MO-2018-202 Accommodation fire on board, fishing trawler Dong Won 701, Timaru, 9 April 2018

1. On 9 April 2018, the New Zealand-registered fishing trawler Dong Won 701 was discharging its catch of fish in the port of Timaru when fire broke out in the accommodation space. Initial attempts by crew to extinguish the fire were unsuccessful, and by the time Fire and Emergency New Zealand attended the vessel, the fire had engulfed much of the accommodation.
2. The firefighting response continued for some eight days until the fire was fully extinguished. The vessel was later declared a total constructive loss. Three crew members and one Fire and Emergency New Zealand firefighter had to be treated at hospital for smoke inhalation.
3. The Transport Accident Investigation Commission (Commission) found that the fire started in a cabin on the officers’ deck, but due to its intensity and duration and the consequent damage to the accommodation structure, it has not been possible to establish how it started.
4. The Commission found that delays in sounding the alarm, the inefficient mustering of available crew and a failure to follow good industry practice for fighting the fire allowed it to spread rapidly through the accommodation.
5. The Commission also found that although the Dong Won 701 complied with the relevant Maritime Rules, the vessel’s structural fire integrity did not meet contemporary standards, and this was a factor in the speed and intensity with which the fire spread.
6. Safety issues identified included that inconsistencies in the application of Maritime Rules Part 40D: Design, Construction and Equipment – Fishing Ships may have resulted in up to 12 fishing vessels operating under the New Zealand Flag not complying fully with the relevant safety standards. A further 50 fishing vessels have been afforded grandparent rights that will allow them to operate indefinitely without meeting contemporary safety standards under the current Maritime Rules.
7. The Commission has made one recommendation to the operator, DW New Zealand Limited, and two recommendations to the Director of Maritime New Zealand.
8. Key lessons arising from this inquiry included:

• safety-critical systems such as fire-detection and alarm systems must be routinely tested to ensure they remain functional at all times in order to give early warning of a fire
• on discovering a fire it is important for the safety of all on board that the ship’s general alarm is used to alert crew to the danger as soon as possible
• it is important to slow or prevent a fire spreading by, as soon as possible, closing all openings that can allow air to feed or be drawn into the location of the fire.

Background

1. The Dong Won 701 was a New Zealand-registered, 82-metre-long fishing trawler. The vessel was owned and operated by Dong Won New Zealand Limited, a subsidiary of the Dong Won Fisheries Company, based in South Korea.

Narrative

1. The Dong Won 701 sailed from Dunedin on 7 March 2018 and spent 33 days at sea before returning to Timaru at about 0640 on 9 April 2018 to discharge the catch.
2. Cargo discharge continued until about 1700 that day. That evening 35 crew members went ashore, leaving the master and eight crew members on board.
3. One of the crew members who had gone ashore at 1945 was the first engineer. The first engineer’s cabin was located on the port side of the officers’ deck (see Figures 1 and 2).
4. At about 2045 an engine room rating in an adjacent cabin noticed smoke entering the cabin through the ventilation duct. The engine room rating decided to investigate and noticed smoke coming from the first engineer’s cabin.

1. The engine room rating opened the first engineer’s cabin door and was overwhelmed by thick black smoke, so closed the door again. The engine room rating then began knocking on other cabin doors shouting “Fire!” to alert the rest of the crew.
2. The ship had an automatic fire-detection and alarm system on board but it had not activated.
3. A deck officer who was coming down the stairs at the time took a portable fire extinguisher to the first engineer’s cabin and together with the engine room rating attempted to fight the fire. However, hampered by smoke they retreated down the passageway through an exit door to an open deck at the back of the accommodation space. They left both the first engineer’s cabin door and the exit door to the outside deck open. They thought this would help clear smoke from the cabin and passageway.

1. Another crew member on the crew deck below the officers’ deck heard the engine room rating shouting “Fire!”. That crew member also began shouting “Fire!” and knocking on cabin doors to alert any crew members on that deck.
2. The master, who was asleep in his cabin at the time, was informed of the fire by a phone call from the bridge. The master went to the bridge to organise a firefighting response.
3. The crew attempted to rig a ship’s fire hose to fight the fire, but could not pressurise the fire hose because they were unable to get the emergency fire pump to deliver water.
4. At about 2130 a number of the crew members ashore learned of the fire and returned to the vessel. At about that time the vessel’s generators shut down, causing a blackout.
5. The chief engineer and first engineer entered the engine room to restart the generators. Their intention was to restore power to run the refrigeration compressors and collect the ammonia refrigerant flowing through the freezer compartments located under the accommodation space that was on fire. The engineers succeeded in restoring power long enough to divert the ammonia into a secure tank away from the fire.
6. At about 2125 a member of the public notified FENZ of the fire. FENZ arrived on the scene at about 2132. By this time the fire was well established and the vessel’s accommodation superstructure was engulfed in flames.

1. FENZ firefighters took control of the scene and evacuated the master and all crew from the vessel.
2. FENZ used multiple low-pressure fire hoses and an aerial monitor positioned on the wharf to boundary cool the side of the vessel.
3. The operations manager for PrimePort Timaru arrived on the scene at about 2215 and instructed the port tug, Te Maru, to assist with the firefighting effort. The tug positioned on the port side of the vessel at about 2230 and started boundary cooling.

1. PrimePort Timaru engaged an independent maritime expert with specialist knowledge in maritime firefighting to assist FENZ with the technical aspects of fighting a fire on board a ship. The maritime expert was on the scene at about midnight the same evening the fire started.
2. The firefighting effort continued for two days, focused on boundary cooling and limiting the amount of water entering the ship (uncontained water in a ship can adversely affect the ship’s stability, and in the worst case can cause it to capsize).
3. On 12 April, with the fire still not extinguished, FENZ decided to inject high-expansion foam into the vessel. The FENZ team cut holes on the upper forecastle deck and injected foam into the lower decks. They also sealed off the accommodation portholes to reduce the supply of oxygen to the fire.
4. It took several days to seal the portholes and inject the high-expansion foam into the vessel.
5. On 17 April 2018 the fire was fully extinguished.
6. Three crew members and one FENZ firefighter had to be treated at hospital for smoke inhalation as a result of the fire or the firefighting effort.
7. Although the fire was fully extinguished, the ship was later declared a total constructive loss.

Scene examination

1. The following is an overview of the damage caused by the fire. A FENZ fire investigation report in Appendix 1 provides a more detailed description of the damage. The vessel suffered fire and heat damage to areas forward of the main winches on the upper deck, as shown in Figure 6.

1. The accommodation superstructure and area forward of the superstructure suffered severe heat damage and buckled in several areas. The rear of the superstructure was less affected: the protective paint was still relatively intact and there was no buckling of the upper deck.
2. A ventilation damper located above the bridge was found in the open position.

1. All cabins located on the port and starboard sides of the officers’ deck were destroyed by the fire (see Figure 8 and Figure 9). The first engineer’s cabin suffered the most fire damage. The severity of the damage reduced with the distance away from the first engineer’s cabin.

Introduction

1. Fire on board any ship is a serious event. Ships are necessarily designed with a number of high-fire-hazard machinery and electrical installations in close proximity to accommodation and cargo spaces, each with its own fire risk. These fire risks are managed through:

• fire-resistant design and construction
• fire-detection and warning systems
• firefighting appliances and systems
• firefighting procedures.

1. In this case the fire occurred while the ship was in port, where shore-based firefighting resources were available (Refer Transport Accident Investigation Commission Report MO-2017-205). However, because ships spend the majority of their time at sea, remote from shore assistance, ship firefighting systems are designed around self-sufficiency when it comes to managing the risks and consequences of fire.
2. The following analysis considers each of these aspects in relation to the fire on board the Dong Won 701, and discusses two safety issues:

• some aspects of the crew response to the fire did not meet industry good practice
• safety issues identified included that inconsistencies in the application of Maritime Rules Part 40D: Design, Construction and Equipment – Fishing Ships may have resulted in up to 12 fishing vessels operating under the New Zealand Flag not complying fully with the relevant safety standards. A further 50 fishing vessels have been afforded grandparent rights (a provision in which an old rule continues to apply to an existing vessel while a new rule applies to all future vessels. Those exempt from the new rule are said to have grandparent rights) that will allow them to operate indefinitely without meeting contemporary safety standards under the current Maritime Rules.

Cause of the fire

1. Due to the intensity and duration of the fire and the consequent damage to the accommodation structure, it was not possible to determine conclusively the cause of the fire.
2. Based on the observed burn patterns and the nature of the damage that occurred, the area of origin was determined to be the first engineer’s cabin on the officers’ deck. This hypothesis is supported by witness accounts, particularly those of the engine room rating who first discovered the fire, and the crew member on the deck below, who was able to confirm that initially there was no fire in the cabin directly below the first engineer’s cabin, or anywhere else on that deck.
3. Figure 11 shows a plan of the first engineer’s cabin, reconstructed from the ship’s plans and according to interviews with crew. It shows multiple potential sources of ignition, mainly electrical sources.
4. The point of origin was considered to be at or just above the floor level beside the rubbish bin, next to the first officer’s desk. The burn patterns on the ceiling and the warping of the steel plate where the cabin bulkheads were fastened supported this conclusion, as did the accounts of those who entered the cabin during the initial firefighting effort.

Fire detection and alarm

1. The Dong Won 701 was fitted with an automatic fire-alarm and fire-detection system for the accommodation spaces. The system had been installed on board between 2015 and 2016.
2. Each cabin was fitted with a photoelectric-type smoke detector connected to a fire alarm panel installed on the bridge. The smoke detector sent a signal to the fire alarm panel when smoke was detected. The fire alarm panel displayed the location of the fire and automatically triggered a general alarm throughout the ship.
3. Smoke detectors of the type installed in the cabins could detect smoke at an early stage, even before it became obviously visible.
4. The early detection of fire is critical to the safety of ship and crew. Early detection allows crew to respond immediately and extinguish the fire by direct attack before it escalates beyond control.

5. During this fire the fire-detection system did not detect the fire or sound the general alarm. Due to the damage caused by the severity and duration of the fire, it was not possible to determine why it did not function automatically.

6. Fire-detection and alarm systems are critical systems that would normally be routinely tested in accordance with manufacturers’ instructions. As the on-board maintenance records were destroyed in the fire, it was not possible to check these for compliance with such instructions.

7. The crew responsible for testing the fire alarm system explained that the fire alarms were “tested”, but they were unable to describe anything that resembled a routine regime for checking that all components of the fire alarm system were functional.

8. Possible reasons for the system not activating include:

• a fault with the smoke detector in the cabin
• an interruption in power supply to the system
• the system being left in manual mode.

1. An interruption in power supply was unlikely, as the system had a dual power supply to it and there had been no reported power supply issues prior to the fire. A fault with a single detector was also unlikely, as other detectors should have activated the alarm as the smoke spread to other areas; this did not happen.
2. The system having been left in manual test mode could not be ruled out as the crew regularly left the alarm system in manual mode to avoid nuisance alarms triggered by exhaust fumes, hot work etc. The manual mode is not designed to be used as the primary operation mode. In manual mode the audible fire alarm could only be heard on the bridge and required the officer on watch to investigate and raise a general alarm if necessary.
3. Regardless of why the system did not activate automatically, there were manual push-button alarms located on every deck that would have bypassed the automation and activated the fire alarm throughout the ship. Pushing one of these buttons would have been the best method of raising the alarm for everyone on board. None of the crew pushed a manual button.

Firefighting procedures and equipment

Safety issue: Some aspects of the crew response to the fire did not follow industry good practice.

1. Containing and extinguishing a fire quickly and effectively is critical for preserving life and property. Once the initial individual direct attacks on the fire prove unsuccessful, the response would normally focus on containing the fire and using all available resources to extinguish it.
2. The crew of the Dong Won 701 had all received approved shore-based firefighting training. They were all required to be current with the vessel’s firefighting procedures. This would normally have been achieved during the crew induction on board and fire and emergency drills, which according to the operator’s (DW New Zealand Limited’s) maritime transport operator plan were scheduled to happen four times each year.
3. DWNZ had different checklists for responding to a fire when out at sea and when alongside. When out at sea, the Dong Won 701’s Emergency Checklist for Fire/Explosion required the crew to take a number of actions on discovering a fire. The checklist was broadly compliant with industry good practice. However, there was no mention of holding a crew muster to account for everyone on board. DWNZ’s Vessel Emergency Alongside checklist required the crew to evacuate the vessel and muster at an unspecified muster station. However, the crew did not evacuate the vessel until ordered to do so by FENZ, and the master was unable to confirm that all his crew were safely off the vessel. Emergencies that occur in port are problematic in that regard, because not all crew will necessarily be on board. In this case only nine of the 44 crew members were on board to initially contain and fight the fire. Several important procedures were not followed, of which some were likely attributable to so few crew being available to respond.
4. An important aspect of containing a fire is to deprive it of oxygen. The standard procedure for achieving this is to close all doors and openings to the space where the fire is located. After the retreat from the initial attempts to make a direct attack on the fire, the cabin door was left open – so too was the door leading from the passageway to the open deck. Also, the ventilation flaps supplying fresh air to the accommodation were left open.
5. With a free flow of oxygen to the fire, it quickly spread from the first engineer’s cabin to engulf the accommodation spaces within a matter of minutes.
6. The master’s designated position in an emergency was on the bridge. However, by the time he was alerted to the fire the bridge was rapidly becoming engulfed in fire. Consequently the master was unable to use the communication equipment to summon help.
7. The master went to the open deck aft of the bridge, where a number of crew had mustered and attempted to organise a full muster and form teams to fight the fire. However, several crew members took their own courses of action, with some proceeding to the engine room to manage the ammonia risk and others re-entering the accommodation space to continue attacking the fire on an individual basis.
8. This uncoordinated response to the fire continued until FENZ arrived and took command of the scene, having been called by a member of the public.
9. Some crew members attempted to initiate firefighting by preparing fire hoses on the port and starboard sides of the upper deck. However, they were unable to work the portable emergency fire pump to pressurise the fire hoses.
10. In summary, the delay in all crew being alerted to the fire was a missed opportunity to extinguish it using portable firefighting equipment before it escalated out of control. Then, because the immediate and surrounding areas were not shut down, the fire was able to spread rapidly throughout the accommodation space before an effective firefighting effort could be mustered.

Fire-resistant design and construction

Safety issue: Inconsistencies in the application of Rule 40D may have resulted in up to 12 fishing vessels operating under the New Zealand Flag not complying fully with the relevant safety standards. A further 50 fishing vessels have been afforded grandparent rights that will allow them to operate indefinitely without meeting contemporary safety standards under the current Maritime Rules.

1. Fishing ships entered into the Fishing Vessel Register under the Fisheries Act 1996 (the Fisheries Act) are required to meet applicable design, construction and equipment rules in Rule 40D. Rule 40D prescribes the minimum requirements for the design, construction and equipment of New Zealand fishing ships, which include standards for structural fire protection. Rule 40D came into force in 2000.
2. The application of some parts of Rule 40D depends on the date when a ship was constructed or ‘converted to’ a fishing ship. Rule 40D states that fishing ships constructed before 27 May 2004 (pre-2004 ships) are not required to meet some standards of design, construction and equipment contained in Rule 40D. Fishing ships constructed after 27 May 2004 (post-2004 ships) are required to meet all of Rule 40D.
3. Under the Fisheries Act, either a New Zealand-registered fishing ship or a foreign-registered fishing ship issued with an exemption under section 103A(1) of the Fisheries Act can apply to be registered in the Fishing Vessel Register. In around 2016 changes to the Fisheries Act meant that all foreign-registered fishing ships had to be registered as New Zealand fishing ships to remain on the Fishing Vessel Register.
4. Around that period the owners of many foreign-registered fishing ships began registering them as New Zealand fishing ships. For each ship this meant determining whether it was a pre-2004 ship or a post-2004 ship for the purposes of Rule 40D, and there was some inconsistency among surveyors in how this was done.
5. In 2017 Maritime New Zealand discussed its interpretation of pre- and post-2004 vessels with surveyors. Maritime New Zealand’s view was that vessels constructed outside New Zealand that had been first entered into the Fishing Vessel Register in New Zealand after 27 May 2004 were considered post-2004 vessels, and therefore were required to meet all the applicable standards of Rule 40D.
6. The Dong Won 701 had been constructed in Japan in 1971 and registered in South Korea (in 2016 the Dong Won 701 changed its registry to New Zealand). In 2000 the Dong Wong 701 had been entered into the Fishing Vessel Register as an exempt ship, and entered into the New Zealand safe ship management system. As it had been both constructed and entered in the New Zealand system prior to 2004, it was considered to be a pre-2004 ship, and as such was ‘grandparented’ and deemed compliant with Rule 40D.
7. ‘Grandparent rights’ is a common regulatory tool used internationally in recognition of the difficulty in applying modern shipbuilding safety standards to old shipbuilding techniques, where often the cost of meeting new standards outweighs the benefits.
8. An adverse effect of applying grandparent rights to older standards is that the crews are not afforded the same level of safety as, and therefore are more at risk than those on newer vessels constructed to newer standards.
9. For example, the corridor bulkheads in the accommodation spaces of a new ship must be constructed of non-combustible material. The standard stairwells on newer ships are required to have B-class (bulkheads so constructed as to be capable of preventing the passage of flame to the end of the first one half-hour of the standard fire test) self-closing doors at one end to slow the spread of fire between decks.
10. The internal corridor bulkheads and cabin doors on the Dong Won 701 were of hardboard or similar wood-product construction and suffered complete combustion in the fire. The stairwells on the Don won 701 had no doors fitted between decks. Consequently the fire spread rapidly to the decks above.
11. It is highly likely that a similar fire on board the Dong Won 701 while at sea, with more crew and no ability to step ashore, would have had more severe consequences. This made it all the more important that fire-detection systems were working and that the fire response was fast and effective with all firefighting equipment working properly.
12. Given the health and safety implications for crew working on older grandparented fishing vessels, the Commission sought information from Maritime New Zealand about the status of the New Zealand fleet. This revealed potential inconsistencies in the application of Rule 40D. This was because it was not clear from the rule that ships entering the system after 2004 should have been made to comply fully with Rule 40D, until Maritime New Zealand issued its guidance to surveyors in 2017. Consequently, prior to 2017, operators and surveyors were applying Rule 40D inconsistently.
13. As of June 2018 there were 63 active commercial fishing vessels, over 24 metres in length, registered in New Zealand. Of the 63 fishing vessels, 60 had been constructed or registered outside New Zealand.
14. Of these, 50 had been first entered into the Fishing Ship Register prior to 27 May 2004 and were therefore surveyed as pre-2004 ships, in accordance with Rule 40D.
15. The remaining 13 commercial fishing vessels had been entered into the Fishing Ship Register after 27 May 2004. Twelve of these vessels had been constructed at various dates before 2004 and as such, according to the Maritime New Zealand guidance issued in 2017, should have been surveyed as post-2004 vessels and fully complied with the standards in Rule 40D.
16. Maritime New Zealand was unable to establish from records whether these remaining 12 fishing vessels were correctly surveyed as post-2004 vessels.
17. It is likely that some of these fishing vessels are not fully meeting the applicable design, construction and equipment standards prescribed in Rule 40D, depending on their year of construction and the applicable foreign rules according to which they were built. In some respects they are no different from the other 50 vessels that were afforded grandparent rights prior to 2004. As with the 12 post-2004 fishing vessels, the safety standards will vary depending on their year of construction and the applicable foreign rules according to which they were built.
18. All grandparented fishing vessels can remain in the system indefinitely, because there was no time limit placed on the grandparent rights.
19. A useful variation to the grandparent rights in future would be to put a cap on the year of construction applicable to the rule to prevent very old vessels entering the system and/or limit the number of years a vessel is allowed to operate before it is either upgraded to meet modern standards or withdrawn from the system. Otherwise, there is a risk that over time the average age of fishing vessels in the New Zealand Fishing Vessel Register will increase and, potentially, safety standards will fall further behind contemporary standards.
20. The Commission has made recommendations to the director of Maritime New Zealand to address this issue.

1. The fire started in a cabin on the officers’ deck, but due to its intensity and duration and the consequent damage to the accommodation structure, it has not been possible to establish how it started.
2. The fire-detection and alarm system did not for some undetermined reason automatically sound the general alarm as it should have, and the crew did not activate the alarm manually on detecting the fire. Both delayed the firefighting response.
3. The crew’s response to the fire did not comply fully with company procedures and good industry practice.
4. The structural fire integrity of the Dong Won 701, although complying with the relevant Maritime Rule, did not meet contemporary standards, and this was a factor in the speed and intensity with which the fire spread.
5. Due to the inconsistency of how Maritime Rules Part 40D: Design, Construction and Equipment – Fishing Ships was applied to ships entered into the New Zealand Fishing Ship Register after 2004, there are up to 12 ships that likely do not meet the standards required of the rule.
6. The provisions of the current Maritime Rules Part 40D: Design, Construction and Equipment – Fishing Ships potentially allow older fishing vessels that do not have to comply with contemporary safety standards to remain in the system indefinitely.

General

1. Safety Issues are an output from the Commission’s analysis of factors that have contributed to the occurrence. They typically describe a system problem that has the potential to adversely affect future operations on a wide scale.
2. Safety Issues may be addressed by safety actions taken by a participant, otherwise the Commission may issue a recommendation to address the issue
3. Recommendations are made to persons or organisations that are considered the most appropriate to address the identified safety issues.
4. In the interests of transport safety, it is important that safety actions are taken, or any recommendations are implemented without delay to help prevent similar accidents or incidents occurring in the future.

Safety issues

1. Some aspects of the crew response to the fire did not meet industry good practice.
2. Inconsistencies in the application of Rule 40D may have resulted in up to 12 fishing vessels operating under the New Zealand Flag not complying fully with the relevant safety standards. A further 50 fishing vessels have been afforded grandparent rights that will allow them to operate indefinitely without meeting contemporary safety standards under the current Maritime Rules.

Safety actions

General

1. The Commission classifies safety actions by two types:

   (a) safety actions taken by the regulator or an operator to address safety issues identified by the Commission during an inquiry that would otherwise result in the Commission issuing a recommendation

   (b) safety actions taken by the regulator or an operator to address other safety issues that would not normally result in the Commission issuing a recommendation.

Safety actions addressing safety issues identified during an inquiry

1. Since the accident DWNZ (the owner) has taken the following safety actions:

   All crew of the Dong Won 701 involved in the incident were debriefed and offered counselling. This was followed by a general safety meeting with crew and one on one meetings with senior officers.

   For the remaining two vessels in the Dong Won fleet:

   (a) DWNZ held safety meetings to discuss the immediate lessons of the incident. Drills were also held on both vessels with fire in port as the exercise scenario (photos of the drills, and records attached).

   (b) Fire detection system and maintenance were verified in asset management systems.

   (c) All fixed fire-fighting CO2 flooding systems checked and verified for operation, similarly all fire dampers checked.

   (d) All cabin electrical fittings inspected by ship’s engineers (photos attached). Portable appliance testing (PAT) tags verified (photos attached).

   Steps implemented in the medium term

   DWNZ has implemented the following medium term steps:

   DWNZ senior management directed a complete review of corporate safety management and the MNZ [Maritime New Zealand] approved Maritime Operator Safety System. The system has been completely rewritten and reissued together with a new Maritime Operator Transport Plan. The reissue has included new corporate HSE [health, safety and environment] and “Stop Work” policies and procedures for contingencies.

   Senior Management, Ships officers Guard Safety and crew held general safety meetings on board accompanied by Guard Safety staff to explain policies and commitment to safe operations. Drills conducted on board, witnessed and debriefed (debriefing document attached).

   Both remaining vessels subject to formal safety assessment and internal audit, recommendations made in regard of personnel training, procedure implementation and vessel asset improvements.

   Further advanced training by local fire and safety training contractor to crew (supporting information attached). Heaters in cabins fitted with securing / protection guards (photos attached).

   Housekeeping and escape routes subject to increased inspection and scrutiny by vessel management. Both remaining vessels were due to conduct refits, this included some interior structural work. As part of the safety assessment, all newly installed/replaced structure (deckheads bulkheads) was specified to be of suitable fire-resistant materials to current standards. Galley ventilation systems overhauled.

   All crew and contractor vessel familiarisation inductions were reviewed, revised and recorded. Permit to Work systems aligned to best practice, on board permit officers trained.

   Steps implemented in the longer term

   DWNZ has implemented the following longer term steps:

   New safety management system rolled out for trial on one vessel, this included procedures to enhance contingency response including development of the crew training matrix.

   Prior to docking, both remaining vessels were attended by Guard Safety and a general safety meeting held with a translator on hand. Permit to Work system fully implemented with vessel staff controlling all contractor activity. Contractor inductions given to all non DWNZ staff attending on board.

   With the co-operation of the Lyttleton dry dock management, a fire drill was conducted, and a general evacuation of the dry dock took place. This exercise was debriefed followed by a general safety meeting for all crew and vessel management.

   Ongoing safety training for all crew including refresher firefighting training. Safety specialists staying on board to observe fishing operations and safety drills.

2. Since the accident Maritime New Zealand has taken the following safety actions

   The issues around whether a vessel is a pre or post 2004 vessel is being actively considered by Maritime NZ as part of a wide ranging reform project of Maritime Rules Part 40 series. This reform project began in 2018 and has involved regular engagement with recognised surveyors to identify how matters involving challenging rules and or confusion about the application of rules can be improved pending the regulatory changes that will necessarily result from the reform of domestic commercial vessel standards. The draft guidance on pre-post 2004 vessels is an example of work Maritime NZ initiated with surveyors for that purpose. General exemptions were also issued for classes of vessels affected by outdated rules. These are published on our website www.maritimenz.govt.nz/rules

   Maritime NZ continue to work closely with the sector and surveyors to support better compliance and clarify rules under the existing law pending the outcome of the 40 Series reform project. This includes holding regular surveyor seminars and, over that last two years, issuing nine position statements and nine interim technical notes that provide supporting information on technical issues or areas related to the maritime rules. This has included guidance on how to ensure commercial vessels imported into New Zealand from Australia comply with Maritime Rule Part 40A, 40C and/or 40D; and guidance to support commercial ships owners to better understand when a modification or repair to their ship may be major and how this applies to pre and post 2004 vessels. The guidance also outlines operator duties to obtain design approval for an in-construction survey of a major modification or repair.

Safety actions addressing other safety issues

1. None identified.

General

1. The Commission may issue, or give notice of, recommendations to any person or organisation that it considers the most appropriate to address the identified safety issues, depending on whether these safety issues are applicable to a single operator only or to the wider transport sector. In this case, recommendations have been issued to the owner of the vessel Dong Won New Zealand Limited, and the Director of Maritime New Zealand.
2. In the interests of transport safety it is important that these recommendations are implemented without delay to help prevent similar accidents or incidents occurring in the future.

To the owner of Dong Won New Zealand Limited

1. The Dong Won 701 did not have the same level of structural fire protection as new fishing vessels and relied on other fire-protection strategies such as enhanced fire-alarm systems and robust crew training to ensure that the overall fire safety of the vessel was on a par with that of new ships.

   The delay in all crew being alerted to the fire was a missed opportunity to extinguish it using portable firefighting equipment and before it escalated out of control. Then, because the immediate and surrounding areas were not shut down, the fire was able to spread rapidly throughout the accommodation space before an effective firefighting effort could be mustered.

   On 26 September 2019 the Commission recommended to the owner of the Dong Won 701 that they assess the overall fire safety of each vessel in their fleet and ensure that the risks and consequences of fire are reduced to as low as possible, including ensuring that crews are appropriately trained and practised in responding to fires. (007/19)

2. On 11 October 2019 Dong Won New Zealand replied:

   DWNZ does not consider that the first two paragraphs of the above form part of TAIC’s recommendation. Rather, they are factual determinations made by TAIC, elements of which DWNZ does not agree with.

   The construction of Dong Won 701

   DWNZ is not alone in operating vessels built to previous construction standards. We understand that essentially very few deep sea vessels in New Zealand are new vessels.

   Construction rules are in a state of constant change due to new materials, construction methods and design. Owners of vessels are not required or expected to meet the new standards every time a rule changes. Rather they are encouraged to take a performance based approach and take what practicable and reasonable steps they can to meet the intent of the new rule. Rules allow for this internationally right across shipping.

   Response to the fire

   DWNZ does not agree that there is a proper factual basis for saying that the crew were delayed in being alerted to the fire or that an opportunity was missed. The fire occurred in port. DWNZ procedure, as per common industry practice, is for the crew to attempt a first response and raise the alarm with FENZ. If the first response fails, the crew then evacuate the vessel and await FENZ. Unlike most, if not all, other New Zealand deep sea commercial fishing operators, DWNZ trained all of their crew members to some degree in fire-fighting. This is well in excess of any regulatory compliance requirement. Other operators generally only train those in a designated response team, which would mean a minority of the crew. The fact the crew staged an unsuccessful first response and, despite that, then assembled a fire team to try to contain the fire is to their credit. The action of the first responders in leaving the burning cabin door open may not have been a conscious decision and they may not, in any event, have been able to shut it.

   Accordingly, DWNZ does not agree that the first two paragraphs of 007/19 should be published, given they are not part of TAIC’s recommendation.

   DWNZ recognised some of the challenges of fire safety on board their vessels and prior to the incident had installed improved detection systems on all their vessels. Immediately following the incident, DWNZ management took significant steps in directing a third party review of their entire vessel safety management systems. Many of the action points arising from the review align with the TAIC recommendation. In the intervening period, many action points have been completed and there is a process of ongoing continuous improvement to address safety issues across a range of issues on board including asset management, training and procedural development.

   Accordingly, we are instructed that DWNZ will implement what it understands to be TAIC’s recommendation (paragraph 3 of 007/19), but, as explained above, DWNZ has already implemented measures which align with that recommendation. We explain this below in more detail.

   Actions taken by DWNZ after the incident

   Paragraphs 32 – 34 of our letter dated 2 September 2019 set out the steps DWNZ took after the incident. We provide further detail below.

   Safety management system

   Immediately after the incident, the CEO and senior management of DWNZ conducted an internal investigation of the circumstances surrounding the incident, what lessons could be learned and what improvements could be made.

   Management directed a complete review of the corporate HSE management system and its implementation. DWNZ considered that the existing regulatory mandated and audited Marine Operator Safety System (MOSS) was not effective in managing the hazards present. DWNZ engaged a third-party organisation specialising in commercial fishing vessels to conduct the review, develop a better MOSS safety management system and follow up with an implementation and training programme.

   The new system was trialled on the DWNZ vessel Dong Won 519 starting in January 2019. Following a second review, the system was issued to the Dong Won 530 in September 2019. The system included new corporate policies, procedures, standard operating instructions and training / competence processes.

   Vessel inspections and crew competence assessments

   In parallel with the development of their safety management system, DWNZ also organised independent third-party specialists to carry out a series of inspections and assessments of Dong Won 519 and Dong Won 530. These assessments considered safety issues including: fire prevention, containment and escalation control, watertight integrity and vessel stability, and factory and machinery safety. 

   The assessment and inspections included:

• at-sea operational assessments, conducted by a specialist with industry experience sailing on board;
• pre–dock inspection: an inspection of the vessel with a safety system focus in order to identify an assessment of the condition of the vessel and improvements to be made;
• attendance on board during dry dock and maintenance periods: identifying further possible improvements, conducting crew training and verifying corrective actions; and

• conducting in-port emergency drills.

  Each vessel’s hazard register was developed with the results risk assessed for controls. Inspections and assessments included contingency drills conducted on board followed up by a debrief, assessment and corrective action follow up. Recommendations from these assessments and inspections were considered for risk level and prioritised accordingly for action.

  Recommendations include actions in regard of the vessel, procedures and personnel training /competence.

  Specific actions to date

  We have attached, as Appendix 1 [see Appendix 4 of report], a comprehensive list of the actions taken by DWNZ following the incident. Most of these have been implemented and there is a process in place for ongoing improvement, hazard identification, corrective action and verification of controls.

To the Director of Maritime New Zealand

1. A review of records revealed inconsistencies between surveyors when applying Rule 40D. Some were not aware that ships entering the New Zealand Fishing Vessel Register post-2004 were required to comply fully with all of Rule 40D in accordance with the Maritime New Zealand advisory to surveyors issued in 2017.

   Potentially there are 12 fishing vessels not complying fully with Rule 40D to varying degrees, depending on their year of construction and the applicable foreign rules according to which they were built.

   On 26 September 2019 the Commission recommended to the Director of Maritime New Zealand that they take any measures available to them to make post-2004 fishing vessels comply with as many of the design, construction and equipment standards prescribed in the current Rule 40D as are reasonable and practicable. (008/19)

2. On 10 October 2019 Maritime New Zealand replied:

   We agree with this recommendation. Maritime New Zealand is undertaking a review of Maritime Rules Part 40 Series, which is intended to address this issue definitely. Maritime New Zealand will, in the meantime, continue to work with vessel owners, operators and surveyors to adopt an approach to the pre-post 2004 concept in a way that seeks to achieve safe standards.

   The 40 Series Reform is a long-term, collaborative project that intends to ensure that the rules for design, construction and equipment for domestic (non-SOLAS) ships are fit for purpose. Maritime NZ is working actively with the sector to ensure that survey and oversight of vessels continues under the existing law pending the outcome of the reform project.

   Because of the scale of the reform being undertaken in this project, Maritime NZ believes the new rules, if accepted by the Minister, would likely come into effect in 2023.

   As maritime rule amendments take some time Maritime NZ is proposing to undertake work within the next 12 months to provide further interim guidance to industry on this issue.

3. There are 50 fishing vessels on the New Zealand Fishing Vessel Register that have been afforded grandparent rights under Rule 40D and consequently have not been required to comply with the more modern safety standards captured by Rule 40D. The safety standards on these vessels will vary depending on their year of construction and the applicable foreign rules according to which they were built.

   There is a risk that over time the average age of fishing vessels on the New Zealand Fishing Vessel Register will increase and, potentially, safety standards will fall further behind contemporary standards.

   On 26 September 2019 the Commission recommended to the Director of Maritime New Zealand that they work with the Ministry of Transport to amend Rule 40D to put appropriate measures in place to ensure that aging fishing vessels are not permitted to remain in the system indefinitely without being required to meet contemporary safety standards. (009/19)

4. On 10 October 2019 Maritime New Zealand replied:

   We understand the intent of this recommendation is aimed at ensuring that safety standards do not fall behind and place people at risk. To that end, Maritime NZ is progressing work on comprehensive reform of the Maritime Rules Part 40 series.

   Maritime NZ will advise the Minister of Transport, through the Ministry of Transport, of any proposed changes to maritime rules when the work is completed. If the Minister accepts the proposals Maritime NZ makes at the conclusion of its work, it is estimated that the earliest that such new rules could come into effect would be 2023.

1. Safety-critical systems such as fire-detection and alarm systems must be routinely tested to ensure they remain functional at all times in order to give early warning of a fire.
2. On discovering a fire it is important for the safety of all on board that the ship’s general alarm is used to alert crew to the danger as soon as possible.
3. It is important to slow or prevent a fire spreading by, as soon as possible, closing all openings that can allow air to feed or be drawn into the location of the fire.

1. On 10 April 2018 Maritime New Zealand reported a fire on board the fishing trawler Dong Won 701, which had started the previous night while the vessel was berthed at the Port of Timaru.
2. The Transport Accident Investigation Commission (Commission) opened an inquiry under section 13(1) of the Transport Accident Investigation Commission Act 1990 and appointed an investigator in charge.
3. On 10 April 2018 three investigators from the Commission travelled to Timaru to conduct interviews and gather evidence. The Commission engaged professional interpreters to provide Korean and Indonesian translation services.
4. The investigators were unable to board the vessel on 10 April 2018 as the vessel was still on fire.
5. The Commission obtained as evidence closed-circuit television (CCTV) footage from the port security cameras.
6. On 18 April 2018 two investigators boarded the vessel to conduct a scene examination and gather evidence for the inquiry. Two fire investigators from Fire and Emergency New Zealand (FENZ) accompanied the Commission’s investigators for the purposes of establishing the cause of the fire.
7. FENZ produced a fire investigation report. The Commission received a copy of that report as evidence.
8. On 20 April 2018 a protection order was put in place to preserve the evidence.
9. On 18 May 2018 the protection order was revoked
10. On 22 November 2018 new information was presented to the Commission, so another protection order was put in place to preserve the evidence while the Commission conducted further enquiries.
11. On 13 December 2018 the second protection order was revoked.
12. On 26 November 2018 two investigators returned to Timaru to conduct interviews with an independent maritime expert who had assisted with the firefighting effort on the Dong Won 701, and the engineering superintendent of the Dong Won 701.
13. On 26 June 2019 the Commission approved the draft report to be circulated to six interested persons for comment.

• ‘The person who noticed a fire should shout "Fire!", and contact the bridge
• Sound the fire alarm, and arrange the emergency fire-fighting station
• The Master must take position on the bridge
• check the place where fire occurred
• Manoeuvre the ship to an area where the wind is weak to prevent expansion of the fire during the navigation If above is not possible, block and seal the area
• Check for dead or wounded crew and most of all take actions to save lives
• Light the related light and post the related shapes
• Stop cargo handling or bunkering if there is a fire
• Block ventilation and the automatic fire door
• Stop the electric power
• When necessary, stop the engine
• Remove any sources of fire and cool the place near the fire
• Master considered in E/R fire, being using fixed fire-fighting equipment.
• (In this case, escape in E/R is the first priority)
• When the ship is in or near a port, report to the port authority, shore fire station agents about the size and strength of the fire
• Prepare for the International Shore Connection’
• Listen to VHF Ch. 16
• If the ship is sailing when a fire occurred, check the ship's position
• Turn on the deck illumination at night
• If the ship is sailing, turn on light not under command/raise up shapes
• Inform the Radio Operator of the ship's position. When necessary, send the distress signal (SOS call) and VHF (Mayday Repeat)
• When necessary, prepare for rescue, tug, or abandon ship
• Check for causes of the fire
• Check the extent of damage to the ship
• Check the extent of damage to cargo
• Check the extent of damage to shore facilities
• Report to the Designated Person and When necessary, ask for assistance from the shore-based management