Marine transportation safety investigation M21P0297

TSB has completed this investigation. The report was published on 31 July 2024.

Table of contents

    Loss of containers overboard and subsequent fire
    Container vessel ZIM Kingston
    La Perouse Bank, British Columbia

    The occurrence

    On 21 October 2021, the container vessel ZIM Kingston, with 21 crew members on board, rolled 36° and lost 109 containers overboard while drifting at La Perouse Bank, about 27 nautical miles south of Ucluelet, British Columbia (BC). A number of containers on deck were also damaged.

    The investigation determined that the ZIM Kingston experienced parametric rolling. Parametric rolling occurs when sea conditions converge with vessel-specific factors in a precise way, resulting in dangerous rolling motions. The forces created by the vessel’s extreme motions were the precipitating factor for the container loss.

    Around 36 hours later, while the vessel was anchored off Victoria, BC, a fire broke out in a damaged container that held dangerous goods (potassium amyl xanthate). The fire then spread to 5 nearby containers, 2 of which also held xanthates and 3 of which held tires and other consumer items. The fire burned for 5 days before it was declared extinguished.

    The on-board fire response followed industry and company guidelines and was conducted in an efficient manner. The ZIM Kingston had a contract with a U.S.-based emergency response company, which meant that the vessel had access to specialists who provided guidance throughout the emergency response and a team of trained personnel who were able to board the vessel to help contain the fire. The use of these shore-based specialized personnel, as well as vessels of opportunity, contributed to limiting the extent of the fire.

    In November 2021, 4 of the containers lost overboard were recovered from the shores of northern Vancouver Island, along with various debris from the containers. In July 2023, an underwater survey located 29 containers on the ocean floor in proximity to the occurrence site. Ongoing beach cleanups have found debris that is likely from the ZIM Kingston washing up along large stretches of the BC coastline.

    In order to better understand the motions that the ZIM Kingston experienced in this occurrence, the TSB contracted the National Research Council Canada to construct a scale model of the vessel. Testing with the scale model was then conducted in a basin where the occurrence conditions were simulated. The testing found that parametric rolling could develop regardless of whether the model was drifting or underway, and that the largest roll motions were observed when the model was in head and following sea conditions. The testing also found that parametric rolling could occur in significant wave heightsSignificant wave height is an average measurement of the largest 33% of waves (Source: National Oceanic and Atmospheric Administration, National Weather Service, “Significant Wave Height,” at https://www.weather.gov/mfl/waves [last accessed 17 July 2024]). as low as 2.6 m.

    The investigation identified safety deficiencies that led the Board to issue 2 safety concerns: the first relates to the need for comprehensive guidance for managing the risk of parametric rolling and the second relates to Canada’s preparedness for marine emergencies.

    Comprehensive guidance for managing the risk of parametric rolling

    Managing the risk of parametric rolling is complex. Not only is it difficult to predict exactly when a parametric rolling event will occur, but once extreme rolling starts, it may not be possible to stop the dangerous motions before negative consequences occur, such as container loss. For this reason, there must be a focus on monitoring for the conditions that give rise to parametric rolling so that preventive measures can be taken when the conditions are present. Doing so requires bridge crew to have formal policies, comprehensive procedures, and effective tools for managing this risk.

    The vessel owner had not developed procedures or provided specific tools to support the bridge crew on the ZIM Kingstonin making assessments and managing the risk of parametric rolling; as a result, this risk was not being effectively monitored and no mitigation measures were put in place as the vessel held offshore.

    The International Maritime Organization (IMO) is generally recognized as the international body best positioned to develop and disseminate guidance to the marine industry; however, its circular addressing the risk of parametric rolling has not been updated in over 17 years. Furthermore, the circular has only minimal operational guidance on parametric rolling and does not offer any guidance with respect to policies, procedures, training, tools, or services related to the management of risk associated with parametric rolling. Lastly, the circular also characterizes parametric rolling as a heavy weather phenomenon, whereas model testing of the Zim Kingston conducted for the investigation determined that it could occur in moderate sea states.

    The IMO recently published its Interim Guidelines on the Second Generation Intact Stability Criteria, which will minimize the risk of parametric rolling and will provide a consistent approach to address risk across the international shipping industry. However, the timeline for incorporation of these guidelines into the International Code on Intact Stability, 2008 is uncertain, and it is not clear whether the guidelines will apply to existing vessels. The guidelines also do not address the training of crew with respect to this issue.

    The Board is concerned that the absence of up-to-date comprehensive industry guidance for the management of parametric rolling may cause company policies, procedures, tools, and training to be inconsistent, ineffective, or absent altogether, which could lead to more container loss occurrences, along with their associated negative outcomes for safety and the environment.

    Canada’s preparedness for marine emergencies

    On commercial vessels, crew are trained and equipped to handle many marine emergencies with on-board resources. However, an emergency can quickly shift to one where outside resources are needed. The occurrence involving the ZIM Kingston demonstrated some of the challenges involved in responding to a marine emergency in Canadian waters. It also raised questions about the availability and capability of Canadian resources to do so.

    After the fire broke out on the vessel, it was largely due to fortuitous circumstances that a rapid and effective response using outside resources could be initiated. These same circumstances may not necessarily be present when responding to future occurrences, underscoring the need for a careful look at Canada’s preparedness.

    Canada does not require pre-arranged plans for fire response or marine salvage, unlike the U.S. In addition, the Canadian Coast Guard does not directly participate in marine fire suppression activites as part of incident response, nor does it have fire suppression capabilities to directly respond to a vessel fire. While this occurrence took place at sea, previous TSB investigations have shown that there are also issues around preparedness when vessel fires occur in Canadian ports. Outside of ports and harbours, the options for responding to shipboard fires are even more limited should the on-board fire response be unsuccessful in suppressing the fire.

    Canada’s preparedness for other types of marine emergencies, such as occurrences involving hazardous and noxious substances (HNS) is also a concern. Canada does not have a plan for how to respond to occurrences involving HNS, although it does have a plan for occurrences involving oil. Recognizing a need for improvement, the federal government has announced that it intends to develop a single system to respond to all marine pollution incidents regardless of their source, with a goal of responding to these incidents in a timely manner that minimizes impact on human health and the environment. In addition, Transport Canada (TC) intends to develop regulations to strengthen preparedness requirements for industry, for example, by requiring vessels to have arrangements for firefighting and salvage services, and by having a response specialist who could work with the federal departments and other partners to manage any incident.

    This occurrence, and many others, have shown that while the Canadian Coast Guard has the capacity to evacuate crew members that are injured or at risk, there are systemic gaps in other aspects of responding to emergencies on vessels. While TC is proposing the above-noted changes to address these gaps, in practice the only concrete action that has been taken so far is the 2023 amendment to the Canada Shipping Act, 2001 that gives the Governor in Council the ability to make regulations regarding emergency arrangements. At June 2024, TC indicated that work to develop these regulationsis expected to continue over the next 4 years, subject to the government’s regulatory priorities.

    In the interim, the Board is concerned that there are gaps in Canada’s preparedness for marine emergencies that exceed the response capacity of a vessel’s crew, posing a risk to vessels, the environment, and the health and safety of the general public.

    Investigation information

    Map showing the location of the occurrence

    M21P0297

    Loss of containers overboard and subsequent fire
    Container vessel ZIM Kingston
    La Perouse Bank, British Columbia

    Investigator-in-charge

    Image
    Photo of Zillur Rahman

    Zillur Rahman began his career as an engineering cadet and currently holds a Transport Canada Class-1 (Motor) Certificate of Competency. In his 25 years of experience as an engineer, he has held several positions both sea-going and shore-based, with such companies and organizations as: Neptune Orient Lines (now American President Lines); Mediterranean Shipping Company; Barber Ship Management; and BC Ferries. His experience includes work with tankers, chemical tankers, bulk carriers, container ships, and roll-on-roll-off passenger ferries.


    Photos


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    Class of investigation

    This is a class 2 investigation. These investigations are complex and involve several safety issues requiring in-depth analysis. Class 2 investigations, which frequently result in recommendations, are generally completed within 600 days. For more information, see the Policy on Occurrence Classification.

    TSB investigation process

    There are 3 phases to a TSB investigation

    1. Field phase: a team of investigators examines the occurrence site and wreckage, interviews witnesses and collects pertinent information.
    2. Examination and analysis phase: the TSB reviews pertinent records, tests components of the wreckage in the lab, determines the sequence of events and identifies safety deficiencies. When safety deficiencies are suspected or confirmed, the TSB advises the appropriate authority without waiting until publication of the final report.
    3. Report phase: a confidential draft report is approved by the Board and sent to persons and corporations who are directly concerned by the report. They then have the opportunity to dispute or correct information they believe to be incorrect. The Board considers all representations before approving the final report, which is subsequently released to the public.

    For more information, see our Investigation process page.

    The TSB is an independent agency that investigates air, marine, pipeline, and rail transportation occurrences. Its sole aim is the advancement of transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability.