The Ministry of Manpower (MOM) has completed its investigations into the fire
which had occurred onboard the vessel Almudaina on 29 May 2004,
at the shipbuilding and repairing yard of Keppel Shipyard Ltd (KSL).
MOM's investigations revealed that a flash fire had occurred
inside the vessel's No. 3 Starboard Cargo Oil Tank (No. 3S COT) and killed seven workers.
On the day of the accident, seven workers were carrying out hot-work
to replace some structural steel brackets inside the No. 3S COT.
At about 1pm, sludge at the tank's bottom at the aft of the No. 3S COT
was ignited by sparks or molten metal from the hot-work being carried out above.
The sludge was residue from the cargo previously held in the tank.
It should have been cleared before hot-work was carried out.
The fire spread from the aft of the tank and subsequently led to a flash fire inside the tank.
Prior to the accident, on 24 May 2004,
cleaning to remove sludge was carried out in No. 3S COT at areas
where hot-work was to be carried out.
The area to be cleaned included the entire bottom of the tank.
On 27 May 2004, an application for a hot-work permit was submitted
by the company's Steel Foreman after initial cleaning was completed.
This was followed by a hot-work assessment conducted by the
Safety Assessor in No. 3S COT.
During the inspection, the Safety Assessor instructed further cleaning to be done.
Under the Permit-To-Work system in the Factories (Shipbuilding and Ship-repairing) Regulations,
the Safety Assessor is required to make a physical inspection of the site of the intended work and its
surrounding areas to ensure that there are no hazards or dangers present.
He should only endorse the hot-work permit application
after he is satisfied with the results of his inspection.
However, in this case, the Safety Assessor endorsed the hot-work permit
without re-inspecting No. 3S COT to ensure that the areas
that required further cleaning had in fact been cleaned.
The hot-work permit was then submitted to and approved by the Project Manager.
Consequently, the residual sludge was ignited by sparks or molten metal from hot-work being carried out.
The fire spread from the aft of the tank and subsequently led to a flash fire inside the tank,
killing seven people.