Analysing the Factors Behind KM Mutiara Sentosa 1

Fire Accident
Putu Gede Andhika Nidyatama
4215101051
Double-Degree Marine Engineering Department
Institute of Technology Sepuluh Nopember

I. Introduction

Several weeks ago, exactly on Friday, 19th May 2017, there was an accident occurred
in Masalembo islands, Sumenep, Indonesia. The 134m long, 2130 dwt ro-ro passenger ferry
KM Mutiara Sentosa 1 caught fire. The fire erupted from a vehicle near the forepeak on the
car deck. The crew attempted to fight the blaze but were unable to contain it. The fire
consumed other vehicles and quickly spread down the length of the vessel. Authorities were
alerted and the captain of the KM Mutiara Sentosa 1 ordered all passengers and crew to
abandon ship.

The number of people rescued in not quite certain. Reports state from 154 to 190
passengers and crew were rescued and were taken ashore. Over 40 passengers were taken
to a nearby hospital for medical treatment. Reports do confirm that at least five passengers
had been killed in the fire. Authorities state there is a search for more than 28 passengers
who remain missing. An exact number of passengers on board may not be determined.
Authorities have launched an investigation into the incident.

II. Ship General Information

Figure 1 KM Mutiara Sentosa (Before Accident)

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Type : Ro-Ro Ship

Flag : Indonesia

IMO : 8718471

Callsign : YCRY

Year Built : 1988

Length : 134 m

Breadth : 21 m

Draught : 5.6 m

Speed (Avg/max) : 14.7 kn / 20.8 kn

III. Discussion

Referring to the type of accident, which was a fire accident, the author decided to
analyse the factors of the incident by using the SHELL-Model. As we know, SHELL-Model
are basically used to analyse an accident from 4 different kind point of view. By using
SHELL-Model also, we can discover a new way of considering another perspective.

Figure 2 SHELL-Model

First, is by seeing through the Liveware Central Liveware. This is the interface
between people, concerned in the leadership, co-operation, teamwork, and personal
interactions. In this case, there are some point to be taken from the Liveware Central
Liveware analysis, which are:

1. The Captain of the ship doesnt trust himself and crew to handle the fire, so he
asked all the passenger to abandon the ship.
2. There is a poor coordination between the port officer regarding the amount of
fuel stored inside the fuel tanks, supposedly if there is a vehicle being
transported, the vehicles fuel tank must be emptied first.

Second, by seeing through the Liveware Hardware. This is the interaction between
the human machine. In this case, there are some point to be taken from the Liveware
Hardware analaysis, which are:

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 1. There is no inspection before the vehicle enters the vessel. The inspection is
needed to know what is loaded up inside the vehicle.
2. The goods need to be categorized so that the placement on-board can be put
separated.

Third, by seeing through the Environment Liveware. This is the interaction

between the subject and the environment. In this case there are limited points regarding
this analysis, which only:

1. KM Mutiara Sentosa 1 is sailing towards the Masalembu Island, which are

known for its mystical environment.

Last, by seeing through the Software Liveware. This is the collective term which
refers to all the laws, rules, regulations, standard operating procedures etc. In this case, the
document data are limited due to the limited publication regarding legal papers. The points
are:

1. Neither the port officer or the captain didnt watch carefully the manifest of
what each vehicle is loaded up with.

IV. Solutions

From each of the analysis point stated above, the author has some solutions so that
this kind of accident doesnt happen again, or can be minimized.

1. Make sure every vehicle loaded up into the vessel, its fuel tank are empty.
2. Cross-check the manifest for the goods that the Ro-Ro vessel loaded up so the
dangerous goods can be separated.
3. Some source says that the crew try to put out the flames by relying on the
sprinkle, but that is not how it is supposed to be handled since it is caused by a
chemical reaction.
4. Generally, check-up the ship condition so that it could face any water condition.