REPORT OF COURT
m.v. “Forresbank” O.N.148857
In the matter of a Formal Investigation held at 10 Carlton House Terrace, London, S.W.1 on the 20th, 21st, 22nd and 23rd days of July, 1959, before J. Roland Adams, Esquire, Q.C., assisted by Captain J. E. Cooper, O.B.E., and Mr. Ivor J. Gray into the circumstances attending the abandonment, subsequent stranding and total loss of the British motor vessel “Forresbank”.
The Court having carefully inquired into the circumstances attending the above-mentioned shipping casualty, finds for the reasons stated in the Annex hereto, that the said abandonment and subsement total loss of the “Forresbank” was due to a disastrous fire which broke out in the engine room of the said vessel during the middle watch on the 9th November, 1958, which fire could not be extinguished by the resources available on board the said vessel, which was justifiably abandoned and thereafter stranded and became a total loss.
Dated this ninth day of October 1959.
J. ROLAND ADAMS, Judge
We concur in the above Report
J. E. COOPER
IVOR J. GRAY
ANNEX TO THE REPORT
At about 0220 hours local time on the 9th November, 1958, a disastrous fire occurred in the engine room of the British motor vessel “Forresbank” then in course of a voyage from Cape Town to Durban in light condition save for the presence of small quantities of cargo in the ‘tween decks. From the moment of its detection by the engineer officer of the watch this fire was beyond any means of control available to those on board the vessel and in consequence of its rapid spread the master ordered the vessel to be abandoned some two hours later. Although the vessel had a good offing from the coast When abandoned the weather had so far deteriorated by the time tug assistance arrived that, there being then nobody on board the casualty, it was impossible for the tug to make a connection and the “Forresbank” was blown ashore by the strong winds and has become a total loss.
It is in these circumstances that the Minister of Transport and Civil Aviation directed that a Formal Investigation should be held into the casualty by a Wreck Commissioner.
The Minister, in the exercise of his powers under Section 465 of the Merchant Shipping Act, 1894, ordered a preliminary inquiry into the casualty to be held. Mr. Richard Edward Knowles, who was the officer appointed to hold that inquiry, gave evidence to the Court which clearly demonstrated that he had carried out his task with a high degree of care, detective insight and professional skill.
The Court understands that the conclusions which he presented to it in evidence did not differ from those at which he had arrived in the course of his preliminary inquiry, and considers it noteworthy that nothing emerged at the Formal Investigation to displace any of Mr. Knowles’s conclusions; nor does it appear to the Court that further investigation has thrown any fresh light upon a preventable cause of shipwreck.
It was stated by learned Counsel instructed by the Treasury Solicitor for the Minister in opening that “The purpose of this Inquiry is to inquire into the cause of a fire”, and he made it clear from the outset that the Minister was not suggesting that the certificate of any officer should be dealt with. Although the evidence revealed a number of lapses on the part of certain officers from the high standards which ought to be maintained in the Merchant Navy the Court is unable to find that any of those lapses amounted to a wrongful act or default causing or contributing to the loss of the vessel, and is content to record those lapses in the form of direct extracts from the evidence of the officers concerned, with its observations thereon, as provided by Section 466 (6) of the Merchant Shipping Act, 1894.
The “Forresbank” was a steel twin screw dry cargo motorship of the open shelter deck type, classed 100 A.1 with Lloyds Register of Shipping with Freeboard and was 33 years old. The registered particulars were, Port of Registryâ€”Glasgow; length 420.10 feet, breadth 53.90 feet, depth 26.50 feet, gross tonnage 5155.03 and register tonnage 3115.43. The engine room was situated amidships between Nos. 3 and 4 hatchways. The accommodation was all above the shelter deck, the Asiatic crew in the forecastle. the master and navigating officers forward of No. 3 hatchway, the engineers in side houses on each side of the machinery casings and the radio officer and wireless cabin in a house above the engine room, abaft the skylight.
Four lifeboats, one of which was fitted with a motor, were mounted on the boat deck under radial davits, two on the port side and two on the starboard side. The propelling machinery, entered in Lloyds Register of Shipping with the notation L.M.C., consisted of two direct acting, vertical, six cylinder internal combustion engines, each of the four stroke single acting type, air injection, to give about 2500 I.H.P. total.
Abaft and between the two main engines was an oiltight flat on which two oil settling tanks were fitted, the fore part of the tanks being in a line 3 feet aft of No. 6 cylinders and the tank bottoms 2 feet 6 inches below the line of the cylinder tops.
There was a natural draught oil-fired Scotch boiler at the forward end of the engine room in a recess into the deep tank.
Electric supply was derived from 3â€”65 kw 220 volt generators placed in the engine room (port side), two being diesel driven and the foremost steamd-riven. Most of the auxiliary machinery was electrically driven and was in the starboard after end of the engine room.
Fuel oil was carried in numbers 2, 3, 4, 6 and 7 double bottom tanks and also in numbers A, B, C and D tunnel deep tanks.
The ship when loaded had a speed of about 10 knots on an average daily consumption of about 9.5 tons.
On the day of the casualty the following certificates were in force:
(a) A Safety Equipment Certificate issued by the Government of the Union of South Africa at the request of the Government of the United Kingdom at Durban the 28th October, 1958, and valid until the 27th October, 1960.
(b) An International Load Line Certificate issued at London on the 13th November, 1956, by Lloyds Register of Shipping, and valid, subject to annual survey, until the 12th November, 1961.
(c) A Safety Radiotelegraphy Certificate, issued under the authority of the Government of New Zealand at Wellington, on the 14th April, 1958, and valid until the 13th April, 1959.
The ship was well found as regards anchors, cables, steering gear, compasses, direction finder, echo sounder, charts, deep sea sounding machine and hand lead.
The information obtainable about previous repairs dates back to 1952, when in May to August of that year major repairs were carried out at Smith’s Dock, North Shields. On this occasion both main engines were taken ashore in parts for the purpose of re-riveting and stiffening the seatings.
The owners have no record of any alterations having been made to the overflow system from the settling tanks as installed when the ship was built. Comparison with the sister ship shows that a considerable modification was in fact made. This modification virtually eliminated the safety overflow system. On the occasion of the refit at North Shields the settling tank mountings were overhauled and new cables to the two float level indicator switches were provided.
The machinery was under running survey, the last cycle being completed in November, 1956, at Hamburg. On the occasion of the special survey at Hamburg in November, 1956, both settling tanks were emptied, cleaned and examined internally, but no repairs were found necessary. At New Orleans in February, 1958, repairs to the wiring and settling tank float switches were carried out according to the following specification:â€”
Approximately 40 feet of conductor cables for tank level float switches renewed.
Float switches repaired as found necessary for same to operate properly.
On completion recommended all parts disturbed and tested to be in good working order.
The ship had been regularly inspected by surveyors to Lloyd’s Register of Shipping, the last special survey having been carried out in October-November, 1956, at Hamburg. The last annual load line survey was carried out in January, 1958, at Liverpool by a ship surveyor to Lloyd’s Register of Shipping.
At 1600 hours on the 5th November the “Forresbank” left Cape Town bound for Durban having on board the Master and 54 members of crew including the master’s wife borne on the articles as a supernumerary. The draught on departure was 11 feet 11 inches forward, and 14 feet 8 inches aft. On board were approximately 208 tons of deadweight cargo and bunkers to the extent of approximately 273 tons of Shell marine diesel oil distributed between No. 3 double bottom tank, “A” tunnel deep tank and possibly a few tons in B, C and D tunnel tanks. The remainder of the tanks including the deep tanks, forward of the engine room, were ballasted. The vessel was fully equipped and was considered by her master to be in a seaworthy condition. Two certificated deck officers in addition to the master were carried. The chief engineer also was certificated, but the second engineer was sailing on a dispensation granted at Liverpool in December, 1957.
The Court is anxious not to overload this report with irrelevant matter even though some prominence was given to such irrelevancies during the course of the hearing. In the opinion of the Court the matters dealt with in Question 7 (infra) have no bearing upon the causes of the fatal fire. Their only significance is that they required the almost continuous attention of all the engineer officers over a period of upwards of 12 hours, and it was probably owing to pre-occupation with this repair that a small fire occurred in the engine room at about 2130 hours on the 6th November, in the following circumstances.
Before the completion of the repairs the senior third engineer had reason to go up to the cylinder tops from the lower platform and on his way his attention was directed to the port settling tank which was overflowing. He was able to see oil fuel running down the outboard side of the forward-facing side of the tanks, and he immediately shouted, Stop the pump”, and whether as a result of the shout or because of some other prompting the electrically-driven oil fuel transfer pump was almost immediately shut off. Almost at the same moment he saw a sheet of flame between the No. 6 (aftermost) cylinder of the port engine and the port settling tank. He then shouted “Fire”, and the engine room staff, with the aid of two-gallon foam fire extiniguishers, were able rapidly to put out the fire. It would appear that the flames on this occasion were about one foot in height and seemed to rise from the after end of the exhaust manifold of the port engine. Other engineers who saw this fire said that afterwards they saw oil fuel running down the forward-facing and port outboard sides of the port settling tank and that a quantity of oil had accumulated on the oil tight flat on which the settling tanks stand.
The Court is satisfied that the port settling tank overflowed on this occasion because the electrically-driven centrifugal transfer pump was not stopped when the tank was full, and that the failure to stop the pump at the right moment was due to a misunderstanding between two of the hard-pressed junior engineers.
It is pertinent here to notice that the port and starboard settling tanks were each fitted with an indicator controlled by a float and that the indicator balance weight was designed to actuate a lever-operated switch, and it was intended that this switch should be put into the “off” position by simple mechanical action when the indicator showed the tank to contain 1,600 gallons. As has been stated the cut-out switch mechanism for each tank had been overhauled at New Orleans in February, 1958. This was done to the chief engineer’s satisfaction but it is clear upon the evidence that at the time of the casualty and for some considerable time before neither switch was operating.
The reactions to this fire on the part of the ship’s personnel are of interest and important. The chief engineer, John McIntyre MacLachlan, who holds a Chief Engineer’s Steam Certificate of Competency with diesel endorsement and who had been with the Bank Line for about 27 years, was asked a number of questions about the settling tanks and about the first fire and the relevant passages of his evidence are here set out:â€”
” (Q) It was said that when you were filling up either one or other of the settling tanks, when the indicator came down to ‘Full: 1600 gallons’, that operated the trip switch and cut off the electric motor to the oil transfer pump? (A) Yes.
” (Q) Was that trip switch working? (A) No.
” (Q) When did it stop working? (A) I do not knowâ€”several months before the accident.
” (Q) Was it mended at New Orleans? (A) Yes.
“(Q) How long did it work after it was mended? (A) Quite some time-several months, I should say”.
. . . .
” (Q) Can you tell the Court anything about the fire in the engine room on the 6th? (A) There was a little bit of fire at the after end of the port exhaust manifold, but when I got there it was more or less just fumes and smoke. The lads had been at it with extinguishers.
” (Q) That was all that went on when you arrived? (A) Yes…
” (Q) Where were the fumes coming from? (A) From the after end of the exhaust manifold.
” (Q) Which engine? (A) The port engine.
” (Q) Can you say anything about the port settling tank at that time? (A) I did not see much leak coming from the port settling tank at that time.
” (Q) Did you see any leak? (A) A little.
” (Q) Where? (A) From round the side of the tank.
” (Q) The port side? (A) The port side.
“(Q) When you say ‘leak’, do you mean leak or overflow? (A) Well, leak or overflowâ€”a very small overflow”…..
” (Q) What did you do about it” (the leak)? (A) We were pretty busy and we did not get around to that thing.
“(Q) The answer is ‘Nothing,’ is it? (A) Nothing.
” (Q) You are the chief engineer. Did you make any enquiry? You had had a fire when you saw (sic) fumes, and the fumes were coming from the exhaust pipe of the after end of the port engine? (A) Yes.
“(Q) Did you enquire of the officer of the watch: ‘How did that fire come about? What caused it?’? (A) He could not give me any answer
. . . .
“(Q) Did you ask the officer of the watch, ‘How come these fumes I have seen coming from the exhaust pipe and the after end of the port engine?’? (A) Yes. I asked Mr. Docherty”. (Junior third engineer).
” (Q) What did he report to you? (A) He said he did not know how it happened.
” (Q) If the officer of the watch did not know how it happened, what did you do to find out yourself how it happened? (A) At that time we were very busy.
” (Q) Is the answer nothing? (A) Nothing.
. . . .
” (Q) All you saw this time was a little oil coming down outside the port settling tank, and some fumes coming from the exhaust pipe at the after end of the port engine?. (A) Yes.
“(Q) You are a man of considerable experience. Did you not put the two together and say, ‘This is rather funny, I must enquire into this’? (A) I am afraid I let it slip; I slipped up there”.
The second engineer, James Wilson, who was sailing under a dispensation, had said in a deposition: “Following the repairs to the settling tank cutout switches at New Orleans in February, 1958, I assumed they were in order. It was never reported to me that they were not working”, and in evidence he gave the following answers:â€”
” (Q)…. What do you know about these switches? (A) When I made my statement I assumed they were in working condition.
“(Q) You assumed they were in working condition and you never used them? (A) Not myself.
“(Q) You never yourself had occasion to use them because you never so filled up the tank that it would be within fifty gallons of the indicator getting into such a position that the motor would be cut out? (A) Yes.
“(Q) I think what we want your help about is this. Other witnesses who have been here have said that they knew these switches were not working, and it is rather odd that you, as the second engineer, although you never had occasion to see whether they were working, thought that they were working. That is a very different attitude, yours being different from theirs, is it not? (A) Yes”.
On the more immediate topic of the fire on the 6th he gave the following answers:â€”
” (Q) Have you any idea as to what caused the fire and what was burning? (A) The port settling tank appeared to be leaking. There was oil on the grating and also oil on the angle of the tank, front and side, where it was running over the port settling tank.
” (Q) Where was it running over the port settling tank? (A) On the angle of the tank, on the front and on the side.
” (Q) What have you got in mind when you say running over’? What does that mean? You used the words ‘running over’, so would you explain? (A) Oil running down the side of the tank. It appeared to be an overflow.
” (Q) It appeared to be an overflow? (A) Yes.
” (Q) Have you got any reasons as second engineer for thinking how an overflow could have happened? (A) I assumed it was coming from the hole through which the indicator wire went through the tank.
” (Q) How would it come out of there unless the tank was full? (A) The tank would have to be full.
” (Q) Would it not have to be overfull? (A) Yes.
” (Q) It would have to be pressed up, would it not? (A) Yes.
” (Q) What would cause that? (A) The pump down below.
. . . .
” (Q) At this time was the pump working or was it not working? (A) When Mr. Docherty called ‘Fire’ I immediately told the fifth or sixth engineer to shut the pump off.
” (Q) So that at the time when you heard the word ‘Fire’ you called out, ‘Shut off that pump’? (A) Yes.
” (Q) Do you now know whether the pump was working at that time? (A) The pump was running.
” (Q) It was running? (A) Yes.
“(Q) So this was the position on the 6th: someone called out ‘Fire’ and the pumping up into the port settling tank was going on? (A) Yes.”
. . . .
” (Q)…. But what do you thinkâ€”in your own mindâ€”from the evidence you have given and from what you know about it, was the cause of the fire on the 6th? (A) The oil getting on to the exhaust manifold.
” (Q) How did it get there? (A) It must have come down the side of the tank. The weather was rough and some of it must have spilled over, got on to the platform and seeped down from the edge of the plate on to the exhaust manifold.
” (Q) How did it get out of the tank? (A) In my estimation it came out through the hole where the wire went in.
” (Q) Through where? (A) The hole in the top of the tank where the wire went through, the indicator wire.
” (Q) That is a half-inch hole? (A) Yes.
” (Q) You would not get very much oil out of that, would you? (A) There was not very much oil coming down the side of the tank.
” (Q) Yet a fire was started? (A) Yes.
” (Q) Is that really what you think? (A) Yes, that is what I thought then ”
The junior second engineer, Brownlie, dealing with the settling tanks gave evidence as follows:â€”
” (Q) Supposing you do not turn off the electric motor to the pump, what happens? Is there an electric cut-out, or anything of that sort? (A) There was one but it was not working.
” (Q) For how long had it not been working, so far as you can remember, Mr. Brownlie? (A) Seven or eight months.
” (Q) Had you seen anything of an engineer superintendent during those seven or eight months? (A) No, sir.
” (Q) Did you yourself say anything about the cut-out? (A) It is a trip switch.
” (Q) Did you say anything about the trip switch? (A) No, sir, not to the superintendent”.
. . . .
” (Q) Was there a separate switch to each tank? (A) Yes.
” (Q) Was each of those switches out of action? (A) Yes.
” (Q) Had each been out of action about the same length of timeâ€”you gave us seven months earlier? (A) Yes.
” (Q) Had they been deliberately disconnected? (A) No, sir, not to my knowledge.
” (Q) What had caused them to go out of action? (A) I do not know, sir.
. . . .
” (Q) Was the whole engineer staff of the ship aware that they were not working? (A) Yes.
” (Q) Do you know whether the fact that they were not working had ever been reported? (A) I reported it.
” (Q) To whom? (A) The chief engineer.
” (Q) Did you ever log the fact that you had reported it? (A) No, sir”.
. . . .
” (Q)…. when you said that you reported the fact of the cut-off switches being out of action to the chief engineer, do you remember how long before the fire that wasâ€”was it about a month or two? (A) More, sir.
” (Q) When was it? (A) Somewhere around the end of March or the beginning of April, I believe it would beâ€”March or April.
” (Q) Is that about the same date when you think they first broke down, when you said seven or eight months, or later than that? (A) That would be about it.
” (Q) They had I think been overhauled, or the indicator system had? (A) Yes.
” (Q) When was that done? (A) It would be about February.
” (Q) That was in New Orleans? (A) Yes.
“(Q) Were they working satisfactorily on the completion of that overhaul? (A) Yes; they worked for about three weeks”.
The only other witness whose evidence about the first fire is of importance is the master, Captain Bruce Thomas Simmonds, the holder of a Foreign-going Master’s Certificate (Steamship), obtained in October, 1953. When the fire occurred Captain Simmonds was in his cabin when he heard a shout of, “Fire in the engine room”. He went straight to the engine room and on his arrival there found the fire was already out although smoke and fumes were still present in the engine room. Captain Simmonds questioned the chief engineer and the second engineer about what had happened and was informed by the second engineer that there had been some carelessness with the filling of the settling tank and that it had overflowed. According to the master, the second engineer did not tell him whose was the carelessness, nor did he say what the nature of the carelessness was, but simply that “it had been allowed to overflow”.
Captain Simmond’s evidence continued:â€”
” (Q) Were you satisfied with that or did you ask or cross-question anybody about it or make any further investigations yourself? (A) I was satisfied that the fire had been put out most efficiently. I was satisfied it was out and I was also satisfied that they knew what had happened and I certainly did not expect it to happen again”.
No entry relating to this occurrence was made in the log at the time.
Then, after having been questioned about the possible connection between the first and second fires, Captain Simmonds was asked:â€”
” (Q) Looking back, do you think that you paid quite enough attention to the first fire when it was first reported to you? (A) Possibly not.
” (Q) Did you in fact ask for a succinct statement from the chief engineer on what he was saying was the cause of the first fire? (A) A written statement?
” (Q) No, any kind-though written would have been the best of all, of course? (A) No; I was satisfied that they knew what had happened.
” (Q) Yes, but were you satisfied that you knew what had happened? (A) I took their word for what had happened.
” (Q) What did they suggest to you had happened? (A) Carelessness as regards filling the settling tank and it had overflowed.
“(Q) did you get as far as wondering or asking what sort of carelessness? (A) No, sir”.
The Court has to try to place itself in the position of men who have experienced a minor fire, easily extinguished, the cause of which they thought they knew and understood. So viewed the matter calls for leniency in judgment. At the same time the Court is of opinion that a higher standard of discipline, vigilance and alertness might have led to such an examination of the causes of the first fire and inspection of the tank which was known to have overflowed as to lead to the discovery of the state of affairs which was later revealed to be and which the Court is satisfied was the cause of the major disaster.
The engine room of this vessel was without question managed in a slack and slovenly fashion. The evidence bristles with justification for this criticism. Although the uncertificated engineer officers showed human qualities of a high order in some respects and were no doubt doing their best to “work up” an old and perhaps rather heartbreaking engine room, they lacked the authority and the personality to overcome the poor tone and low standard set by the chief engineer. There was evidence before the Court that it is hard in these days to secure the services of good certificated engineers. If this be so it is for the Ministry and the shipping organisations to study the causes of this difficulty and to sponsor determined efforts to overcome it.
The fire which led directly to the abandonment and loss of the “Forresbank” occurred in the middle watch on the 9th November, 1958. Junior Second Engineer Brownlie and Fifth Engineer Paul had come on watch at midnight and had found both main engines running at about 118 r.p.m. but with No. 3 cylinder of the starboard engine out of action. The fuel oil for the auxiliary boiler and main engine was being supplied from the port settling tank which at about midnight is said to have contained 700 gallons. The starboard settling tank was full and the outlet valves from that tank to the main engine and the boiler were shut.
On taking over the watch Junior Second Engineer Brownlie was concerned about the condition of the bilges. It appears that water was over the tank top and the engineer who had handed over to Brownlie had stated that he had been unable to pump the bilges. Brownlie and Paul immediately set to work to try to clear the bilge suction valves and the strum boxes which were fouled and blocked with rags, waste paper and pieces of wood said to have been left behind by shore repairers. Even after a good deal of work by both engineers of the watch it was still impossible to clear the bilges and this state of affairs must have caused the senior engineer of the watch considerable uneasiness of mind. It is another of those matters which have suggested to the Court that this was not a well-maintained engine room and that the discipline in it was lax and the control by the chief engineer happy-go-lucky.
After having worked towards clearing the bilges up to about 0200 hours Junior Second Engineer Brownlie appreciated that the time had come to change over the settling tanks. According to him some 300 gallons from the port settling tank had been consumed in the first two hours of the watch so that when the change-over took place, and upon the assumption that it had contained about 700 gallons, some 400 must have remained at midnight. The Court finds difficulty in accepting that even so old a vessel as this could have consumed 300 gallons in two hours; this is equivalent to about 14 1/2 tons per day and it must be remembered that there was other evidence that the ship when loaded and making an average speed of ten knots at 115 r.p.m. had an average daily consumption of 9 1/2 tons. There is no reason to suppose that Junior Second Engineer Brownlie did not manipulate the valves correctly or that he did not start the fuel oil transfer pump at approximately 0200 hours although as has already been indicated the Court cannot accept that any of these times were accurately observed. They certainly were never logged.
Having started the pump, Junior Second Engineer Brownlie went back to the business of clearing the bilges, he himself being at the forward end of the engine room on the port side while Fifth Engineer Paul was at work on the starboard side. In the position in which he was working Junior Second Engineer Brownlie could not see the indicator on the port settling tank. It was apparently the assumption of all the engineers who ever operated the fuel oil transfer pump for the purpose of filling up the settling tanks that the pump delivered oil at the rate of 50 gallons per minute but the Court finds it difficult to believe that this was an established constant rate. It must have varied with any changes or fluctuations in the supply of electricity, the viscosity of the oil and the condition of the pump itself. Junior Second Engineer Brownlie relied on the engine room clock for the purpose of measuring the period necessary to deliver 1,000 gallons to the tank. According to Junior Second Engineer Brownlie he turned aside from what he was doing to look at the engine room clock and seeing that it stood at “approximately 2.20” went and stopped the fuel oil transfer pump, then went to a position from which he could see the indicator and saw that it was registering 1400. Having done that he went over to the starboard side of the engine room to see how Fifth Engineer Paul was progressing with his work of clearing the bilges and a moment or two later was walking aft on the starboard side of the ship with Paul when they met the Asian donkeyman who was in a state of panicâ€”shouting, screaming and gesticulatingâ€”and upon looking in the direction to which he was pointing they saw “a wall of flame” blazing up and dropping down at the after end of the engine room, obscuring the settling tanks from their view. Both officers made attempts to use two-gallon fire extinguishers but in the opinion of the Court the fire had already obtained such mastery that these attempts were useless, and this phase of the occurrence came to an end when both engineer officers reached the tunnel door. What was done thereafter, in so far as it is not covered in the answers to the questions, is dealt with in a later paragraph.
It is now known, because it was discovered by Mr. Knowles after the stranding of the vessel, that there was a hole about six inches in diameter in the top of the port settling tank. This aperture was left in the top of the tank owing to the removal, at some time unknown, by some person unknown, for a purpose unknown, of the plate originally fitted to cover the aperture and it is quite obvious that large quantities of oil could escape from this hole even in smooth sea conditions if the tank was pressed up by the pump and in rough sea conditions even if the tank was a little slack. It is a remarkable feature of this case that nobody on board this ship knew that the top of the tank was in this condition and no evidence was called before the Court to suggest how the absence of the covering plate came about.
Junior Second Engineer Brownlie is convinced that he stopped the fuel oil transfer pump at a time which he believes to have been 0220 hours and that the indicator then showed 1,400 gallons. The Court is not forced by the evidence in this case to make a finding which impugns the truthfulness of this witness. The Court is not satisfied that the fuel oil transfer pump was delivering at a steady and constant rate of 50 gallons a minute; it may have been delivering at a higher rate. The Court is not satisfied that Junior Second Engineer Brownlie knew precisely at what hour he started the fuel oil transfer pump nor the precise hour at which he switched it off. There was evidence that the indicator had sometimes failed to record the amount of oil in the settling tank correctly through some form of sticking or from a dislocation of the wire. The Court is of opinion that considerable overflowing from the port settling tank had occurred before Junior Second Engineer Brownlie stopped the pump and that a fire which may have started as a small one like that on the 6th increased through the ignition of the considerable quantity of oil which must have been in the save-all tray leading in due course to combustion of the oil in the tank itself. The Court had reliable evidence that fuel oil of the kind in use in the “Forresbank” will under test conditions ignite without a spark or flame at a temperature of about 550ÂºF. The exhaust manifolds (which were cooled by water when the engines were new but had been the subject of a modification which did away with the water-cooling) were constantly at a temperature considerably in excess of that figure and once the oil in the save-all caught fire very high temperatures would quickly develop all round the settling tanks.
The Court, having been invited by Counsel for the Ministry of Transport and Civil Aviation to regard this investigation as one primarily directed to the causes of the fire, the Court considers it unnecessary to deal with the action taken by the officer of the watch, the master and the radio officer beyond what appears in the answers to the questions, save to say that these matters do not call for criticism.
It is, however, proper to signalise in this Annex the Court’s admiration of the humanity, courage and devotion to duty of Junior Second Engineer Brownlie and Fifth Engineer Paul in reentering the engine room in the circumstances described in the answer to Question 15. These young officers were in grave peril of themselves being overcome by the heat and smoke in the engine room and they did all that men could do to try to save the donkeyman, Assad Ali, whose agonising death all must sympathetically deplore.
It is difficult in the circumstances of this case to pass judgment upon any person or persons in respect of what the Court believes to have been the most important single factor leading to this calamity, viz. the opening in the top of the port settling tank. The tops of the settling tanks are only about 2 feet 6 inches below the deck head and no routine inspection of the engine room would be likely to take any of the ship’s engineers on to the top of the tank. The Court feels, however, that the covering plate must have been removed at some time in connection with some cleaning or repair of the settling tank and/or its indicator and in the opinion of the Court when a chief engineer knows that a tank of this sort has had to be opened up for any purpose the proper practice is for a complete examination of the tank by the ship’s engineers to be made before it is put back into service so that any blunder on the part of e.g. shore repairers, who are not infallible, may be detected by those who have to continue to work the ship. Unfortunately in this case it is impossible to discover when this covering plate was removed so that no blame can be imputed to any named individual on that account.
One or two consequential and collateral matters fall now to be considered. The Court is asked in Question 3 whether the life-saving appliances and the fire-extinguishing appliances of the “Forresbank” were in accordance with the statutory requirements and properly maintained. The Forresbank” sailed on her last voyage with all the necessary official certifications in these respects although the statutory requirements had not been strictly complied with under either head. So far as the life-saving appliances are concerned the Court is satisfied that the deficiency, which lay in the non-operability of the motor lifeboat, was of no importance in the events which happened and that the official who granted the certificate in this respect was justified in allowing the “Forresbank” to sail from Durban to Cape Town and back, voyages which he properly regarded as coasting voyages. So far as the fire-extinguishing appliances are concerned, these were unsatisfactory in a number of details, owing to the fact that a change-over from one type of hose to another was in progress and not all the nozzles had been fitted to the new hoses; but since in the opinion of the Court the fire-extinguishing appliances carried in this ship could have had no effect upon this conflagration by the time it had been detected, the matter is of little importance.
It is quite certain that in the circumstances of this fire the two-gallon extinguishers, which were the only ones ready to hand when the engineer officers became aware of the fire, turned out to be little better than playthings. Whether one or more ten-gallon extinguishers would have made any impression upon the blaze is uncertain. Those carried in this engine room became inaccessible as soon as the fire got a hold. It is emphasised that careful thought must be given to the positioning of larger extinguishers at strategic points in engine rooms so that a reasonable chance of finding one or more to be accessible at the commencement of a fire may be assured. It is well known that modern developments have led to the equipping of new ships with much more satisfactory fire-fighting appliances. It is all the more important that attention be given to this matter in older vessels still trading.
The question of the emergency diesel-driven fire pump is dealt with only because some general lessons may be learned from the fact that although the diesel engine could easily be started, the pump. positioned at the height above the water at which it stood at the material time, could not be got to deliver water. Evidence as to the performance of this pump prior to the casualty is unsatisfactory and conflicting. There is no doubt but that it failed completely on the 9th November. This fault would have been revealed on previous occasions and noticed on survey if positive isolation of its piping system had been insisted upon. There is no evidence that such insistence was ever made. A pump situated aft should not be thought of in theoretical terms which may assume a lift of as much as 20 feet in still conditions. With a vessel in ballast trim pitching may expose the suction and cause fluctuations of intake with the possibility of complete failure; the hull lines aft, moreover, create conditions very different from those obtaining in a static installation. Mr. Knowles, speaking of this pump said: “…. the lighter the draught when placed as in this ship, the more one has to resort to some rather constant priming to get the thing to suck. But once it draws we have found it very efficient indeed”. A flooded suction should avoid any necessity for priming which seems to have caused difficulty and frustration on the “Forresbank”. An electrically-driven unit placed lower down in the vessel would reduce the lift the pump is required to achieve. The Court must leave further consideration of this matter to the experts.
The Court was further asked the question (Question 6): “Was the ‘Forresbank’ in all respects seaworthy at the commencement of her voyage from Cape Town?” This is a difficult question and the reason for asking it in the general context of this case is not clear. Learned Counsel instructed by the Treasury Solicitor for the Minister, in making his submissions to the Court as to what would be the proper answer, said: “My instructions are, Yes, but bearing in mind two matters, the minor matter …. (irrelevant) …. and the perhaps not quite so minor matter of the uncovered hole in the port settling tank, my instructions are that that of itself would not make her unseaworthy”. Learned Counsel for the owners submitted that the test which the Court ought to apply as a matter of law in saying whether the ship is unseaworthy or not is: “What would a prudent master do if faced with the decision to take her to sea or not?” It is clear that there is no single standard of seaworthiness applicable to all cases. As a matter of law the question would be one for a Court to direct itself upon as it would direct a jury. Doing its best to act upon that principle the Court feels able to answer the question propounded in the affirmative notwithstanding the answer of Mr. John Davidson, engineer superintendent of the Bank Line to the following question put by the Court which is here recorded because it has received outside publicity: “(Q) If the top of the settling tank was in the condition you see there (viz. with the 6-inch diameter hole uncovered) and if there were no automatic tripswitches operable controlling the filling of the settling tanks, given those two postulates, what is the answer to the question: was the vessel seaworthy? (A) No”.
One or two relatively minor matters which have no direct bearing on the cause of this casualty must now be noticed. (a) The evidence in this case failed to satisfy the Court that boat drills coordinated as between the deck and engine room departments were held at proper intervals.
(b) Attempts to use the smoke helmet breathing apparatus revealed the fact that extensions to the 60 foot length of hose provided with each set of equipment could not be made owing to the nonmatching of the unions. Apparently equipment is supplied with one 60 foot length of hose and no allowance was made for the fact that it may be necessary to increase the length of hose in order to ensure that the bellows may remain in a smoke-free air space. (c) The evidence tended to show that no one in the deck department knew anything about the emergency fire pump in the steering flat.
Since it is possible to envisage disasters in which the whole of the engine room staff is cut off or disabled, it would seem proper that the deck department should have knowledge of and means to operate a pump of this sort.
QUESTIONS AND ANSWERS
The Court’s answers to the questions submitted by the Minister of Transport and Civil Aviation are as follows:â€”
Q. 1. By whom was the “Forresbank” owned at the time of her loss, and who was her designated manager?
A. The Bank Line Limited, 102 Hope Street, Glasgow; James Goddard Young, 21 Bury Street, London, E.C.3.
Q. 2. Where, when and by whom was the “Forresbank” built?
A. Glasgow; 1925; Harland and Wolff Limited.
Q. 3. Were (i) the life-saving appliances (ii) the fire-extinguishing appliances of the “Forresbank” (a) in accordance with the statutory requirements and (b) properly maintained?
A. See Annex.
Q. 4. Did the “Forresbank” leave Cape Town for Durban at about 1600 local time on the 5th November, 1958?
Q. 5. Was the “Forresbank” under the command of the master, Bruce Thomas Simmonds, and did she carry a crew of 55 hands all told and no passengers?
Q. 6. Was the “Forresbank” in all respects seaworthy at the commencement of her voyage from Cape Town?
A. See Annex.
Q. 7. (a) During what period on the 6th November, 1958, was the starboard engine stopped?
A. From 1049 hours to 2322 hours.
Q. (b) What was the cause of the stoppage?
A. A bottom-end bolt of the No. 3 unit sheared.
Q. (c) What repairs were then effected to the starboard engine?
A. Two bottom-end bolts were renewed and No. 3 exhaust valve was drawn. This allowed the engine to run on five cylinders.
Q. (d) While the starboard engine was stopped did the “Forresbank” proceed on her port engine only?
Q. (e) When the starboard engine was set under way again, was it normal in every respect?
A. No, it was working on only five cylinders with the exhaust of No. 3 open to the atmosphere.
Q. 8. (a) At about what time on the 6th November, 1958, did a fire occur in the engine room of the “Forresbank”?
A. Shortly after 2130 hours.
Q. (b) Where was the seat of the fire?
A. The after end of the exhaust manifold of the port engine.
Q. (c) How was the attention of the engineer officers drawn to the existence of this fire?
A. By visual observation.
Q. (d) Was fuel oil being pumped into the port settling tank at the time the fire broke out, and, if so, by what means?
A. Yes, by the fuel oil transfer pump.
Q. (e) Who tackled the fire, and with what appliances?
A. Members of the engine room staff; with two-gallon fire extinguishers.
Q. (f) How long did it take to extinguish the fire?
A. About five minutes.
Q. (g) What damage was caused by the fire?
A. No apparent damage.
Q. (h) What was the cause or origin of the fire?
A. Oil overflowing from the port settling tank, coming in contact with the exhaust manifold at the after end of the port engine.
Q. (j) Was the existence and extinguishment of the fire reported by the engine room to the bridge and, if so, when and by whom?
A. See Annex.
Q. (k) Were (i) any enquiries subsequently made as to the cause and origin of the fire, and (ii) were any steps then taken to prevent a similar fire occurring?
A. See Annex.
Q. 9. (a) Who were on watch in the engine room during the middle watch, commencing midnight 8th/9th November, 1958?
A. Ronald Craig Finley Brownlie, junior second engineer; Robert Walter Paul, fifth engineer.
Q. (b) At the commencement of the watch what engines were running, and what auxiliary machinery was in operation?
A. The port engine, and the starboard engine on five cylinders. One of the two oil fuel units; the steam-driven air and circulating pump for the condenser; the steam-driven electric generator; the electrically-driven bilge and ballast pump; the electrically-driven piston cooling pump; the electrically-driven general circulating pump, supplying water to the main engine cooling system, refrigerator, sanitary water, fire and wash deck, piston cooling water cooler and lubricating oil cooler; the electrically-driven lubricating oil pump.
Q. (c) From what source was the oil for the main engine and auxiliaries being supplied at the commencement of the watch?
A. The port settling tank.
Q. (d) What was the state of the bilges at the commencement of this watch, and what action was then taken in regard to the bilges?
A. Full, and the suctions obstructed with rags and other debris, with water over the tank tops; attempts were made to clear the bilge suction valves and strum boxes.
Q. 10. (a) At about what time during the said middle watch was it decided to change over the fuel oil settling tanks?
A. About 0200 hours; but it is doubted whether this or any subsequent time was accurately observed.
Q. (b) Who made this decision?
A. The junior second engineer.
Q. (c) What action was taken, and by whom, to carry this decision into effect?
A. The appropriate valves were opened and closed respectively, and the electric oil fuel pump started by the junior second engineer, Brownlie.
Q. (d) Was the oil fuel transfer pump stopped thereafter and, if so, when and by whom?
A. See Annex.
Q. (e) At this time was the automatic cut-out operational?
Q. (f) What readings were shown on the tank float indicator during this period?
A. See Annex.
Q. (g) Were these readings accurate?
A. See Annex.
Q. (h) During this period how much oil was there in the oiltight flat?
A. Oil to a depth of one to two inches.
Q. 11. (a) What duties were being performed by the junior second engineer, Brownlie, at about 0220 local time on 9th November, 1958?
A. Attending to the condition of the bilges (see 9 (d)), and glancing from time to time at the indicator on the port settling tank.
Q. (b) What duties were being performed respectively at about the same time by (i) Junior Engineer Paul and (ii) Greaser Ahmedi?
A. (i) Attending to the trouble in the bilges; (ii) oiling a pump at the starboard after end of the engine room.
Q. (c) Was there an outbreak of fire in the engine room at about this time?
Q. (d) How was the attention of the engineer officers first drawn to the existence of the fire?
A. By the shouts and gesticulations of the donkeyman, Assad Ali.
Q. (e) What was the appearance and character of the fire when first seen by the engineer of the watch?
A. A wall of flame.
Q. (f) What then appeared to the engineer of the watch to be the seat of the fire?
A. The after end of the engine room.
Q. (g) On becoming aware of the existence of the fire what action did the junior second engineer take?
A. Operated a two-gallon foam fire extinguisher handed to him by the greaser, directed it down on to the tank tops, telephoned the bridge, stopped both main engines, moved to the tunnel door. (See Annex).
Q. (h) On becoming aware of the existence of the fire what action did the junior engineer take?
A. Took a two-gallon fire extinguisher, advanced towards the fire, operated the fire extinguisher, operated another partly exhausted fire extinguisher discarded by the junior second engineer, moved to the tunnel door. (See Annex).
Q. 12. (a) What drew the attention of the officer of the watch (on the bridge) to the existence of the fire?
A. The stopping of the main engines and the sight of sparks coming from the engine room skylight.
Q. (b) What action did he then take?
A. Upon being ordered by the master to ring the fire alarm, went forward to the forecastle and rang the ship’s bell.
Q. 13. (a) Upon being aroused what action did the master take?
A. Got out of bed, put on a boiler suit, went to the starboard door of the engine room, met the chief engineer on the deck and learned that a man was trapped below. Went aft to check the use of the breathing apparatus, returned amidships and checked that the wireless officer was on duty, ordered the second officer to check the ship’s position by dead reckoning, supervised the closing of skylights, vents and openings; after satisfying himself that the trapped man had perished, ordered the steam smothering to be opened. (See Annex).
Q. (b) What orders did the master give?
A. See (a) above.
Q. (c) How were these orders carried out, and by whom?
A. See Annex.
Q. 14. (a) Meanwhile what action was being taken by the engineers to control the fire?
A. See 11 (g) and (h).
Q. (b) What orders were given to the radio officer, and with what results?
A. To transmit an S.O.S. message; this was picked up by shore stations at Durban and Cape Town and by the British steamship “City of York”.
Q. (c) Was there at this time water in the fire main and, if not, why not?
A. Yes; but there was no pressure after the electricity failed.
Q. (d) What happened about this time to the ship’s lighting?
A. It flickered and went on and off for a short time, and then failed altogether.
Q. (e) Was the emergency diesel driven fire pump then resorted to, and, if so, with what result?
A. The diesel engine driving the pump was started, but water could not be drawn and none was delivered.
Q. 15. (a) How was the greaser, Sultan Ahmedi, got out of the engine room?
A. By the courageous action of the junior second engineer, Brownlie, who, having got out of the engine room by the tunnel door, reentered it in his ordinary clothes and without any breathing apparatus, in thick smoke and intense heat, located the greaser by seeing the gleam of his electric torch, seized him by the hand and pulled him to the tunnel door.
Q. (b) What attempts were made, and by whom, to rescue from the engine room the donkeyman, Assad Ali?
A. The junior second engineer, Brownlie, after getting the greaser into the tunnel, returned again into the engine room where he could hear the donkeyman shouting, but was overcome by the heat and smoke and only just managed to get out of the engine room himself. A few minutes later the fifth engineer, Paul, entered the engine room wearing a smoke helmet and penetrated almost to the forward bulkhead, but was unable even to hear the donkeyman; Paul had to be pulled out of the engine room since the bellows were delivering smoke-laden air to the smoke helmet.
Q. (c) Were these attempts successful and, if not, why not?
A. See (a) and (b).
Q. 16. (a) At about what time did the master order the steam smothering to be turned on?
A. About 0300 hours; but it appears that this was fitted only in way of the boiler.
Q. (b) What effect on the fire did this have?
Q. (c) At about what time was an S.O.S. message sent out?
A. About 0245 hours.
Q. (d) What were the results of such message?
A. The only result of any materiality was the arrival of the “City of York” at about 0900 hours.
Q. (e) What did the radio officer do with the portable lifeboat radio?
A. Placed it in No. 3 lifeboat.
Q. 17. (a) At about what time did the master give the order to abandon ship?
A. About 0430 hours.
Q. (b) At this time what was the state and extent of the fire?
A. Flames from the engine room skylights were reaching nearly to the height of the funnel; flames were coming out of the top of the funnel. The fire had reached the wireless room, the boat deck was alight in various places, the engineers’ accommodation was burning furiously and access to No. 4 boat was barred by the flames.
Q. (c) Was the ship abandoned by the 54 survivors using the ship’s boats without further casualties?
Q. (d) At this time what was the state of the weather, wind and sea?
A. Clear; wind about south-westerly, force 2; moderate swell.
Q. (e) While the boats were in the water what action was taken with regard to the portable lifeboat radio, and with what result?
A. It was floated from No. 3 lifeboat to No. 1 lifeboat, in which the wireless operator was, whereby it sustained such damage by wetting that it became useless.
Q. 18. (a) At about what time was the ship reboarded?
A. At about 0630 hours.
Q (b) With what motive was the ship reboarded; and by how many men?
A. It having been observed that the fire had diminished, it was hoped that further firefighting might be possible and that with the ship manned it would be practicable to effect a towage connection with a tug which was expected to be on the way; twelve men.
Q. (c) Was the portable lifeboat radio then set up, and, if so, with what result?
A. Yesâ€”see 17 (e).
Q. (d) Was the emergency diesel driven fire pump then started, and, if so, with what result?
Q. (e) What other attempts to fight the fire were then made, and with what result?
A. Attempts were made to keep the burning decks under control with buckets of water, replenished from the domestic pump which was on the fore side of the engine room and still accessible.
Q. (f) At this time what part or parts of the ship were seen to be on fire?
A. The engineers’ accommodation having been completely burnt out no flames were visible there but the steelwork was red hot; wooden decks in the side alleyways were burning.
Q. 19. (a) Was there an explosion below at about 0730 local time on 9th November, 1958?
Q. (b) What then happened to the fire?
A. The whole midships section became a mass of flame.
Q. (c) What orders did the master then give, and with what result?
A. To abandon ship again.
Q. 20. (a) At about what time did the m.v. “City of York” come on the scene?
A. About 0900 hours.
Q. (b) Did the “City of York” rescue all survivors of the “Forresbank?”
Q. (c) At this time what was the state of the weather, wind and sea?
A. Clear; about south-westerly, force 6; heavy swell.
Q. 21. (a) At about what time did the tug “A. M. Campbell” arrive?
A. About 1700 hours.
Q. (b) At this time what was the state of the weather, wind and sea?
A. Clear; wind about south-westerly, force 7; very rough sea and heavy swell.
Q. (c) As a result of discussion between the masters of the “Forresbank” and the tug what decision was reached?
A. That the survivors should proceed to Durban in the “City of York” and that the tug should continue to stand by the “Forresbank”.
Q. (d) Did the “City of York” then proceed to Durban with the survivors from the “Forresbank”.
Q. (e) After the departure of the “City of York” what action did the tug take, and with what result?
A. Attempted to fight the fire with the aid of a fire pump, with a capacity of approximately 1,500 gallons per minute. When this attempt had to be abandoned, stood by and manoeuvred, keeping the casualty in sight as long as possible.
Q. (f) At about what time did the tug find the “Forresbank” stranded?
A. At about 0415 hours on the 10th November.
Q. (g) In what position did the stranding take place?
A. About 5 miles south-west of Rame Head.
Q. (h) Were any attempts made to refloat the “Forresbank”, and, if so, with what success?
Q. 22. (a) How many lives were lost and saved respectively?
A. One; fifty-four.
Q. (b) What were the circumstances in which loss of life occurred?
A. See 15 (b) and (c).
Q. 23. What was the cause of the fire which originated in the engine room about 0220 local time on 9th November, 1958?
A. The overflowing of fuel oil from the port settling tank, leading to oil becoming ignited through contact with the exhaust manifold at the after end of the port engine.
Q. 24. Was the fire referred to in Question 23 caused or contributed to by the wrongful act or default of any person or persons? A. No.
J. ROLAND ADAMS, Judge
J. E. COOPER
IVOR J. GRAY
The following appeared at the Inquiry:â€”
MR PETER BUCKNILL and MR GEORGE BEATTIE (instructed by the Treasury Solicitor) appeared as Counsel for the Minister of Transport and Civil Aviation. MR H. V. BRANDON (instructed by Messrs. Thomas Cooper & Company, 27 Leadenhall Street, London, E.C.3) appeared as Counsel for the owners (The Bank Line, Limited, 102 Hope Street, Glasgow) and the designated manager (James Goddard Young) of the m.v. “Forresbank”. MR R. F. STONE (instructed by Messrs. Ingledew, Brown, Bennison & Garrett, 136-138 Minories, London, E.C.3) appeared as Counsel for the master (Captain Bruce Thomas Simmonds) and the chief engineer (John McIntyre MacLachlan).
The following witnesses were called:â€”
MR RONALD CRAIG FINLEY BROWNLIE, junior second engineer on the “Forresbank”
MR ROBERT WALTER PAUL, fifth engineer on the “Forresbank”
MR JOHN McINTYRE MacLACHLAN, chief engineer on the “Forresbank”
MR JAMES WILSON, second engineer on the “Forresbank”
MR APURBA MUKHERJEA, junior third engineer on the “Forresbank”
MR NOEL ERIC DENDER, fifth engineer on the “Forresbank”
CAPTAIN BRUCE THOMAS SIMMONDS, master of the “Forresbank”
MR IVOR GAVIN MACAULEY, chief officer on the “Forresbank”
MR JOHN RUSSEL BEALE, second officer on the “Forresbank”
MR FREDERICK ALEXANDER SKINNER, acting third mate on the “Forresbank”
MR ALFRED ALASTAIR LAMONT, radio officer on the “Forresbank”
MR JOHN DAVIDSON, senior superintendent engineer employed by Messrs. Andrew Weir & Company
CAPTAIN ALEXANDER SCORBIE, chief marine superintendent to Messrs. Andrew Weir & Company
CAPTAIN RICHARD GERALD GARDNER, nautical surveyor and examiner employed by the Government of South Africa
MR RICHARD EDWARD KNOWLES, of the Ministry of Transport and Civil Aviation.
The depositions of the following were read:â€”
SULTAN AHMEDI, greaser on the “Forresbank”
REGINALD EDGAR CATTEL MORTON, master of the tug “A. M. Campbell”
PATRICK DOCHERTY, junior third engineer on the “Forresbank”.
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