The occurrence
On 21 October 2021, the container vessel ZIM Kingston, with 21 crew members on board experienced parametric rolling, 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. Around 36 hours later, while the vessel was anchored off Victoria, BC, a fire broke out in a damaged container that held dangerous goods. The fire then spread to five nearby containers and burned for five days before it was declared extinguished. One of the crew members was subsequently treated for smoke inhalation.
In November 2021, four 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 another 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; debris was also found as far north as Alaska, U.S.
The investigation identified safety deficiencies that led the Board to issue the following two safety concerns.
Comprehensive guidance for managing the risk of parametric rolling
Parametric rolling results from the interaction of two elements—the wave characteristics in a seaway and the stability characteristics of a vessel—and leads to the sudden onset of extreme roll angles for a vessel. 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 access to formal policies and comprehensive procedures for managing the risk of parametric rolling. They must also have effective tools to monitor the numerous conditions affecting their vessel’s motions, analyze the risk of parametric rolling, and implement mitigating measures when necessary.
A post-occurrence analysis of the pertinent vessel and environmental parameters in the time leading up to the occurrence showed that the ZIM Kingston was at risk of developing parametric rolling and that this risk was identifiable using some of the guidance material generally available to the industry. However, the risk was not identifiable with the guidance on board the vessel at the time of the occurrence. Without formal policies and comprehensive procedures to support an assessment of risk related to parametric rolling, the master had to rely on his knowledge and experience to evaluate the safety of the vessel as it maintained a holding pattern in the open ocean. The master had a general understanding of the conditions that can lead to parametric rolling and the actions to take if it happened, but he had never experienced parametric rolling firsthand and had never completed a quantitative assessment of risk specific to parametric rolling.
Investigations by other agencies into previous occurrences involving parametric rolling point to similar inconsistencies and inadequacies with respect to the training of bridge crew and the adoption of procedures and tools to support them in managing the risk of parametric rolling. Although there are a substantial number of resources available that target a variety of audiences and present different guidance for assessing the risk of parametric rolling, none of these resources provide comprehensive guidance to help vessel owners, charterers, and bridge crew manage the risk of parametric rolling effectively.
Comprehensive guidance about parametric rolling should be presented in an accessible and understandable way. It should help bridge crew practically apply this information, by providing specific directions about when risk assessments should be done, how they should be done, what results represent unacceptable risk, and what mitigating measures should be considered. It should address the need for bridge crew to have effective tools to manage the risk of parametric rolling and an understanding of the merits and limitations of these tools. It should also address the need for training so that policies, procedures, and tools can be used to full effect by vessel crew. Finally, comprehensive guidance should address the need for company policies and procedures to foster a shared understanding of the risk around parametric rolling among all parties involved (owners, charterers, bridge crew) and to ensure that bridge crew receive support in making safety-related decisions.
The International Maritime Organization (IMO) is generally recognized as the international body best positioned to develop and disseminate comprehensive guidance to the marine industry; however, its circularInternational Maritime Organization, MSC/Circ. 1228, Revised Guidance to the Master for Avoiding Dangerous Situations in Adverse Weather and Sea Conditions (11 January 2007). addressing the risk of parametric rolling has not been updated in over 17 years and the investigation identified several shortcomings with it. For example, 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. The circular also characterizes parametric rolling as a heavy weather phenomenon, whereas model testing of the ZIM Kingston found that parametric rolling could develop 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 recently published IMO Interim Guidelines on the Second Generation Intact Stability Criteria 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. Similarly, it is unclear, at the time of report writing, whether the work of the IMO Subcommittee on Carriage of Cargoes and Containers will address the issues identified in this investigation.
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.
The vessel operator’s pre-existing emergency response contract was instrumental in the success of the fire response. Although emergency response specialists can be hired on an emergency basis, a pre-existing contract can improve the timeliness of the response because vessel information can be shared with the response specialists in advance, allowing a response plan to be prepared in advance.
While this occurrence took place at an anchorage outside the Port of Vancouver, previous TSB investigations have also shown that there are issues around preparedness when vessel fires occur in Canadian ports. Following an investigation into a shipboard fire on the bulk carrier Tecumseh in the Port of Windsor,TSB Marine Transportation Safety Investigation Report M19C0403. the Board issued a safety concern about the adequacy of resources in Canadian ports for responding to shipboard fires. Outside of ports and harbours, the options for responding to a shipboard fire are even more limited should an on-board fire response be unsuccessful in suppressing a fire.
Canada’s preparedness for other types of marine emergencies, such as occurrences involving hazardous and noxious substances (HNS), is also a concern. For pollution-related occurrences, Canada does not have a plan for how to respond to occurrences involving HNS, although it does have a plan for occurrences involving oil. The federal government has recognized the need to improve preparedness for HNS occurrences and has announced that it intends to develop a single national system to respond to all marine pollution incidents, regardless of their source, in a timely manner that minimizes impact on human health and the environment. In addition, Transport Canada (TC) has proposed to make 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 regulations is 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.
The occurrence
On 21 October 2021, the container vessel ZIM Kingston, with 21 crew members on board experienced parametric rolling, 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. Around 36 hours later, while the vessel was anchored off Victoria, BC, a fire broke out in a damaged container that held dangerous goods. The fire then spread to five nearby containers and burned for five days before it was declared extinguished. One of the crew members was subsequently treated for smoke inhalation.
In November 2021, four 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 another 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; debris was also found as far north as Alaska, U.S.
The investigation identified safety deficiencies that led the Board to issue the following two safety concerns.
Comprehensive guidance for managing the risk of parametric rolling
Parametric rolling results from the interaction of two elements—the wave characteristics in a seaway and the stability characteristics of a vessel—and leads to the sudden onset of extreme roll angles for a vessel. 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 access to formal policies and comprehensive procedures for managing the risk of parametric rolling. They must also have effective tools to monitor the numerous conditions affecting their vessel’s motions, analyze the risk of parametric rolling, and implement mitigating measures when necessary.
A post-occurrence analysis of the pertinent vessel and environmental parameters in the time leading up to the occurrence showed that the ZIM Kingston was at risk of developing parametric rolling and that this risk was identifiable using some of the guidance material generally available to the industry. However, the risk was not identifiable with the guidance on board the vessel at the time of the occurrence. Without formal policies and comprehensive procedures to support an assessment of risk related to parametric rolling, the master had to rely on his knowledge and experience to evaluate the safety of the vessel as it maintained a holding pattern in the open ocean. The master had a general understanding of the conditions that can lead to parametric rolling and the actions to take if it happened, but he had never experienced parametric rolling firsthand and had never completed a quantitative assessment of risk specific to parametric rolling.
Investigations by other agencies into previous occurrences involving parametric rolling point to similar inconsistencies and inadequacies with respect to the training of bridge crew and the adoption of procedures and tools to support them in managing the risk of parametric rolling. Although there are a substantial number of resources available that target a variety of audiences and present different guidance for assessing the risk of parametric rolling, none of these resources provide comprehensive guidance to help vessel owners, charterers, and bridge crew manage the risk of parametric rolling effectively.
Comprehensive guidance about parametric rolling should be presented in an accessible and understandable way. It should help bridge crew practically apply this information, by providing specific directions about when risk assessments should be done, how they should be done, what results represent unacceptable risk, and what mitigating measures should be considered. It should address the need for bridge crew to have effective tools to manage the risk of parametric rolling and an understanding of the merits and limitations of these tools. It should also address the need for training so that policies, procedures, and tools can be used to full effect by vessel crew. Finally, comprehensive guidance should address the need for company policies and procedures to foster a shared understanding of the risk around parametric rolling among all parties involved (owners, charterers, bridge crew) and to ensure that bridge crew receive support in making safety-related decisions.
The International Maritime Organization (IMO) is generally recognized as the international body best positioned to develop and disseminate comprehensive guidance to the marine industry; however, its circularInternational Maritime Organization, MSC/Circ. 1228, Revised Guidance to the Master for Avoiding Dangerous Situations in Adverse Weather and Sea Conditions (11 January 2007). addressing the risk of parametric rolling has not been updated in over 17 years and the investigation identified several shortcomings with it. For example, 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. The circular also characterizes parametric rolling as a heavy weather phenomenon, whereas model testing of the ZIM Kingston found that parametric rolling could develop 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 recently published IMO Interim Guidelines on the Second Generation Intact Stability Criteria 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. Similarly, it is unclear, at the time of report writing, whether the work of the IMO Subcommittee on Carriage of Cargoes and Containers will address the issues identified in this investigation.
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.
The vessel operator’s pre-existing emergency response contract was instrumental in the success of the fire response. Although emergency response specialists can be hired on an emergency basis, a pre-existing contract can improve the timeliness of the response because vessel information can be shared with the response specialists in advance, allowing a response plan to be prepared in advance.
While this occurrence took place at an anchorage outside the Port of Vancouver, previous TSB investigations have also shown that there are issues around preparedness when vessel fires occur in Canadian ports. Following an investigation into a shipboard fire on the bulk carrier Tecumseh in the Port of Windsor,TSB Marine Transportation Safety Investigation Report M19C0403. the Board issued a safety concern about the adequacy of resources in Canadian ports for responding to shipboard fires. Outside of ports and harbours, the options for responding to a shipboard fire are even more limited should an on-board fire response be unsuccessful in suppressing a fire.
Canada’s preparedness for other types of marine emergencies, such as occurrences involving hazardous and noxious substances (HNS), is also a concern. For pollution-related occurrences, Canada does not have a plan for how to respond to occurrences involving HNS, although it does have a plan for occurrences involving oil. The federal government has recognized the need to improve preparedness for HNS occurrences and has announced that it intends to develop a single national system to respond to all marine pollution incidents, regardless of their source, in a timely manner that minimizes impact on human health and the environment. In addition, Transport Canada (TC) has proposed to make 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 regulations is 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.