinana to ADI: Fax re: Quotation to supply end fittings, dated 23 Mar 98 Maximo Work Order 9755991/01 (CCP 007), dated 23 Mar 98 (Mr Morland’s signature only) Enzed Contract Change Proposal 007 (End fittings) dated 23 Mar 98 NTSU8 Incoming Mail Cover sheet for WMO 317/98 dated 25 Mar 98 WMO to ADI: Fax WMO 317/98 re: Approval of Maximo Work Order 975991/01, dated 25 Mar 98 Maximo Work Order 975991/01 (CCP 007) dated 24 Mar 98 ADI to Enzed: Letter re: Approval of Contract Change Proposal 007, dated 25 Mar 98 Fax Transmission Report: ADI Limited, dated 25 Mar 98, 15:43 Opening and Closing Report WESTRALIA Main Engines Fuel Supply and Return Lines Work Instruction A1161, 2 pages, unsigned, undated
C-18 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
Pages from Manual (?), labelled: PC.2 pages 1-2; diagram; PC.3 pages 1-2; PC.4 pages 1-4; PC.5 pages 1-2; PC.6 pages 1-3; Plate No. 222 (2 pages) Pielstick Engine Service Bulletin Number 78 Issue 2 (front page only) ADI Despatch and Receipt Advice No. 2519: Activity A1161, record of Basin Trial, dated 23 Apr 98 ADI Transmittal Note 0799 to Activity A1161, re: completion of Work, dated 30 Apr 98 Lloyd’s register of Shipping to ADI: Fax F203/98 re: List of all LR Type Approved Products for hose assemblies and flexible hoses, dated 11 Feb 98 (13 pages attached) Enzed Test Certificates for Hydrostatic Pressure Tests. Certificate Numbers: 471, 477-533, 536-539 282 Audit Report of Engineering Dept 26/27 Mar 97 RESTRICTED, including Audit MR011 Selection Form for HMA Ships ANZAC, ARUNTA, SUCCESS, TOBRUK, MANOORA, KANIMBLA, WESTRALIA and LEEUWIN (IN-CONFIDENCE)
283 WESTRALIA to MHQ: Minute 7/1/7 re: Inspection Follow-Up Report dated 11 Aug 94 MR012
284 WESTRALIA: Inspection Report - Marine Engineering Department Inspection of 07 Mar MR013 94, dated 17 Mar 94
285 WESTRALIA 1996 Refit: Visit by FMEA3 to conduct LOE Technical Written Examinations MR018 and attend Refit Progress Meeting – Report dated 10 May 96 Summary of WESTRALIA Refit 1996 by FMEA3 286 LEUT Jones: Minute 74/8/3 re: Marine Engineering Officer’s Supercession Certificate - MR024 PART 1, dated 8 Nov 96
287 List of TM200’s for AMP 12 MR025
288 Base line schedule contractors AMP12 (No. 113 006), dated 14 Apr 98 MR026
289 Base line schedule contractors AMP12 (No. 113 008.1), dated 21 Apr 98 MR027
290 Video - Removal of flexible fuel hoses – WESTRALIA SME MR032
291 Video - Removal of flexible fuel hoses – WESTRALIA PME MR033
292 Video - Overall Views of Engine Room MR034
293A OAWA: File No. T93/04271 Part 1: Lloyds Survey WESTRALIA MR036A
293B OAWA: File No. T93/04271 Part 2: Lloyds Survey WESTRALIA MR036B
294 LEUT Shawcross’ notes on AMP12 meetings MR044
295 TM200 for Work order 975911 ‘Manufacture and install flexible fuel lines on both M/E’s’, MR046 dated 01 Feb 98
296 Extracts from OAWA SOP’s: MR048 Annex A to OAWA SOSOP 1 Pt 1-QM OAWA SOSOP Part 1 – Quality Manual SOP 101: Procedure for Originating OAWA Correspondence SOP 102: Procedure for the Control of Correspondence Entering, Within, and Leaving OAWA SOP 112: Procedure for Handling Maintenance Control Records (TM200) {Not applicable to WESTRALIA} SOP 113: Procedure for Complying with Financial Regulations SOP 117: Internal Compliance Audits
C-19 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
SOP 200: Procedure for Arranging and Controlling Contract Work for WESTRALIA Audit and Validation – OAWA SOP 304 – Monitoring Progress of Contractor Related Tasks Associated with DLM Activities in Western Australia SOP 500: Procedure for the Preparation of Work Instruction for PNR-O Use SOP 501: Procedure for Arranging and Controlling Occasional Work Diagram Showing Internal Audit Process Diagram Showing Certification (External) Audit Process Various Blank Forms 297 Brown and Root work file 966079 AMP 10 ‘Overhaul M/E Injectors’ MR049
298 LSS WESTRALIA file N059JFP973882, For Work order 966079 O’Haul and Service 32 MR050 M/E Fuel Injectors, Opened 28 Sep 96: Cancelled Work Order for Manufacture of Main Engine Fuel Hoses MR050A Work instruction 3883 MR050B TM200 for overhaul and servicing ME fuel injectors MR050C Authorisation for Job 3882 MR050D 299 Brown and Root Work File 966073 AMP 10 ‘Overhaul 14 M/E Air Timing Vvs’ MR051
300 LSS WESTRALIA file N059JFP973909, For Work order 966073 Overhaul 14 M/E Starting MR052 Air Timing Valves, opened 28 Sep 96
301 WESTRALIA: TSM172 Configuration Change Register - WESTRALIA (26 Folios) MR053
302 FIMA SOP 020 - Procedure for Handling MCRs (TM200), Issue 10, approval date 03 Dec MR058 96
303 AMP 10 Management Report - Brown and Root Document No. N059-5051-RX-001, Dated MR071 07 Mar 97
304 OAWA File T/96/07548: AMP10 MR073
305 WESTRALIA to WMO: Minute MEO 26/96 re: Authorisation to sign off work for AMP10, MR078 dated 18 Nov 96
306 Blank SG2 - old version with shading MR079
307 Video - Boroscopic Testing of Fuel Lines ER007
308 DSTO to ASACLO: WESTRALIA Fire Damage, Preliminary Modelling of Fire ER011
309 LEUT Walter to WP30 PM: Minute WP30INT 001/98 re: Results of Testing CO2 System – ER013 Manifolds and Pipework on16 Jun 98, dated 17 Jun 98
310 Marine Safety Agency: Report into Failures of Low Pressure Fuel Systems on Ships’ Diesel ER015 Engines, MSA Research Project 401, January 1997
311 Chemistry Centre to BOI: letter 98F0039 re: Analysis of Diesel Fuel from WESTRALIA, ER023 dated 3 Jul 98
312 WESTRALIA: Medical Standard Operating Procedure - Emergency Stations MED007
313 WESTRALIA: Medical Standard Operating Procedure - Casualty MED008
314 WESTRALIA: Medical Standard Operating Procedure - Action Stations MED009
315 WESTRALIA: Medical Standard Operating Procedure - Toxic Hazard MED010
316 WESTRALIA: SMET Training records - NPEMS MED011
C-20 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
317 WESTRALIA: Audit report of Medical Department 11 Mar 97 MED015
318 WESTRALIA: Sea Training Group Reports - Medical: MED019 Minor Casualty Exercise (DCX 101), dated 17 Feb 97 Man Overboard, dated 17 Feb 97 Minor Casualty Exercise (SSFB), dated 17 Feb 97 Major Casualty Exercise (101), dated 4 Feb 97 Toxic Gassing - Freon, dated 4 Feb 97 319 Dr Paul Mark to BOI: Letter re: List of Adult Transport Box (Medical transfers) Contents, MED023 dated 27 Jun 98
320 WESTRALIA: Organisational chart LEG004
321 Notes summarising work on fuel lines - LEUT Booker, undated LEG005
322 Support Command – Navy Report: Review of Contracting Procedures, Reference LEG007 9/01699/XX, FONSC 690/96, dated 25 Jul 97
323 WESTRALIA: Incumbents not Holding Billet Pre-requisites (list with course titles) LEG010
324 WESTRALIA: List of Items collected from HQ1 by LEUT Fallens/LEUT Ritchie LEG012
325 Chart of Corporate and Contractual Arrangements: ADI/ENZED/JETROCK LEG025
326 Chart relating to Dawsons - ADI development LEG026
327 Signals from HMA Ships SYDNEY, DARWIN and SUCCESS listing personnel and OT007 material transferred to WESTRALIA on 5 May
328 Extract from Ship’s Log HMAS ADELAIDE from 1135 to 1420, 05 May 98 as recorded by OT008 SBLT D.L. Scully
329 HMAS ADELAIDE: Bridge Comms Log 0259Z-1312Z 05 May 98 (certified copy) OT010
330 HMAS ADELAIDE: Bridge Narrative of 05 May incident (certified copy) OT011
331 HMAS ADELAIDE: WAXA Co-ord Log 05 May 98 OT012
332 HMAS ADELAIDE: Operations Room narrative 05 May 98 OT013
333 Senior Psychologist, WA to BOI Note re: CISM Team Member List OT015
334 Package from HMAS DARWIN re: Assistance on 5 May - 4x statements, Copy of OOW OT017 notebook 05 May 98, copy of Ship’s log 05 May 98
335 Audio Tapes (HMAS DARWIN Bridge), Four tapes numbered 18-21 inclusive OT018A- D
336 NAVCALS Fremantle: Circuit tapes 1-4 OT019A- D
337 MHQAUST WEST Operations Narrative Fire Onboard WESTRALIA Tuesday 5 May 1998 OT020 (Typed copy - 4 pages, written copy - 6 pages, other hand notes 9 pages)
338 Video – WESTRALIA Engine Room (Channel 7) OT027
339 Extract from Communication Operator’s Logs OT031 A- Coastal Common B- Harbour Warning C- Coastal Operations D- WAXA 340 Transcript of “Today Tonight” Story on Maintenance Management, aired 11 Jun 98, Channel OT033B
C-21 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
7
341 Photographic Proof Sheets of all Photographs Taken by RAN Photographers (STSC) OT035
342 Royal Australian Navy Critical Incident Stress Management Operating Manual, Sep 94 PUB003
343 Magazine article, ‘Voyage data recorders - are black boxes benefical?’ Marine Engineering PUB016 Review May 98
344 ENZED Franchise Agreement, ENZED Fremantle, Todd Hydraulic Pty Ltd ACN 009 084 PUB018 988, Trading as ENZED Fremantle
345 OAWA - Brief for CMDR Coverdale (Handover notes), 18 Sep 97 PUB020
346 WESTRALIA: List of personnel onboard 05 May 98, including date joined SR001
347 WESTRALIA: Watch and Station Bill effective 5 May 98 SR002
348 WESTRALIA: Standing Sea Fire Brigade effective 5 May 98 SR003
349 Service record for CO - CMDR E.S.D Dietrich (personal details removed) SR004A
350 WESTRALIA to MHQ: Copy of draft signal re: Personnel Borne without Mandatory Billet SR010 Pre-requisites(BPRs) Incumbents Not Holding Pre-requisite Requirements, NPEMS report of 02 Feb 98 SR011 CO WESTRALIA to NTCA-W: Minute 72/23/2 re: Billet Pre-requisite Training Bids for SR009 1998, dated 30 Apr 98 CO WESTRALIA to MHQ: Minute 72/23/2 re: Reporting Lack of Billet Pre-requisites and SR008 Permanent Posting Directions on Joining HMA Ships, dated Mar 98
351 Service record for POMTPD3 Alan John Morland (personal details removed) SR014A
352 CFM to BOI: Minute re: BOI Submission - Management of Maintenance for WESTRALIA, SUB010 dated 22 May 98
353 Det Norske Veritas to BOI: Letter DTP245/JEWA-98/27169 re: Engine Room Fires in SUB015 DNV-Classed Vessels (Statistics and one graph included), dated 20 May 98
354 Mr John Moody to CN: letter re: Fuel leaks and fires with pielstick engines, dated 09 May SUB017 98
355 CFEWA to BOI: Minute re: Configuration Change Management, Certification, Classification SUB021 and Command Interface Problems, Documentation and Instructions, Usage Upkeep Cycles, Quality Procedures, dated 05 Jun 98
356 Mr R.G. Benton to CO STIRLING: letter re: Automatic Fire Detection and Protections SUB027 Systems, undated
357 Mr David McDonald to Minister of Defence: Alternative to CO2 Drench System, dated 06 SUB029 May 98, and forwarding documentation
358 LSEW Quigley (HMAS TORRENS) to CO HMAS TORRENS, Minute re: Equipment SUB032 Currently Used for NBCD, dated 20 May 98
359 Mr William F. Pugh to BOI: Letter re: Modifications to Crossley Pielstick Engines to SUB038 Prevent Fuel Lines Splitting, dated 26 Jun 98
360 WESTRALIA to MHQ: Signal 041205Z May 98 re: Exercise Report for Apr 98 – DCL008 RESTRICTED (IN CONFIDENCE)
361 WESTRALIA: Material State Report dated 27 Aug 96 -RESTRICTED (IN DCL009 CONFIDENCE)
C-22 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
362 WESTRALIA: Exercise Statistics 01 Jan 97 to 11 May 98 –RESTRICTED (IN DCL010 CONFIDENCE)
363 MHQ Audit Report AF/35/1/100 re: WESTRALIA Management and Organisation DCL030 Audit 27 Feb 97, dated 14 Mar 97 - RESTRICTED (IN CONFIDENCE)
364 WESTRALIA to MHQ: Signal 050030Z Jun 98: Occupational Health and Safety DCL044 Incident Report – RESTRICTED (IN CONFIDENCE)
365 Extract from HMAS STIRLING Medical Log 4, 5 May 98 (IN CONFIDENCE) MED013
366 LEUT Slaven to BOI: Medical Officer’s Report - AB N. Street (IN CONFIDENCE) MED024
367 WESTRALIA: Engineering Sea Check 8 Apr 94 - RESTRICTED (IN CONFIDENCE) MR014
368 WESTRALIA: Engineering Sea Check Jul 97 – RESTRICTED (IN CONFIDENCE) MR015
369 WESTRALIA: Engineering Sea Check 01 Oct 97 - RESTRICTED (IN CONFIDENCE) MR016
370 Observations of WESTRALIA in Forgacs Dockyard 29 March/ 2 April 1996 (Various MR017 Authors) – COMMERCIAL IN CONFIDENCE (IN CONFIDENCE)
371 Original pages from E103 and E25 - including prices COMMERCIAL IN MR035 CONFIDENCE (IN CONFIDENCE)
372 Bundle of documents re 1996 refit. COMMERCIAL IN CONFIDENCE (IN MR045 CONFIDENCE)
373 Defence Quality Assurance Activity Report: WESTRALIA AMP10. From file MR072 T/96/07548 (1) COMMERCIAL IN CONFIDENCE (IN CONFIDENCE)
374 HMAS ADELAIDE to HMAS STIRLING: Signal 070030Z May 98 re: List Personnel OT016 and Material Transferred to WESTRALIA on 5 May. RESTRICTED (IN CONFIDENCE)
375 Signals pack from NAVCALS Fremantle 05 May 98 Personnel and Material OT022 Transferred to WESTRALIA on 5 May. RESTRICTED (IN CONFIDENCE)
376 Senior Psychologist WA to Senior Psychologist HMAS PENGUIN: Summary Report SUB023 SPWA 40/98, 206/11: CISM Interventions Following Fire in WESTRALIA 5 May 98, dated 08 Jun 98 - STAFF IN CONFIDENCE (IN CONFIDENCE)
377 Senior Psychologist WA to Senior Psychologist HMAS PENGUIN: Minute SPWA SUB024 41/98, 206/11: Summary Report - CISM Follow-up, PSM Support, Individual Debriefing and Individual Counselling Following Fire in WESTRALIA 5 May 98, dated 08 Jun 98 – STAFF IN CONFIDENCE (IN CONFIDENCE)
378 POCK B.S. Mercer statement
378A POCK B.S. Mercer supplementary statement (IN CONFIDENCE)
379 ABBM K.T. Spanswick statement
379A ABBM K.T. Spanswick supplementary statement (IN CONFIDENCE)
380 ABET D.R. Hunter statement
381 ABRO L.J. Emmerton statement
382 LSSTD T.M Lillimagi statement
383 LSSTD V.E. Nix statement
384 CMDR A.G. Robertson RAN statement
C-23 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
384A CMDR A.G. Robertson RAN supplementary statement (IN CONFIDENCE)
385 ABBM B.W. Knox statement
386 LSBM C.L. Durnan statement
386A LSBM C.L. Durnan supplementary statement (IN CONFIDENCE)
387 CMDR A.H. Johnson RAN statement
388 CHAP K. Gebski RAN statement
389 CHAP B.J. Yesberg RAN statement
390 ABMT M.J. Liddell statement
390A ABMT M.J. Liddell supplementary statement (IN CONFIDENCE)
391 LCDR R.J.. Smith statement RAN
392 Detective Senior Constable W. Hawes WA Police Service statement
393 ABBM J.A. Lambert statement
394 Copy of Form 7 (Summons) to Mr S. Ridland, Lloyd’s Register of Shipping Folio 356 BOI to Lloyd’s Register of Shipping: Fax BOI(W) 58/98, Requesting information SUB040 Lloyd’s Register of Shipping to BOI: Fax H61 re: Answers to questions in BOI Minute Folio 296 58/98 + Folio 371
395 BOI to Lloyd’s Register of Shipping: Fax BOI(W) 58/98, Requesting information SUB040 Lloyd’s Register of Shipping to BOI: Fax H61 re: Answers to questions in BOI Minute Folio 296 58/98 + Folio 371
396 Lloyd’s Register (Fremantle) to LR London: Fax F 754/97 re: Fitting of Flexible Hoses to SUB041 WESTRALIA Main Engines put on Hold, dated 16 Apr 97 Lloyd’s Register (Fremantle) to Brown & Root Engineering: Fax S/PWM/dhm re: Aeroquip type FC234AQP Hoses not approved, requirement to reinforce with wire braid, and burst test to five times maximum pressure, 08 Jan 97 Lloyd’s Register (Fremantle) to LR London: Fax F2055/96 re: Check to see if Aeroquip FC234 AQP Hose is acceptable for intended use, 29 Nov 96 Brown & Root Engineering to Lloyds: Fax N059-S0152 re: Request to see if Aeroquip FC234 AQP is acceptable for intended use, dated 29 Nov 96, with Aeroquip data sheets attached 397 WESTRALIA: Diagram of Aft Section (Side View)
398 Metlabs Report 8D27/M1 - Examination of Damage to Charge Air Rail Segments, dated 6 ER028 Jul 98
399 ABMT P.K. Justice statement
400 ABMT P.K. Justice supplementary statement
401 Dr Goodwin to BOI: Notes on Mr G. Kelly report, dated 06 Jul 98 ER029 Dr Goodwin to BOI: Notes on Mr T. Casey report, dated 06 Jul 98 ER030 Dr Goodwin to BOI: Notes on Mr P. Burge report, dated 07 Jul 98 ER031 Dr Goodwin to BOI: Notes on Mr M. Barker question, dated 07 Jul 98 ER032
C-24 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
Dr Goodwin to BOI: Notes on Wartsila NSD meeting, dated 07 Jul 98 ER033 401A Overhead transparency prepared by Dr G. Goodwin - Bosch PF58 Pump – Feed Gallery Pressure 85% Load, Test No. 1111152, dated 17 May 90
401B Overhead transparency prepared by Dr G. Goodwin – Enlarged Section of E401A, with figures added
401C Overhead transparency prepared by Dr G. Goodwin – Enlarged Section of E401A without added figures
401D Overhead transparency prepared by Dr G. Goodwin – Enlarged Section of E401A with new figures and new peaks added
401E Overhead transparency prepared by Dr G. Goodwin - Drawing of Hose Connection Assembly
402 ADI to Wartsila NSD: letter RPLSS8-157/98 re: Work Packages for AMP 10 – and tender MR082 response requirements, dated 12 Feb 98 MR077 Copy of ADI work order A1161
403 Watmarine Engineering Services Inspection Certificate Job No 637: WESTRALIA Port MR085 Supply Fuel Rail date 7 Jul 98 Watmarine Engineering Services Inspection Certificate Job No 637: WESTRALIA Port Return Fuel Rail date 7 Jul 98 Watmarine Engineering Services Inspection Certificate Job No 637: WESTRALIA STBD Supply Fuel Rail date 7 Jul 98 Watmarine Engineering Services Inspection Certificate Job No 637: WESTRALIA STBD Return Fuel Rail date 7 Jul 98 404 BOI to Phillips Fox Lawyers: Fax BOI (W)116/98 re: Questions on aspects of Mr Casey’s Folio 421 report, dated 07 Jul 98 Mr T.P. Casey to BOI: Fax Response to BOI 116/98, dated 08 Jul 98 ER035
405 ADI advertisement in Naval Supply Newsletter (Journal of the RAN Supply Support Organisation), June 1998
406 Dr P.Burge supplementary statement
407 WOMT C. Bottomley second supplementary statement
408 Video: Removal of Fuel Hoses – PORT 14 Supply, 8 Return, 9 Return MR084
409 WESTRALIA: Enlarged photo of Tally Plate Fuel Pump No 8 PME
410 ADI to WMO: letter RPLSS6-891/97 re: WESTRALIA RPLSS Team, dated 17 Apr 97 Folio 399
411 ASACLO to BOI: minute 98/00185 ASACLO 313/98, re: ASACLM Input to BOI, dated 07 SUB043 Jul 98, enclosing: Minutes of ADI RPLSS Pre AMP 12 Meeting of 10 Mar 98 Minutes of ADI RPLSS Meeting held 04 May 98 OAWA to ADI-RPLSS, AFSCLO: T97/10305 re: Management of Maintenance Availabilities, dated 20 Nov 97 ADI to ASACLO: letter RPLSS6-485/98 re: WESTRALIA RPLSS Contract CAPO No. MACS (WA) 0044 Contract Change Proposal No. 1 (additional manning), dated 26 Feb 98 ASACLM to DCLM: Minute ASCLO 59/98 re: WESTRALIA RPLSS Contract Change Proposal 0001 – Liability Approval, Dated 24 Apr 98
C-25 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
412 Mr Wilhelm MISD to ASACLM: Fax MISD-S1047/98 re: Design Agency Signatories, MR086 dated 08 Jul 98
413 Deakins Graham & James Lawyers to Australian Maritime Safety Authority: letter 988864:cb:111054 re: Request to confirm information on: MSC Circulars, IMO, SOLAS, ADI and RAN, dated 29 Jun 98
414 Wartsila NSD to BOI: Fax re Information received with AMP 12 Work Instructions and Folio 440 action taken by Wartsila, dated 08 Jul 98
415 Jackson McDonald Lawyers to BOI: Fax DBC:944391 re: Replies to questions asked of Mr MAN040 Ridland with transcript references, dated 08 Jul 98 (Folio 439)
416 WESTRALIA: Commanding Officer’s Standing Orders BR004
417 Audio tapes - WAXA Co-Ord (3 tapes). BR011A- C
418 WESTRALIA: Daily Orders 05 May 98 BR014
419 WESTRALIA: Damage Control Equipment Status DCL006
420 WESTRALIA: Watertight integrity log. 2-5 My 98 DCL022
421 WESTRALIA: Transcript of DCL027 (control board for OCCABA) DCL028
422 WESTRALIA: Triage groups card DCL033
423 WESTRALIA: OCCABA control board with chinagraph pencil entries on rear from HQ1 DCL038
424 Extracts from Kirks Fire Investigation (4th edition), Prentice-Hall, Inc., New Jersey, 1997. DCM016 Pages 23-24, 377-384
425 MSA Product description - RAN Emergency Life Support Respiratory Device (ELSRD) The DCM031 military version of MSA Lifegard Annex A to MISD-M0918/98 re: Testing of ELSRD material DCM031 A
426 WESTRALIA: Engineering Department List EL014
427 WESTRALIA to DSCM, FMEO: Minute 72/23/2 (5) re: Marine Technical Sailors – EL021 Machinery, Engine Room and Auxiliary Machinery Operators Certificates Training Summary, dated Jun 98, unsigned
428 Dr Richard Bryant to BOI: letter re WESTRALIA Fire: Critical Incident Stress Management, ER026 dated 04 Jul 98
429 Fire and Emergency Services Authority of Western Australia to BOI: Fax re Inspection of ER034 Navy AUER-BD88 CABA (OCCABA), dated 08 Jul 98
430 Fire and Rescue Service of Western Australia: Report on “WESTRALIA” Fire Detection ER036 System
431 NBCD Qualifications - WESTRALIA Ship’s Company LEG018
432 ANLO-UK to BOI: Fax ANLO 178/98 re Engineering Drawing and Specification Request, MAN020 enclosing diagrams of supply and return rails and cylinder fuel pumps, 13 May 98
433 SOLAS 1960/SOLAS 1974 (6 pages) MAN037
434 DTI and Scalar for Ship’s Medical Emergency Team (SMET) Course MAN038 Folio 422
C-26 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
435 DTI and Scalar for Leading Seaman Medical Course. MAN039 Folio 424
436 Medical Certificate for Mr Alan Morland dated 26 Jun 98 (IN CONFIDENCE) Folio 343
437 Medical Certificate for WOMT Jones dated 30 Jun 98 (IN CONFIDENCE) Folio 357
438 Extracts from Medical records: (IN CONFIDENCE) MED017 i A- POMT Smith, B- MIDN Pelly, C- ABMT Carroll, D- LSMT Meek
439 Extracts from Medical records: (IN CONFIDENCE) MED018 i A- ABMT Liddell, B- LSMT Smith, C- POMT Francis, D- POMT Hollis, E:LSFF Nunn, and F: AB Street
440A WESTRALIA: Occupational Health & Safety Log (OS6) commenced 20 Jun 94 (IN MED CONFIDENCE) 022A
440B WESTRALIA: Occupational Health & Safety Log (OS6) commenced 01 Jan 98 (IN MED022 CONFIDENCE) B
441 Deacons Graham & James Lawyers to BOI: Fax 988864:dp:110938 re ENZED Invoice no MR057 F96202 to ADI Ltd (attached)
442 Bundle of documents re: ADI internal QA audits, with comments from management MR068
443 List of TM200s for AMP12 MR069
444 Documents on Maintenance of Fire Detection System conducted Mar 98 MR070
445 MISD to BOI: Minute MISD-M1005/98 re: Documentation relating to SG2 No. AMP MR083 10/001 Dated 27 Nov 96, dated 02 Jul 98. Covering: WMO Fax WMO961/96 – SG2 Braided Fuel Lines SG2 No. AMP 10/001 Quote No. 915-Q (Ches Engine Reconditioning) for removal of old lines, manufacture and fit flexible lines Data Sheet for Aeroquip FC234 AQP Hose Four diagrams MISD Marine to SOFRACO: Fax MISD- Re: Proposed changes to WESTRALIA’s Pielstick Engines Record of Conversation: Re point of contact, requirement to contact Rolls Royce MISD to OAWA: Fax MISD-M2205/96 re: MISD do not exercise DAA, Action to take 446 Transcript of Two Bridge tapes from HMAS ADELAIDE on 5 May. OT002C
447 Media Monitors TV clips of ship during incident. OT005
448 Video of TVW 7 “Today Tonight” Story on WESTRALIA, aired 11 Jun 98 OT033A
449 LCDR D.R. Crouch RAN supplementary statement
450 Letter of Mr Pugh re: original submission and reply on fuel lines splitting on Crossley SUB045 Pielstick Engines dated 7 July 1998 (Folio 455)
451 BOI to ASACLM: Fax BOI(W) 145/98 re: Pielstick Reliability Modification No 78, dated Folio 520 29 Jul 98. Covering: Fax from ANLO-UK, Fax from Rolls Royce Fax re: Cost and installation (Folio 520 covering folios 492 and 491)
C-27 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
452 Fire Scene Examination Report WESTRALIA 5 May 1998 – WA Police Service (Detective ER043 Senior Constable W Hawes, Arson Squad), dated 15 Jul 98
453 Functional Tests of CO2 System WESTRALIA, Protection Engineering dated 27 Jul 98 ER046
454 BOI to MCAUST: Minute BOI (WEST) 8/98, re: Compartment Escape Routes, dated 02 Jun Folio 103 98
455 BOI to COMFLOT: Minute BOI (WEST) /98, re: Annual Continuous Training (ACT) - Folio 27 Exercise DC 18, dated 19 May 98 (Vol 2)
456 BOI to COMFLOT: Minute BOI (WEST) 7/98, re: Re-entry into compartments after major Folio 69 fire fighting efforts, dated 27 May 98
457 Modelling of the WESTRALIA Fire, DSTO AMRL Report No. DSTO-TR-0698, S.R. ER042 Kennett, G.I. Gamble and Jun-De Li
458 Marine Fire Prevention, Firefighting and Fire Safety, Delgado Fire School, New Orleans, PUB030 Maritime Training Advisory Board, Extracts
459 Rolls Royce to ANLO-UK: Fax re: Tests to study pressure fluctuations on the fuel inlet ER037, system on a PC2.2 engine, dated 10 Jul 98 (Report in French); English translation attached ER037A
460 Analysis of Fire Casualty Records: Research into failures of fuel systems, IMO Sub- ER010 Committee on Fire Protection FP42/INF.6, dated 13 Oct 97
461 FHRM to given distribution list (including DCO and PSOs), re: WESTRALIA Fire – OT036 Personnel Aspects Lessons Learnt, dated 11 Jun 98
462 Guidelines to Minimize Leakages from Flammable Liquid Systems, IMO MSC/ Circ.647 PUB026 dated 06 Jun 94
463 NSC Specification No A201864: Depot Level Overhaul and Testing of RAN OCCABA Sets, MR092 dated 11 Dec 92
464 Section 7. Service, Maintenance, Test and Storage – Tables with Federal Republic of PUB024 Germany requirements for equivalent of RAN OCCABA
465 Interspiro Technical Data on SAVOX 100 Compact Radio Interface, SAVOX 200 Radio PUB023 Interface, SAVOX Helmet-com
466 Symposium – Fire and Incendiarism, Problems of carbon monoxide in fires, Journal of PUB021 Forensic Sciences, Vol 7 No. 4, October 1962 pp379-393
467 Frequency of Pressure Pulses in the Propulsion Engines of WESTRALIA, Dr Goodwin, 3 ER045 Aug 98
468 WESTRALIA: Ship’s Standing Orders, Extract: Chapter 9, Medical and Dental BR005C
469 ADI Service Design Control Procedure, SP04.01 Issue 2.2, Effective from 30 Apr 1997. MR060A From ADI Technology Standard Procedures dated 30 April 1997. SUPERCEEDED by E471
470 ADI Local Service Design Control Procedure, LSP04.01 Issue 1, Effective from 05 Jun MR062A 1996. Provided by ADI as an insert to ADI Technology Standard Procedures dated 09 Mar 98.
471 Copy of Quality Endorsed Company Registered Site Certificate No. QEC 5696-4: ADI MR063A Limited – Technology Group, Refit Planning Logistic Support Services, Garden Island WA
472 Notes on WESTRALIA’s Low Pressure Fuel Rail System, undated, unsigned. Author: Mr MR090 Bebbington
C-28 Exhibit DESCRIPTION OF EXHIBIT BOI Ref No. No.
473 Medical Status of Selected WESTRALIA Personnel (IN CONFIDENCE) MED025
474 Protocol 2-4: Tissue Injuries Due to Fire and Heat MED026
475 Astraflex Hoses Technical Data (17 pages) MAN041
476 POMT Knight to SSSS(W), Minute 2071/98 re: Failure of OCCABA ‘O’ Rings, dated 20 Jul SUB052 98
477 LEUT Spehr to FMO: E-mail re: timeline of events 05 May 98 (medical perspective), dated OT037 06 May 98
478 Mr S. Rayner, National Clinical Director – RAN CISM to FMO: Minute 107/98 re: Request SUB013 of Information on RAN CISM, dated 26 May 98
479 LEUT D. Walters supplementary statement
480 Reports on testing of main engine return fuel control system valves and fuel system gauges ER047
481 Dr Goodwin: Comments on Reports at E480 ER049
C-29 ANNEX D TO BOI REPORT: HMAS WESTRALIA FIRE ON 05 MAY 98
TRANSCRIPT OF HMAS WESTRALIA BRIDGE TAPE
(abridged version)
STOP- MODE TIME SPEAKER AUDIBLE WORDS WATCH 0.00 Spoken 1015 NAVYEO 1015 on this day, Tuesday the 5th of April 1998, continuing onto tape to exit Fleet Base West 15.51 Intercom EOOW Bridge, MCR Intercom QM Bridge 15.55 Intercom 1031 EOOW Request emergency declutch port main engine. I have a major fuel leak on my port main engine On Bridge OOW Emergency declutch On Bridge NAV Standby No Standby Stop Engine On Bridge OOW Stop Engine Intercom QM MCR Bridge. Stop engine Telegraphs Beeping (three) Intercom MCR Stop Engine On Bridge NAV I'm not happy to lose both engines. If you'd emergency declutched then could've killed us. Bad call 16.10 Intercom MEO Declutching port main engine Intercom NAV Roger On Bridge OOW Midships 16.20 Intercom MEO Port main engine declutched, shutting down port main engine (Background to NAV Do you want standing sea? MCR?) 16.26 Intercom MEO Affirmative. Request Standing sea fire brigade MCR 16.30 Main 1031.3 QM Standing sea fire brigade muster MCR. Standing sea fire Broadcast brigade muster MCR. On Bridge CO Just say there's a fuel leak, a fuel leak has been reported 16.40 Main Broadcast NAV There is a fuel leak reported on the port main engine. SSFB are mustering in the MCR as a precaution. 16.50 Intercom MEO Bridge, MCR. Port main engine shut down ready to obey telegraphs on STBD main engine Over top HQ1 ....report to HQ1 On Bridge OOW Obey telegraphs STBD main engine 17.36 maxon HQ1, IC Standing Sea are now on the scene 17.38 Intercom MCR Bridge MCR. Aft fire pump running. On Bridge OOW Slowing down 17.41 Intercom HQ1? Roger. Standing Sea's on the scene 17.44 Intercom 1032.44 EOOW Bridge, MCR. Machinery up date. I have approximately 40 percent of my STBD main engine....Ship's electrical load is on both D/As 17.55 Intercom 1032.55 MCR Standing Sea fire brigade are in attendance...... hand over now On Bridge OOW Roger On Bridge NAV This is where you need to know what's going on really closely Joh. If you'd emergency de-clutched, then you probably would've killed the ship. She would have gone straight onto the bank. 18.08 Main 1033 HQ1 HQ1 SITREP fuel..fuel leak reported on the port main Broadcast engine. The engine has been shut down and fuel isolated. Standing Sea fire Brigade on Standby D-1 Broadcast Shawcross HQ1 SITREP. All entrances into MCR to be made through escape hatch in the after hydraulics 18.51 On Bridge NAV What kind of things are you thinking about now, Jo? On Bridge OOW Um On Bridge NAV What's going to happen if this bursts into flames? On Bridge OOW Go to emergency stations On Bridge NAV Okay, so what are going to do as soon as we go to emergency stations? On Bridge OOW Keys.. On Bridge NAV Keys, books, let's get them ready to go. You've got people hanging around. .…got Fiona standing here. I'm not saying get them down there, just get your stuff ready to go so that there's less hassle as soon as we do it. You've already got half your check-offs done for emergency stations, so check them off. On Bridge OOW Yep On Bridge NAV Just get yourself ready 19.35 Intercom MCR Bridge, MCR Intercom QM Bridge 19.38 Intercom MEO Yeah, Port main engine is shut down. We've isolated the cause of the leak which was a leaking banjo bolt around number 11 or 12 unit on port main. We have had a lot of fuel over the port main engine which is still fairly hot. We estimate ETR about 30 minutes but in the meantime we'd like to keep SSFB closed up till we get the fuel cleaned up Intercom CO Bridge Roger 20.06 Fire alarm 1035 (Fire=F) (BELLS) Fire alarm Intercom EOOW Fire, Fire, Fire, Fire in the MCR. Intercom NAV In the engine Room or MCR? Intercom EOOW MCR 20.22 On Bridge 1035.22 NAV Okay. Sir, recommend go to emergency stations On Bridge CO Yes 20.24 Intercom 1035.24 EOOW Request shut down to STBD main engine. STBD engine on fire 20.28 Alarm (BELLS) COXN Hands to emergency stations sir? hands to emergency stations, Hands to emergency stations On Bridge NAV Pipe it - Emergency Stations 20.37 Main F+0.30 COXN Hands to emergency stations, Hands to emergency stations, Broadcast Hands to emergency stations Hands to emergency stations, Hands to emergency stations, Hands to emergency stations On Bridge NAV Is the book gone? On Bridge OOW Yep, book's gone Alarm On Bridge Conole General ....H2S gas alarm On Bridge NAV Disregard 20.52 Intercom AFT DC HQ1, AFT DC request permission to ..... the MCR (?) 21.02 Intercom NAV Okay. MCR , we've also had the H2S gas alarm go off. Would that be from the fire? 21.08 Intercom 1036 HQ1 AFT.... Section(?) SMET team muster MCR via aft (F+1) hydraulics On Bridge NAV Let's stand by to report...…Ex. (ie. XO) On Bridge OOW PO On Bridge NAV Okay...... as required sir? On Bridge XO Have we got someone else on channel 5 up here? CO? What about channel 2?
D-2 On Bridge NAV We're on channel 2 that's what we really need. I need a SITREP on this pretty quickly, stick it onto HQ1, 'cos we've got to decide whether to anchor, and whether we some help in... Radio HQ1 HQ1 21.55 Radio IC SSFB AFT DC. Radio HQ1 SITREP 21.59 Radio 1037 IC SSFB We've got a hell of a lot of smoke coming into the MCR, (F+2) ah..we're not allowed out of the MCR into... On Bridge NAV Okay, let's ease the wheel. Come back to about- 22.20 On Bridge OOW Ease to 10 On Bridge NAV -20 degrees. On Bridge OOW Ease to 20 On Bridge COXN Ease to 20 On Bridge COXN 20 STBD on ma'am 22.28 Alarm (BELLS) On Bridge ...alarm On Bridge/Intercom NAV Yeah disregard. MCR bridge Alarm (BELLS) On Bridge NAV Hell, Just isolate everything 22.49 Radio HQ1 HQ1 SITREP Radio IC SSFB H2S alarm ....evacuating 22.55 Alarm 1038 (BELLS, WHISTLE) On Bridge NAV I can't get any, any comms now sir. I think all we can do- On Bridge CO Give me....., where are we? On Bridge NAV -hard turn to STBD to get the way off sir, and standby to drop the anchor On Bridge CO Can we just get right off and see if... On Bridge NAV We can't just stop.sir On Bridge NAV No, but I recommend we come hard to STBD to get the way off, sir 23.23 On Bridge OOW STBD 30 On Bridge COXN STBD 30 On Bridge Hind Are you happy to...close that ... On Bridge OOW No On Bridge NAV .....Fleet Base WEST, saying that we're... 23.35 Intercom?/ (F+3.30) CO Roger. Evacuate. Report when everybody's evacuated, let's On Bridge get that signal ready to go, eh. On Bridge NAV Okay. 23.41 On Bridge POSY? Very thick black smoke from the stack Ma'am On Bridge OOW Roger On Bridge COX'N? Lost steering.... 23.45 Radio AFT(base?) SITREP, All ... evacuate the MCR and engine room. Hose team report to HQ1 On Bridge ...go to emergency (steering?)... 23.55 On Bridge OOW This won't shut off. They won't shut off. On Bridge ...want the flaps....? On Bridge We've lost everything now. 24.02 On Bridge 1039 OOW Yeah, okay. Lost power. Say again? On Bridge LS Orrell Flaps, do you want the flaps... On Bridge OOW Yes. Check with the Captain 24.10 On Bridge (F+4) Read No radar. On Bridge COXN Lost radar. It's lost everything ma'am On Bridge OOW Yep 24.16 On Bridge Conole Just lost the gyro. On Bridge OOW Yep On Bridge COXN Ma'am, I can't see it. I can't read it
D-3 CO? ...he's just shutting the flaps now... 24.35 Broadcast 1039.35 HQ1Gishubl HQ1 SITREP....all entrances to the engine room are through the fridge flat (?) Radio IC SSFB IC Team 1 On Bridge NAV Okay. Keep fixing On Bridge OOW Yes sir. 24.48 On Bridge NAV I need constant fixes on the chart On Bridge COXN Can you go and reach the top off the compass so I can see grid magnetic? On Bridge OOW Yep, at the moment.... we have ... (degrees of STBD wheel on ....?) COXN? Yeah, I cannot see it at all 25.06 radio 1040 XO HQ1 XO further discussion - blocked by noise 25.26 On Bridge XO XO. How are we going for emergency stations... further discussion - blocked by noise 25.34 On Bridge (F+5.30) LS Orrell Flaps Shut On Bridge CO Roger. Both sides? 25.39 On Bridge POSY? Flaps shut both sides sir. Sound reports are.... NAV Where's the fix? (HQ1 ..HG ...Standby 231..222..?) On Bridge The fixes aren't working the gyro's are down sir On Bridge CO? Okay, ....have we got two pairs from the other side? NAV ...Have you got this fix on the chart? 31 57.58? COXN Switch off the power from... 26.25 On Bridge NAV For the sake of? safe? navigation (room/request?)....recommend On Bridge ...... sir....warship.... On Bridge what's happening is I've.... On Bridge QM ..engineer, sir.. 26.35 radio (F+6.30) LS Nunn IC team 1? radio IC SSFB IC team 1. Where are ya? On Bridge NAV Start (writing all this shit?) down Joh. In fact list, list everything radio LS Nunn Where are you?...I want to see you. radio IC SSFB I was in the fridge flat, where I'm s'posed to be. On Bridge OOW? Still got... On Bridge NAV Every action okay?....including 2 minutes ago MHQ West. 26.47 radio IC SSFB ....where are the other (two? team?) On Bridge COXN? MHQ West advised by telephone... On Bridge indistinct radio Roger 27.20 1042.2 CO (into sound powered phone) Stand by Stand by. We still not have fully evacuated. On Bridge CO Keep this line open...Right we're missing...still got a...check...PO Smith On Bridge COXN? Who're we missing? 27.30 On Bridge CO PO Smith main broadcast? COXN POMT Smith On Bridge XO Smith is reported as a casualty 27.37 On Bridge (F+7.30) NAV Have they evacuated him? On Bridge XO I'm not sure On Bridge CO? Well that's... 27.41 On Bridge XO ...get back to me when you've got...PO Smith On Bridge POSY Roger On Bridge ...have you...indistinct
D-4 On Bridge POSY No ma'am, I've got them ready to go. 27.54 broadcast HQ1..02..indistinct On Bridge CO ...Smith...has been reported as a casualty On Bridge POSY I'll try again on...later. On Bridge CO We're getting....to look for him? On Bridge OOW (On our?) way out. On Bridge CO Roger 28.05 On Bridge OOW Can you read? On Bridge No, not yet 28.11 On Bridge 1043 CO We're okay. We're okay for that. What I need is just to get (F+8) the this casualty out and get the drench going On Bridge COXN? 054, ma'am 28.20 broadcast HQ1 ...aft...to the engine room...AFT DC hose team.. make an entry into the... On Bridge Conole ...one and a half cables off starboard track, sir... On Bridge CO ...so lets, lets just hold off... 28.37 On Bridge (F+8.30) NAV I agree sir, but as soon as we start moving back down towards these shoals... On Bridge XO Its the XO - where have the casualties been evacuated to? (constant noise - steering alarms) On Bridge OOW? ...the casualties are still...hurry up and fix again 29.00 On Bridge 1044 POSY? Starboard side close, sir On Bridge XO ...I'll get back to you 29.07 (F+9) ...the engineer has just (come/rung?) down... On Bridge ...space without... 29.16 On Bridge Petty Officer Hollis, Petty Officer, um... 29.24 On Bridge CO? ...(there's a sea lane?)... On Bridge QM telephone rings Quartermaster. indistinct On Bridge ...go through...SITREP On Bridge right..take a signal On Bridge ...bye, thanks very much...Still there? 29.48 On Bridge 1044.48 Humphrey ...4.5 cables...standby standby...that's, ah, about 3 cables to run Read Just…keep up GPS fixing alright?...trying to...range 30.02 broadcast 1045 HQ1 WO Bottomley…contact HQ1…222 (F+10) NAV Okay, we've got one guy at the moment...I don't care what its for...... understand? radio HQ1... 30.18 Read ....slowly drifting OOW? yep radio-ext HMAS WESTRALIA has been...(up channel?)... Read ...use Rottnest and use all these points here, okay? NAV What channel was that on they were calling us? broadcast Chief Ledlie contact HQ1 extension 222 30.35 radio-ext (F+10.30 Stirling Fremantle Port Authority this is...(STIRLING headquarters?) ) radio-ext (aircraft...?) Over radio-ext Roger we're the...today... we're heading out to the fishing harbour radio-ext FPA ...thank you 30.50 radio 1045.5 (very faint) Roger...keep cooling the bulkheads...(start?) using water... On Bridge (F+11) NAV (drafting signal)....a fire onboard. have an engine failure. We're about to go to anchor here and....
D-5 CO Yep. yeah. And can they stand by to provide assistance if required 31.08 1046 NAV Assistance is being provided..is being tee-ed up by the Port (F+11) manager now, sir. (on radio) Port of Femantle, Warship 'WESTRALIA', channel 12, over. On Bridge POMED Sir. The casualties. ... Smith, Hollis, Francis radio-ext Warship 'WESTRALIA', Port of Fremantle. CO What sort of... NAV (on radio) This is Warship "WESTRALIA". I'm in the vicinity of number 1 buoy at the moment. I've had a fire, major fire, in my engine room. I've lost both my engines. On Bridge POMED ...and smoke inhalation... On Bridge CO ...found... NAV I'm about to go to anchor is this position. 31.29 On Bridge POMED ...Leading Seaman... NAV STIRLING Port manager is organising assistance in the form of tugs at the moment , over. CO Thank you 31.34 radio-ext Roger 'WESTRALIA',....we read you on channel 12 and.... NAV (on radio) Say again? On Bridge COXN I haven't had a report, sir-that's from HQ1 On Bridge ...back again...oh, no its just gone again radio-ext FPA Number 1 deep water? Is that correct? Your position? 31.49 1046.49 NAV Yeah, between number 1 deep water and the fair water buoy at the moment. radio-ext Roger on that. thank you. 31.55 radio ...boundary cool, boundary cool...water... 32.00 1047 CO Okay. They're about to send a hose team in through the after (F+12) - through the fridge flat. PO Smith was last located between the main engines. Okay, The priority at the moment is simply to get them out. NAV (on phone) Say again? 32.25 NAV (on phone) No you're breaking up. Say again? Okay. 0412 254 325 is me. ...If you can't get through on that... 32.38 broadcast 1047.38 HQ1 hot spots: the fridge flat, the aft pump room and the engine room ...now...hose team set up…OCCABA dump...adjacent to…RASCO 32.51 radio-ext ...Port of Fremantle, Victoria Spirit channel 12. radio-ext Victoria S. Victoria Spirit..... 33.00 1048 NAV (on phone?) I suggest it'd be a good idea...I mean, we're (F+13) about to CO2 dump. At the moment I'm circling. I'm stopped....with no, with no power. Attempting to avoid going to anchor because otherwise I won't be able to cut my cable. It looks pretty bad. 33.15 sound powered phone QM Bridge NAV (on phone?) Yeah, just try and get them out here to try and find some... 33.25 On Bridge QM Roger. Sir, ...PO Herridge needs 3 litres of oil... On Bridge OOW? We've still got about 3 knots 33.30 broadcast (F+13.30 HQ1 Midshipman Pelly, Leading Seaman Meek, report to HQ1 ) Yep. 33.38 NAV (On phone) We're not in any navigational danger at the moment. The other thing we may need in a rush...if we get...medivac.
D-6 NAV (On phone) In fact, if possible, if you could get a RHIB moving up here because we can't lower our boats. Thanks, mate. Okay. Thanks mate. CO Who's coming in the RHIB? NAV Nobody at the moment, sir. 34.03 1049 CO I want a doctor NAV Okay (M) ...still emergency... Oh, emergency, is it? 34.10 Read ...two and half cables due south of the nearest (bank?) 34.19 NAV (on phone) Yeah, it's the navigator 'WESTRALIA' again. Can you pass to Ian, in addition to the last.... we request a Doctor 34.25 maxon ...hose team NAV ...yeah. Thankyou. NAV ...still turning away... 34.37 radio ...you in the engine room. Wait. ...engine room radio AFT DC Roger NAV? What was that? On Bridge QM ...from the smoke 34.51 On Bridge NAV Yeah, through the vents. Just pull the back door. 35.06 broadcast 1050 HQ1 Gishubl HQ1 SITREP…AFT DC...the engine room maxon …AFT section base…engine room On Bridge QM I can smell electrical burning, sir On Bridge NAV We've got a fire have we? On Bridge QM It's not burning yet, I'll just turn it off. On Bridge NAV yeah what is it? maxon aft section base 35.20 maxon 1050.2 You have a (green light)? to enter the engine room. maxon Say again… maxon You have a (green light)? on.... maxon Roger On Bridge Conole (faint bridge conversation) drifting…very slowly…roger 35.35 maxon …hose charged...charge hoses... (high pitch squeal - of radio?) 35.46 broadcast (name)…HQ1 On Bridge Read Drifting very slowly north-west, very slowly On Bridge North-east 35.50 On Bridge Read Sorry, north-east On Bridge ....turn On Bridge Read 2 point....2 point maxon AFT DC IC scene 36.08 1051 (sound powered phone) On Bridge COXN Do you want… NAV Not yet. POSY? It's on the way OOW Do you want me to take it away so you've got the light? There goes the up top trip 36.45 broadcast 1052 HQ1 HQ1 SITREP. Hose team from AFT DC has just made an entry through fridge flat 37.08 telephone NAV Let's force--...get somebody in OCCABA up there--it's full of smoke..yeah. Stand by. Have you got much smoke coming out of the funnel now? maxon …AFT hose team… CO Yes CO Still got black smoke coming NAV What's it like? It's calmed down a bit--
D-7 It's still black smoke-- 37.23 CO Still quite thick black smoke. ....standing closer. OOW Have we got any anti-flash up here? QM There's some behind there I think, ma'am. OOW Nat, is yours up here? 37.35 CO …tugs on the bottom…RHIB on the way...I've got helos standing by SPT COXN Bridge. COXN Say again CO …in the MCR…the MCRs evacuated… 37.55 SPT 1052.55 COXN All still. All fuel and oil tanks--say again? Quick closing valves appear to have operated successfully. Roger. 38.00 1053 Conole Navigator, sir
NAV Where was the last one? Conole …sir…with a …5 set… NAV Where are we? NAV We're there. Where was the last fix. 38.20 maxon HQ1 …refrigerant bottles…which have been removed. Also activate the sprays for the acetylene and oxy bottles on site... NAV Ritcho? Where's Ritcho gone? COXN …the MCR...and let them know that all fuel and the still oil tanks appear to have been--quick closing valve has appeared to have functioned correctly. That was from the fire control room. Read Fuel and? Fuel and... Shepard All hands at emergency stations sir 39.08 Read ....have you got someone doing your board? 39.15 1054.15 AOOW The Echo Foxtrots down as well, sir NAV The Echo Foxtrots down as well? AOOW Yes. 39.30 COXN Bridge COXN COXN Okay. Roger sir, hang on Yeah. Captain ....yeah, yes sir. CO Captain, after hydraulics..(is ...in the aft pump room?) and ...oxyacetylene 39.50 NAV I didn't want to do anything at the moment. I didn't want anything. I didn't say I needed anybody on OCCABA. Joh? OOW Yes sir? 40.00 1055 NAV Bring me out a sextant please? OOW Yes sir. NAV And a--and a douglas protractor or a station pointer. Okay. 40.10 Humphries GPS NAV That's still working is it? AOOW Yes, it's working NAV Every two minutes I want a fix maxon (indistinct) 40.28 NAV We're drifting still on the same course.... maxon Bromage AFT DC IC SCENE maxon (AFTDC?) maxon Bromage IC SCENE …call for help from …We are sending in Street and Darwish …. maxon OK Street and Dar? NAV Street and Darwish 40.45 maxon AFT DC I need a report from the hose team
D-8 40.52 maxon ....I need a runner sent up here in intermediate rig to find out what the hell's going on 41.05 1056 POSY .....got the COMCEN's mobile phone NAV okay NAV …no power? 41.15 POSY No power. 41.30 NAV ...standing by for when we lose GPS... Orrell ....HQ1 sir QM …torch and some… COXN Where are you going? QM Just down to my cabin…down… 41.45 COXN ....sir. Have they shut all the roller doors sir? NAV I don't COXN Just--I don't want you going anywhere. You've got everything you need here. NAV Who else, who else we got up here? We got Roberts- 42.00 maxon 1057 After Section base.... HMAS STIRLING…ADELAIDE is on the scene… We've got emergency power back on.... maxon AFT DC On Bridge ...emergency power back.. 42.35 maxon 1057.35 Sellick We have thick, black smoke on the port side 04 Deck near the, ah, magazine and pyrotechnics locker maxon AFT DC Roger NAV Turn it off, Rob 43.03 1058 COXN There's a fault in this NAV Just leave it turned off (coughing) 43.33 maxon 1058.33 AFT DC Runner in intermediate rig immediately, preferably one that is not wet. Four personnel remain in the engine room 44.00 (telephone rings) 44.07 broadcast 1059 HQ1 HQ1 SITREP. The intention is to dump a CO2 (F+24) drench…(AFT DC/IC scene?) is checking the engine room to ensure all personnel are out of the engine room. NAV ...you stay here, Bob…yeah…you go with Heps… 44.43 He's got one there…RASCO…report to the IC 44.55 1100 POSY …stop…request all…close to render assistance…(BT? people?) …signal this… COXN I don't want to know the (VTG/DTG?)… COXN Its been sent through STIRLING? 45.28 POSY Its been sent through NAVCALS STIRLING, PO…..(martin?) 45.42 NAV Okay we'll…not past the fairway buoy yet...how many tugs have you got on the way? Okay. Look, we're not going to get back underway. We're...There's no chance of getting underway… POSY (Snappy?) take over from Robbo (F) Who are you talking to, (F'c'sle?)? I'm just listening.... Quick as you can…Captain… 46.10 broadcast HQ1 …are now going to CO2 drench the engine room…remain (on OCCABA?)… NAV? Say again over 46.20 broadcast 1101 HQ1 ...Drench, drench, drench. CO2 Drench. Drench, drench (F+26) drench. END TAPE (1102)
D-9 D-10 ANNEX E TO BOI REPORT: HMAS WESTRALIA FIRE ON 05 MAY 98
TIMELINE OF THE INCIDENT
Time1 Event Source2
10:31 EOOW reports to bridge - fuel leak PME; requests E91 Bridge Tape emergency declutch 10:32 PIPE - SSFB to MCR for fuel leak PME E91 Bridge Tape
Fire
10:35 EOOW reports to bridge - "Fire in MCR" E91 Bridge Tape 10:35 EOOW reports to bridge - "Fire in Engine Room" E91 Bridge Tape 10:36 PIPE - Hands to Emergency Stations E91 Bridge Tape 10:36 PIPE - SMET muster MCR via Aft Hydraulics E91 Bridge Tape 10:36 Loss of gyros and radars E91 Bridge Tape 10:38 Evacuation of MCR E18 HQ1 Narrative
10:39 MEO recommends CO2 Drench to CO E129 HQ1 Board 10:41 PO SMITH reported as casualty (not confirmed) E16A OOW N/Book 10:46 WESTRALIA makes contact with FPA on VHF E91 Bridge Tape 10:48 Valve 5 open (firemain de-isolated) E129 HQ1 Board 10:49 PO SMITH unaccounted for, Hose Team for re-entry to E16A OOW N/Book search
1 Evidence on times in many cases is conflicting. The times noted are those the Board considers to be the most reliable. 2 Source refers to source of time only, other sources have been used to clarify details of event.
E-1 Hose Team 1
10:50 Hose Team 1 entered MMS E41 Aft DC Board 10:54 Ship reported closed up at Emergency Stations E91 Bridge Tape
11:01 PIPE - CO2 drench E91 Bridge Tape 11:02 Hose Team 1 exits MMS E41 Aft DC Board
11:08 CO2 Drench activated manually E129 HQ1 Board 11:09 Hot spots port 1 Deck aft E41 Aft DC Board 11:14 Aft Pump Room hot spot middle plates (foam) E41 Aft DC Board 11:15 Smoke located Gyro Room E129 HQ1 Board 11:17 Aft Pump Room paint blistering E41 Aft DC Board
11:20 100 ppm CO2 [CO] on Bridge (GX82) (5 min on Bridge) E18 HQ1 Narrative 11:24 Report of 3 casualties being treated and 3 casualties E16A OOW N/Book missing
Hose Team 2
11:26 Hose Team 2 enters MMS via Fridge Flat (Aft DC) E129 HQ1 Board 11:35 Middle/bottom level cooling Aft Pump Room E41 Aft DC Board 11:43 RHIB STIRLING alongside (LEUT Stone and CPOMED E17A OOW N/Book Bonner) 11:43 Sea King over deck for personnel transfer (LEUT E17A OOW N/Book Eggerling) 11:47 Hose Team 2 exits MMS E41 Aft DC Board
Hose Team 3
11:51 Hose Team 3 enters MMS E41 Aft DC Board 11:53 Lombardini flashed up, foam through funnel E129 HQ1 Board 12:05 Hose Team 3 going to middle plates E129 HQ1 Board 12:05 LS Meek found on top plates E129 HQ1 Board
E-2 Hose Team 1
12:10 Hose Team 1 enters MMS E41 Aft DC Board 12:15 Hose Team 3 exits MMS E18 HQ1 Narrative 12:15 Helo over deck E17A OOW N/Book 12:18 SYDNEY, DARWIN, ADELAIDE visual starboard side E17A OOW N/Book 12:20 Tug TAMMAR connected to fo'csle E17A OOW N/Book 12:26 Helo over Deck E17A OOW N/Book 12:28 Seahawk over Deck E17A OOW N/Book 12:29 Casualty reported middle plates E14 Aft DC Board 12:30 Nil hotspots Aft Pump Room E129 HQ1 Board 12:32 Fire Reported Out E41 Aft DC Board 12:34 Hose Team 1 exits MMS E129 HQ1 Board
Hose Team 2
12:30 Hose Team 2 enters MMS E236 Fwd DC Board 12:34 Hose Team 1 exits MMS E129 HQ1 Board 12:40 DARWIN RHIB alongside E17A OOW N/Book 12:50 Tow Line parted E17A OOW N/Book 12:50 Medical Team enter MMS to identify casualties E41 Aft DC Board 12:51 Sea King (STIRLING) overdeck 4-5 passengers (STG) E17A OOW N/Book 12:52 SYDNEY RHIB alongside E17A OOW N/Book
Hose Team 3
12:56 Hose Team 3 enters MMS E41 Aft DC Board 12:58 Hose Team 2 exits MMS E18 HQ1 Narrative 13:13 Seahawk (sic) over deck E17A OOW N/Book 13:14 Tug connected forward (WAMBIRI) E17A OOW N/Book
13:14 MMS smoke reported as 30% E129 HQ1 Board 13:15 DARWIN RHIB alongside E17A OOW N/Book
E-3 Hose Team 1
13:18 Hose Team 3 exits MMS, Hose Team 1 enters MMS E236 Fwd DC Board 13:20 Sharkcat alongside - transfer 45 engineering personnel E17A OOW N/Book 13:23 Submarine (COLLINS) in company E17A OOW N/Book 13:25 Medical Team exits MMS E41 Aft DC Board 13:25 Overhauling complete E41 Aft DC Board 13:30 Cease boundary cooling E18 HQ1 Narrative 13:30 10% smoke reported MMS E41 Aft DC Board 13:32 DARWIN boat alongside E17A OOW N/Book 13:35 Ramfan set up starboard side (1051 Aft DC) E18 HQ1 Narrative 13:36 Hose Team 1 exits MMS E41 Aft DC Board 13:43 5% smoke reported MMS E41 Aft DC Board 13:44 Helo over deck E17A OOW N/Book 13:55 0-5% smoke reported MMS E41 Aft DC Board 13:59 2% smoke reported MMS E18 HQ1 Narrative 14:10 Helo over Deck E17A OOW N/Book 14:16 Medical Team enters MMS to cover casualties E18 HQ Narrative 14:36 LEUT EWINGTON took the ship E17A OOW N/Book 14:49 Ruptured firemain starboard side MMS E18 HQ1 Narrative 14:53 Ruptured firemain in MMS isolated E18 HQ1 Narrative 14:55 Power to internal phones lost E18 HQ1 Narrative 14:56 STIRLING boat alongside - Port Manager embarked E17B OOW N/Book 15:01 Drafts 9.2 Aft, 8.8 Mid, 8.0 Fwd E17B OOW N/Book 15:04 LCDR JEMPSON, PWO N (Naval pilot) took ship E17B OOW N/Book 15:15 Medical Team enters MMS for casualty extraction. One E18 HQ1 Narrative casualty (MIDN Pelly) moved from middle plates to top plates 15:51 Medical Team enters MMS for casualty extraction. Two E18 HQ1 Narrative casualties (MIDN Pelly, LS Meek) moved to fridge flat 16:17 Medical Team exits MMS E18 HQ1 Narrative
E-4 16:42 Casualty extraction suspended awaiting MEO to confirm E18 HQ1 Narrative MMS O2 safe 16:50 Emergency DA refuel to full E18 HQ1 Narrative 17:02 Emergency forward fire pump being refuelled E18 HQ1 Narrative
17:07 MMS O2 safe. MEO approval to recommence casualty E18 HQ1 Narrative extraction 17:07 Medical Team enters MMS without OCCABA for E18 HQ1 Narrative casualty extraction 17:21 Third casualty (PO Smith) moved from MMS to fridge E18 HQ1 Narrative flat 17:34 Last casualty (AB Carroll) moved from MMS to fridge E18 HQ1 Narrative flat 17:38 Medical Team exits MMS E18 HQ1 Narrative 17:47 Cast off WAMBIRI E17B OOW N/Book 17:50 Phones back on E18 HQ1 Narrative 17:52 Connected up WAMBIRI port forward E17B OOW N/Book 17:54 Tug connected E17B OOW N/Book 18:11 First line passed (Parkes 2/3 STBD side 2) E17B OOW N/Book 18:20 Personnel fallen out E17B OOW N/Book 18:24 FWD and AFT DC bases secured E18 HQ1 Narrative
E-5 ANNEX F TO BOI REPORT: HMAS WESTRALIA FIRE ON 05 MAY 98 FIREFIGHTING EQUIPMENT AND TECHNIQUES
This section contains short descriptions and diagrams of
1. The Zones 2. Firefighting Protective Clothing 3. Hose Team Roles 4. Fire Hose Nozzles used during the 05 May Fire 5. Thermal Imaging Camera (TIC) 6. Emergency Life Support Respiratory Device (ELSRD) 7. Open Circuit Compressed Air Breathing Apparatus (OCCABA) 8. Bauer Compressor
The text, hand drawn diagrams and photographs in this Annex have been provided by POMT Corcoran, RANSSSS, Training Faculty-East.
The Zones The Area surrounding the fire is categorised into three zones to assist with the management of personnel and firefighting efforts. The zones extend from the fire in all directions, including on the decks (floors) above and below the fire.
. FIRE ZONE – is the area containing the fire . SMOKE ZONE – is the area surrounding the fire which is filled with smoke PERSONNEL ZONE – this zone surrounds the smoke and fire zones, there is no smoke in this area
F-1 Basic Rig
Firefighting Protective Clothing
Firefighting protective clothing is worn to protect the body, head, hands and feet from radiated heat and flames for a limited time. There are three degrees of protection referred to in this report. Diagrams of each rig are shown.
Level of Zone Protective Clothing Worn Protection Basic Rig Personnel Combat Coveralls (overalls) Anti-flash Hood and Gloves (flame proof) Woollen Socks Boots Intermediate Smoke Basic Rig Rig Breathing Apparatus Full Fire Intermediate Rig Firefighting Fearnought Suit (flame resistent, Rig chemically treated woollen suit) Intermediate Rig Full Firefighting Rig
/ Hose Team Roles
#1 Waterwall
This person uses his hose to provide a wall of water which shields the team from the intense heat which radiates from the fire. This waterwall, or water shield forms a disc like shape in front of the hose team. This waterwall is always in the shielding position.
#2 Attack Hose
This person uses a different type of nozzle to fight the fire. It provides a jet of water and aerates a foam mixture which, when pointed at the deckhead (roof) creates a blanket of foam, falling like snow onto the seat of the fire. The # 2 member fights the fire under the direction of the team leader (#3)
#3 I/C (Team Leader)
This person is in charge of the hose team. They have communications with their scene leader, and fills the role of the team’s eyes and ears. The main piece of equipment that the team leader carries is a thermal imaging camera (TIC). As the only member of the team with a TIC, the leader is the only person able to see through the thick black smoke. The leader relies on touch and nudges to guide their team around the fire zone, using his TIC to show him where the fire is.
#4 Hydrant Operator
The hydrant operator controls the flow of water and foam through the hoses as directed by the I/C. They also assist with handling hoses.
#5 Waterwall/Handler
When entering a compartment through a door, the #5 is a hose handler. If entering through a hatch, the #5 sets up a second waterwall to prevent the escape of smoke and heat from the compartment, and provide additional protection for members entering the compartment.
BA Controller
Each hose team has a controller who records how much air pressure they have on entering the compartment, and calculates how long their air supply will last. The BA controller does not enter the fire zone.
A diagram of how the waterwall, attack hose and team leader work together is on the next page.
F-4 f’
F-5 Fire Hose Nozzles used during the 05 May Fire
Waterwall Nozzle: Elkhart Nozzle
Attack Nozzle: FB5X Foam Branch Pipe
F-6 /---+’7
c f b i ; ;
. Emergency Life Support Respiratory Device (ELSRD)
The ELSRD is designed to be used for escape from toxic or oxygen deficient atmospheres. It provides a limited supply of breathable air (approximately 8 minutes). Once activated and the hood is donned, it is imperative that the user leaves the danger area immediately and proceeds to an area where fresh air can be breathed.
This diagram shows the ELSRD being worn prior to activation of the device.
This diagram shows how the ELSRD is worn once it has been activated.
F-8 Open Circuit Compressed Air Breathing Apparatus (OCCABA)
The RAN OCCABA is a positive pressure, self contained breathing apparatus which operates independently of the ambient temperature. Breathable air is supplied to the user through a full face piece. The rate of supply can be adjusted. The OCCABA has an automatic function which enables the user to switch to ‘positive pressure’ (up to 3.9 millibar) inside the mask, through all phases of respiration. This pressure prevents the ingress of contaminants, protecting the wearer fi-om toxic gases and smoke.
RAti 5sss 1 O c=cAEa4 “ ~MT’ (iWcnr?AAJ. ‘-%==: -.
——— ._ -’ ~ ‘---~- .__ . . . . ‘--’”””---.– -.--L
F-9 The OCCABA has an emergency supply of air, in case the wearer has not reached the personnel zone when their main supply is finished. By pulling the ‘D-Ring’, an additional 8 minutes of air is provided (approximately). Once the D- Ring has been activated, the wearer must immediately evacuate to the personnel zone.
F-10 Bauer Compressor
The Bauer Compressor a portable air compressor used to refill the 0CCABA cylinders so that teams may re-enter the smoke and fire zones.
F-11 ANNEX G TO BOI REPORT: HMAS WESTRALIA FIRE ON 05 MAY 98
BIOGRAPHIES OF BOARD MEMBERS
COMMODORE RICHARD LAMACRAFT RAN
Commodore Richard Lamacraft joined the Royal Australian Naval College in 1964. After graduation from the Royal Australian Naval College and twelve months sea training he attended the Royal Engineering College in Plymouth UK from 1968 to 1972. He graduated as a Bachelor of Science (Engineering) with Honours and completed a Marine Engineering Applications Course.
On return to Australia he joined HMAS MELBOURNE as a watchkeeping Engineer Officer. This posting was followed by the fifteen month Advanced Marine Engineering course again in the UK. Three years service in Navy Office Canberra followed, initially with Marine Engineering Design and then Naval Industrial Policy.
In 1978 he was the Marine Engineering Officer of HMAS PARRAMATTA during her modernisation at Williamstown Naval Dockyard. Two sea posting followed, firstly to HMAS DERWENT as Marine Engineer Officer and secondly to HMAS MELBOURNE as Senior Engineer.
On completion of the Naval Staff Course in June 1982 he was promoted to Commander and became the Destroyer Escort Modernisation Project Director. In 1985 he commenced two years exchange service with the Royal Navy as the Naval Engineer Overseer at Newcastle on Tyne UK. He returned to Canberra in January 1987 to become Marketing Officer for the Inshore Minehunter Project.
In November 1987 he joined the Fleet Maintenance Branch as Deputy Director Fleet Engineering Policy (Ships Systems). He was selected for promotion to Captain in December 1987 and became a member of the Naval Logistics Implementation Team in February 1988. Following completion of the team’s activities he was posted briefly as the Director of Fleet Engineering Policy.
His next posting in March 1989 was to the new position of Director Naval Logistic Policy. He served on the staff of the Assistant Chief of Naval Staff - Materiel as Chief Staff Officer from January 1991 until his posting as Australian Frigate Project Director in August 1991. Highlights of this period included the sea trials, delivery and acceptance into service of the new HMAS MELBOURNE and the launch of NEWCASTLE. He was
G-1 promoted to the rank of Commodore in November 1992 when he became the ANZAC Ship Project Director. During the period from 1992-1997 four ships were launched and two delivered. The Project Office was the first within Defence to be accredited to a recognised Quality Standard (AS 3902).
In January 1998 he was posted to the Defence Intelligence Organisation as the Director General Intelligence Operations. In March 1998 he assumed his present appointment as the first Director of the new Australian Imagery Organisation.
Commodore Lamacraft is a member of the Institution of Engineers (Australia).
G-2 CAPTAIN RUSSELL BRYAN SCHEDLICH RAN
Captain Schedlich joined the Navy in 1977 whilst studying medicine at the University of New South Wales. Graduating MB BS in 1979, he undertook his internship at Gosford District Hospital in that year.
His first posting as a medical officer was to the Naval Air Station, HMAS ALBATROSS in 1980. The following year, he served at sea, initially in the aircraft carrier HMAS MELBOURNE, and then the destroyer escort HMAS SWAN. In 1982 he was posted to HMAS CERBERUS serving there for two years.
At the beginning of 1984 he was promoted to Lieutenant Commander and posted to HMAS LEEUWIN as Senior Medical Officer. Following LEEUWIN’s closure at the end of 1984, he was posted as Senior Medical Officer HMAS STIRLING and Command Medical Officer Western Australia. During his service in the West, he was responsible for the medical management of all diving accident victims in WA, and in 1986 was awarded an Assistant Chief of Naval Staff - Personnel Commendation for this work.
In 1986, he was posted on exchange service to the Royal Navy’s Institute of Naval Medicine, serving in the Undersea Medicine Division in a research and policy-formulating role. On return to Australia in the middle of 1988, he served at the School of Underwater Medicine at HMAS PENGUIN, being appointed Officer-in-Charge in October 1988. He was awarded a Diploma of Diving and Hyperbaric Medicine in that year.
In January 1989, he was appointed Fleet Medical Officer, and promoted to Commander, managing the transfer of that position from its former afloat role to that of a full time staff officer at Maritime Headquarters. He initiated the deployment of surgical support teams into ships of the Afloat Support Force for Exercise Kangaroo 89, and contributed to the deployment of health support in ships proceeding to the Gulf War in 1990.
In 1991 he spent 12 months studying for a Master of Public Health at the University of Sydney, being awarded the degree in 1996 on submission of the necessary treatise.
In 1992 he was appointed Medical Officer-in-Charge of Balmoral Naval Hospital. He supervised the accreditation of the hospital by the Australian Council on HealthCare Standards. Balmoral Naval Hospital was the first ADF facility to gain such accreditation, which is recognition that the quality of its care is the equal of major civilian hospitals.
In May 1993, Captain Schedlich was seconded to Maritime Headquarters to develop a concept for providing surgical and intensive medical care at sea. This project has resulted in the inclusion of a 40-bed Primary Casualty Reception Facility in each of the RAN’s Amphibious Transports, HMA Ships MANOORA and KANIMBLA.
In October 1996, he was appointed, for the second time, to the position of Fleet Medical Officer, being promoted to Captain the following year.
G-3 Captain Schedlich is also Vice President of the Australian Military Medicine Association, the peak professional and scientific body in Australia devoted to the study of military health issues, and editor of its journal.
G-4 COMMANDER E.G.WALSH CSC RANR
Commander Ted Walsh was born in London. He joined the Royal Navy in 1956 as a boy seaman, after spending two years nautical training in the old four masted barque ARETHUSA. He became a Radar Plot Sailor and saw service in HM Ships ROEBUCK, EAGLE, VICTORIOUS, YARMOUTH and BELFAST.
He was commissioned in 1968 and qualified as a Bosun (Plot Radar). He was appointed to HM Ships JAGUAR, LEANDER and LONDON before transferring to the General List of the Royal Navy and qualifying as a Principal Warfare Office in 1974. As a Warfare Officer and later as an Executive Officer he served in HM Ships GLAMORGAN, ANDROMEDA, SIRIUS and DIOMEDE.
Commander Walsh joined the Staff of Flag Officer Sea Training in 1983 as the Staff Seamanship Officer and was responsible for developing and introducing the Defence Watch RAS Team concept. In 1985 he took up an exchange posting in Australia as OIC NBCD School HMAS PENGUIN and then later transferred to the Royal Australian Navy in 1988.
On transferring to the RAN he served on the staff of Director Naval User Requirements as Staff Officer NBCD. He joined Maritime Headquarters in late 1989 as the Fleet NBCD Officer. During his time as FNBCDO he was awarded the Conspicuous Service Cross and was fortunate to become a ‘Peter Mitchell’ prize winner. He remained in Maritime Command until late 1992 when he was posted as the RAN Liaison Office Singapore.
In April 1995 Commander Walsh was posted to Navy Headquarters as the Director of Safety Management-Navy and is currently serving in that position.
Ted is married to Margaret and they have two sons (Simon and Andrew). He enjoys swimming and golf and is a member of the Nautical Institute.
G-5 CAPTAIN C.W. FILOR PSM FNI
Christopher (Kit) Filor is the Inspector Marine Accidents, the Marine Incident Investigation Unit of the Commonwealth Department of Workplace Relations and Small Business.
His first experience as a Mariner was when he became indentured to the BP Tanker Company Limited (UK) in 1960. He gained experience in a variety of tankers trading world wide. He left BP as a Chief Mate in 1970. In 1974 he joined the Cross-Channel ferry service Sealink which travelled between Weymouth/Portsmouth to Cherbourg and the Channel Islands of Jersey and Guernsey. He was appointed to command in 1977 and in 1978 was appointed as a Master of Roll On - Roll Off ferries, a position he filled in three ferries until 1982 when he and his family migrated to Australia.
In November 1982 he took up the position of Marine Surveyor in Devonport, with the then Commonwealth Department of Transport and Construction. In 1984 he was promoted to the position of Executive Officer of the Ship Operations Section in Canberra and later became Director of the Section in 1986. This section was involved with, amongst other things, Marine accident investigations.
On 1 January 1991, he was appointed Inspector of Marine Accidents, when the Marine Incident Investigation Unit was formed as an independent investigation body. This organisation is separate from the regulatory body AMSA.
In all, he has more than ten years experience in Marine Accident investigation. He has been responsible for nearly one hundred published investigations, which have covered such casualties as TNT Alltrans, Sanko Harvest, Kirki and Iron Baron.
In 1993 he was elected a Fellow of the Nautical Institute. He is also a member of the Company of Master Mariners (Australia). In the 1996 Queen’s Birthday Honours Kit was awarded the Public Service Medal for services to Maritime Safety.
G-6 ASSISTANT CHIEF OFFICER L. CUNEO
Assistant Chief Officer Lindsay Cuneo began his firefighting career as a volunteer with the Guildford Volunteer Fire Brigade in Perth in 1972. Following recruit training in 1976, he joined the Western Australian Fire Brigades Board as a permanent firefighter. Over the next ten years he served as a firefighter with the Perth Fire Station and at other location around Western Australia.
In 1986 he was appointed a Station Officer at Perth Fire Station and for two years worked at various stations and platoons throughout the Perth metropolitan area. He was Officer in Charge at the scene of a wide variety of fire and rescue incidents. During this period he laso qualified as a Breathing Apparatus Instructor.
He took up a temporary appointment in 1987-88 as Water Supplies Officer and undertook an analysis of water supply systems, recommending a number of changes that were subsequently implemented by the Fire Brigades Board.
His next appointment was as training officer with the Country Fire Department in June 1988, with a specific brief to improve Western Australia’s training program for volunteer firefighters. He wrote a training manual and developed and delivered officer and skills development programs in both metropolitan and country locations.
When the WA Fire Brigades Board underwent a regional restructure in 1990, he was promoted and appointed to one of the inaugural Regional District Officer positions, responsible for the North East District of the Perth metropolitan area.
Between 1990 and 1993 he was District Officer attached to the Fire Brigade’s Training Academy. He recruited the personnel and established the Training Framework to implement a new modular training program for firefighters. As part of the State Government’s training reform agenda, he and his team wrote the subject modules, designed the curriculum and trained the personnel. Throughout this period he also assisted as a Breathing Apparatus and Rescue Officer.
In 1993 he was appointed District Officer at Perth Fire Station, accountable for the operations of Perth District and the fire service’s Operations Centre. As Superintendent Fire Safety in 1994-95 he was responsible for the organisation’s fire prevention activities.
He took up temporary appointments as Assistant Chief Officer Support Services over several periods in 1994 and was responsible for various functions, including chairing a Ministerial Committee which examined issues regarding the installation of smoke alarms in dwellings in Western Australia. In 1995 he was appointed Superintendent of the WAFBB Training Academy with the dual role of overseeing the development of a new training academy and implementing new training programs.
G-7 He was promoted to the rank of Assistant Chief Officer in 1996. He has held the post of Director Perth Metro South Region, since 1996. His directorate is responsible for fire protection and service delivery by both career firefighters and volunteers.
G-8 ANNEX H TO BOI REPORT: HMAS WESTRALIA FIRE ON 05 MAY 98
GLOSSARY OF TERMS AND ACRONYMS
AB Able Seaman
ADF Australian Defence Force
ADI Australian Defence Industries Ltd
AFFF Aqueous film forming foam
AFTP Australian Fleet Tactical Publication
Aft Pump Room The large compartment immediately forward of the main machinery space which contains pumps for the transfer of cargo (fuel) in and out of the ship
AMP Assisted maintenance period
ASACLO Afloat support and amphibious class logistics office
AVCAT A type of aviation fuel
B (after rank) Boatswain – responsible for ship’s husbandry and seamanship evolutions
Banjo Bolt A bolt for connecting a pipe to a manifold bar Unit of measure for pressure
Basic Rig Firefighting protective clothing consisting of coveralls, boots, woollen socks, and anti-flash gloves and hood. The minimum allowable dress for firefighting.
Blind Pilotage Safety The officer who assists in the safe navigation of the ship, particularly Officer (BPSO) in poor visibility, and provides a check on visual pilotage
BM (after rank) Sailor from the Boatswain’s Mate category - attends to ship’s husbandry and seamanship evolutions
BOI Board of Inquiry
H-1 Bottom Plates The lowest level or floor of the main machinery space
Bulkhead The side or wall of a compartment
CAPT Captain (Rank)
CDRE Commodore
CHAP Chaplain
CISM Critical incident stress management
CK (after rank) Sailor from the Cook category
CMDR Commander
CN Chief of the Navy
CO Commanding Officer
COMCARE The organisation which regulates and oversees the implementation of the Commonwealth Occupational Health and Safety Act 1991
COMFLOT Commodore Flotillas
CPO Chief Petty Officer
CSC Conspicuous Service Cross
CSM Conspicuous Service Medal
DA Diesel Alternator
DC Damage Control
DCN Deputy Chief of the Navy
DCO Defence Community Organisation
DC section base A coordination position which provides resources for dealing with an emergency, as well as directing actions to overcome the emergency
Deckhead The top or ceiling of a compartment
DGPI Director General - Public Information
DI(G) Defence Instruction (General)
DI(N) Defence Instruction (Navy)
DLM Depot level maintenance
H-2 DMEO Deputy Marine Engineering Officer
DPFS Directorate of Personal and Family Services
DSTO Defence Science and Technology Organisation
Emergency Declutch To disconnect the engine drive from the ship’s propeller shaft
Emergency Diesel Driven A pump powered independently of ship’s electrical power to provide Fire Pump water for fire-fighting
Emergency Life Support A small breathing apparatus distributed throughout the ship to aid Respiratory Device escape from smoke filled compartments. It contains approximately 8 (ELSRD) minutes of breathable air
Emergency Stations The process of providing the best organisation under the prevailing conditions to deal with an emergency
EOOW Engineering Officer of the Watch
ET (after rank) Electronic Technician
ETA Estimated time of arrival
ETD Estimated time of departure
ETW (after rank) Electrical Technical (Weapons) Category
Evaporator A machine for converting salt water into fresh water by means of evaporation
FAP First Aid Post
FBW Fleet Base West (located at Garden Island, Western Australia)
FBWHC Fleet Base West Health Centre
(FF) (after rank and Fire fighter primary category)
FIMA Fleet Intermediate Maintenance Authority
Fire Control Room A compartment, remote from the main machinery space that houses (FCR) the controls for activating the ship’s CO2 drench system as well as controls for shutting down fuel supplies to the ship’s main engines and generators
Fire Main The pipe system which distributes water throughout the ship for purposes of firefighting
H-3 FPA Fremantle Port Authority
Fridge Flat The lobby just aft of the upper level of the Main Machinery Space which houses the ship’s main refrigerators and cool rooms
FTO Fremantle Tug Operators
GPS Global Positioning System
HF High Frequency
Hose Team A team of four or five persons who work together to attack and extinguish a large fire
HQ1 A small compartment originally designed as a technical office. It has been adapted as a control centre for shipboard emergencies.
HSF Helicopter Support Facility (at Fleet Base West)
Homeport A ship’s home base
I/C In Charge
IMAV Intermediate maintenance availability
Intermediate Rig Consists of basic rig with the addition of breathing apparatus
International Shore A device which allows the ship’s firemain to be connected to a Connection variety of water connections
ITT Valve Fuel back pressure valves
Junior Sailor A sailor of a Leading Seaman rank and below
KPa Kilopascals
LCDR Lieutenant-Commander
LEUT Lieutenant
Logging The act of writing down and recording data
Lombardini A small portable diesel pump used for pumping out compartments and firefighting
LS Leading Seaman
Machinery Broadcast A public announcement system used between the bridge and the machinery control room
H-4 Main Broadcast A public announcement system used throughout the ship
Main machinery space A large compartment in the aft end of HMAS WESTRALIA which (MMS) houses the ship’s main engines and other machinery
Main switchboard room The compartment within HMAS WESTRALIA which controls the distribution of electrical power throughout the ship
Maximo Software for HMAS WESTRALIA Work Orders
Maxon Radio A hand held UHF radio which is used for communications within the ship
MCR Machinery control room
ME Main engines
MED (after rank) Medical sailor
MEDEVAC An abbreviation of the term Medical Evacuation. Used to describe the process of moving casualties from ships or remote areas to hospital or other substantial medical facilities
MEO Marine Engineering Officer
MHQ West Maritime Headquarters Australia - West
Middle Plates The middle level or floor of the main machinery space
MIDN Midshipman
MISD Manager, In-Service Design
MO Medical Officer
MOU Memorandum of Understanding
MPERV Fremantle Port Authority’s emergency response vessel
MT Marine Technician
NAVCALS Naval Communications Area Local Station
NAVSAFE Royal Australian Navy Safety Program
NBCD Nuclear, Biological and Chemical Defence
NBCDI NBCD Instructor
NBCDO NBCD Officer
H-5 nm Nautical mile
NO Navigating Officer
NOK Next of kin
Not Under Command A ship which is unable to manoeuvre as required by the International regulations for the prevention of collision at sea
NPC (after rank) Naval Police Coxswain
OAWA Ordering Authority Western Australia
OCCABA Open Circuit Compressed Air Breathing Apparatus
OCCABA Control Board A board which is used to record all details of persons wearing/using OCCABA
OHS Occupational Health and Safety
OIC Officer in Charge
OOW Officer of the Watch
OSC On Scene Commander
OTC Officer in Tactical Command
P250 Pump A portable diesel driven pump used for fire main boosting
Pan Call A call used to indicate a very urgent message concerning the safety of a ship and/or personnel. It has priority over all communications except distress traffic.
Pipe Traditional term used to describe the passing of an order over the ship’s public broadcast system
PME Port main engine
PNR Principal Naval Representative (RAN point of contact for contractors)
PO Petty Officer
Pre departure brief A safety brief held between key personnel which covers all aspects of a ship sailing from harbour psi Pounds per square inch
PSM Public Service Medal, Port Services Manager, Peer Support Member
H-6 PSO Personal Services Organisation
QM Quartermaster
RAN Royal Australian Navy
RANR Royal Australian Naval Reserve
RAS Replenishment at Sea
RASCO Replenishment at Sea control position
Re-Flash Sentries Personnel stationed within a fire zone after the fire has been extinguished to prevent any re-ignition of the fire
RFA Royal Fleet Auxiliary
RHIB Rigid hull inflatable boat
RO (after rank) Radio Operator
Rocker Cover Cover over valve operating gear on main engine
RPLSS Refit planning and logistic support services
RS (after rank) Radio Supervisor
SBLT Sub-Lieutenant
Scene Leader The person controlling the scene of a DC incident. He/She provides the communication link between the DC section base and the personnel at the scene dealing with the emergency
(SE) (after rank and Safety Equipment Maintainer primary category)
Sea Check An examination conducted by a Senior Officer’s staff to discover if a ship or a department within a ship meets the required standards
Senior Sailor A Petty Officer or Chief Petty Officer
SG2 Application for Production Permit or Concession
SIG (after rank) Signalman
SJOGHM St John of God Hospital, Murdoch, Western Australia
SME Starboard main engine
SMET Ship’s medical emergency team
H-7 SMN Seaman
Sound Powered Telephone A communications system which operates independently of an external power source
SOP Standard operating procedure
SSD Special Sea Dutymen – Duty positions when coming alongside, sailing, or in confined waters
SSOs Ship’s Standing Orders
Standing Sea Fire Brigade A small team of personnel who will immediately respond to a fire or (SSFB) flood emergency
STD (after rank) Steward
SY (after rank) Signals Yeoman. The senior visual communications sailor onboard
TACCO Tactical Coordinator
Telecon A telephone conversation
Thermal Imaging Camera A device for detecting radiated heat (TIC)
Tiller Flat The compartment within a ship which contains the steering gear. In an emergency the ship can be steered from this position
TM187 Configuration Change Proposal
TM200 Maintenance Control Record
Top Plates The upper floor or level of the main machinery space
TT117 Material or equipment trial proposal
URDEF Urgent Defect
VERTREP An abbreviation of the term Vertical Replenishment. It is normally used to describe the action of a helicopter winching personnel and equipment up or down to a ship.
VHF Very high frequency
Rounds A routine inspection of the ship or machinery conducted by ship’s staff
WAXA West Australian Exercise Area
H-8 WMO WESTRALIA Management Office
WO Warrant Officer
WTR (after rank) Writer
XO Executive Officer
H-9