Re Tyndall; Ex parte Official Receiver

[1977] FCA 15

COMMONWEALTh OF AUSTRALIA

Navlgotlon (Courts of Marine inquiry] Regulatlons

DECISION OF COURT

(2) Here state	matter ~I to	In	the	matter	of an lnqulry as tor2] THE CIRCCUiUISTAECES OF THE FIRE
which nnqu~ry

m.dc

ON THE MOTOR TAWER "CELLANA", OFFICIAL NUMBER 317787

WHEN BERTIIED AT N0.2 WHARF, GORE COVE, NEW SOUTH WALES

ON 29 JUNE 1976.

The Court, having carefully lnqulred as to(*) the clrcumstances of the

fire on the motor tanker "CELLANA", Offlcial number

317787 when berthed at No.2 wharf, GORE COVE, New

South Wales on 29 June 1976.

Finds that *a flre occurred on board the Motor Tanker

"Cellana" at about 0020 on Tuesday, 29 June 1976

whilst berthed at No.2 w)larf at the tanker termlr.al

owned and operated by Shell Refinlng (Australia)

Pty. Limlted at Gore Cove 13 the port of Sydney

In New South Wales and that shortly thereafter s

a consequence of such f l re two members of t he crew

of the vessel namely Bosun Alan Talbot and A/B Seaman

Arnold Higglns dled as a result of asphyxlatlon.

M.T. "Cellana" 1 s owned by Shell Internatlonal Marluc

Limlted of London and was at the relevant tune under

charter to Shell Company of Australia Llmlted. Associated

Steamshlps Llrnlted 1 s the Hanager of the vessel pnslxirlt

to an agreement dated 29 February 1969 between that

company and Shell Company of Australla Llmlted. The

agent for and In the port of Sydney 1 s Union Bulkshlps

Pty. Llmlted.

- 2 -

The vessel was bullt at Whyalla In South Australla in

1968 by Whyalla Shipbullding and Englneerlng Works, a divlsion

of The Broken H111 Proprletory Llmited. It has a registcred

tonnage of 9021.83 a gross tonnage of 16004.57 and a dead

weight of 25,632 tons.	Its port of reglstratlon 1s Geelong
in the State of Victorla.

The vessel has seven sets of cargo tanks, each set

consisting of a centre, a starboard and a port tank. Each

set 1s known by Its respective number followed by the word

"across". In addition there IS, as far as 1 s relevant to

the inquiry, a tank known as the slop tank which 1s used In

closed-circuit tank-washlng operations. Each set of tanks

can be opened to various main lines by means of valves some

of whlch are hand-operated whilst others are operated by

means of compressed air. There are four maln llnes running

fore and aft numbered 1 to 4, 1 and 2 belng on the port slde

and 3 and 4 on the starboard slde of the flying deck. Each

set of tanks has its own interconnecting cross-over line,

I

which in the case of No.5 across is dlrectly connected to No.2 and No.3 malnline by means of valves known as No.5 port cross-over valve and No.5 starboard cross-over valve

respectlvely. All such cross-over valves are manually

operated and requlre some 30 turns from the shut to the

open positlon.

In order had been adopted whereby the dlfferent valves were palnted a dlstinguishlng colour. This system was In force at the relevant tlme. to dlstinguish the varlous valves a system

All malnline valves are manually operated and were

palnted whlte. All cross-over valves were palnted green and

carried the partlcular tank number on a plate situated on the

valve wheel. As stated all cross-over valves are manually

operated. All suction valves were painted red and also

carrled thc partlcular tank number on a similar plate.

b

- 3 -

A l l suc t ion va lves a re opera ted by compressed air and when

so opera t ing r e l a t i v e s h o r t make a f a l r ly loud wh i r r lng no l se du r lng the

t l m e t a k e n t o move the valve from the open

t o t h e s h u t p o s l t i o n .

Or ig ina l ly M.T. "Cellana" was what has been cal led

a black o i l only tanker. I n about mid 1975 t h e s h i p was

conver ted to a whlte 011 carr ier . A s such It 1 s e s s e n t i a l

tha t each of the var ious products be ing car r ied be not

a l lowed to come In contact wlth another . Consequent ly ,

i n August 1975 the Shlp 's Standlng Orders were a l t e r e d so

t h a t v a l v e s t o any cargo tank w e r e t o be opened o r shu t on ly

by a s h i p ' s o f f l c e r o r on t h e d i r e c t o r d e r of such an o f f l c e r

and i n h l s presence. Such o rde r s w e r e still i n f o r c e on 28

June 1976.

The vessel a r r i v e d a t t h e Gore Cove b e r t h a t

approxlmately 1715 on 26 June 1976 havlng made passage

d i r e c t from Geelong, Vlctorla with approximately 21,000 tons

1

of product loaded a t t h a t p o r t . Such product lncluded

naptha , tops , p roduc t s a re h lgh ly vo la t l l e . S .R. g a s , dobane and 3 . V . I . 160B. A l l these

The v e s s e l sailed from Geelong

a t about mid-night on 24/25 June 1976 wl th the same c r e w It

had a t t h e time o f t h e f i r e on 29 June. The m e m b e r s of the

crew t o whom reference is made and/or who gave evidence

before the Inqulry and/or whose s ta tements w e r e t e n d e r e d a t

the Inqui ry are : Captain Roger Trevor FRY, F l r s t O f f i c e r

Arthur Robert GEAKE, Second Of f l cc r James Vlncent FALCONER,

Third Off lcer Gordon Ramsey STEPHEN, Extra Thlrd Officer

Timothy Richard K I N G , Chief Enqincer Leo Vincent SLATER,

Third Enaineer Kenneth DREFERMAN, Shipwriqht David Munorgan

G l b b MC LEAN, Radlo Operator Trevor MITCHELL, Bosun's Mate

Erlc George WAKELING, Able-bodled Seamen : Barry James HOLJRIGAN,

Lachlan MC DONALD, Peter Henry MAIDEN, Char l le DOCHERTY,

Pumpman Anthony PIRRONE, C r e w Artendant John THOMPSON and

Greaser Barry J. KING.

I .

- 4 -

Immedlately after arrlval at its berth at Gore Cove

all necessary steps were taken by the crew to comply with

the relevant Port of Sydney Regulatlons, the practice

recommended by the International Oil Tanker Termlnal Safety

Group as publlshed in the IOTT Safety Gulde, the Shell

Terminal Orders and the Ship's Standlng Orders. These

included the plugging of scuppers, the laying out and

connecting of fire-hoses, the positloning of fire extingulshers

and emergency tow-lines fore and aft, the connecting of static

electriclty llnes from shlp to shore and most importantly

the closing of all cabin port-holes or wlndows and all doors

leading onto the decks. Evldence was glven by Mr Geake the

First Officer that he inspected all cabm wlndows or port-

holes shortly before discharging cargo on 26 June 1976 and

found them shut and the cllps or locking devices thereon

tight. Adlacent to each port-hole or wlndow was a notice

which clearly read :-

These windows to be kept closed durlng any

cargo, ballastlng or gas-freelng operatlon.

l

A similarly worded notlce was on each door opening onto a

deck. Such openings were flttcd wlth two doors, one steel

and one wooden. Both doors carried these notices and those

on the slde of the ship nearest the shore were kept shut at

all times in harbour, whilst those on the outer side of the

ship were shut when not being used a means of access. The

cabins and rooms were air-condltioned.

A t berthing, the Flrst Officer llaised wlth the

appropriate terminal employee In regard to the dlscharging

and loadlng programme which was to be carrled out. This

was in accordance with the Ship's Standlng Orders and meant

that the terminal personnel knew at any given time what

operatlon was belng carrled out on board the "Cellana".

i

Some fifteen minutes after hcrthing discharge

l of the product commenced. Tanks No.1. 2, 4, 5 and 7 across

had been stripped of thelr respectlve product by 2030 on

27 June but none of these tanks had been washed or gas-freed.

Tanks No.3 and 0 across still contained the product known as

i

' tops ' .

i

.. ._

- 5 -

At 2045 on 27 June loadlng was commenced of some 4250

tons of a product known as platformate from the shore termlnal

into the vessel's No.4 centre tank and the set of three No.5

tanks, that is 5 starboard 5 centre and 5 port via No.3

main line.

Platformate 1s a product of 011 refinery between

the range of naptha and gasolene and is a component of

motor gasolene and a major component in avlatlon gasolene.

It is a highly volatile colourless liquid used only

in the blending of petrol and for practical purposes has

qualities and properties slmilar to petrol.

The loadlng of this platfo-mate was stopped at

0715 on 28 June at which time both tanks No.4 centre and

No.5 centre were filled to an ullage of 4 feet whilst tanks

No.5 starboard and No.5 port were fllled to an ullage of

approxlmately 23 feet 9 inches.

I

Evidence was given by the Flrst Officer Mr Geake

that tanks No.5 across were so loaded In order that a

change in the list of the ship from that of l0 o port

to a starboard list could be effected when required during

tank washing operations whlch he kn w were to be carrled out

later In the discharge and loading programme he had prepared

on arrlval at Sydney. This change of list was, at the

appropriate time, to be brought about by permitting the

platformate In tank No.5 centre to transfer by means of

gravity into tank No.5 starboard. To effect this transfer

of the product It was only necessary to open 5 centre and

5 starboard suctlon valves whlch would then pernnt the prodwt

to leave 5 centre by means of the suctlon valve and run along

5 crossover line and enter 5 starboard tank through 5 starhocrd

suction valve. In order to prevent any of the platformatc

entering lnto either Xo.2 or 3 malnllrle It was cssentlal that nelther No.5 port or starboard crossover valves be opened durlng the transfer.

.

I - 6 -

After loadlng this platformate, the discharge of

the 'tops' from tanks No.3 and No.6 across vla No.2 mainllne

was commenced at 0730 on 28 June. These se& of tanks were

stripped by 2110 that day and after flushing out the l l n e s

used in the dlscharge of this cargo it was intended to wash

and gas-free tanks N0.3 across, commenclng with No.3 starboard,

then No.3 centre and finally No.3 port. Shortly before

commencing to wash No.3 port tank the m-built list of l0

to port would be changed to a starboard list by transfexrlng

platformate from No.5 centre to No.5 starboard as described

above. Because of the position of the suctlon valves to N0.3 starboard and No.3 port tanks a port list was preferred whllst washing No.3 starboard tank and a starboard list

preferred whllst washing No.3 port tank.

N0.2 malnllne was to be used -In the tank-washlng

operation to No.3 across. Before the tank-washing operation

was commenced a Shlp's Standing Order procedure of "lining-up"

I

was carried out. Thls included the checking of all valves

on No.2 malnline, on the line to the particular pump to be used, on the llne to the slop tank and on the line to which were fitted the Butterworth washing machlnes. This chcck

was carried out by the deck crew watd.1 under the supervislon

of the Second Officer Mr Falconer. This watch commenced at

2000 and was to remain on duty until 0800 the next morning.

During this check No.5 port cross-over valve was checked shut.

Thereafter No.5 port cross-over valve should have

remamed shut. This is the valve which separated any product

In No.5 cross-over from No.2 malnline. Immedlately after the

fire was contained and extlngulshed it was found that thls

valve was in the fully-open poslt;on. No order had been

given by the deck o-fflcer on duty for this valve to be opened

:

during the tank-washlng operation referred to. Indeed this

1 valve had bcen shut after completing loading of the ~JlatfoKIIk~t?

at 0715 on 28 Jur.0. No operatlon had thereafter been carried

out requiring this valve to bc opened. As stated It was chc-!ckcd

shut when "linlng-up" for t3nk-washing shortly before 2150 on

28 June.

- 7 -

I

As a result of this valve belng opened during the

transfer of product from 5 centre to 5 starboard platformate

entered No.2 mainllne whlch was then belng used to wash one

of the tanks of No.3 across. Consequently the platformate

was forced by pump and gravity along N .2 malnllne lnto the

slop tank whlch had previously been fllled wlth water to an

ullage of 14 feet for the tank-washlng operatlon. The

"escape" of this platformate into N0.2 rualnline caused

the slop tank to flll rapldly and overflow through that

tank's inspection port which was opened durlng such washmg operatlons. Splllage of the platformate rapidly occurred. It ran across the main deck to the port-slde then aft along

the port accommodation space, the ship at the tlme having

a slight bow-up angle. As the scuppers were plugged the

level of the platformate in the accommodation space lncreased

to a level of some 4 to 6 inches before it spllled over the slde of the vessel. The port side of the shlp at thls point

was approxlmately 115 feet from the shore wall of the termnai

and almost abreast of some 011 burning force-draught bollers

situated approxlmately 15 feet in from'this wall. A t the

tlme certain of the boilers were llt and operating. The

weather at the tlme was flne wlth llttle or no wlnd.

Certaln calculations were given to the Inquiry

as to the quantlty of platfoxmate spilled ranglng from approximately 2,200 to 3,600 gallons together wlth the

tune requlred for such splllage ranglng from 36 to 49

mlnutes. Whatever the correct gallonage, there 1s little

doubt it was sufflclent under the prevalling condltlons

to spread out over the surface of the water and cause a

volatlle vapour In and about the furnace area and that the

heat of or the actual flame of the 011 burning furna- ,es was

the cause cf the lgnltion of such vaponr. Thereafter flames

rapidly spread back across the water to the vessel and	up
the port-side to the accommodation space cxslng fire

together wlth smoke on the maln deck arra at that point

and to the deck and flttlngs above and	t'3 other surloundlnq
areas.

.

- 8 -

The fire commenced at approximately 0020 on 29 June.

As stated above, lnunedlately after the fire was

extinyulshed It was found that No.5 port cross-over valve

was fully opened. Also durlng the fire flghting operatlons

the cabin window of cabin No.4 was found to be opened. Thls

window opened onto the port aczommodatlon space where the

platformate had accumulated prior to spilling overboard. At

all relevant times cabin No.4 was occupled by able-bodled

seaman Barry James Hourlgan.

At or about 2340 on 28 June the following persons

were on or about the main deck: the Third Officer, Mr

Stephen, Bosun's Mate Wakeling, A/B Hourlgan A/B MC Donald

and several Palnters and Dockers who had come on board at about

230 for the purpose of mopplng out No.3 across after the

washing and the gas-freeing of those tanks.

At 2340 when he knew that the washing of 3 centre

was almost completed the Thlrd Officer Mr Stephen hlmself I

opened No.5 centre and No.5 starboard suctlon valves to

commence the transfer of platformate to brlng about the

desired alteration to the ship's list. ht thls tlme he checked No.5 port cross-over valve shut. To open these

valves and check the cross-over valve he had to be on

the main deck. At this time the Bosun's Mate and the

two seamen were on the main deck at No.3 centre flnlshlng

off the washlng of that tank.

Shortly after the flre a prellmlnary lnvestigation pursuant to S.377A of the Navlgatlon Act was carried out hy

a Captain Fcarson. AS two members of the crcw had apparently dled as a result of the flre certain investigations wcre also

made by the New South Wales Pollce. Members of the crew who

were on hard at the time of the fire wcre intcrvlewed hy

those carrylng out these two mves~lqac~ons. No one,

lncludlng A/B Hollrigan admitted topc!w-Iq cahln No.4 wmd3w.

Nor was there any evidence to show thc circumstances how

when and by whom No.5 port cross-over valve was opened after

2340 on 28 June.

- 9 -

Some tlme after thls inquiry commenced A/B Hourigan

and Bosun's Mate Wakellng volunteered lnformatlon to Counsel

assisting the Inquiry In the presence of Counsel representlng

the Seamen's Union of Australla relating t,: the openlng of

No.5 port cross-over valve shortly before mldmiyht on 26/29

I

June by A/B Hourigan and the circumstances under whlch it

was stated to have been opened.

Both the Bosun's Mate and A/B Hourigan gave evidence

before the Inquiry. This evidence disclosed that since mld

1975 when the shlp was converted to a whlte oil carrlcr any

tank-washing operations In port would normally have been

carried out under the supervision of the deck offlccr with

the Bosun In charge of the seamen maklng up the deck ganq.

At about mid-day on 28 June, Bosun's Mate Mr Wakellng was

informed by the Bosun that he. the Bosun, was unable to

perform the duties relatlve to the tank-washing operations

which were programmed for later In the evening and asked

the Bosun's Mate to stand in for hlm. Shortly before 2130 L

one of the duty seamen informed the Bosun's Mate that they

were ready for washlng No.3 across. The Bosun's Mate then

! went on deck and spoke with the Second Offlcer, Mr Falconer

who informed him that the "linlng-up" for the tank-washing

had been done and the washing of the tanks was to be carried

out in the following sequence: 3 starboard, 3 centre then

3 port vla No.2 mainllne. The Bosun's Mate then asked

Mr Falconer "which ones are you golng to put the list over

on later". Mr Falconer replled "5 centre to 5 starboard".

Up to this polnt of tune the Bosun's Mate had not

taken part in any of the unloading or loadlng of cargo

i in Sydney. He was unaware what No.5 centre contained at

the tlme and he did not make any inqulry as to Its contents.

In his evldence he stated that "I thought maybe It could

have been ballast".

It appears that the Bosun's Mate had not takcn

part in any tank-washlng operations since the ship's convers;on

- 10 -

i n 1975. Pr lor there to he had been In charge of thc seamen

carrylng out tank-washing operat lons on two occasions only.

A t t h a t t i m e h l s b e l i e f was t h a t t h e Bosun or the Bosun ' s

Mate cou ld g ive o rde r s t o seamen t o open and shut valves

durlng tank-washing operations b u t not when handling cargo.

After completing the washlng of N o . 3 centre a t about

2340 the Bosun's Mate knew t h a t t h a t was t h e time when t h e

l i s t of the ship should be a l t e r e d . A t t h l s tlme he , and two

of the seamen I n the deck gang includlng A/B Hourigan were

i a t or about No.3 centre. The Bosun's Mate says he then

s a i d t o t h e seamen "We w i l l go down t o f l v e and cross-over ready

f o r t h e list". Hourigan proceeded a f t a l o n g t h e p o r t slde

w h i l s t t h e o t h e r seaman proceeded a f t a l o n g t h e s t a r b o a r d

s ide towards Xo.5 across .

The Bosun's Mate I n t e n d e d t o p r o c e e d a f t t o No.5

c e n t r e b u t was then spoken to by one of the Painters and

Dockers about some l l g h t i n g equlpment t h a t was requlred.

After a mlnu te or two, he proceeded af t and on reaclung

No.5 across saw Thi rd Off icer , M r Stephen standing on t h e

f lying deck. Mr Stephen in€ormed h m t h a t " t h e y a r e a l r l g h t ,

they are open". A t t h a t tune, A/B Hourlgan was 011 t h e p o r t

s i d e I n l l n e w l t h No.5 across . The Bosun's Mate d ld not see

whether A/B Hourlgan had touched No.5 port cross-over valve.

When g iv lng h i s ev ldence be fo re the Inqu l ry he s t a t ed he

was then sure tha t he had to ld A/B IIourlgan t o open t h a t

p a r t i c u l a r v a l v e . F u r t h e r h e s t a t e d t h a t h e a t a l l times

b e l i e v e d t h a t t o t r a n s f e r t h e c o n t e n t s from one tank i n

a set n o t o n l y t o o p e n t h e p a r t l c u l a r s u c t l o n v a l v e s t o t h e of th ree to another tank i n t h a t set it was necessary

two

tanks b u t a l so the c ross -over va lves .

A/B Hourlgan hho gave h l s ev ldence ea r i i e r t han

the Bosun's Mate swore t h a t hc! opened No.5 port cross-over

v a l v e a t t h l s t i m e on the ins t ruc t lons of the Bosun ' s Mate

under the circumstances descrlbed. I t wzs appa ren t t ha t

A/B Hourj.gan did not have any rral knowledge of the funct lor ,

l o f t h e v a r ~ o u s v a l v e s the va lve and llnc-.s involved. When he opened

no o f f l c e r was nearby nor had hc heard any

- 11 - .

I	officer give any order to anyone that	5 port cross-over valve	was
to be opened. .

l His explanation for failing to tell and indeed denylng

that he had opened such valve when asked by Captaln Peerson

and the New South Wales Pollce offlccr during thelr rerpcctlve

inqulries was that he then dld not wish to admlt even to

himself that he had done something whlch he then realised

had brought about the death of two of his ship mates In

some way not fully understood by him. The same reasoning

applied to the Bosun's Mate. He, havlng realised that

A/B Hourigan had In hls evidence before the Inquiry owned

up to the openlng of the particular valve, felt no restralnt

and freely stated on oath that he was then sure that he gave

A/B Hourigan the lnstructlon to pen the valve. He admitted that

he had made a mistake in so dolng but such mlstake was a

genulne one based on lnexperlence and a lack of a full. under-

standing of the piplng and valve arrangements on board the

shlp. The feelings of both the Bosun's Mate and A/B Hourigan

I are, in the clrcumstances, understandable and the xplanation

for withholdlng lnforrnatlon shortly aftpr the tragic event should be accepted. There was no evldence that the opening of the particular valve at the time was other than the

result of a mistake or ignorance.

Evidence was given that for some years it was good

tanker practice for valves whlch were not to be opened or

shut be lashed in the shut or opened position. The purpose

of such lashing was to glve an added warning to anyone

intending to open or shut a lashed valve to make an Inquiry

why the valve is so lashed. In fact, thls practice was used

on board the "Cellana" from time to timc and lashlnqs were

available on the cargo-room bulkhead. Perhaps under the

clrcumstances at the time No.5 port c~-oss-ove~ vdvc should

have been lashed for added precaution but it 1s clcar that

even if it had been so lashed A/R IIourlgan having been

lnstrxtc+d by the Bosun's Mate o oprn the valve would have

slmply xernoved the lashing and then opened it.

i

I

- 12 -

The valve in question having been opened permltted

p la t fo rma te to enter the s lop t ank whlch then overflowed.

Thls tank i s i n l i n e w l t h No.7 across and 1 s s i t u a t e d o f f - c e n t r e

t o t h e p o r t side of t he sh ip . The u l l age meter from which

i s read the leve l of the contents of the tank 1s lust forward

o f t he po r t s ide door of t h e pump room. I t w a s the duty

of the pumpman t o check the reading of t h l s meter p e r i o d i c a l l y

during tank-washlng operatlons. No set per iod of tune was

l a i d down when t h l s was t o be done nor w a s any record of such

readlngs kept . The ev idence d i sc loses tha t In p rac t l ce the

pumpman would step ou t from t h e pump room onto the main deck

and make the reading every 2 0 m i n u t e s o r so. On the n lght of

2 8 June the pumpman l e f t t h e pump room t o go t o t h e r e c r e a t i o n

room f o r a smoke and a d r i n k o f t e a a t some t l m e prior t o

mldnight and in fac t was i n t h a t room when t h e f l r e b r o k e o u t .

Evidence disclosed that it was t h e p r a c t l c e f o r t h e d u t y

d e c k o f f i c e r t o permlt t h e pumpman t o l e a v e t h e pEmp room

during tank-washing for such breaks when convenient.

Thl rd Off icer , M r Stephen sCated that he dld not

g lve the pumpman permlssion to leave the pumproorn on t h i s

occasion. The pumpman M r Plrrone was called a s a witness

before the person dressed in whlte overal ls request ing permission	Inquiry.	H:s	evidence was tha t he	spoke	to	a
t o

l eave the pump room f o r a smoke. Owing to t h e l i g h t i n g

on deck a t t h e t l m e he could not be c e r t a l n t h a t t h e man

he spoke t o was the Thi rd Off icer .

As a r e s u l t of t h e pumpman's absence the u l lage

meter t o t h e s l o p t a n k was n o t r e a d d u r i n g t h e c r i t i c a l

minutes before midnlght and the following 20 minutes

thereaf te r . Again , shor t ly before midnlyht the Thi rd

Officer had gone t o the cargo room inurledlately above the

pump room t o w r i t e up the deck log 2nd hand ove r to h l s

r e l i e f . H i s re l lef was t o be t h e Sccond Off lcer MC Falconel-.

An extra Third Off lcel-- . Thlrd O f L x ? r Kino had ]olnr.rl thc

s h i p in Geelong and t h l s o f f l c c r wab to stand watch with

Mr Falconer. i n t h e cargo room chscussinq the various matters then For same time M r Stephen and Nr King rcmalnt?d

!

taking piace. The hand over to3k longel than normal as

- 13 -

Mr Stephen was anxious to satlsfy hlmcelf that Mr King

fully understood his duties. Meanwhile the Secocd Officer had come on deck and after some time had cause to go aft

to the cargo room. He then dlscovered the overflow from

the slop tank. ImmedJate action was taken by hlm to close

down the pump whllst the Third Offlcer Mr Stephen ran from

!	the cargo room forward along the flying deck to ciose the
two No.5 suction valves. The pumppan vas sent for and by
the tlme he arrlved on deck lgnitlon of the vapour had occurred
and flames rapidly spread back onto thc s!np and rlght up to
the slop tank. No preclse time could bc glven as to the
tlme between that when the overflow was first notlced to that of ignitlon but it was only minutes. Almost immediately
the fire commenced the fire alarm bells were activated. On
!	the raising of this alarm the duty Engsneer Officer and Greaser immediately caused the necessary pumps and machinery
to be started to put water under pressure on the flre-flghtlng
lines. The air-condltionlng a n t and fans were closed down and the Chlef Engineer proceeded to the foam room to start

i

the foam for the shlp's monltors.

Meanwhile on deck both members of the cLew and

the Painters and Dockers understandably scattered. Many

jumped over the starboard side whilst those up forward

hurriedly left the shlp by the gangway. The Second Officer

Mr Falconer was able to get hold of the fresh water hoses

leadlng onto the ship from the shore and with the asslstance

of the Bosun's Mate who had left the ship by the gangway

commenced flghtlng the fire. €Ils actlon demonstrated that

the flre could be contained and other crewmen returncd

on board to assist. By this time pressure was on the

fire-fighting mains and the monitors fitted 03 the ship.

The lmmedlate pan:c had left and .several of the oCflce1-s

and crew fought and controlled the E i r e . There 1s no

doubt that Mr Falconer's courage and devatlon to ddty 'was

,

instrumental ln bringmg order out Q?? chaos and his actions

aze dcservlng of the hlghest commendation.

Meanwhile a general alarm had been Lai.sr:o. Thc

- 14 -

l n l t l a l l g n l t l o n and subsequent f i re had been seen by t h e

duty of South Wales Flre Brlgade f icer a t the Mar i t lme Serv lces tower . The New

were a le r ted and appliances

from Crows Nest, Lane Cove, Chatswood and Neutral Bay and t h e Rocks

were a t t h e t e r m i c a l I n a very shor t t l m e and o f f i c e r s

and men o f t he Br lgade a s s i s t ed in ex t ingu i sh lng the f i r e .

The d u t y p a t r o l f i g h t f l o a t was on the scene wlthln l o t 0 15

rnlnutes of the coinmencement o f t h e f i r e .

When men were f l g h t i n g t h e f i r e i n t h e p o r t

accommodation	space i t was	s e e n t h a t t h e	wlndow	t o c a b l n
No.4 was open.

Tendered In evidence w e r e photographs of various

c a b i n s a d ~ a c e n t t o t h e p o r t accommodatlon space. One needs

i

o n l y t o compare the photograph of No.4 cabm wi th the

o t h e r s t o see t h e damage r c s u l t m g from t h e wlndow belng

open. The f i t t i n g s t o t h e c a b l n a r c almcst completely

burnt . The deck-head and v e n t l l a t i o n s h a f t are charred

t

ruins . I f of the shut t ing of portholes and ever c lear evidence of the value and importance

wlndows o f cab lns in t anke r s

s u c h a s t h l s is required then an examlnatlon of these photo-

graphs w i l l readi ly demonstrate It.

A s s t a t e d No.4 cabln was a t a l l r e l e v a n t tlmes

4

k occupied by A/B Hourigan.

Endence showed t h a t c a b i n s w s r e no t genera l ly

locked nor d id they a t the time o f t h e f i r e h a v e s e l f -

shut lng doors . Access t o c a b l n s was accord ingly f ree

t o any person who might wlsh t o e n t e r . A/B IIourlgan

denied tcuchlng the wlndow a t any time a f t e r J v l n i n g t h e

s h l p a t Geelong. I t was sugges ted tha t the window may

have been shut but not proper1 y doggcd o r c l l p p c d a t t h e

time of t h e f l r e and t h a t i n some way t h e window was opened

d u r l n g t h e f i r e . *.is 1s cont rary t@ t h e ev idence of t h e

F i r s t O f f l c e r M r Geake t h a t h e h a d c h c k e d a l l wlndows m d

por tholes shut on a r r i v a l a t S y d m y . I t 1 s c l e n t h a t t h c

Window ha? lxen open4 fo r	svmc’ t l m c i and a t t h e	t i m c c f
the overf1.o~ of

. . the platformate. There was i n s u f f l c i n n t

.

- 15 -

b u t t h e r e i s no d o u b t t h a t t h e f a c t t h a t It was opened was

a m a t e r i a l f a c t o r i n t h e s p r e a d l n g o f t h e f l r e l n b o a r d

in the cabin a rea and thereby caus lng smoke and h e a t

I	t o p e n e t r a t e i n t o t h e c a b l n s o c c u p i e d	by	t h e	two
deceased crewmen.

I t was suggested that Thlrd Off icer ML Stephen

a t some t i m e p r l o r t o t h e discovery of the cverflow of

platformate should have become aware t h a t t h c l l s t of

t h e s h i p which should have occurred i f t h e t I a n s f e r of

product from No.5 c e n t r e t o No.5 s ta rboard was tak ing p lace

as in tended was not in fac toccurnng and tha t he should have

real lsed that t o e f fec t the des i red change something was amiss. The evldence was t h a t

of l ist would take up t c 45

minutes and the degree of change of l l s t woAd be so s l l g n t

t h a t on t h e p r o b a b i l l t l e s u n l e s s one de l ibera te ly looked

for the change It would not be not lceable .

A check of the sh lp ' s log showed t h a t a l l m u s t e r

1

and d r i l l s r e q u i r e d t o be car r led out under the Navqauon (Muster

and D r i l l s ) Regulat ion had in fact been csrrxd out . Thls was

I

conflrmed by the ora l ev idence of var lous wi tnesses .

As s t a t e d , t h e r e 1s l i t t l e doub t t ha t t he ign l t l on

of the platformate vapour	was causrd by	the flame	OL	h e a t
o f t h e b o i l e r s r e f e r r e d t o .

I t was submitted on behalf of the owners of the

te rmina l , She l l Ref ln lng (Australia) Pty. L l m l t e d , t h a t

wh i l s t i t Court of Marlne Inquiry to detenunc- would be p rope r and wl th l :~ lu r l sd l c t lon fo r t he

how t h e f i r e a f f e c L l n g

the ship occurred the Court ought not properly answer cer ta ln

ques t lons r e l a t ing t o t he sho re ope~atlons. The submlsslon

was p r l m a r l i y d l r e c t e d t o t h e CL;urt'c. power cf 1.nqulry 111

r e l a t l o n to the mal-functlon of 'the fin?- f l g h t l n g rnqnltor

I n s t a l l e d n e a r No.2 Wharf and the operat;on s f the boller:.

under th-. t hen e s i s t l ng cond i t ions . The submlssion cer ta lniy

has wel.ght bl;t I n view oi t he f ind lngs it 1s unneceesary

t o make ilny f lnal detcrmlnarlan theregn. On thc ?VI dcr7ce

. . .

- 16 -

!	it
is clear the angle through tha t even i f the shore monltor had opeIated

whlch the monltor could have been

t r a l n e d w a s such t h a t foam from it could not have

been effect lvely placed on any f i r e i n the port

accommodatlon space of t h e s h i p .

Again t h e poslt ion and the use of t h e b o i l e r s

ashore came under crltlclsrn by t h o s c r e p r e s c n t l n g c e r t a i n

partles. The evldence w a s t h a t t h e p a r t l c u l a r b o l l c r s

had been sopoaltsnned for some twen ty yea r s , t ha t bsllers

w e r e necessary a t a l l t e r m l n a l s f o r h e a t l n g o p e r a t l o n s ,

that a l l S t a t u t o r y R e g u l a t l o n s r e l a t i v e t o boilers and

a t t e n d a n t s were ful ly complied w i t h and during the per lod

r e fe r r ed to t anke r s had used the ber th lng , loading and

unloading fac l l i t l es a t No.2 wharf when the said b o i l e r s

would have been opcratlng. Evidence was a l s o g i v e n t h a t

pe r lod ica l l n spec t ions of t h e termlnal by members of t h e

N e w South Wales Flre Brigade, by m e m b e r s of t h c Maritlme

Serv ices Board and by Lnspectors of the, N e w South Wales

Department of Labour and Industry had been carrled out.

N o complaint followmg any such inspectlcn had been rece lved

by Shel l Ref in lng (Aus t ra l ia ) P ty . L l m i t e d .

The Inqui ry was Informed t h a t f o l l o w m g t h e

i

f i re cer ta ln modi f lca t lons t o t h e ship w e r e c a r r i e d o u t .

These included bel l t o t h e slop tank. (1) t h e f i t t l n g of a high level warnlng

I

Such system would warn i f t h c

u l l age wl th in tha t t ank dec reased below a set measurement:

( 2 ) t h e f i t t l n g of an appa ra tus to all cabm and passagcway

i d o o r s t o make t h e same self-closing: ( 3 ) t h e i n s t a l l l n g of a

wash p l a t e between t h e maln deck and t h e accomrnodatl.on spaLe

to prevent- product running a f t i n t c that space In the event

of a been securely locked and sp i l l age and ( 4 ) t h a t a l l p o r t - h o l e s and kmdows had

could only b. unlozked by means

of a spec la l key o r devlce whlch W& placed i n a glass-Crofiicd

sea l ed ~ D Y . a d ~ a c e n t t o e a c h p o r t - h d e G r wlndow.

1

. . ,

- 17 -

The Inquiry was informed that Shell Refining

(Australia) Pty. Llmited the owner and occupler of the

terminal at Gore Cove had since the flre, caused the

partlcular furnaces to be extinguished whenever a tanker

1s berthed at No.2 wharf. Further, it was intended that

the boiler and furnace area be bricked up to prevent as far

as possible any volatlle vapour caused by an overflow from

any ship In the area enterlng such area.

The questions upon which t e Minlster for Transport

i	has requested the Court to make	findmgs are answered	as
follows :-

Question 1

When, where and by whom was 'Cellana' bull-?

Answer 1

In 1968 by Whyalla Shlp Bullding and Enqmeerlng

Works at Whyalla.

Question 2

On 29 June 1976 and at all materLa1 tunes what

persons or bodies

(a) owned,

! I

(b) operated, or

(c) managed

'Cellana' and what was the nature of thelr

respectlve interests In the shlp?

Answer 2

Shell Company of Australia Limited chartered

the shlp from Shell International Marine

Limlted of London. The ship is managed

by Associated Steamships Llmited.

Question 3

What was

(a) the time and date of the arrlval

of 'Cellana' at Gore Cove,

(b) the port from whlch 'Cellana' had

come,

(c)	the nature of the cargo opcrations
undertaken on 'Cellana' after x-llval?

-	Answer 3	(a) 1715 on 26 Jane 1976
(b) Geelong, VlcCoria
(c) Dlscharglng of petioleml pruduccs from

tanks 1, 2 , 4, 5 clnd 7 across and loading

of some 4250 long tons of plat€orntatfA

Into No.4 cantre, and 5 acrass:, arid th2rc3iter

- 18 -

Question 4	When did the fire start	on board 'Cellana'
on 29 June 1976?
Answer 4	0020 on 29 June 1976

Questlon 5	What was the preclse location	f 'Cellana'
during the flre?

Answer 5	Port-slde-to at No.2 Wharf, Gore Cove, New South Wales
Questlon 6	What were the weather conditlons In the vicinlty of ICelIana' immediately prlor to the flre on
29 June 3.976?
Answer 6	Fine and clear, llttle or no wind.
Question 7	What was the mannlng of the vessel on the night
of the flre and did it comply wlth the relevant

' regulatory requirements?

Answer 7 On 28 June 1976 the "Cellana" was manned by 42 officers and men made up as follows :- Master; First, Second Thlrd and Extra Third

l

Mates; Chlef Englneer; Second, Thlrd, Fourth

!

and Flfth Englncers; Electrician; Kadlo

Offlcer: Shlpwrlght: Bosun: Bosun's Mate.

8 A/B Seamen: 1 Ordinary Seaman: 1 Deck Boy;

2 Crew Attendants: 2 pumpclen: 4 Greasers,

Chlef Steward and 3 Stewards: Chlef Cook

and 2 Cooks and 2 Cadets. The evldence dld not

disclose that such mannlng was other than as

1 required by relevant regulations.

__ .

/

!

- 19 -

Quest ions Wfilch officers and crew of the vessel were on

duty on the nlght of the fire and what. were the

nature of their duties?

Answer 6 Officers: Thlrd Offlcer Mr Stephen on duty as

deck officer to 0001 29 June to be relleved

by Second Offlccr Mr Falconer and extra

Thlrd Offlcer Mr Klng at that time, Fourth

Englneer Mlller In Englne Room. Relieved by

Thlrd Englneer Drederman shortly after mldnlqht.

Crew: Bosun's Mate Mr Wakeling

Seamen A/B's: Hourlgan, Malden and MC Donalcl

Pumpman Mr Pirrone, Greaser Mr	B. King in
Engine Room.

Question 9 Were any persons other than the crew aboard

'Cellana' immediately prior to the start of

the fire and, if so, by whom were they employed

and f o r what purpose and what were they dolng?

Answer 9	A gang of Palnters and Dockers employed by
Jubilee Engineering and under Supervlsor D.G.
Campbcll arrlved on board at 2310 on 28 June 1976

l

and were stlll on board at the tlme of the

outbreak of the fire. Thc Palnters and Dockers

were carrylng out mopping-up operatlons after

the shlp's crew had performed tank-washlng and

gas-freeing operations to h'o.3 across.

Mr Hughes, an Industrial Chemist employed by

R.K. Newman and Co., Analysts had also COKIE

on board at 2310 on 28 June 1976 but had

left the ship sometlmc prlor to nudnlght after

testing N o . 3 starboard for gas and glving a

clearance for t'nat tank prlor to the Painters

and Dockers enterlng It. The Chemlst then

left the ship InLcndlng to rr3turn at 0015

on 29 June when he antlcipated yas-€rr.cl?g c ? f 3 0 . 3

centre w9uld be completed. He was not on board

at the outbreak of i-hc fire.

Question 10	What was the nature, quantity hnd dlsposlticn
of thr cargo, 3~allast ar,d slop tank water c,n
board ' C e l l m a ' i~unedlate1.y prior to the ska; t
of the fire?

'. - 20 -

Answer 10 A l l tanks had bcen s t r lppcd of the p roducts

brought from Geelong. No.4 centre and No.5 centre

had been loaded t o an ullage of 4 f ee t w l th

p l a t f o m a t e from the t e rmina l . No.5 starboard and

por t t anks had a l so been loaded wlth platformate

t o an ul lage of 23feet 6 Inches. The quant l ty of

platformate I n thcsc tanks was : 4 c e n t r e , 14C1 tons:

5 centre , 1853 tons: 5 s t a rboa rd , 406 tons and 5

p o r t , 455 tons.

No b a l l a s t was c a r r l e d . Thc slop tank was f i l l e d

wi th wa te r t o an u l l age o f abou t 14 f ee t 6 lnches

p r i o r t o tank-washing. Transfer of platformate from

No.5 c e n t r e t o No.5 s ta rboard by means of grav l ty

had commenced a t about 2340 on 28 J-une. Thereaf te r

No.5 port cross-over valve was opened. Thls permit ted

p l a t fo rma te to en te r No.2 mam l j n e whlch was then

belng uscd for the tank-washlng operat lons. Plat-

formate then could and dld enter the s lop tank causlnc;

t h a t t a n k t o f l l l rapldly and an overflow and spll lage

of the product occurred.

Question 11 WGE any of the cargo tdnks of 'Celland' not In a

g a s f r e e s t a t e i m m e d i a t e l y p r l o r t o the s t a r t o f

k

t h e f i r e and what gas f r e e c e r t i f l c a t e s h a d becAn

i s sued , when and by whom?

! Answer 11 No.3 s tarboard tank was the only tank that had been

cleared of gas . The Chemlst had glven a verba l

c l ea rance fo r thls tank and had Intended ~ s s u i n g a

c e r t l f l c a t e f o r h'o.3 s t a rboa rd , cen t r e and p o r t on

complet ion of the gas-freeing operat ions.

Quest ion 1 2 What o p e r a t l o n a l a c t l v l t l e s were b e m y c a r r l e d o u t

on board 'Cellana' immediately p r i o r to t h e s t a r t

o f t h e f l r e , who authorized these and whcn were any

s u c h a u t h o r i t l e s 1 ~ 5 u e d ?

Answpr 1 2 (a) No.3 port cargo tank was belng icnchlne was??ed

using water from t h e p a r t l y f i l l e d s l o p t a n k ,

! eductlng back t.o tl~e slcp tank In what should

have been a crmplctely closed c l r c u l C opzrat lon.

(b) I n what should has~e b w n a completely closcd

c l r cu l t g rav l ty t r ans fc l - o f p l a t fo rma te , from

No.5 c e n t r e t a n k t o Ko.5 s tarboard tank.

The opcra t ldns wcrc autho:-1*;ed by orders frcm the

F l r s t o f f i c e r i%: C;e;ke t o t h e Scconn Off lccr Mr

Falconer who entered orders i n the rouqh Deck Loa.

- 2 1 -

Quest lon 13 Who w a s i n charge of and supervls lng each

such operat ion?

l Answer 13 Thl ra Officer M r Stephcn w a s t he du ty Deck Offlcer

and as such had the direct con t ro l o f t hc ope ra t ion .

Quest ion 14 What check procedures , I f any , were c a r r l e d o u t

1

t o	ensu re tha t on ly au tho r i sed ope ra t ions o rde red
by	t h e Master or h i s r e p r e s e n t a t i v e were t ak lng

p l ace on 'Cellana' .

- Answer 14 SupervJ.sion w a s by Thi rd Off icer M r Stephen who

from time t o time up u n t i l 2340 checked the ul lage

meter o f t he slop tank. The duty Fumpman M r P l r rone

a l so checked th l s u l l age meter u p u n t l l t h e t l m c

I

he l e f t the pmp room area t o go t o t h e r e c r e a t i o n

room a t some tlme prior t o mldnight.

Quest lon 1 5 Were the check procedures , i f any,

( a ) c a r r i e d o u t I n accordance with

the sh lp ' s s t and lng o rde r s :

(b ) adequate ?

Answer 15 (a)There were no s h l p ' s s t a n d i n g orders r e l a t l n g

t o t h e i n t e r v a l of time detween readlngs of t h e

ullage meter o f t h e slop tank. EvldmCe of var lous

wltnesses nomlnated dlfferent per lods, ranging from

10 t o 20 mlnutes.Plor was It nomlrlatcd w h s e

r e s p o n s l b l l l t y It was t o r e a d t h c meter. !The

prac t l ce appa ren t ly was t h a t t h e pumpman and

the du ty deck o f f l c e r b o t h d l d so, There

w a s no record kept of such readlngs and cdch d id no t

know when o r how o f t e n t h e o t h e r t o o k them.

(b) N o .

Question 16 Were t h e o f f l c e r s and crew d c q u a t e l y t r a i n e d a n d

i n s t r u c t e d t o c a r r y ollt t h e o p c r a t l o n s t a k i n g

p l ace on 'Cellana' immediately before and a f t e r

t h e start of the f l re?

A n s w e r	16	As t o Officers:
There i s no cvL&nze t3 sugqcst t h a t t h e y were
no t so t r a m e d and instructed.
&to C r e w :
As regards cargo and tank-washing operatlons
I f t h e shxp':, stand1r.g o r d e r s weic obeyed then

t h e crew were a d c q u z t c l y t r a l n d i1cd I n s t r u c t e d .

- 22 -

As to fire-flghtlng operations, the crew were

adequately trained and Instructed. so as to

comply with the then Statutory Regulations.

Question 17	Were all proper safety procedures and precautlons
observed and taken on 'Cellana' before and after

: the start of the fire?

Answer 17	Yes.
Question 18	What was the cause, or what were the causes of
the fire?
Answer 18	The opening by A/B Hourlgan of No.5 port cross-over
valve, the overflow and splllage of the platformte.
the contact of platformate vapour with the operating boiler ashore and as regards flre heat and smoke within the ship itself and in particular to the crew accommodatlon on the port side the fact that cabin No.4 window was not shut and adequately clipped or bolted.
Question 19	What was the nature and extent of the fir , and
of the damage caused by the flre both aboard and off the ship?
Answer 19	Extensive fire damage was' done I such accommodation
area: cabln No.4 was completely burnt out, the
superstructure and deck head panelling to that
cabln and the passageway d~oining were also
severely damaged. Fire damage also occurred to the poop deck (port side) and up the shlp's
funnel .
Questlon 20	m a t were the clrcumstances surrounding the spread

!

of the flre to the interior f the vessel?

- Answer 20 The fire spread to the lnterior of the shlp

through cabin No.4 wlndow which was then open.

Photographs of the varlous cabins ad~acent to

the port accomnodatlon space deck area graphically

show the necesslty that all port holes and windows

of tankers be kept shut when cargo and tank-washing

operatlons are m progress.

!

Question 21	Did any persons die and were any persons ~ n ~ u r c d
as a result of the flrc and, r f so, who wcre thpy
and what caused the death OK ~ n ~ u r y as the C ~ S P
may be?

. I

- 2 3 -

* .

Answer 21 Yes. Bosun Alan Talbot and A/B Seaman Arnold

Higgins who died as a resuit of asphyxlation caused

by smoke resultinq from the fire.

Questlon 22	Did any defect in materlal used ln the construction
of the vessel or any defect in the layout of the
vessel itself contribute to the death or in~ury of
any person?
Answer 22	No evidence was tendered to suggest any such defect. The cabin llnings were of appcoved material when the
ship was bullt In 1968.
Question 23	When the fire started what steps were taken o account
for and ensure the safety of all persons then on board
'Cellana'?
Answer 23	Members of the crew and the painters and dockers
hurriedly left the ship either by ]umplng overboard
or by the gangway. Certain painters and dockers immedlately left the area and returned home. There was no gangway log showing which members of the shlp's crew were on shore leave nor the actual number of psinters and dockers who had boarded the shlp before
the fire. Thls did lead to some confuslon as to w h o

l

were in fact aboard durlng the fire but 111 no way

delayed the attempts of Captaln Fry, members cf

the crew and Fire Brigade Offlcers and flremen to

enter the cabins ln the forward section of the

accommodation space where the bodies of the two

deceased men were subsequently found.

! Question2 Did the fire flghtlng appllances carried on 'Ccllana'

comply wlth relevant statutory requlrements and were

they serviceable at the tlme of the flre?

Answec 24	Yes
Questlon 25	At the outbreak of flre on 'Cellana' was water and
foam immediately avallable from the hydrants on hoard
and ashore?
Answer 25	The flre pumps and th? T o m machlne on board were
immedlately brought lntc-, operatlon on the soudm,g of
the flre alarm. Ashcl e a ring main surroundcd tllc
terminal and on No.? Whdrf shore hydrznts and hcses
were available ready fcr use.

..

- 2 4 -

Quest lon 26 What s t e p s w e r e taken and by whom wcre they

taken to ensure that water and foam were made

a v a i l a b l e t o t h e h y d r a n t s on 'Cellana'?

Answer 26 A s t o t h e f i r e pumps, these w e r e s t a r t e d by

Thlrd Engineer M r Dreverman on the soundlng

of the f l r e a l a rm whi l s t Ch ie f Eng inee r M r S l a t e r

I

a l s o a t t h a t tune en te red the foam room and

1

caused foam t o be a v a i l a b l e a t t h e s h i p ' s m o n i t o r s .

Quest ion 2 7	Were any o t h e r f i r e f l g h t l n g d e v l c e s a v a i l z b l e i n t h e v i c i n l t y t o a s s l s t i n e x t i n g u l s h i n g t h c
f i r e a n d , I f so, when and by whom were they
brought into operat ion and with what resul t?

A n s w e r 27 I n i t i a l l y Second Off lcer M r Falconer used Chic. f r e s h

water hose from the shore to f ight the f i r e .

T h e r e a f t e r t h e s h l p ' s f l r e pumps and malns were

used. A shore foam moni tor s l tua ted on a

pylon close t o t h e s h l p ' s p o r t q u a r t e r m a l - f u n c t i o n e d

b u t It 1s c l e a r t h a t even i f t h i s m o n i t o r h a d

worked no foam therefrom could have been trained

i n t o o r on t h e p o r t s i d e ,accommodation space or

i n t o c a b m No.4 through the open window o f t h a t

cabin. I t is poin ted out tha t the occupiers of

the te rmina l were under no s t a t u t o r y d u t y t o

in s t a l l o r ma in ta in such mon i to r .

The duty Mari t ime Service f l re f loat . a t tendcd

wi th in a very short space of t i m e and did play

its p a r t I n cool ing down t h e h u l l o f the sh ip

d u r i n g t h e l a t t e r p a r t of t h e f i r e .

Questlon 2 0 Were the services of the Metropol l tan Fire

Brlgade cal led on, and l.f -so

( a ) when, how and b y whom

( b ) how many un i t s a t t ended Gore Cove

( c ) what tlme dld each a r r lve

( d ) were t h e un3.t.s o f a s s l s t ance

111 e x t l n q ~ i s l l ~ ng the f l r e ?

Answer 20 Y e s . A g e n e r a l f l r e aAarm was i s sucd by

pcrsonncl s ta t loned L n thc Naritlrne Services

I	Tower. Unlts from Crows Nest. Lane Cove,
Chatswood, Ncutral Ray and the Rock.? attended
and a s s i s t e d i n f i y h t l n g t h e f l l - c . Two o n l t s

- 25 -

arrived almost simultaneously at	0 0 2 0	m
29 June 1976.

Q u e s t i o a	Were the offlcers and crew of 'Cellana'
adequately tralned and lnstructed In
flre fighting?
Answer 29	At the time all officers and crew of the ship
had been lnstructed ln fire-fightlng to the
extent laid down by Statutory Regulations.
Questlon 30	Did 'Cellana' have proper and adequate fire
fighting and emergency procedures or drllls

1

and, If so,dld all officers and crew members

carry out those procedures or drills?

Answer 30	The emergency procedures and drills were
proper and adequate so as to comply with
Statutory Regulhtions. At the tlme of the
outbreak of the fire most members of the crew,
believing that a holocaust was about to occur,
rapidly left the shlp. Most xeturned to the
ship and asslsted ln the contalnlng, controlllng

1

and extingulshing the flre when, following the

couraqeous actions of Second Officer Mr Falconer,

it was demonstrated that the flre could be	so
contained.

Question 31

At the time of the fire what persons o bodies owned, occupled, managed and controlled the harbour works and oil terminal installation

lmmediately ad-~acent to 'Cellana'?

Answer 3 1

Shell Refining (Australia) Pty. Limlted.

Question 32

Was the fire caused or contributed to by any

of the procedures assoclat-ed with the use

or operation of thoec w3rk.s and lnstallatlons

or in thelr layout, and if so, in what manner?

Answer 32

Yes to the extent that the bollsrs sltuated

some 150 feet from the ship caused the lnltlal

ignition of the platformate vapol'r.

Q u c s t i o a

What. approvals were nmded €0~- the layout and

operatlon of those works and ~nskallatlons

and any ancillary equipment operating thereor.,

and, lf any, wexc thEy Obtdlnej. and	currmt at
the time?

- 26 -

Answer 3 3

The evidence does not suggest other than that

any necessary authorities were obtained and were

current.

- Question 34 Was the fire caused or Contributed to by the

negligence or default of any person or persons

on 'Cellana' or on shore and, if so. who was

or were the persons whose negligence	or default
so caused or contributed?

Answer 34	There was no evidence of any criminal negllgence on the part of any officer or member of the crew of the shlp. It is clear that A/B Hourigan knew that valves were not to be opened or shut wlchoct
an order of an offlcer but it is accepted that he

!

did recelve an instruction from Bosun's Mate

Wakeling to open No.5 port cross-over valve.

Further he was aware that at the time such

instruction was glven to him no offlcer was In

the viclnlty. With regard to the Bosun's Mate,

his evidence that he had had no experlence in

!	tank operatlons slnce the shlp was converted to a white oil carrier 1 s accepted. Further there is some doubt as to what was the posltion prior
to such conversion as to the authority of the
Bosun or the Bosun's Mate as regards issulng
instructlons to gearmen to open or shut valves
during tank-washing operatlons elther m port
or at sea.
As regards the cause of the spreading of the flre
inboard to the accommodation space there is no
doubt thls resulted from the fact that cabin Ko.4 window was opened. There 1s lnsufficlent eyJidmce
to show when or by whom or for what purpose khls
window was opened.

Question 35 Was the death of or 1n~ui-y to any crew membrr

occasloncd by the negllgence or default of any

person or persons on 'Cc1lar.a' cr on shorc and,

if so, who was or were thc: perso11 or persons whose negllqence so caused or contrlbuted?

. b

- 2 7 -

Answer 35	Tnere 1 s no doubt that the death of the two crewmen was occasioned by the flre within the
ship. ~ l s o see Answer 34.
Questlon 36	Was the death of or lnjury to any crew member
occasloned by any deflclency In 'Cellana' emergency procedures or drllls?
Answer 36	NO.

Recommendations

1. It is recommended that in closed-circult tank-

washlng operations that a procedure be adopted and enforced

that a crew member be responslble for the reading of the

slop tank ullage eter er at regular perlods to be determined

after careful calculations and conslderatlons by ships

officers and that on each occasion a readlng of such

meter is made a record thereof be kept and that such

record to be readily avallable for Inspection	by the duty
deck offlcer or any other offlcer.

2 . In the light of the vidence glven before

this Inqulry therc IS a strong case for cstablishlng

in various ports	In Australla a coarse of trainlng for
all officers and	crew of tankers ln practical flre fightlng

under simulatea condltlons of fire lnvolvlng petrolem

products and ln the use of all equlpmcnt that may requulred courses should be compulsory.

I

!

3

DECISION OF COURT - Continued

Dated thls I day of 4-J) , 1977

(-J WUnT

Member.

Mcrnber.

I dlsscnt from the abovonientloned decwon. and my vmtten rczbons for so dlssc?tlny

are annexed liereto

‘NE cnncur In the abovernentloned dcclslon -t