Best Practices for Successful Casualty Investigations

A void within a stow of containers in a hold as the result of structural failure of a unit lower in the stack.

By David Myers

The final success of any fire or explosion
investigation is dependent on the management of the incident.

Fire and explosion incidents on board vessels have always
presented challenging situations for the marine industry.
However, with the industry as whole facing ever-increasing
financial pressures, many of those who suffer from a fire or
explosion are seeking out cost saving measures during
investigations. As a result, local surveyors or inexperienced
investigators are sometimes appointed in place of a more
qualified and experienced expert. Often, these local surveyors
will lack the detailed knowledge and/or resources necessary to
conduct the investigation to a suitably high standard. This means
that short-term savings often deliver poor value for money in the
long term and offer a false economy.

If an investigation is not carried out with best practice, all
interested parties risk serious financial and legal disadvantage.
Among those at risk are vessel owners and operators, managers,
charterers, sub charterers as well as those whose cargo was being
transported. Along the way, insurers for all the above parties -
P&I, H&M or cargo underwriters - are also stakeholders at
risk.

A Best Practice Approach

While some incidents are small and manageable, other fires and
explosions occur extremely rapidly during the same chaotic event.
On these occasions, fires can cause explosions and explosions can
cause fires. When an incident occurs on a vessel at sea or in a
port, the primary concern must be to ensure the safety of the
crew and others on board, extinguish the fire and minimize the
damage to the vessel and the cargo. However, steps that are taken
after safety is assured are also vital, and often mishandled.

A crucial decision to be made as soon as the incident has been
stabilized is to decide which experts will be needed on the
ground. The correct selection is essential in order to determine
the chronology of events at the earliest possible stage in the
investigation. If this is established correctly, then the
investigation will set off on the right path. During this initial
response, a properly equipped, trained and experienced
investigator or team of investigators with a keen eye for detail
should be mobilized. They should correctly identify, evaluate,
collect, process and analyze evidence in a timely manner, as well
as managing the scene and all individuals in attendance.

Fires and explosions are not simple matters; they can occur
within very complex systems on board a vessel. Investigators
working to determine the cause of an incident can benefit
significantly from the support of a highly skilled and qualified
multi-disciplinary team. Ship fires and explosions may require
the expertise of, for example, marine engineers, metallurgists,
fuel chemists, naval architects and cargo scientists, as well as,
of course, fire and explosion investigation expertise.

In addition to this multi-disciplinary team of experts, there may
also be other experts, surveyors and personnel representing
various interested parties and authorities attending the scene.
This all needs to be managed effectively to ensure the scene is
not compromised and only appropriate and accurate information is
provided to other attending interested parties.

Complex Fire and Explosion Scenarios

Many fires and explosions on board ships occur within the cargo
spaces during carriage of bulk or containerised cargoes, either
as a result of the hazardous nature of the cargo itself (e.g.
bulk DRI, bulk coal or containerized calcium hypochlorite) or
because of operations and equipment associated with cargo
carriage (e.g. fumigant explosions/fire or fires caused by buried
cargo lights). In this instance, a fire expert with a working
knowledge of cargo matters should draw on the expertise of a
cargo scientist who can ensure the investigation reaches a timely
and successful conclusion.

In another scenario, if a fire occurs in an engine room, a fire
investigator can examine the scene and determine the seat of the
fire, source of the fuel, ignition source and map the fire
development, growth and spread. However, most engine room fires
are a consequence of some machinery or operation failure so to
understand how the affected systems operate, and why a machinery
malfunction or human error may have occurred to cause the fire or
explosion, the fire expert will need the support of a marine
engineer in the first place. Hence, the forensic investigation
into the root cause of many engine room fires often evolves
solely into an engineering exercise. Other resources may also
need to be brought to bear, such as metallurgy, fuel chemistry,
etc.

Often the actions of the crew in fire-fighting operations need to
be investigated. This requires the fire investigator to have both
interviewing skills and the ability to gain a rapid and full
understanding of the ship's fire and safety equipment, aided by
the input of a marine engineer.

The Cost of Poor Evidence

In addition to assembling the right investigation team,
meticulous and painstaking collection, examination, preservation
and assessment of evidence provides the highest likelihood of
ultimately explaining the cause of a fire or explosion incident.
This best practice approach will help prevent the change or loss
of invaluable evidence, something that can be difficult, or even
impossible, to rectify at a later date. This, in turn, can have a
significant impact on the outcome of the investigation. For
example, if an investigator does not identify critical evidence,
or fails to collect evidence appropriately, their investigation
may not add probative value if a case proceeds to litigation.

As legal proceedings are likely to begin months, or even years
after the event, the opportunity to collect additional evidence
has often passed before errors in an investigation are
discovered. In addition to this, the collection of inaccurate or
inconclusive evidence may necessitate a new expert to review the
investigation. These costs will be in addition to the costs
associated with appointing the surveyor or inexperienced
investigator who was not ultimately able to provide the service
required by the client or during legal proceedings.

Reducing Long-Term Costs

Although some owners and operators may be reluctant to commit to
a perceived higher initial cost, appointing a qualified,
recognized and experienced fire investigator or investigation
team from the outset is likely to offer significantly better
value for money in the long term. The collection, preservation,
and analysis of all necessary evidence, managing all parties in
attendance at an incident, and presenting evidence clearly and
accurately in court is essential to streamline the investigation
process and therefore minimise long term costs. A qualified,
experienced and multi-disciplinary team is likely to be the
quickest route to a successful result.

The Author

David Myers is part of Brookes Bell's fire and investigation
team, and has attended and managed and investigated fire scenes
in a wide variety of environments, including those occurring
within and outside the marine industry.

(As published in the February 2017 edition of
Marine News
)

Mar 9, 2017

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