Wreck report for 'Samwater', 1947

Crown Copyright Reserved

No. 7948

S.S. "SAMWATER"

THE MERCHANT SHIPPING ACT, 1894

REPORT OF COURT

In the matter of a Formal Investigation held at County Sessions House, Islington, Liverpool, on the 22nd, 23rd and 24th May, 1947, and at the Royal Courts of Justice, Strand, London, W.C.2, on the 19th July, 1947, before Mr. K. S. Carpmael, K.C., assisted by Lieut-Commander C. V. Groves, Dr. A. M. Robb and Mr. J. Shand, into the circumstances attending the loss of s.s. "Samwater" which was abandoned off Cape Finisterre on the 29th January, 1947, owing to an outbreak of fire, and finally stranded on the North Coast of Cies Island where she became a total loss.

The Court, having carefully inquired into the circumstances attending the above-mentioned ship-ping casualty, finds. for the reasons stated in the Annex hereto, that the loss of the "Samwater" was primarily due to the wrong placing of the lever on the hot filter on the oil supply line on the starboard boiler, allowing leakage of oil under pressure which ignited on contact with the boiler front or boiler end.

Dated this 20th day of August, 1947.

KENNETH CARPMAEL, Judge.

We concur in the above Report.

QUESTIONS AND ANSWERS.

The Court's answers to the questions submitted by the Ministry of Transport are as follows:-

Q. 1. By whom was the s.s. "Samwater" owned at the time of her loss, and for how long had she been so owned?

A. The Minister of Transport since 14th July, 1944.

Q. 2. By whom was the s.s. "Samwater" managed at the time of her loss, and for how long had she been so managed?

A. The registered manager at the time of her loss was Herbert Gladstone McDavid of Glen Line Ltd., 20 Billiter Street, London, E.C.3, registered as from 1st December, 1945. The vessel had been managed by Glen Line Ltd., from 16th August, 1943.

Q. 3. By whom was the s.s. "Samwater" built?

A. Bethlehem Fairfield Shipyard Inc. of Baltimore, U.S.A., in 1943.

Q. 4. On what voyage was the s.s. "Samwater" lost?

A. On a voyage from Australia to Europe via Capetown where the oil fuel in use at the time of her loss was taken on board on or about 7th January, 1947.

Q. 5. On what date and at what position was the s.s. "Samwater" lost?

A. 29th January, 1947. The "Samwater" was abandoned about 4.30 a.m. in a position Lat. 42° 41'N. Long, 10° 13'W. approximately 40 miles to the Southward and Westward of Cape Finisterre, and finally stranded on the North Coast of Cies Island where she became a total loss.

Q. 6. What was the number of the crew all told at the time of the loss of the s.s. "Samwater"?

A. 41.

Q. 7. How many passengers was the s.s. "Samwater" carrying at the time of her loss?

A. 5.

Q. 8. How many members of:-(a) the crew, (b) the passengers, lost their lives in the casualty.

A. (a) 18, (b) 2.

Q. 9. Was the s.s. "Samwater" properly equipped and seaworthy for the ordinary perils of the sea when she sailed on what proved to be her last voyage?

A. Yes.

Q. 10. What fire fighting appliances did the s.s. "Samwater" carry, and where were they positioned on the ship?

A. The fire fighting appliances were as follows and placed as indicated:-

Deck Arrangements.

9 Fire stations on open deck each having one 2½ inches hydrant and 60 feet of fire hose with director.

6 Fire stations in accommodation each having two 1½ inches hydrants and one length of 30 feet fire hose with director.

7 Hand fire extinguishers 2½ gallon U.S. "Commander" pump type, three in accommodation and four in store rooms.

2 "Wilbur" Hand extinguishers tetrachloride type, one in wireless room one in motorboat.

1 "Foamex" fire extinguisher, steering engine space.

3 "Alfite" CO2 type Hand extinguishers, one in bosun's store forward and one each in forward and after mast houses.

8 Fireman's hatchets, one on fore deck, one in poop, and six in accommodation.

2 Smoke helmet equipments, oxygen bottle type, one in wheel-house, and one in engine-room near entrance.

1 Portable power fire pump with 30 feet suction head and 150 feet delivery hose with nozzle. (Capacity approximately 40 gallons per minute). Stowed in accommodation aft.

Engine Room Arrangements.

3 Fire stations each having one 1½ inches hydrant together with fire hose and director, two on starboard side and one on port side of engine room. Also two spray nozzles on starboard side, stowed near the respective fire stations.

1 thirty gallon foam extinguisher on the starboard side of engine room just abaft the starboard boiler.

6 Hand fire extinguishers.

In addition to the above the machinery space was provided with a main CO2 smothering gas installation consisting of thirty 50 Ib. cylinders stowed in a room at the after end of the port lower deck space, with pipe distribution under both engine and boiler platforms: the emergency control for operating the system was in the cross alley-way on the main deck near the entrance to the engine room.

Fire Pumps.

Two ballast pumps in after port corner of engine room having fire main connections, and either pump capable of serving the rising 4 inch fire main to deck hydrant service. Capacity about 60 tons per hour.

The engine driven forward sanitary pump also had a fire main connection, full capacity about 60 gallons per minute. Normally this pump at sea would be on sanitary service.

Q. 11. Were the fire fighting appliances (a) adequate, (b) in proper working order generally, and particularly with regard to the machinery space on the last voyage?

A. Yes.

Q. 12. Were the life-saving appliances adequate and satisfactory, and in particular the davits launching and release gear of the lifeboats?

A. The life-saving appliances including the davits and launching gear were adequate and satisfactory. The lifeboats were fitted with releasing gear which is not prescribed by Ministry of Transport regulations. It is considered that the releasing gear would function satisfactorily, provided the vessel had little or no headway at the time of launching, but that with substantial headway on the vessel the gear was unlikely to work. No attempt was in fact made to use the gear in any of the boats. This matter is considered in detail in the Annex.

Q. 13. Was the launching and release gear of the lifeboats thoroughly understood by the ship's officers and crew?

A. The launching gear of the lifeboats was thoroughly understood by the ship's officers and crew. It would appear that there was no real knowledge of the releasing gear which was never used when boats were launched for practice.

Q. 14. Were the lifeboats successfully launched?

A. Only one lifeboat, the forward boat on the port side, was successfully launched. The forward boat starboard side was put into the water but only the after fall was disengaged. The forward fall was cut away by those in the after boat which it was fouling. Most of the occupants of the forward boat scrambled into the after boat while the latter was hanging in the falls above them. The after boat starboard side was put into the water where the after fall became disengaged. The boat was towed alongside by the forward fall and shortly afterwards the davit parted whereupon the boat capsized and the occupants were thrown into the water. Efforts to right the boat were successful and most of the occupants managed to get back into the boat but it remained waterlogged. The after boat port side was lowered but before it was in the water the forward fall became disengaged, probably due to the swell, and the occupants were thrown into the water. The boat was left hanging by the after fall.

Q. 15. If all the lifeboats were not successfully launched was the failure due to the launching tackle and equipment, or was it due to conditions such as wind, weather, sea, movement of the ship?

A. The difficulties in launching the boats were due to the headway of the vessel. This point is dealt with in detail in the Annex.

Q. 16. Had lifeboat drills been carried out regularly, and had any difficulty been experienced with the lifeboats or any other of the life-saving appliances?

A. Ordinary lifeboat drill had been carried out regularly, and one boat had been placed in the water during the voyage from Australia at Mombasa. Except as described in the Answers to Questions 13 and 14 no difficulty had been experienced with the lifeboats. Some difficulty was experienced by some of the survivors in the use of the "Victory" type of life-jacket supplied to the vessel. This matter is dealt with in the Annex.

Q. 17. Did a fire break out in the s.s. "Samwater" on the 29th January, 1947?

A. Yes.

Q. 18. If so, at what time was the fire discovered, and where did it originate?

A. The fire was discovered shortly after 4.0 a.m. The fire originated at the hot filter situated at the inboard forward corner of the starboard boiler.

Q. 19. When the outbreak of fire was discovered was all necessary and proper action taken as quickly as possible.

A. No. This matter is dealt with in detail in the Annex.

Q. 20. If the necessary and proper action was not taken or was not taken as quickly as it might have been, was any person in authority on the ship to blame? If so, whom?

A. No individual in authority was to blame. This matter is dealt with in detail in the Annex.

Q. 21 (a). Was the supply of steam to the engine room turned off immediately the fire was discovered?

(b). If the supply of steam to the engines was not so turned off, why was this not done?

A. (a). No.

(b). This was not done in the first instance in the engine room by the engineer on watch, because he left the engine room for the purpose of shutting off the fuel oil by the hand wheel on the main deck as he was unable to reach the valve in the boiler room. When later it was desired to shut off steam, the hand wheel for operating the stop-valve from outside the engine room could not be reached owing to smoke and fire. The matter is dealt with in detail in the Annex.

Q. 22 (a). Was the supply of oil fuel to the burners turned off at the earliest possible moment?

(b). If the oil fuel was not so turned off, what was the reason for such failure?

A. (a) and (b). The oil fuel was not turned off immediately in the machinery space because the fire was in the region of the fuel pumps thereby prcventing access to the stop valves, and further because the valves on the fuel line from the port settling tank were inaccessible because of smoke.

Q. 23. Was the ship's fire alarm sounded?

A. No. The correct fire alarm was by ringing of the ship's bell and this was not done. The alarm bells however which were fitted during the war did sound, but there was no evidence to show whether this was deliberate or accidental.

Q. 24. Were failures of the steering gear of the s.s. "Samwater" reported shortly after the outbreak of fire? If so, what was the cause of such failures?

A. Two failures occurred, the first being temporary for a short time and the second permanent. The first was probably due to gas bubbles in the telemotor system caused by the heat, and the second to destruction of the system by the fire.

Q. 25. Was the s.s. "Samwater" equipped with wireless signalling equipment, and was such equipment (if any) affected by the fire on board?

A. The "Samwater" was equipped with transmitting and receiving wireless apparatus. The normal source of power supply was from the ship's mains, but there was an emergency supply of 24 batteries. There was also a boat's wireless equipment. Not long after the outbreak of the fire the main supply failed owing to the fire.

Q. 26. Was there an emergency or temporary wireless transmitter, and did this prove effective at the time of the casualty? If not, why not?

A. See Answer to Question 25. For some reason which could not be explained, the rectifying valves did not light up when the emergency power supply was brought into use. This failure was apparently not due to the fire.

Q. 27. Did the master give orders for the s.s, "Samwater" to be abandoned? If so, was such an order the proper order to give in the circumstances, and was it given at the proper time.

A. Yes. The order was a proper one and given at the proper time.

Q. 28. What were the conditions on board at the time the order to abandon ship was given:-

(1) as to state of fire;

(2) as to crew;

(3) as to passengers.

A. (1). The whole of the machinery space was ablaze, and the fire had spread to the accommodation. Flames were issuing from the funnel. There was also smoke or sparks coming from Nos. 3 and 4 holds.

(2) and (3). All the crew and passengers were mustered on the boat deck at boat stations. There was no panic.

Q. 29. What is known of the fate of the "Samwater" after she was abandoned?

A. The "Samwater" eventually sank on the northern side of Cies Island about 63 miles to the southward and eastward of where she was abandoned.

Q. 30. Was the loss of the "Samwater" together with the loss of the lives of 18 members of the crew and 2 passengers caused or contributed to by the wrongful act or default of her Owner the Minister of Transport, her registered manager (Mr. Herbert Gladstone McDavid), her managers (Glen Line Ltd.), her master (Captain Peter Dunsire) or her chief engineer (Mr. Charlie Goldsworthy Mathews)?

A. No.

Annex to the Report.

This Inquiry was held in Liverpool on the 22nd, 23rd and 24th May, and in London on 19th July, 1947.

Mr. Vere Hunt (instructed by The Treasury Solicitor) appeared as Counsel for the Minister of Transport, Mr. J. V. Naisby, K.C. (instructed by Messrs. Alsop, Stevens & Co. of Liverpool) appeared on behalf of the Managers of the ship, The Glen Line Limited, Mr. J. B. Hewson (instructed by Messrs. Ingledew, Brown, Bennison & Garrett of London) appeared on behalf of the Master and the Navigators' and Engineer Officers' Union, Mr. R. E. Gething (instructed by Messrs. Alsop, Stevens & Co.) appeared on behalf of the Chief Engineer, and Mr. Neil Maclean appeared on behalf of the National Union of Seamen who were made a party to the Inquiry upon application by Mr. Maclean.

The s.s. "Samwater", official number 169923, of the port of London, was a flush deck steel, single screw cargo ship with steam machinery situated amidships. The engines and boilers were situated in one compartment. The vessel had two decks and a double bottom in the way of the holds and the machinery space.

The vessel was built in 1943 by Messrs. Bethlehem Fairfield Shipyard Inc., Baltimore, Maryland, U.S.A. The Yard number was 2210.

The vessel was owned by His Majesty, represented by the Minister of Transport. The Managers were Messrs. Glen Line Ltd., 20, Billiter Street, London, E.C.3.

The Registered dimensions were:-

422.8 feet × 57.0 feet × 34.85 feet

The Tonnages were:-

The vessel had seven watertight bulkheads separating the following compartments:-

On the upper deck amidships a steel deckhouse surrounded the engine and boiler casing and accommodated the crew, mess rooms and galley. The top of this deckhouse formed the boat deck. On the boat deck a steel deckhouse surrounded the steel boiler casing and accommodated the officers.

On the bridge deck over this erection was a steel deckhouse which surrounded the steel boiler casing and accommodated the master, wireless operators, wheel house, chart room and wireless room.

The vessel had steel bulwarks all round the upper deck except for a short distance at the after end.

There were five main hatchways (one to each cargo hold). The hatch covers were wood, laid fore and after on transverse shifting beams.

For battening down the hatchways there was the usual arrangement of tarpaulins, battens, wedges and lashings, in accordance with the requirements of the Load Line Rules.

The vessel had one triple expansion reciprocating steam engine built in 1943 by the General Machinery Corporation, Hamilton, Ohio, U.S.A. and two oilfired watertube boilers built in 1943 by the Combustion Engineering Co., Inc., New York, U.S.A.

The vessel had the following lifeboats on each side of the boat deck, under mechanical davits:-

One 22 feet steel lifeboat certified for 31 persons.

One 22 feet steel lifeboat with motor and certified for 25 persons.

There were four rafts certified for a total of 80 persons. There were 70 lifejackets distributed throughout the cabins; the spares were in a box on the bridge deck. There were 14 circular lifebuoys. There were two sets of line-throwing apparatus. The life-saving appliances were inspected by a Ministry of Transport Surveyor at Southampton on the 31st July, 1946, and were certified as being in a satisfactory condition.

The navigation lights and sound signals were inspected by a Ministry of Transport Surveyor at Southampton on 31st July, 1946, and were certified as being in a satisfactory condition.

The vessel had the following types of Wireless Telegraphy apparatus:-

The wireless telegraphy apparatus was last inspected at Southampton on 26th July, 1946.

The vessel was classed-American Bureau + Al (E). She carried a Load Line Certificate issued by The British Corporation Register of Shipping and Aircraft on 10th July, 1944, to expire 17th August, 1948.

The assigned summer and winter freeboards were 9 feet 8 inches and 10 feet 3¼ inches respectively. The winter freeboard was applicable at the time of the casualty.

The ordinary main engine control valve and gear were located at the starboard forward corner of the engine, but there was an extension spindle to the steam stop valve fitted on the main deck close to a ladder leading up to the bridge deck.

The two boilers were placed on either side of the machinery space at the forward end.

The two oil fuel settling tanks, which each had a capacity of 53 tons, were arranged at the side of the ship abreast the boilers. The high and low suction and filling valves for the settling tanks. were fitted at the inboard forward corners of the tanks, and had extended spindles to deck sockets on the lower deck; on the port side the sockets were in the steward's store room.

The hot filter for the fuel oil, where the fire must have originated, was fitted about two feet from the inboard forward corner of the starboard boiler. The oil fuel service pumps were placed between the hot filter and the forward bulkhead of the machinery space; extended spindles to the steam stop valves of tlie oil fuel pumps were fitted on the main deck in the starboard forward alleyway. The hot filter had two chambers, only one of which should have been in use at a time; each chamber had a cover held in place by a hinged strong back with a securing nut. The flow of the oil to be filtered was directed to one or other of the chambers by a two-tier plug fitted in a chest between the chambers. The flow of the oil was by way of the top of the chest past the top of the plug to the chamber in use, down through the filter basket, out by the bottom port of the plug to the lower part of the chest and thence to the fuel line to the burners. The position of the plug was controlled by a horizontal lever which could be swung through 45 degrees from the central position. A projection was fitted on the underside of the lever, and when the lever had been swung through 45 degrees the projection came into contact with the lid of one or other chamber, so limiting the swing of the lever. At the end of the 45 degree swing of the lever the ports permitting entry to, and exit from, the chamber towards which the lever was pointing were fully open, and the ports permitting entry to, and exit from, the other chamber were completely closed.

There was no information on board the ship about the arrangement of the control plugs and ports of the filters, either in the form of a drawing or a book of instructions, and because the boilers had been continuously under steam since the engine-room complement at the time of the casualty had joined the ship there had been no opportunity to make an examination of the filter and become familar with the arrangement of the control plug and ports. In the course of his evidence the second engineer stated that when the operating lever was in the middle position the supply of oil to the filters was shut off. In fact, when the lever was in the middle position oil could flow into and out of, both filtering chambers. This point did not emerge until the third day of the hearing, and it was not until the sitting on 19th July that the full facts about the control plug and ports were proved.

The description above relates to the filter as originally fitted, but not to the filter as it was in use in the "Samwater" during the fatal voyage. Prior to that voyage the operating lever had been removed arid re-fitted upside down. The projection then pointed upward and no longer functioned as a limiting stop, with the result that the lever could be swung right round through a full circle instead of being limited to a swing of a quarter circle. The reason for that change is not definitely known. The engineroom officers of the "Samwater" at the time of the casualty had all, or nearly all, joined the ship in August, 1945, and the officers whom they relieved did not give any reason for turning the handle upside down, if indeed they had made the change. It is, however, surmised that the change had been made as a safety measure. With the handle as originally fitted there was nothing to prevent the securing nut on the strong-back to the cover of the chamber in use being slackened in error and so permitting an escape of hot oil under pressure; in the absence of information about the filter an attempt to open the chamber under pressure would be a possible error. With the handle fitted upside down, and no limitation of the swing, it could be swung over the securing nut for the cover of the chamber in use, and so reduce the possibility of the wrong chamber being opened.

Whether the reversal of the lever was intended as a safety measure or not it did, in fact, introduce another danger, a danger which was disclosed only when full details of the arrangement of control plug and ports became available. It has been noted that when the plug had been turned through 45 degrees from the central position there could be flow of oil to and from only one chamber. When, however, the plug had been turned sufficiently far for the lever to be over the securing nut, there was a slight restriction of flow from the chamber in use and therefore a small excess pressure on the cover; and when the plug had been turned through about 12 degrees more there was not only a further and serious restriction in the flow from the chamber, but there was admission to the other chamber. Thus the reversal of the operating lever, and the elimination of the limiting stops, made it possible for the lever to be swung past the proper working position to such a position that hot oil would be admitted to the chamber not in use, and if an attempt were made to open that chamber in order to clean the gauze of the filter there would be leakage of oil. It was established in evidence that it was necessary to use a hammer to swing the lever and it was therefore possible for the handle to be knocked just too far over.

The "Samwater" at the time of her loss was in the course of a voyage from Australia to Europe. She had called in at Capetown and left again on 7th January, 1947, having taken in 730 tons of oil fuel. She was carrying a cargo of wool, concentrates, etc. The total crew were 41 and there were five passengers, of whom 18 of the crew and 2 of the passengers lost their lives as a result of the fire hereinafter described.

Everything went normally until the morning watch of 29th January, 1947, when the vessel was about 40 miles to the southward and westward of Cape Finisterre. The watch in the engine room was changed at 4.0 a.m. and the next watch consisted of the second engineer Mr. Robert Cumming, a greaser Griffiths and a fireman Coombs.

The first duty of the greaser on coming on watch was to oil round the engines which he did; after that he left the engine room in accordance with the practice prevailing in order to make tea.

The first duty of the fireman was to change the four burners on the starboard boiler and this he was seen to do by the second engineer. This operation probably took between 5 and 10 minutes. The next duty of the fireman was to clean the hot filter which had been in use during the previous watch. The first thing to be done should have been to close the drain at the bottom of the filter, then swing the lever round from one operating position to the other, thereby bringing the new filter into use. Next the drain of the old filter should have been opened, the securing nut of the strong back eased back and the strong back opened, thereby enabling the gauze of the filter to be withdrawn and cleaned.

It is quite clear that the fire must have occurred during this operation and there are various possibilities as to how:-

(a) the oil escaped in the first instance, and

(b) thereafter became ignited.

The fireman Coombs, who unfortunately lost his life as a result of the casualty, could not be described as an experienced fireman. He had signed on in Adelaide some six weeks earlier in order to get to England with a view to taking a medical degree. He was intelligent, the job was not a difficult one, and it is considered that, with the tuition he had received from the second engineer, he was sufficiently competent to do the work.

It is, however, clear that neither the second engineer nor any other engineer, can have been fully conversant with the details of the filter, and any instruction given to the fireman was probably limited to the fact that the operating lever should be over the securing nut of the filter in use, and that with the lever in that position the cover of the chamber remote from the operating lever could safely be opened. It is certain that the fireman was not instructed that if the lever was not swung far enough, or was swung too far, there would be admission of oil to the filtering chamber which had been in use and from which it was intended to withdraw the gauze for cleaning.

Accordingly, it is possible that the fireman swung the lever too far over and then commenced to open a chamber to which he had unwittingly allowed entry of hot oil under pressure. In such a circumstance there would be a horizontal discharge of hot oil from the chamber as soon as the strong back had been slackened back and the cover cracked from the jointing. Oil forced out horizontally would come into contact with the boiler front or boiler end; and on the end there was an inspection door the plate of which could be very hot if the brickwork lining was broken. On this the oil may have sprayed. Alternatively, there may have been a faulty joint on the cover of the chamber which the fireman had brought into use, and a horizontal spray of oil caused in that way. It has been shown that swinging the operating lever over the securing nut caused a slight increase in the pressure on the cover, and swinging the lever beyond that position through a further 10 degrees transformed the slight increase of pressure into a serious increase. Hence there was the possibility of leakage from the cover of the chamber in use even although the lever had not been swung far enough for there to be flow of oil into the chamber which was to be cleaned. There had been some leakage from the cover of the chambers; this was proved by the fact that on the instructions of the chief engineer the second engineer had made a canvas cover for the filter soon after they had left England for Australia on her last round voyage.

Alternative possibilities of the way the oil was forced out of the filter are that there was dirt preventing a tight joint, or the asbestos packing ring being out of place or worn. Of the alternatives the Court considers that the first considered above was the most likely, namely escape of oil while the filter was about to be cleaned with the lever in the wrong position.

Another possibility as to the manner of ignition was that Coombs was smoking. There was no evidence that he was in fact smoking, and there was some evidence that smoking was not allowed. It is clear, however, that one of the other firemen regarded smoking as a normal practice. Coombs was a smoker and the possibility that he was doing so at the time cannot be excluded. On the other hand it is difficult to see how ignition could have taken place through smoking, as the force of the oil under pressure would probably have put the match, or lighter, or cigarette out. It is true that the conditions were more or less favourable for an explosive mixture being formed, but nothing was observed by the second engineer which pointed to any kind of explosion. On the whole the Court is inclined to rule out any question of ignition having taken place through smoking.

It is clear, however, that considerable danger can be caused through smoking, and it is considered that more drastic measures are necessary to prevent a continuance of the practice in the stokeholds of oil burning ships especially where, as in the case of the "Samwater", there is no separate boiler room.

The first the second engineer knew about the fire was seeing the fireman Coombs run past him pointing towards the stokehold. The time must have been shortly before 4.10 a.m. Coombs went up the engineroom ladder and disappeared from the engine room. It is clear from the evidence of one of the survivors who saw him shortly after he left the engine room that Coombs was suffering from shock and that there were splashes of oil on his right arm; and it is a reasonable presumption that Coombs had been burned.

The second engineer, having seen Coombs pointing as described above, walked towards the space between the two boilers and on getting just past the after end of the starboard boiler saw a large fire which seemed to be settled in the hot filter area round the service pumps. The fire was a large one above his own height and some of it was spraying over towards the port boiler. It was impossible to reach the pumps to turn them off. The first instinct of the second engineer was to call the chief engineer by means of the voice pipe to the latter's room, attracting attention by a buzzer, and then shouting up the voice pipe. The second engineer did not wait for a reply but his message was in fact heard and appreciated by the chief engineer.

The second engineer next attempted to reach the valves of the port settling tank which was the one in use at the time and probably contained about 25 to 30 tons of oil. He was, however, unable owing to smoke to go any further than just round the after corner of the port boiler. This attempt was obviously the correct thing to do and had it been successful it is probable that the fire would have burnt itself out in a comparatively short space of time. Had a smoke helmet been available in the machinery space itself and not above on the engine room casing, it might well have enabled the second engineer to reach the valves. This point will be dealt with later when certain recommendations are made.

The next thought uppermost in the second engineer's mind, as described by him in evidence, was to shut the fuel oil off in order to stop the fire. To do this, he had in mind first of all to reach the oil fuel pump controls in the starboard forward alleyway on the main deck. He stated that he was unable to get up the ladder as the smoke was too thick and he therefore ran aft along the tunnel and up the after tunnel escape. As it turned out, it was unfortunate that he neither telephoned to the bridge nor stopped the main engines. This is said not by way of criticism because it is clear that the second engineer Mr. Cumming acted with presence of mind and initiative in all that he attempted.

The second engineer's estimate of the interval that elapsed between the time Coombs pointed and the time he (the second engineer) entered the tunnel was 2 to 3 minutes at the most. It is clear that everything happened very quickly as can be realised when it is stated that the abandonment of the vessel was practically completed only about 20 minutes after the fire started.

The second engineer on leaving the tunnel and reaching the deck ran forward to the starboard forward alleyway where the extension spindles to the valves of the oil fuel pumps were placed. These controls he operated successfully. When he was at the controls the chief and third engineers had also arrived there.

There were three things essential to be done at this stage, namely:-

There was no necessity for all three engineers to have been together at any one of the extended spindles under consideration.

At the time the second engineer was turning off the oil fuel pumps it would obviously have been possible for one of the other engineers to have been working the main engine stop valve which was only a few yards away on the same deck in the cross alleyway. Later on when thought was given to this matter access to the valve proved to be impossible. More important still, one of the engineers should have been sent at once to the extension spindles of the valves on the port settling tank, which were situated on the port side on the lower deck. This is where the second engineer went after shutting off the oil pumps. Access to the settling tank valves was through the steward's storeroom and further delay was caused by the steward having to be summoned to bring his keys. Unfortunately the "T" keys for working the extension spindles were kept inside the engine-room door in the after cross alleyway. Why this was done did not appear, and a recommendation on this point will be made hereafter.

Whilst steps were being taken by the chief and third engineers to obtain access to the extension spindles of the valves on the settling tank the second engineer went to the after engine room door in the cross alleyway to try to get the "T" key, but owing to the smoke was unable to go through the door. The key was kept only about three feet inside the door, and had a smoke helmet been available the key could almost certainly have been obtained. The smoke helmet supplied to the engine room department was however kept in the same place as the key, and no one seems to have thought at that time of fetching the smoke helmet which was kept on the bridge, although this was later on brought into use by the deck department at the spot where earlier its use might have saved the situation.

In the meantime the chief engineer had taken no steps at all to inform the master of what was happening. It is clear that he was taken by surprise both by the fire and by its rapid progress. This was largely due to his never having thought out what should be done in the event of a fire, and by reason of essential keys not being kept in the right place, namely at the extension spindles. Owing to the key not being available the oil from the port settling tank, 30 tons of it, must have gone on feeding the fire. Had the valves been closed at the beginning, the fire must have died down after a comparatively short time.

When it was found that the settling tank valve could not be closed the chief engineer gave orders for the CO₂ gas to be turned on. This was done by its remote controls, but owing to ventilation and draught can have been of little if any use. The vessel had headway, the tunnel doors forward and aft were open and there was, in consequence, very considerable draught up the funnel which must have carried the gas away. After the CO₂ gas was turned on a belated attempt was apparently made by the chief and second engineers to reach the extension spindle of the main engine stop valve in the forward cross alleyway; but by this time access to the extension spindle proved to be impossible owing to the smoke. The chief engineer proceeded to the boat-deck and for the first time reported to the master on the position.

The first that was known on the bridge of a fire was at 4.10 a.m. when the chief officer, who had come on watch at 4.0 a.m. noticed a smell of burning when he was in the chart room with the second officer checking the ship's position. Both officers returned to the bridge at once and when it was found that no reply was obtained on the engine-room telephone, the second officer was sent to find out what was wrong. The chief officer then went below to the master's room to report, after which he returned to the bridge and about the same time heard the alarm bells ringing. These bells were the war time emergency alarm and were not the recognised fire alarm. It did not appear by whom the alarm was rung or whether the alarms rang by reason possibly of a short circuit.

The court is satisfied that although the proper fire alarm was not ordered or sounded, this was not a cause of any loss of life as all passengers and crew were in fact assembled later at the boats.

Shortly after the chief engineer reported to the master, it was apparent that the fire was very serious and was spreading to the accommodation. The master accordingly gave orders to abandon ship. The time at which this order was given must have been about 4.20 a.m. Attempts were made first of all to lower the two starboard boats because by this time the wind was about abeam on the starboard side. The vessel, however, still had substantial headway and in consequence there was great difficulty in successfully launching the boats. The releasing gear was designed only to operate when a boat was waterborne with the falls more or less vertical. With headway on the vessel, this position was unattainable. No attempt was made to use the gear in any of the boats. Indeed there was no evidence that anyone knew how to use the gear which had never been worked at any boat drill. The forward boat on the starboard side was the first to be lowered into the water. Owing to the headway it was unmanageable at first and drifted astern under the after boat which was then being lowered. Some of the occupants in the forward boat managed to scramble into the after boat, and eventually the forward falls were cut with an axe and the boat drifted astern. The after boat was lowered into the water and the after fall was unhooked. The boat was towed alongside and shortly afterwards the forward davit broke whereupon the boat overturned. Efforts to refloat it by those thrown into the water were successful and most of its previous occupants were able to get back into the boat which however remained waterlogged. The next boat to be lowered was the after boat on the port side, a motor boat. Unfortunately the forward fall became unhooked probably owing to the swell and the boat remained hanging by the after fall. The forward boat was successfully launched as the headway was by now reduced to a knot or so.

As a result of the mishaps to the boats 18 of the crew and 2 of the passengers were missing when the boats were subsequently picked up by a passing vessel and must be presumed drowned.

There were some criticisms of the "Victory" life jackets supplied, but these were of a comparatively minor nature and it is considered unnecessary to set them out in detail as an undertaking was given that further experiments would be carried out on behalf of the Minister in the light of the evidence.

As stated above the survivors were picked up by a passing vessel. This was a Swedish vessel the "P.L. Pahlsson" which had been seen by the master of the "Samwater" about 4 or 5 miles away on the starboard beam on a southerly course. Efforts had been made by means of an Aldis lamp to get in touch with her before the order to abandon ship was given. These were however unsuccessful. So also were efforts to send out distress signals by wireless. This was due in the first place to failure of the main supply of electricity owing to the fire, and secondly to an unexplained failure when the emergency supply of power by battery was used. It is very doubtful whether even if efforts to use wireless had been successful signals would have been received by the Swedish ship owing to there being no one on board her on wireless watch at the time. In these circumstances it was a pity that rockets were not used in order to attract attention.

This lamentable casualty has brought to light a number of matters in which there ought to be improvement, and the Court desires to put forward the following recommendations:-

KENNETH CARPMAEL, Judge.

Issued by the Minister of Transport in London, October, 1947.

LONDON: PUBLISHED BY HIS MAJESTY'S STATIONERY OFFICE

To be purchased directly from H.M. Stationery Office at the following addresses:

York House, Kingsway, London, W.C.2; 13a Castle Street, Edinburgh, 2;

39-41 King Street, Manchester, 2; 1 St. Andrew's Crescent, Cardiff;

Tower Lane, Bristol, 1; 80 Chichester Street, Belfast

OR THROUGH ANY BOOKSELLER

1947

Price 6d. net