NTSB: Firefighters Should Have Stayed Out of Grande Costa D'Avorio Blaze

In a hearing Tuesday, the National Transportation Safety Board approved final conclusions from the investigation of the fire aboard the ro/ro Grande Costa D'Avorio at Newark in 2023. The investigators confirmed that the fire started when the Jeep Wrangler that longshoremen used as a pusher vehicle overheated and burned inside the cargo bay, catching other nearby vehicles on fire.

Grimaldi ro/ros like Grande Costa D'Avorio carry thousands of used cars from the U.S. to Africa, including "forklift" cars that are so damaged that they won't roll and "non-runner" vehicles that have to be pushed aboard. Terminal operator Ports America's local unit in Newark was in the practice of using ordinary passenger vehicles as pusher trucks to shove non-running but still-rolling cars up the loading ramp and up the interior ramps inside the ro/ro.

The pusher that caught fire was a Jeep Wrangler, and NTSB noted that it was in use in an "industrial application for which it was not intended." This particular vehicle model was subject to a recall notice because its transmission had a tendency to overheat under extreme offroad use. Overheating would cause the transmission fluid to boil out of the housing and contact hot engine parts or exhaust piping, where it would catch fire. To address this known problem, the recall required installing an audible hot oil alarm and a warning light on the dashboard; the Jeep had had this service done - but the alarm was just a warning, not a shutoff.

On the day of the fire, Grande Costa D'Avorio was loading 920 used cars for export, including nonrunners. At about 2100 hours, a longshoreman was driving the Wrangler on his 38th push run of the day up the ro/ro's interior ramps - a far heavier task than the offroading conditions addressed by Jeep's recall. He was shoving a nonrunner ahead when he heard a clunk, and he saw "fireballs" dripping from underneath the vehicle.

Security camera footage shows the Jeep Wrangler making its final run as a pusher vehicle (USCG)

Based on the recall notice, the evidence from the scene and the extreme duty cycle imposed on the Jeep, NTSB concluded that the casualty was caused by the decision to use a vehicle that wasn't designed for the application - resulting in its transmission oil boiling over and catching fire on hot engine parts.

The Jeep operator was not able to get the fire out with an extinguisher, and the ship's fire alarm system went off, alerting the crew. 22 minutes after the fire was discovered, the master ordered the space sealed off and the fixed CO2 firefighting system discharged. However, the crew could not close the Deck 12 garage door because there was no external control to operate it. In order to close it, one crewmember would have had to stand inside the burning space, hold an actuator button down to shut themselves in with the smoke and fire, then make their way 120 feet aft to a ladder well on the port side - between tightly parked cars. (The lack of a button on the ramp side of the door was a SOLAS violation, according to NTSB, but the class society told the agency that it was acceptable because the door stays closed while at sea and does not need to be operated under way - only in port.)

The captain agreed that closing the door with crewmembers on the fire side would be unsafe, so the garage door stayed open. The CO2 system was discharged anyways with the door still fully open; an ATF study performed after the fact found that if the crew had had a practical way to close the door, the CO2 would have put out the fire.

When firefighters arrived on scene, the incident commander ordered a squad into the space to attack the fire. The local fire department's decision to open and close other compartment boundaries for moving personnel in and out further reduced the CO2 concentration and the fixed firefighting system's effectiveness, NTSB concluded, "ultimately increasing the severity of the fire." NTSB noted that this decision was contrary to normal marine firefighting practice.

Two firefighters went missing in the space and a SAR effort began. The compartment's ventilation system was turned on to clear smoke - removing the rest of the CO2 and introducing fresh oxygen. The two missing men tragically lost their lives inside the space, and the fire burned for days.

NTSB believes that the two firefighters were exposed to unnecessary risk when they were ordered into the CO2 flooding zone without being informed that it had been activated. The incident commander did not communicate the fact that the CO2 system had been discharged to the personnel entering the ship; at one point, a fire battalion chief even climbed a ladder well and opened a hatch to look in, despite the risk of asphyxiation on the other side. "His breath was taken away," said NTSB investigator Bart Barnum.

NTSB found that most of the local first responders had not recently taken marine firefighting classes, and they were not familiar with the vessel's fire control plan or with CO2 flooding systems. "Lack of marine vessel firefighting training left the land based firefighters unprepared to respond to a vessel fire, resulting in an ineffective response that contributed to the fire's spread, vessel damage and led to the firefighters' casualties," NTSB concluded.

Ultimately, NTSB's staff believes that local Newark firefighters should never have entered the space to fight the fire. "The best method to extinguish that fire was to work with the crew to close the Deck 12 door and allow the CO2 to function," said Barnum.

The NTSB has issued a recommendation to AAPA to inform all port authorities of the risks of the dangerous misuse of passenger trucks as pusher vehicles. It also asked seaports to help out their local fire departments to increase awareness, adopt basic vessel familiarization and firefighter training among first responders.

NTSB also recommended that the Grande Costa D'Avorio's class society should change its guidelines to require SOLAS fire doors to be closeable from both sides.