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MV ZIM KINGSTON Incident Response National After-Action Report

Table of Contents

1. Executive Summary

On October 21, 2021, the containership MV ZIM KINGSTON reported to the Marine Communication and Traffic Services (MCTS) and relayed to Sector Puget Sound, that their vessel heeled 35 degrees in heavy swells and lost approximately 40 containers overboard, 20 from the starboard side and 20 from the port side, approximately 38 nautical miles west of the entrance to the Juan de Fuca Strait, off the coast of Vancouver Island, BC. The vessel’s port side pilot ladder was destroyed but is still onboard. CCG responded from the point the cargo went overboard and continued to manage the incident, and shoreline clear up until the vessel was secured at the Delta Port World facility Nanaimo on December 3, 2021.

While programs have ongoing activities, the ZK After-Action Report (AAR) covers October 21 to December 3, 2021.

Senior Management requested that the Office of Incident Management’s Continuous Improvement team facilitate the writing of the ZK AAR for a broader lens to include input from the national programs’ perspective and the regional management and tactical response, which provides a more holistic view of the incident response.

This is the first National AAR produced using the new Continuous Improvement Framework.

2. Incident Overview

While conducting slow transits north and south at the entrance to the Juan de Fuca Strait awaiting an offload berthing slot to open at the Port of Vancouver, the MV ZIM KINGSTON experienced heavy seas from a strong low-pressure system that impacted the coast of British Columbia on October 21, 2021.

The Maltese-flagged, 260ft vessel, is a 4,253 Twenty-foot Equivalent Unit (TEU) capacity containership built in 2008. During the storm the ship rolled and a total of 109 containers fell overboard at Cape Flattery.

Type: Shipping Container
Run by: Danaos Shipping
Built: 2008
Flag: Malta
Deadweight Tonnage: 50,000

2.1 Vessel Casualty (Transport Canada) and Cargo Loss (Canadian Coast Guard)

On October 21, 2021, the containership MV ZIM KINGSTON reported to the Marine Communication and Traffic Services (MCTS) that their vessel heeled 35 degrees in heavy swells and lost approximately 40 containers overboard, 20 from the starboard side and 20 from the port side, approximately 38 nautical miles west of the entrance to the Juan de Fuca Strait, off the coast of Vancouver Island, BC. The vessel’s port side pilot ladder was destroyed but is still onboard.

The vessel reported it had no permanent list and the lost containers were general containers with no dangerous cargo. The vessel requested safe anchorage near Vancouver to arrange for a Pilot to proceed to Vancouver anchorage.

The Marine Occurrence Report (MOR) email issued by MCTS Prince Rupert included the following:

A Navigation Warning (NAVWARN) was posted for the area asking that any commercial or local traffic in the area report any sightings of the lost containers.

Lacking the cargo manifest, all containers afloat were treated with caution. Canadian Coast Guard (CCG) worked with the United States Coast Guard (USCG) to locate containers and plot their drift patterns.

TC continued to pursue the owner for the cargo manifest.

On October 22, 2021, TC received the cargo manifest. It was shared with CCG through MCTS and Western Regional Operations Center (ROC).

In total four containers were identified as carrying dangerous goods. Two went overboard and the other two remained onboard the vessel.

TC continued to seek further details about the dangerous goods in the identified containers.

2.2 Search and Rescue (SAR)

On October 23, 2021, the MV Zim Kingston, at anchor on Constance Bank, with 21 people onboard, reported a fire onboard the vessel within their cargo containers. Due to the dangerous goods onboard, firefighting assistance was requested.

On October 23, 2021, through the coordination of JRCC, CCG SAR evacuated sixteen crew members.

2.3 Environmental Response (ER)

From October 24 to 29, 2021, the remaining five crewmembers remained onboard working with two contracted offshore supply vessels with firefighting capability (MAERSK TENDER and MAERSK TRADER), and a tug to cool down the containers surrounding the fire.

This strategy was used due to the hazardous materials in the containers on fire. Applying water directly to them would have resulted in greater fire and/or explosion. The fire in the containers was allowed to burn down, which was effective.

There were initially four containers on the vessel that contained TIBOUREA DIOXIDE (UN 3341) and POTASSIUM AMYL-XANTHATE (UN 3342). Of those four, two containers went overboard and sunk to the bottom. The two containers that fell overboard were deemed non-persistent in the marine environment.

The two containers that remained on the vessel were damaged and were of concern because in that environment the products, if exposed to moist air, would cause a chemical reaction and the containers would become combustible. These are the two containers that caught fire, however, for firefighting purposes and to avoid a greater explosion the containers were allowed to burn down.

Environment and Climate Change Canada (ECCC) confirmed that the containers that had sunk would be considered non-persistent in the marine environment. The dangerous goods were deemed fully soluble and expected to break apart in water and bioremediateFootnote 1 quickly in the ocean. Their impact to the marine environment would be felt for a short-term and localized to the area where hydrolyzed.

Similar to pollutants from the washout from the firefighting efforts, such dilution made any pollution countermeasure strategy unnecessary.

2.4 Incident Management (IM)

On the evening of October 23, 2021, CCG stood up a UC to manage the incident. Different configurations of the UC were established during the response. This was necessary to coordinate the multi-pronged and multi-partner response, including fire suppression, pollution mitigation, collection of environmental data, vessel casualty management, container recuperation, shoreline debris clean-up, response partner and community engagement, and communications to the public.

Unified Command is a component of the Incident Command Post. Those identified in the UC are usually on-scene, have authority to respond and direct their resources. Those assisting and cooperating agencies within the ICP and on-scene may differ from those within the UC as they support and provide assistance in accordance with their own mandates and may change over the lifecycle of an incident.

Members of the UC

An Incident Command Post (ICP) was established with the following supporting response Department/Agencies:

ICP Resources for the vessel fire

ICP Resources for the container loss

On October 26, 2021, TC representatives joined the ICP in a supporting capacity as technical specialists. W̱SÁNEĆ (Tsartlip, Tseycum, and Tsawout First Nations) also joined the UC on October 26, 2021.

On October 27, 2021, the owner of the MV Zim Kingston performed a detailed inventory of containers. The initial 40 containers were then estimated to be 109 containers lost overboard.

The National Incident Management Team (NIMT) was not activated.

In CCG Headquarters, national support was provided to Western Region ICP through the Environmental Response (ER) and the Vessels of Concern (VOC) programs.

Programs provided daily strategic updates for senior management regarding response activities, status of vessel and status of cargo containers.

November 19, 2021, CCG stood down UC for this incident. Program officials from TC and CCG continued to work toward moving the vessel to a sheltered location until it could be unloaded and continued container clean-up activities.

2.5 Resources Identified to Support

2.6 Vessel Clearance for Transit

On October 29, 2021, the Vessel owner’s Classification Society (Det Norske Veritas - DNV) completed their inspection of the vessel. TC inspectors conducted a separate inspection.

Ships’ crew and salvage crew focused on securing the cargo for ship movement.

The Classification inspection report for the vessel was completed on November 2, 2021. The hull structure, vessel stability, life-saving appliances, navigation system, propulsion and vessel maneuverability were found unaffected by the fire incident and the fall of containers onboard at the time of survey.

Also, on November 2, 2021, all measures to secure the vessel’s cargo during ship movement were completed.

2.7 Vessel Transit to Nanaimo

The MV ZIM KINSTON left Canadian waters to enter the Vessel Transit System at approximately 0930 on December 3, 2021, and transited through US waters until approximately 1300.

Automatic Identification System (AIS) records indicate that only one CCG SAR Lifeboat was part of the convoy. AIS records indicate that the USCG Cutter Wahoo entered into Canadian waters to join the convoy.

The vessel was in compulsory pilotage waters when it departed from Constance Bank and was required to embark a pilot as a matter of normal operations.

The vessel stayed at anchor in Nanaimo until December 11, 2021, then it was berthed at the Delta Port World / Duke Point facility in Nanaimo.

Unloading began on December 12, 2021. Hanging, damaged and toppled containers were prioritized.

On December 21, 2021, while unloading operations were taking place, a fire broke out in the remaining cargo. It took ships’ crew and Delta Port World facility workers 1 ½ hours to extinguish the fire. CCG was not involved in this incident.

The vessel departed Canada on February 8, 2022, enroute to Hong Kong.

Prior to the MV Zim Kingston’s departure from Canada, DFO Legal Services successfully negotiated an agreement with the vessel’s Protection and Indemnity (P&I) Club (on behalf of the vessel, the owners of the vessel, and for the Club itself):

2.8 Environmental Monitoring

Throughout the incident, air monitoring teams with equipment were deployed to the vessels tending the MV Zim Kingston and onshore to evaluate the air pollution risks from the smoke coming off the vessel. The readings showed the toxicity levels were in acceptable ranges, and never reached a level where evacuation was required. ECCC had no air quality concerns. 

An EU was stood up as part of the ICP, which included multiple departments that provided input to the UC.

Terrestrial air monitoring was stood down on November 2, 2021.

ECCC conducted water column sampling at the incident site and had no concerns about the water quality.

2.9 Container Tracking

MCTS issued a NAVWARN regarding the drifting containers and asked that any commercial or local traffic in the area report any sightings of the lost containers.

At the outset of the pollution incident, CCG notified all the West Coast Vancouver Island First Nations through the ER area response plan and notification process. A request was issued to report any sightings of containers.

CCG worked with USCG and ECCC to monitor/plot the drift patterns of the containers that went overboard. Poor weather conditions challenged trajectory modelling efforts and efforts to track the adrift containers.

TC National Aerial Surveillance Program (NASP) and CCG resources conducted several overflights to observe, record and report on the ship’s lost containers.

The weather conditions were dynamic and limited operations and communications throughout the response and container clean-up efforts.

2.10 Report of Containers/Debris Washing Ashore

Post-vessel fire, the owner assessed the extent of damage and reported that their initial reporting of 40 containers overboard was increased to 109.

The containers lost at sea were reportedly carrying mostly general cargo (toys, games, sports equipment, furniture/bedding, electrical machinery equipment, general household goods, footwear/clothing, photography/optical equipment, and vehicle parts).

As previously identified, in total there were four containers with non-marine polluting dangerous goods (TIBOUREA DIOXIDE (UN 3341) and POTASSIUM AMYL-XANTHATE (UN 3342)). Two went overboard, two were on the vessel and were involved in the fire.

Incoming reports identified that four containers had drifted to the north and beached on the northwest tip of Vancouver Island in the following areas:

Image described below

Image depicts the movement of the containers northwest of the tip of Vancouver Island

Image described below

Images shows the containers drifting 12nm northwest of the tip of Vancouver Island

Additional debris were reported to wash up along the shores of the following areas:

Image described below

Image shows the locations of the containers washing up along the shoreline

2.11 Container Clean-up Operations (October 27 to November 24, 2021)

The owner of the vessel took a proactive role throughout the response and hired Resolve Marine Limited, a salvage contractor, to track and remove any containers found.

Clean-up operations commenced on October 27 and continued through November 24, as reports were received, and weather conditions permitted.

The owner’s response was robust and utilized qualified personnel, following appropriate regulations, and using industry best practices. The contractor was cooperative with federal authorities and kept in communication with the owner’s representative; that information was shared with CCG for use while in the ICP.

The owner contracted private industry, non-profit organizations, and First Nations (FN) communities for container and beach clean-up operations including:

Clean-up plans, which included site environmental assessments, were developed by the owner’s representative submitted to and approved by UC.

Clean-up of debris/garbage was removed from the area and transported for appropriate disposal/recycling.

Containers and debris in impacted areas were remediated as per the MV Zim Kingston Incident Debris Removal and Endpoints Plan (DREP). DREP is a document that delineates the UC agreed satisfactory end points for clean-up operations.

CCG monitored and supported clean-up operations. This was accomplished by:

2.12 CCG & Owner’s Representative Engagement

The owner’s representative was cooperative and engaged within the UC regarding the fate of the containers and their continued remediation. The CCG continued to engage with the owner’s representative as their single point of contact post-incident.

At the time of the incident, the Coast Guard didn’t issue any direction to compel the owner to take action. The owner was deemed cooperative and collaborative. If it would not have been the case, the Coast Guard could have issued a direction to the owner specifying, for example, that debris in a particular location(s) be cleaned up within a given timeframe.

3. On-going activities

These activities were executed while the ICP was activated, and CCG continued to carry-out after the ICP was demobilized:

Public safety messages were on-going that if the public came across a container, they had been asked to avoid opening it and call the CCG’s toll-free number to report its location immediately.

CCG continued to monitor the affected area through opportunities for aerial surveillance by flying over the known affected areas if a NASP flight or a CCG Helicopter was in the area.

4. Incident Review and Methodology

4.1 Methodology

Data Collection

This National After-Action Report builds upon the Western Region’s document entitled “DRAFT 1.5 – MV Zim Kingston Incident Response and Hazardous and Noxious Substances Incident Review – July 2022”, hereafter referred to as the 2022 HNS Review. That document resulted from “an in-depth, multi-pronged review of the MV Zim Kingston incident,” including reviews by subject matter experts (SMEs), debriefs of Incident Command Post staff, and a workshop with responding agencies and stakeholders involved in the incident.

Western Region stated that the 2022 HNS Review did not provide recommendations with its findings but was intended to guide senior management in making their own, higher-level recommendations. CCG National Headquarters (NHQ) also conducted a Hotwash meeting on November 15, 2021, with Directors General of Fleet & Maritime Services and Response and program Directors, as well as staff involved in the incident. This Hotwash focused only on actions taken by NHQ.

The National AAR has relied on the incident briefing materials produced as events unfolded, the 2022 HNS Review and the NHQ Hotwash, as well as several additional follow-up meetings. Multiple discussions and meetings were conducted to solicit additional and specific feedback to contribute to this report's generation.

The Western HNS Engagement and AAR meetings provided discussion points for senior management and tactical findings for more immediate action by the Region. The NHQ Hotwash provided some points for action by NHQ staff. The National AAR has extracted findings from the HNS Review’s findings and the NHQ Hotwash.

4.2 Review of Other Documentation

Other documents outside of the MV Zim Kingston incident were reviewed to help identify recurring issues and assess new ideas and best practices. The relevant documents reviewed mainly related to HNS rather than container searches or SAR.

Previous Incidents

Exercises

Reports

CCG Manuals

5. Analysis

The success of the response to the MV Zim Kingston incident was largely, as noted by participants, due to a combination of planning, inter-agency coordination, the willingness of the owner to take response measures and hire appropriate response service providers, the deep experience levels of responders, international partnerships, as well as the willingness and cooperation of all participants to work together.

General Summary

Findings and Implementation

5.1 Incident Management Approach and Modeling

The CCG, along with the members of UC and other key response partners and stakeholders, had a variety of factors to consider when determining the most appropriate approach to managing the response.

By nature of the incident centering around combustion (release) of a Hazardous and Noxious Substance product on water, the Environment Unit (EU) was an instrumental component of the ICP and the multifaceted response. The EU was tasked with significant responsibilities that included conducting situational awareness calls with stakeholders and partners. Representation in the EU was, resultingly, robust with participants spanning federal and provincial departments and agencies, First Nations, and the legal representative for the ship owner.

The ship fire and on-going cargo loss response presented UC with an additional consideration: how to effectively manage two concurrent consequences that were not co-located geographically. While various models could have been leveraged, ultimately a divisional model was selected and implemented. This model divided responders into Division A and Division B, both of which were centrally managed by one ICP. Division A was tasked with coordinating and executing the response to the ship fire, while Division B searched for and coordinated recovery, as applicable, of the lost containers and cargo. Coordination functions such as coordination calls with the owners, the ports, the Indigenous groups, and media was conducted by Division A.

The divisional model is also reflective of the significant efforts that were developed and dedicated to the cargo loss and recovery effort under Division B. These efforts included trajectory modeling and a surveillance operation, including by air, to assist in searching for cargo containers and commodities at sea, and/or onshore in remote and expansive geographical areas, engagement with the owner’s representative, receiving reports of containers/debris, and monitoring container/debris cleanup operations.

Container and debris impacted areas have been remediated as per the MV Zim Kingston Incident DREP. The DREP is a document developed to inform and facilitate both initial clean-up efforts of beached containers and their debris, as well as future monitoring of environmental conditions within the area of impact. It was the first incident in which a DREP was developed and used by CCG. The document also provided the end point targets that established when clean-up operations and monitoring would cease. This document was established by the EU in agreement with the UC, and signed by the Canadian Coast Guard, Environment and Climate Change Canada, the Responsible Party, and the Province of British Columbia.

As per the guidelines within the DREP, a short-term monitoring program involved conducting an environmental assessment immediately following the initial clean-up response. The long-term monitoring program was to be repeated at 3, 6, 9 months from initial impact. It was noted that there were no listed start and end dates for the 3, 6 and 9 month monitoring. As there were multiple sites that had differing dates, there was uncertainty at times regarding the timing for the next follow-up.

An additional success during the response was the functional participation of the ship owner, through legal representation. Throughout the incident, the ship owner’s representative attended and supported the ICP. The willingness of the ship owner to actively participate influenced the overall positive outcome of the response.

The National Incident Management Team (NIMT) was not activated in Headquarters for this incident. This incident was originally reported as a SAR response through the National Incident Notification Protocol (NINP), so was not closely examined from an Environmental Response (ER) or a Vessels of Concern (VOC) lens.

Initially, the incident did not appear complex from program-specific viewpoints; however, the combined components, and potential complications became more evident as the incident unfolded. A marine casualty resulting in a wreck is still within the CCG’s authorities under Part 1 of WAHVA. National support was provided to the Western Region ICP directly through the ER and the VOC programs.

Information requests were being made from national headquarters programs to regional subject matter experts directly, rather than following the information flow process. The information was not always being shared with the National Command Centre (NCC), nor was it included in their briefings and situation reports.

Incident reporting can experience challenges, depending on the time zone difference. For this incident, the Regions reporting timelines did not align with the Minister’s briefing cycle. Due to the high profile of incident and the department having a new Minister, there was a significant draw from both HQ program staff and specific regional program personnel to brief senior leadership.

Additionally, there had been a media infraction early in the incident. Due to the unauthorized release of information to the media, communication processes were tightened to limit the flow of information and ensuring appropriate levels of approvals.

6. Summary of Findings

Finding 1: Mandate and Authorities

The incident highlighted gaps in the working policy of participating federal agencies and departments as compared to their explicit mandates. Confusion on the bounds of authority impacted assumptions regarding operational roles and where and when involvement of certain agencies began and ended.

At times during this incident, groups such as CCG JRCC, CCG ER, and Transport Canada struggled to operate in a coordinated manner. Assumptions among response partners about individual roles and responsibilities occasionally contributed to delays and confusion in the execution of tactical assignments, as well as coordination and communication with other stakeholders and partners (First Nations and local authorities). The incident emphasized the critical importance of strong relationships among response partners and how these relationships can help to minimize confusion during a response which was observed during the management of the incident.

While the responsibilities and authorities of Federal entities involved in a hydrocarbon incident are widely understood, this clarity did not extend to Hazardous Noxious Substances incidents. The gaps in the understanding of mandates were acutely highlighted when the fire onboard the MV Zim Kingston was deemed extinguished, and the structural integrity of the ship had been evaluated as stable by Transport Canada naval architects.

For the CCG, the current understanding of their mandate suggested that their role in the response ended at this point. However, the cargo recovery operation had not concluded. The conclusion of the fire and stand-down of Division A alongside the ongoing cargo recovery of Division B, caused a misunderstanding as to whether another federal entity would assume the Incident Commander (IC) role. Ultimately, the CCG continued to fill the role until the cargo recovery transitioned into the ‘project’ phase. Once in the project phase, the VOC Program continued to work on the cargo recovery.

The vessel was under a Maltese flag, where Malta is a state party to the Nairobi Convention. This means that whether this occurred in the Exclusive Economic Zone (EEZ) or within Canadian waters, the vessel is subject to the obligations under WAHVA s.19 reporting a Maritime Casualty and WAHVA s.20 - marking a wreck.

The owner or master of the vessel “must ensure that all reasonable steps are taken without delay to mark the wreck.” At the time of the incident, CCG had not yet established standards and processes internally on what the standard for marking was, therefore was not in a position to enforce its obligations. However, CCG worked with the owner to provide directions on measures that the owner took.

Under WAHVA, the owner of a vessel is liable for any loss, damage costs or expenses for 6 years from the date of the maritime casualty that caused the wreck. The authorities are all discretionary and are identified as ‘the Minister may.’ In this instance, the MV Zim Kingston’s liability ends October 20, 2027. In addition, there is a concurrent 3-year time bar clause on bringing an action for costs which begins the moment a wreck becomes a hazard. Once a container is found and assessed to be a hazard, CCG has 3 years to recover costs and expenses within the October 20, 2027, window.

A Maritime Casualty means a collision of ships or other incident of navigation, or other occurrence onboard a ship or extremal to it, resulting in material damage or imminent threat of material damage to a ship or its cargo.

Hazard Definition in WAHVA means any condition or threat that poses a danger or impediment to navigation or may reasonably be expected to result in major harmful consequences to the marine environment, or damage to coastline or related interest to one or more States. CCG authorities under WAHVA for a part 1 supersede TC’s authorities to address obstruction to navigation under the Canadian Navigable Waters Act (CNWA s.14.2).

WAHVA s.21 allows the Minister to direct the owner to take measures considered practicable and proportionate to locate, mark and/or remove the wreck. There are considerations around the words “practicable” and “proportionate” that need to be evaluated with legal services on a case-by-case basis because these have specific meanings under the law.

As the vessel was readying departure from Canada, CCG facilitated through legal counsel an ‘Order to Designate a Representative’ for the vessel. This is an informal process to ensure CCG has a representative in Canada in the event a hazard is determined related to the containers in the future.

If a designated representative is identified for the vessel, it provides CCG with capability to issue a direction, enforce failure to comply with a direction and cost recover the measures CCG had to take if needed. The Agreement brokered was in reference to any statutory orders under sections 21 of WAHVA and 180 CSA2001 and can be served to their solicitors. Without an owner’s representative in Canada, CCG would face significant challenges locating the owner and cost recovering for measures taken to address the hazard. For cost recovery, CCG must demonstrate the container/debris is posing a hazard.

Recommendations:

  1. CCG needs to further clarify and communicate the mandate in our training and in our engagement with external partners.
  2. That CCG continues to explore opportunities for vessels in the area to search for the missing containers, and to advise the Coast Guard of any sightings.
  3. That CCG engages with industry to confirm how they are expected to conform to the international system of buoyage to meet the obligation to mark a wreck under WAHVA.

Finding 2: Hazardous Noxious Substances (HNS)

Hazardous and Noxious Substances have by definition fallen under the Canada Shipping Act, 2001 definition of marine pollutant, and were formally defined as such when amendments to the Canada Shipping Act received royal assent in June 2023. Marine pollutant incidents involving hazardous and noxious substances now fall under the CCG’s core mandate of marine pollution response and the CCG evaluates marine pollution incidents on a case-by-case basis to ensure an appropriate response to the type of pollutant present. Personnel tasked to the oil spill regime are working at full capacity to address existing operational demands.

HNS response differs significantly from oil spill response. This is largely due to the physical characteristics of HNS compared to oil. When released, HNS can sink, float, dissolve or evaporate. These characteristics are not typically seen in most oil products when introduced into the marine environment. As such, the overall objective of HNS response would typically be monitoring or management, as opposed to physical recovery of the product. HNS response requires a more in-depth analysis of health and safety considerations for responders and the public due to the varying physical characteristics of released substances.

HNS refers to any substance other than oil which, if introduced into the marine environment is likely to create hazards to human health, to harm living resources and marine life, to damage amenities or to interfere with other legitimate uses of the sea.

The risks that can accompany increased marine traffic include the potential for incidents involving the cargo being transported, particularly if the cargo contains HNS.

Fortunately, a privately owned firefighting capable rig tending vessels happened to be in Victoria harbour at the time of the incident and was able to be contracted by the ship’s owner to assist with the containment and eventual extinguishment of the fire onboard the MV Zim Kingston. There is limited marine firefighting capability in the Vancouver/Victoria area which could result in response delays if needing to search marine firefighting capable vessels and the transit times from their respective areas.

The ICP drew on available personnel, particularly from Environment and Climate Change Canada and Transport Canada, that were able to offer technical expertise on the products involved. Information was also obtained from subject matter experts located in the United States; however, at times, this advice contradicted the guidance that was being shared between the federal departments and the ICP.

Recommendations:

  1. That CCG develop HNS plans and procedures and provide training to enable CCG personnel to operate safely in an HNS environment.
  2. That HNS scenarios be included in operational planning and exercises.

Finding 3: Marine Firefighting

There are certain types of maritime incidents to which CCG does not have the capabilities to appropriately respond. Presently, CCG does not directly participate in marine fire suppression activities as part of maritime incident management response, nor does it have fire suppression capabilities, policies, or procedures in place to directly respond to a marine vessel fire.

This incident highlighted gaps in marine firefighting capacity that exist on Canada’s West Coast. As previously mentioned, CCG does not have firefighting capability on its vessels. If fire suppression is required, the CCG could request the services of the Department of National Defence (DND) firefighting ship stationed at Canadian Forces Base Esquimalt, BC. In the case of the MV Zim Kingston, the DND firefighting ship did not have the technical capacity to project water at a height that would suppress flames on such a large containership. For this event, the owner contracted two privately owned firefighting ships capable of effectively fighting a fire on a containership that were in the area. The chance of nearby firefighting ships for future HNS marine incidents cannot be relied upon.

Recommendations:

  1. That CCG undertake an environmental scan to compile regional/national marine firefighting suppression capabilities and capacities that could be contracted if required.
  2. CCG will consider the inclusion of firefighting capacity on future leased emergency towing vessels, based on the recommendations that are approved by Government as a result of the National Strategy on Emergency Towing.

Finding 4: Tracking of Container Loss

In the immediate aftermath of the container loss, the United States Coast Guard (USCG) deployed a buoy and were able to identify 28 objects which were deemed to be containers, in the vicinity of the initial cargo loss. The USCG system deployed was an Automatic Identification System (AIS) Datum Marking Buoy (DMB) which allowed real- time data on the general drift direction of the debris field. The deployment of the buoy was in coordination with CCG in addition to other assets being deployed to track the field debris. These included the Transport Canada National Air Surveillance Program (NASP) aircraft, CCG Helicopters, and satellites. Of the 109 cargo containers, only 4 made land fall, while the remainder are assumed to have sunk.

The CCG was able to leverage its strategic relationship with the USCG in providing ship and cargo incident tracking support since the incident happened in transboundary waters. The USCG deployed tracking buoys on behalf of the CCG, as part of the CANUS Joint Contingency Plan as CCG does not have the capability to aerially self-deploy tracking buoys themselves.

Reliance on the USCG to support the deployment of tracking buoys, particularly in or near Canadian territorial waters, is problematic. Should the USCG be unable to assist in deploying these buoys in the future or in areas beyond adjacent operational locations, it is not clear how - or whether the CCG would be able to gather the information these buoys provide.

Recommendations:

  1. That CCG continue to work with partners to identify gaps, seek solutions to address gaps and support the advancement of tracking and modelling capabilities utilizing the latest science and technology.
  2. CCG to explore tracking options, similar to those used by the USCG to enhance CCG’s capability of tracking buoy deployment, objects, pollution and debris in an ocean’s environment.

Finding 5: Cargo Manifest

Information about cargo on vessels inbound to Canada is reported in advance and held by Transport Canada and Canada Border Services Agency. Reported details include the location, quantity, container identification number(s) and a general description of how the product is packed. During an HNS incident (including during the MV Zim Kingston response), Transport Canada and Canada Border Services Agency provided select details to the Incident Command Post (ICP) to aid in the response. The depth and timeliness of receiving this information is critical to support a safe and effective response to mitigate expanding impacts to the responder, the crew, public safety, and the protection of the environment.

Fulsome information was eventually acquired and used by the ICP, but it was not immediately available for use in the initial decision making. Responses, especially HNS-related, are guided by the identification and understanding of the compounds/products involved. Depending on the product, response methods can differ.

Internal incident information flow, or lack thereof, can enable or hinder successful response operations. Having access to detailed information about the nature of the cargo, particularly if HNS products are onboard, informs safety precautions and supports the development of appropriate tactical strategies for the protection of the crew, responders, the public and the environment.

The health and safety of the crew, responders and the public are of paramount importance. In an HNS response, comprehensive information about the products involved is crucial for restoring the safety of people and the environment.

Within the first day of the incident, CCG received the cargo manifest from ZIM Integrated Shipping Services for the overboard containers. The cargo manifests contained Harmonized System Codes and descriptions of contents based on the Harmonized System of Classification from the World Trade Organization, hence only broad descriptions of goods were known. This means, specific details of the container contents and packing materials was not listed in the manifest given it is not a requirement.

In total four containers were identified as carrying Dangerous Goods. Two of these containers went overboard while two remained onboard the vessel. The two containers that fell overboard were known to contain hazardous materials (TIBOUREA DIOXIDE (UN 3341) and POTASSIUM AMYL-XANTHATE (UN 3342)). Both substances were also identified in the containers that caught fire onboard the vessel.

Recommendations:

  1. That CCG explore options on how to improve critical information internally/externally during an incident with partner departments.

Finding 6: National Incident Management Support

The National Incident Management Team (NIMT) was not activated in Headquarters for this incident. This incident was originally reported as a SAR response through the National Incident Notification Protocol (NINP), so was not closely examined from an ER or a VOC lens.

The incident did not appear complex from program-specific viewpoints; however, the combined components, and potential complications became more evident as the incident unfolded. National support was provided to the Western Region ICP through the ER and the VOC Programs.

The feedback received resulted in conflicting opinions on whether the NIMT should have been or should not have been activated.

Recommendations

  1. CCG reviews the NIMT activation process and requirements and conducts further training and awareness for its members to promote clarity and awareness of the NIMT’s role.

Finding 7: Communications

Notifications

As the preliminary response to the incident progressed, several large conference calls were organized by the CCG’s Regional Operations Centre (ROC), to obtain situational awareness from partners and to provide information, to inform the participants. The attendees of these calls were identified from the CCG’s Area Response Plans. It was observed that these conference calls were too large, with up to 100 individuals on (some simultaneously representing the same agency or Nation). In these circumstances, efficient and productive discussion was extremely difficult, coupled with the technical difficulties of the large meeting population, for example, open microphones, bad audio quality, delayed connections, and phone call-ins being unable to see the screen.

A noted area of dissatisfaction for First Nation partners was the notification procedure. The CCG correctly assessed that the notification from municipalities and First Nations regarding the smoke observed at the time of the incident was the responsibility of the EMBC. However, the CCG did not consider the public’s perception of the vessel’s nature, anchored in full view of Southern Vancouver Island. They also did not consider the likelihood of familiarity and the intended use of CCG notification tools for any vessel-related incidents. The first concern being fire management, followed by the growing concern about the containers at sea, indicated that the CCG had to inform them immediately, using the Area Response Plan Notification Process.

Incident reporting can experience challenges, particularly if there is a difference in time zone. For this incident, the reporting timelines for the Region did not align with the Minister’s briefing cycle. Due to the high profile of incident and the department having a new Minister, there was a significant draw from both HQ Program and regional staff to effectively brief senior management and the Minister due to the unsynchronized schedules.

External Communications

Communication is multidirectional; the ICP both receives and contributes to information between the response teams, the public and the UC. The public and local communities can be significant sources of “on-the-ground” information in addition to receiving updates from the ICP to maintain situational awareness and their safety. Public messaging during this incident was conducted across various mediums, notably through social media.

It is important to control messaging to ensure that accuracy is maintained. While process is a tool, existing processes can be challenged by the nature of an emergency. During the incident, CCG communications issued via social media were coordinated by communications personnel in the Regional ICP and National Headquarters in Ottawa. In combination with incident factors, including the time change, communications personnel adapted (outside of standing processes) to the situation to produce and issue public messaging.

Additionally, there had been a media infraction early in the incident. Due to the unauthorized release of information to the media, communication processes were tightened which limited the flow of information to ensure appropriate levels of approvals.

Recommendations:

  1. That CCG continues to review, evaluate, and adjust communication protocols to support timely, accurate public messaging during incidents.

7. Next Steps

7.1 Change Monitoring

Changes made through the Continuous Improvement Action Plan (CIAP) should collect data that relates specifically to changes made and implemented. An endpoint should be specified, where changes made are considered fully accepted. This endpoint could be following successful use in an incident, event, or exercise, or one of each.

8. Continuous Improvement Action Plan

The CIAP document itself should be simple. It identifies the change or changes required, who will be responsible for implementing those changes, who can approve them, and a timeline with milestones.

The CIAP provides the what, who, why, where, and when. Improvements, while falling under an Office of Primary Interest, often require consultations with Offices of Complimentary Interest.

The CIAP will consist of a one-paragraph description of the incident, event, or exercise. The next step is to assign a responsible director who will address the recommendations for the Findings identified in the AAR. This information should come directly from the appropriate AAR Section and include Issue or concern (why there may be an improvement needed); Context (observations in past incidents and by SMEs) and Recommendation (what needs to be done and by whom).

Establishing a timeline is an important step in the process to ensure the CIAP is completed in a reasonable amount of time. Estimated dates should be identified for each task. Things to consider are the expected milestones; the required approvals; the writing of progress reports and scheduling meetings; and finally, their completion. The completion will demonstrate an expected end state for the CIAP.

9. Conclusion

It is proposed that the Office of Incident Management Continuous Improvement Team be responsible for overseeing the implementation of the CIAP, monitoring and tracking CIAP action items in collaboration with programs and regional positions.

Senior level management is responsible to approve the recommendations and to ensure they are implemented for continuous improvement of CCG’s response to incidents and correcting deficiencies to meet its readiness and preparedness levels.

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