The Britannia Steamship Insurance Association Limited · Ship Gross Tonnage: 3474 ... the bridge...
Transcript of The Britannia Steamship Insurance Association Limited · Ship Gross Tonnage: 3474 ... the bridge...
Workshop review: MAIB Report
Fire in the engine room
Ship Gross Tonnage: 3474
Ship Overall Length: 98.6 meters
Ship Safe Manning: Minimum 8 Crew
Ship Onboard: 10 Crew members
Introduction
Introduction
▪ 18th August 2015
▪ About 12nm of a UK port
▪ Weather condition: Wind: F4
▪ Sea state: Moderate
Introduction
▪ Underway engine room in UMS mode
▪ When dredging engine room is manned
▪ At approximate 20:00:1 hour before arrival, the bridge contacted the on duty
call Engineer Officer (3E) to prepare for loading operations
▪ Dredging/ Loading operations commenced 21:24 and usually took 5 hours
Available Power and Generator Capacity
▪ The CE assessed equipment and gave approval with satisfaction for
operations
Shaft
Generator
No 1
Auxiliary
Generator
No 2
Auxiliary
Generator
No 3
Supply to the dredging/
loading equipmentShip Operations Electrical Load
Faulty/Under
maintenance
Emergency
Generator
Emergency Loads to
Ship Supply Only
Engine Room Situation
▪ The last communication from ER to the Bridge was at 21.24
▪ The 3E discovered a fuel oil leak on the No.2 Generator low pressure fuel
return pipe
Shaft
Generator
No 1
Auxiliary
Generator
No 2
Auxiliary
Generator
No 3
Supply to the dredging/
loading equipmentShip Operations Electrical Load
Faulty/Under
maintenance
Emergency
Generator
Emergency Loads to
Ship Supply Only
Fuel Oil Leak
Incident
▪ The 3E attempted to fix or reduce the leak by removing the hoop bracket as
the fretting, place of leak, was behind it
Leak and partially detached hoop bracket Defective fuel pipe and the point of fretting
.
▪ It is possible that sparks from the portable angle grinder ignited the atomised
fuel and his fuel drenched clothing
Dredging operation
commenced
Bridge Fire Panel
Fire in ER
Bridge officer deactivated
alarm twice alarm reactivated
Crew mustered
upon the bridge
Master sees smoke
escaping from aft engine
room vents
Bridge called to ECR
but twice. No answer
CE was about to head
down to the ECR
3E confirmed a fire and
he was injured
CE instructed 3E to
vacate the ER
Master instigated
emergency procedure
Fire party – 2E & AB
Bosun – Closing ER vents
On scene commander – CE
21:24
CO missing asleep
The Time Line
23:12
23:14
Master recovers dredging
equipment
Carried out concurrently with
fire fighting preparations
23:15
Stopped the
dredging pump
18th August
2015
3E missing (ER)
3E
On duty
The Time Line
CE and Bosun reached
the main deck
3E exits from ER in physical
trauma and burnt clothes
3E walks unaided
3E informs fire location
The CE informs Master via VHF
Ships power fails
23:22
Emergency generator starts
3E to Cook for first aid
Bosun closing ER vents
CE opens main deck access
door. Fire too severe for fire
party to enter
Dredging retraction failsBridge: 2E fire gear
assisted by CO
Mess: AB fire gear
assisted by AB and
Cook
CO leads fire party
The Time Line
2E returns along the
starboard void
2E reunited with fire team
contacts Master via VHF
Master calls MAYDAY!
Muster complete CO2
releasedMaster requests for a
personnel muster
CO2 release delayed due
confusion of 2E locationCE requests for CO2
release via VHF
50% of the CO2 bottles functioned.
CE manually released remainder
Coastguard notified
of CO2 release
Ships port
anchor deployed
23:38
2E proceeds to starboard void
space alone opens the ER
access door
23:25
23:36
Requests evacuation
of 3E
Boundary cooling and
temperature monitoring
The Time Line
01:37
Helicopter departed with the
3E to hospital
3E was placed in a stretcher and
manoeuvred to the stern
winching point
Lifeboat provides medical
support
00:13
19th August
02:50
Master notifies Coastguard
that the fire extinguished
23:56
Coastguard 15mins with lifeboat,
35mins with rescue helicopter
Coastguard updated
23:52
Work Groups
Discuss and conclude in work groups on the topic given
One team member to present on the observations and opinions
Fire Control
Group
Ships
Command
Group
ISM
Human
Element
Group
Outcome
▪ The 3E sadly passed away in hospital two days later
▪ The 3E post-mortem examination results showed the cause of death as
multiple organ failure
▪ Ship was subject to salvage and was out of action for some weeks
Standing Orders/ SMS
Despite CE standing orders and other entries into SMS:
▪ 3E informed neither CE or bridge of the fuel leak?
▪ Possible reason; culture on board of lone working and absence of regular
communication
Standing Orders/ SMS
UMS patrol alarm when periods in ER covered by lone watchkeeper:
▪ Deemed to be impractical
▪ As UMS patrol alarm was not used, the SMS required watchkeeper to
communicate with bridge every 15 minutes
▪ This practice had been allowed to lapse
Standing Orders
CE standing orders required duty engineer to progress routine and planned
maintenance tasks whilst on lone watch:
▪ This condoned a practice which was not consistent with guidance in Code of
Safe Working Practice (UKMCA) 2015 Edition (this is applicable to UK
registered ships)
Equipment
High energy sparks from the portable angle grinder was the probable cause of
the fire:
▪ Sparks generated from the use of fixed and portable angle grinders is not
currently acknowledged as an ignition source
PPE
Overalls were not 100% cotton
▪ Company policy was changed from polyester / cotton overalls to cotton as
per MSN1731
▪ Despite this, majority of engineers continued to wear high visibility polyester
cotton type
▪ 3E was wearing polyester cotton type and when soaked in diesel became
an extremely flammable garment
▪ Even fire resistant material would be likely to ignite and continue burning
Cause
A combination of vibration and material loss of the fuel pipe bracket resulted in
the fretting of the pipework. The fretting resulted in a hole in the low pressure
fuel line below engine room plates
Leak and partially detached hoop bracket Defective fuel pipe and the point of fretting
Safety issues relating to accident
▪ 3E initial repair attempt may be rationalised through his experience and
positive attitude, however the use of an angle grinder is difficult to understand
▪ 3E would have been aware that isolating the fuel system would have stopped
the main engine and loading programme
▪ Professional pride that drove him to complete the task on his own?
Safety issues relating to accident
▪ An uncoordinated approach to the ER led to the fire team being separated
▪ A direct result of the two firefighters ‘suiting up’ in widely different locations
and no re-muster and briefing from the fire team controller
▪ CE and 2E opened different access doors to ER while alone and without
fire fighting medium for protection
▪ Had two doors been opened simultaneously a through draft could have
increased the intensity of the fire
Safety issues relating to accident
▪ CE activated CO2 and then entered CO2 room with no breathing apparatus
or testing the atmosphere
▪ Contrary to Master’s standing orders 3E medical attention was left to the
cook who hadn’t the training to attend such serious injuries
Safety issues relating to accident
▪ Ship Capt Medical Guide (SCMG) guidance that cooling of extensive burns
should be avoided as hypothermia will result was not consistent with
independent medical advise received by the MAIB
▪ It was concluded that whatever medical action was taken it was unlikely that
the 3E would have survived
Other safety issues
▪ Lone ER watchkeepers not only risks a loss of contact in a potentially
hazardous environment but also encourages individuals to act autonomously.
Action taken by MCA
▪ Code of safe working practice to address hot work hazards of sparks in fixed
and portable angle grinders
▪ MSN 1870 to introduce a standard for overalls in ER and areas where there
is a risk of fire
▪ SCMG to provide clear guidance on appropriate medical treatment for serious
burns.
Action taken by Company
▪ Fleet directive on PPE requirements
▪ Fleet directive on inspection of fuel systems
▪ Fleet directive on inspection of high temperature surface insulation and spray
shields