Recommendation Date
Recipient Name
Dong Won
Text
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.
Reply Text
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.
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.
Related Investigation(s)