Dutch Safety Board investigation finds SAR response gaps

During the subsequent two and a half hours, the fire continued to spread, while the MIRG had yet to arrive on scene. Based on visuals from the Coastguard aircraft, the Coastguard Coordination Centre concluded just after 02:00 that it was not a firefighting operation that was required but a Search and Rescue operation (SAR). The large amount of smoke meant that the crew of the Fremantle Highway were no longer able to reach safety by their own efforts. Because no SAR helicopters were on hand to airlift them off, seven crew members felt forced to jump overboard from a great height.

As a result of jumping, they were seriously injured; one of them died as a result of his injuries. The crew members who had jumped overboard were rescued from the water by rescue lifeboats and later taken to the port of Lauwersoog. The SAR helicopters eventually took the remaining sixteen people off the vessel and flew them to Groningen Airport Eelde. From there they were taken to various hospitals. All those on board were exposed to thick smoke for a long period of time.

If it is to be properly prepared for future incidents at sea, the emergency response system must be put in order as quickly as possible. That will require various improvements, as regards both the Coastguard and the relevant safety regions. To prevent current and future problems from continuing, the Dutch Safety Board makes the following recommendation.

Proactive action Coastguard

In the emergency response to the Fremantle Highway, the Dutch Safety Board noted that during the first few hours the action taken by the Coastguard was mainly reactive. That was also because, according to international agreements, it is the captain who bears final responsibility for the situation on board a vessel where safety, security, and environmental pollution are concerned. The fact that the captain bears this ultimate responsibility does not mean, however, that the Coastguard must only act on the basis of the information it receives from the vessel.

The Coastguard could adopt a more proactive approach so as to obtain a clear picture of the situation out at sea, prepare for various possible scenarios, and if necessary deploy the right units in good time. It can do this, for example, by requesting more information or by quickly forming a picture of the situation for itself on the basis of its own observations. A more proactive approach on the part of the Coastguard need not conflict with the final responsibility of the captain, as long as no compulsory measures are imposed on the vessel.

In cases involving serious danger to persons or the environment, the Dutch Maritime Accident Control Act (Wet bestrijding maritieme ongevallen) does, however, authorise the Coastguard to resort to measures of a more compulsory nature.

Interference between maritime firefighting and rescue

Although firefighting on board a vessel is the responsibility of its crew, the Netherlands has a maritime firefighting team that can provide assistance. In the case of the Fremantle Highway, it became apparent that deploying this team can interfere with efforts to rescue those on board. The helicopters needed to evacuate the crew were not at their base because they were already on their way to pick up the firefighting team.

This interference between the two objectives – with rescue capacity being fully occupied by the maritime firefighting team – is particularly detrimental in the case of fires on board cargo vessels, because the crew then cannot be airlifted off by helicopter if that proves necessary. In the case of fires on board (large) passenger vessels, with far more people on board, evacuation by helicopter is not really an option due to the limited capacity such aircraft have. Another difference between deployment of the team on cargo vessels and passenger vessels is that the likelihood of this being effective – with the fire being extinguished and/or casualties prevented – is much greater in the case of a fire on a passenger vessel than on a cargo vessel.

Reconsidering the added value of the maritime firefighting team in various different scenarios and potential interference with rescue capacity will enable choices to be made that will reduce the complexity, and thus the vulnerability, of the emergency response system.

An ongoing problem

The main conclusion of this investigation is that the Coastguard is not sufficiently able to assume control in the event of a complex emergency response operation. The Dutch Safety Board already arrived at similar conclusions regarding the Coastguard in previous investigations, most recently in 2015 in a report on medical assistance after a diving accident in the North Sea. In that report, the Dutch Safety Board identified the underlying cause as being that the directing parties had not enabled the Coastguard to carry out its duties properly.

That is still the case today: the directing parties do not provide the Coastguard with sufficient support in implementing the improvements needed to fulfil its coordinating role more effectively in emergency response operations at sea. Particularly if additional manpower or resources are needed for such improvements, it can take a long time for the directing parties to reach agreement because they do not always prioritise this and because no single party is prepared to take ownership of the problem.

This needs to change. To resolve this ongoing problem, collective commitment and decisiveness are needed, with a single party or individual being put in charge of implementing the necessary improvements.

Recommendations

a) To the Minister of Infrastructure and Water Management, the Minister of Defence, and the Minister of Justice and Security

1. Commit collectively to putting the emergency response system in order as quickly as possible and ensure that it remains so, in preparation for future incidents at sea. Appoint a specific, mandated director to coordinate the necessary improvements. Make improvements as regards at least the following points:
   
   a. The digital exchange of information between the Coastguard Coordination Centre and the relevant partners in the emergency response chain, for example by linking it to the Integrated Communication and Information System for Emergency Communications Centres.
   
   b. The Coastguard Coordination Centre’s assessment and decision-making processes, training and exercises, by having them link up with and, where appropriate, conform with the onshore crisis management system.
   
   c. The way a picture is acquired of incidents at sea, at least by properly requesting information when an incident is reported and by enabling faster perception based on first-hand observation of incidents.
   
   d. The preparedness of relevant safety regions for receiving a large number of casualties from an incident at sea.

In its investigation, the Dutch Safety Board found that it is unclear which scenarios actually require deployment of the maritime firefighting team. The Dutch Safety Board’s investigation also shows that the emergency response in the Fremantle Highway situation involved an undesirable degree of interference between the tasks of maritime firefighting and rescue. With a view to preventing unwanted interference between different tasks in the future, the Dutch Safety Board makes the following recommendation:

b) To the Minister of Infrastructure and Water Management

Develop an approach for preventing and dealing with undesirable interference between the provision of assistance at sea and other (Coastguard) tasks. Apply that approach in any case so as to clarify which scenarios actually require deployment of the maritime firefighting team and to address the issue of possible interference between the team’s deployment and the rescue of persons on board in the context of those scenarios.

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