Findings from TSB investigation M21P0297: Fire aboard container vessel ZIM Kingston

Investigations conducted by the Transportation Safety Board of Canada (TSB) are complex, as an accident is rarely the result of a single cause.

In the case of the October 2021 occurrence involving the ZIM Kingston (M21P0297), several factors led to the container loss and subsequent fire. The four findings below are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence. In addition, the TSB made three findings as to risk and five other findings during the course of the investigation. 

Findings as to causes and contributing factors

These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.

  1. While the ZIM Kingston was holding offshore at La Perouse Bank awaiting a berth at the Port of Vancouver, British Columbia, it encountered environmental conditions that, in conjunction with the specific characteristics of the vessel itself, resulted in the onset of parametric rolling.
  2. The parametric rolling caused the vessel to roll 36° to both port and starboard. The forces that resulted from these extreme motions were the precipitating factor causing the loss of 109 containers overboard and damage to other containers that remained on board.
  3. The vessel owner had not developed procedures or provided specific tools to support the bridge crew on the ZIM Kingston in 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.
  4. Water ingress inside a damaged container holding potassium amyl xanthate in bay 14 generated a reaction that caused a fire to ignite inside the container and then spread to 5 other nearby containers.

Findings as to risk

These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.

  1. If there is no comprehensive, up-to-date guidance to industry in the management of parametric rolling, there is a risk that company policies, procedures, tools, and training in this regard will be inconsistent, ineffective, or absent altogether, leading to continued container loss occurrences and their associated negative outcomes for safety and the environment.
  2. If masters are provided with loading plans that do not respect the limits set out in a vessel’s cargo securing manual and masters accept the risk of sailing with lashing forces that exceed safe limits, container vessels will sail with a reduced margin of safety to protect against container loss.
  3. If Canada is not prepared to respond to marine emergencies in Canadian waters, there is a risk that these emergencies will not be managed in a timely and effective manner, endangering vessels, their crews, the environment, and the health and safety of Canadians.

Other findings

These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.

  1. Model testing by the National Research Council Canada identified that parametric rolling can occur in significant wave heights as low as 2.6 m, far less than those encountered at the time of the occurrence.
  2. The on-board response to the container fire followed industry and company guidelines and was conducted in an efficient manner. The use of shore-based specialized personnel and vessels of opportunity contributed to limiting the extent of the fire.
  3. Danaos’s contract with an emergency response company meant that the ZIM Kingston 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 fight the fire.
  4. Canada does not have a program to monitor and assess the long-term impacts of lost containers or the debris from lost containers, and the impacts on marine ecosystems are relatively unknown.
  5. Electronic inclinometers provide more data about a vessel’s roll angles than analog inclinometers and also provide data about a vessel’s roll period, making them more useful for safe navigation and accident investigations. 

Investigations conducted by the Transportation Safety Board of Canada (TSB) are complex, as an accident is rarely the result of a single cause.

In the case of the October 2021 occurrence involving the ZIM Kingston (M21P0297), several factors led to the container loss and subsequent fire. The four findings below are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence. In addition, the TSB made three findings as to risk and five other findings during the course of the investigation. 

Findings as to causes and contributing factors

These are conditions, acts or safety deficiencies that were found to have caused or contributed to this occurrence.

  1. While the ZIM Kingston was holding offshore at La Perouse Bank awaiting a berth at the Port of Vancouver, British Columbia, it encountered environmental conditions that, in conjunction with the specific characteristics of the vessel itself, resulted in the onset of parametric rolling.
  2. The parametric rolling caused the vessel to roll 36° to both port and starboard. The forces that resulted from these extreme motions were the precipitating factor causing the loss of 109 containers overboard and damage to other containers that remained on board.
  3. The vessel owner had not developed procedures or provided specific tools to support the bridge crew on the ZIM Kingston in 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.
  4. Water ingress inside a damaged container holding potassium amyl xanthate in bay 14 generated a reaction that caused a fire to ignite inside the container and then spread to 5 other nearby containers.

Findings as to risk

These are conditions, unsafe acts or safety deficiencies that were found not to be a factor in this occurrence but could have adverse consequences in future occurrences.

  1. If there is no comprehensive, up-to-date guidance to industry in the management of parametric rolling, there is a risk that company policies, procedures, tools, and training in this regard will be inconsistent, ineffective, or absent altogether, leading to continued container loss occurrences and their associated negative outcomes for safety and the environment.
  2. If masters are provided with loading plans that do not respect the limits set out in a vessel’s cargo securing manual and masters accept the risk of sailing with lashing forces that exceed safe limits, container vessels will sail with a reduced margin of safety to protect against container loss.
  3. If Canada is not prepared to respond to marine emergencies in Canadian waters, there is a risk that these emergencies will not be managed in a timely and effective manner, endangering vessels, their crews, the environment, and the health and safety of Canadians.

Other findings

These items could enhance safety, resolve an issue of controversy, or provide a data point for future safety studies.

  1. Model testing by the National Research Council Canada identified that parametric rolling can occur in significant wave heights as low as 2.6 m, far less than those encountered at the time of the occurrence.
  2. The on-board response to the container fire followed industry and company guidelines and was conducted in an efficient manner. The use of shore-based specialized personnel and vessels of opportunity contributed to limiting the extent of the fire.
  3. Danaos’s contract with an emergency response company meant that the ZIM Kingston 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 fight the fire.
  4. Canada does not have a program to monitor and assess the long-term impacts of lost containers or the debris from lost containers, and the impacts on marine ecosystems are relatively unknown.
  5. Electronic inclinometers provide more data about a vessel’s roll angles than analog inclinometers and also provide data about a vessel’s roll period, making them more useful for safe navigation and accident investigations.