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Firefighters and crew were engulfed in a ball of flame after opening the boiler room door aboard the ferry Dieppe Seaways.
The blast injured 10 people, after fire broke out in the furnace as the DFDS vessel approached Dover’s Eastern Docks on May 1, 2014.
A report carried out by The Marine Accident Investigation Branch (MAIB), has concluded that poor communication and a lack of planning led to the accident.
It has revealed that “liaison between the team from Kent Fire and Rescue and the ship’s staff, and subsequent control of fire fighting, were incomplete and not fully co-ordinated.”
In the final report, MAIB said: “An initial entry into the port boiler room was attempted, which resulted in a back draught with an accompanying fireball that caused a number of casualties and necessitated the shutdown of the compartment.”
When the door was closed, first aid treatment for burns was given on-board to six of the ship’s crew and four firefighters.
“An initial entry into the port boiler room was attempted, which resulted in a back draught with an accompanying fireball that caused a number of casualties"
Those in need of more care were taken to east Kent hospitals.
KentOnline reported that three firefighters were treated in a specialist burns unit after suffering burns to their heads and forearms the next day.
Some 315 people were evacuated from the ship as nine engines - and 45 firefighters - were sent to the scene along with a dozen ambulances.
“The nature of the fire was such that it created a succession of small explosions, some of which were powerful enough to cause the burner unit to hinge open,” the report said.
It was some hours later before it was deemed safe to re-enter the compartment.
A crack in the thermal oil heater coil has been pinpointed as the cause, allowing thermal oil to enter the furnace.
When it had been put out, the lasting result saw mechanical damage throughout the boiler room including damage to electrical cables on lighting and monitoring circuits.
There were also significant smoke damage which meant that much of it needed replacing.
The report said the training programme was designed to make sure that all crew members received it.
It was made up of vessel familiarisation, periodic musters and specific exercises including fires, flooding collision and evacuation.
They were usually held in Calais when the ship was berthed.
It said the watch manager who led the team until the door was opened had 20 years experience of firefighting.
It concluded the crew’s first response was “timely and appropriate” following the fire alarm and external communication with Dover Port Control and requesting the firefighters attendance.
Information given to passengers and the mode of disembarkation were also well considered.
It said: “The chief engineer remained focused on fighting a fire within the port thermal oil heater without full recognition of its potential to spread to the port boiler room.
“It is apparent that he was drawing on his previous experience without being fully aware or appreciating the significance of the different situation with which he was now faced.”
It said that the KFRS watch manager was right to take the situation at face value but there was “significant time to develop an entry plan through careful investigation” and that a risk assessment should have been done.