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THE COMMONWEALTH OF THE BAHAMAS

M.v. Splendour of the Seas

IMO Number 9070632

Official Number 9000121

Report of the investigation into the

forward engine room fire which occurred on the

22nd October 2015

THE BAHAMAS MARITIME AUTHORITY

The Bahamas conducts marine safety or other

investigations on ships flying the flag of the

Commonwealth of the Bahamas in accordance with the

obligations set forth in International Conventions to

which The Bahamas is a Party. In accordance with the

IMO Casualty Investigation Code, mandated by the

International Convention for the Safety of Life at Sea

(SOLAS) Regulation XI-1/6, investigations have the

objective of preventing marine casualties and marine

incidents in the future and do not seek to apportion

blame or determine liability.

It should be noted that the Bahamas Merchant

Shipping Act, Para 170 (2) requires officers of a ship

involved in an accident to answer an Inspector’s

questions fully and truly. If the contents of a report

were subsequently submitted as evidence in court

proceedings relating to an accident this could offend

the principle that individuals cannot be required to

give evidence against themselves. The Bahamas

Maritime Authority makes this report available to any

interested individuals, organizations, agencies or

States on the strict understanding that it will not be

used as evidence in any legal proceedings anywhere in

the world.

Date of Issue: 11th May 2017

Bahamas Maritime Authority

120 Old Broad Street

LONDON

EC2N 1AR

United Kingdom


CONTENTS

1. Glossary of abbreviations and acronyms

2. Summary

3. Details of Involved Vessel(s) and Other Matters

4. Narrative of events

5. Analysis and discussion

6. Conclusions

7. Recommendations

List of Appendices:

I. Wärtsilä Site Survey Conclusions and Recommendations

II. Wärtsilä technical bulletin 4610T002

III. Lucius Pitkin LPI, Inc. Evaluation of Failed Fasteners Conclusions and

Recommendations


1 GLOSSARY OF ABBREVIATIONS AND

ACRONYMS

AE - Auxiliary Engine

BMA - Bahamas Maritime Authority

°C - Celsius

CCTV - Closed-circuit television

CO2 - Carbon dioxide

DG - Diesel Generator

DMT - Diesel Maintenance Team

DNV-GL - Det Norske Veritas – Germanischer Lloyd

ECR - Engine control room

EEBD - Emergency escape breathing device

EOOW - Engineer officer of the watch

GMT - Greenwich mean time

HFO - Heavy fuel oil

HP - High Pressure

kW - Kilowatt

LP - Low Pressure

LPI, Inc - Lucius Pitkin Incorporated

m - Metre

m3 - Cubic Metre

MARPOL - International Convention for the Prevention of Pollution from

Ships

MGO - Marine Gas Oil

MSC/Circ - Maritime Safety Committee circular

NM - Nautical mile

Nm - Newton Metre

OOW - Officer of the watch

QCV - Quick Closing Valves

SECA - Sulphur Emission Control Area


SOLAS - International Convention for the Safety of Life at Sea 1974, as

amended

STCW - International Convention for the Standards of Training,

Certification and Watchkeeping for Seafarers 1978, as amended

UHF - Ultra High Frequency

UTC - Universal co-ordinated time

VDR - Voyage Data Recorder

***

1


2 SUMMARY

2.1 At 0752 on 22nd October 2015 the Royal Caribbean Cruise Limited vessel

Splendour of the Seas suffered a machinery space fire on diesel generator

number 1 (DG1) in the forward engine room. When the fire broke out the vessel

was on passage from the Greek ports of Mykonos to Argostoli. Due to the

consequences of the fire the vessel diverted directly to Venice under its own

power generated using the aft engine room propulsion units only.

2.2 A few minutes prior to the fire occurring, a large fuel leak was observed from

the hot box on DG1 at the forward, outboard drive end of the engine. DG1 is

located on the starboard side of the forward engine room. There were two

generators in use at the time each operating at 80% load.

2.3 The leakage of fuel was observed to be flowing through gaps of the hot box

covers. Fuel was also spraying onto the rocker covers and was impinging on the

engine exhaust manifold cladding. When the leaking fuel vapours ignited, heat

was intense and smoke propagation was rapid and dense. The engine had been

stopped from the Engine Control Room (ECR), 40 seconds prior to the ignition.

2.4 Within 10 seconds of the fire starting there was an attempted simultaneous

release from the ECR of fixed firefighting installations Ultrafog and flexi fog.

The Ultrafog system, however, did not function due to fire-damaged cables.

CO2 was not deployed. During the firefighting procedures, the tank tops were

smothered with foam from the fixed foam eductor system.

2.5 Code Bravo1 was initiated by the 2nd engineer in charge of the 0400 to 0800

watch resulting in the fire parties mustering at their designated locations. The

initial control point was in the provision area on deck 1 working alleyway (I-

952). This was changed due to the development of smoke to the forward end of

the working alleyway, adjacent to the table tennis area. Finally, the location was

changed to the forward passenger stair landing on deck 2.

2.6 A total of 12 crewmembers were trapped in three workshops on deck 0 in the

forward engine room during the course of the incident. These workshops are

located as follows: mechanical workshop (port side deck 0), electrical workshop

(starboard side forward deck 0) and deck workshop (starboard side aft deck 0).

The electrical workshop is directly adjacent to the seat of the fire. The crew

could not escape due to the intense heat and heavy smoke generated by the fire

and remained trapped inside the respective compartments. Later they all

managed to escape and suffered minor smoke inhalation in the process.

1 Code Bravo is announced over the public-address system to indicate to all crew the presence of a fire

onboard. 2 Colloquial term used to describe the main service corridor running through the vessel forward to aft,

accessible to crew only, named after a large interstate (highway) in the United States of America.

2


2.7 Inspection revealed that number 2A fuel pump forward outboard stud was

sheared and that the forward inboard nut was not in place but laying at the

bottom of the hot box. The stud was found to be sheared flush at the engine

frame. Both aft fuel pump securing nuts were in place and secure. The 2A fuel

pump LP fuel supply and return manifold was partially open at the forward end

with an open gap of 2mm. Three manifold securing bolts were sheared and lying

at the bottom of the hot box. The aft lower bolt was in place and secure. The

source of the fuel leak was from the open gap created by the bolts shearing on

the Low Pressure (LP) manifold flange.

2.8 Of the 2626 passengers and crew onboard there were no injuries with the

exception of 25 crew and 2 passengers who were treated for minor smoke

inhalation. The Master determined that it was not necessary to transition to

emergency stations however it did become necessary to activate the crew

responsible for evacuation and crowd management in order to evacuate

passengers and crew from the affected areas as efficiently as possible.

***

3


3 DETAILS OF INVOLVED VESSEL(S) AND OTHER MATTERS

3.1 The vessel was constructed in 1996 in the Chantier De L’Atlantique Shipyard,

France and at the time of the incident, was under classification with Det Norske

Veritas - Germanischer Lloyd (DNV-GL). The vessel was owned by Splendour

of the Seas Inc. and operated by Royal Caribbean Cruises Limited. The

following principal particulars were noted:

Official Number 9000121

IMO Number 9070632

Call Sign C6TZ9

Built Chantier De L’Atlantique, St Nazaire, France,

1996

Length Overall 264.26 metre

Breadth 32.00 metre

Draught 7.9 metre

Tonnage 69472 (Gross)

Tonnage 37971 (Net)

Class Entry Passenger Ship

Class Notation DNV +1A1

Propulsion 5 x Wartsila 12V46B, 2 x 21.1 MW propulsion

motors (Diesel Electric)

Brake Shaft Power 58500.00 kW

Complement3 46 (Condition 1)

128 (Condition 2)

Capacity 2,074 passengers, 720 crew

3 Condition 1 is for when the ship operates with no passengers onboard

Condition 2 is for when the ship operates with full complement of passengers onboard.

4


Figure 1: Splendour of the Seas general arrangement plan (GA plan of double bottom, tank top, deck 0 and

starboard aspect)

5


3.2 The vessel is powered by five diesel-electric engines driving five generators

powering twin fixed pitch propellers at 11,700kW each. Main propulsion is

suplemented by 2 bow thrusters of 1,500kW each and a 1,700kW stern thruster.

3.3 At the time of the incident the vessel was classed with Det Norske Veritas –

Germanischer Lloyd (DNV-GL) and all statutory certificates remained valid.

3.4 All crew carried appropriate documentation as required by the Standards of

Training, Certification and Watchkeeping (STCW). All document holders had

the necessary endorsements provided by the Commonwealth of the Bahamas

and complied with the vessel’s Safe Manning Document.

3.5 The vessel’s fire detection and extinguishing system met the required standards

under the International Convention for the Safety of Life at Sea (SOLAS)

requirements.

3.6 In June 2016 the vessel was sold to Thomson Cruises and renamed the m.v Tui

Discovery. At the same time the vessel changed registration to the flag State of

Malta.

***

6


4 NARRATIVE OF EVENTS

4.1 On the 22nd October 2015 the Splendour of the Seas was on passage from

Mykonos to Argostoli in Greece. The vessel departed Mykonos the previous

day at 1529(GMT +3). At the time of the incident the vessel was in position

37˚19´N 20˚50´E on a heading of 325° at a speed of 15 knots with a scheduled

arrival in Argostoli at noon on the 23rd October. The vessel was operating in

Universal Co-ordinated Time (UTC+3) and all references are based upon this

time zone.

4.2 There were two generators in use, DG1 in the forward engine room and DG3

in the aft engine room, each operating at 80% load.

4.3 At 0750 the 1st Electrical Engineer observed a significant fuel leak on DG1 in

the forward engine room. He reported the leakage by phone, located in the

electrical workshop, to the 2nd Engineer on watch in the ECR. The 1st

Electrical Engineer then continued his duties and remained in the electrical

workshop. The 3rd Engineer on watch was instructed to inspect the reported

fuel leak whilst the bridge were informed to decrease speed in order to reduce

engine load by the 2nd Engineer. The fuel leak was described by the 3rd

Engineer as “being like a waterfall flowing from open gaps on the hot box”.

At this point DG2 was prepared for starting. Shortly after an alarm was

registered in the ECR stating the following: [DG1 A BANK FO HP PIPE

LEAKAGE] followed by [DG1 FO INLET LOW PRESSURE] and the stand

by [FO/DO BOOSTER PUMP STARTING]. The bilge alarm for the

[FORWARD ENGINE ROOM STBD AFT BILGE WELL] also activated just

prior to the fuel leakage alarm. The bilge wells are quite small and the high

volume of fuel leaking down the side of the engine to the bilge could account

for this alarm.

4.4 CCTV footage shows fuel spraying in the area between the rocker covers on

unit’s 2A and 3A (see figure 8). The 1st Engineer along with the 3rd Engineer

on watch observed the fuel leak which was leaking heavily out of the hot box

running down the side of the engine to the bilge and instructed the 2nd

Engineer on watch in the ECR to stop the engine immediately. There is no

engine emergency stop located on deck 0; it is located on the local engine

control panel at the drive end of the engine. A fire hose was prepared and laid

out by the 1st Engineer but not charged or used.

4.5 The engine emergency stop button in the ECR was activated and the engine

shut down. The vessel’s power was maintained by DG3 from the aft engine

room. The Officer of the Watch (OOW) was aware that there was only one

generator on load and when his assistant asked him if he should call the Master

he answered “No”, for reasons not determined during the course of the

investigation. The Chief Engineer who was in the technical office adjacent to

the ECR heard the noise of the engine turbo chargers surging caused by

emergency stopping and immediately attended the ECR.

7


4.6 Approximately 40 seconds after the engine had been shutdown with the

emergency stop, a fire erupted at 0752 in vicinity of the hot box between

cylinders A2 and A3. Immediately the fixed installation systems were released

however it was later determined that only the Heien-Larssen flexi fog system

activated. The Ultrafog system had a fault due to a fire-damaged cable and did

not deploy.

4.7 Dense smoke generation was rapid and was observed to encompass the

complete engine room within 15 seconds. DG2, which had now started, was

shut down by the emergency stop in the ECR by the Chief Engineer.

4.8 Code Bravo was announced at 0753 from the bridge and fire teams assembled

shortly after. Only three fire teams could be assembled due to the number of

technical crew, made up of firefighters in the event of an emergency, who were

trapped within the workshops located in forward engine room.

4.9 Fuel continued to leak heavily after the emergency stopping of the engine as

the quick closing fuel valves (QCV) had not been closed and the fuel booster

pumps continued to run until 0755, at which point the Staff Chief on attending

the ECR closed the QCV on the ECR panel. The fuel feeder pumps were

stopped at 0758.

4.10 The 1st Electrical Engineer who was the first person to report the fuel leak was

trapped in the electrical workshop with the Engine Foreman. He heard the

noise of a turbo charger barking which would have been the engine shutting

down by the emergency stop. This was followed approximately 1 minute later

with the sound of gushing water, which was the flexi fog being released. When

an attempt to open the workshop door was made the fire was raging outside

preventing their escape. After which smoke entered the workshop through the

vent duct. The vent flap was then closed followed by another attempt to open

the workshop door where there was now thick black smoke but no fire. There

was one EEBD in the electrical workshop but it was reported that the operating

instructions were not easily identified. After an estimated 20 minutes both

crew members wet their overalls with cold water and ran together through the

thick smoke to the working alleyway. They reported to the Environmental

Officer that they had escaped from the electrical workshop prior to making

their way to their respective emergency stations.

4.11 Fire teams equipped with fire suits and breathing apparatus accessed the

forward engine room to fight the fire and commenced boundary cooling. The

activation of the fixed firefighting installation system significantly reduced

further fire precipitation after the initial flare up. The lower level and the tank

top bilges were also on fire and the fixed foam system was activated. The flexi

fog and fixed foam was stopped at some undetermined stage of the

proceedings.

4.12 Initially 12 crewmembers were trapped in the three workshops due to the

intense heat and dense acrid smoke generated by the fire. Once alarms were

activated escape from the workshops located on deck 0 in the forward engine

8


room was not possible due to the rapid development of heat and smoke. There

were 2 crew in the electrical workshop who were able to escape, however, 3

crew in the mechanical workshop and 7 crew in the deck workshop remained

stranded in these locations for over 1 hour from the start of the fire. The 3 crew

in the mechanical workshop were the last to escape at 0910 assisted by one of

the fire teams who had a charged fire hose arranged for waterwall protection.

The trapped crew suffered from minor smoke inhalation and were treated on

board in the medical centre. In accordance with the fire control plan there is

only one Emergency Escape Breathing Device (EEBD)4 located in each

workshop.

4.13 The Master made an announcement over the public-address system at 0824

providing an update on the progress of the emergency situation stating that the

fire was under control. He also stated that they were currently dealing with

smoke extraction. This was subsequently broadcast in German, French and

Italian.

4.14 At 0832 the fire was confirmed as being extinguished.

4.15 A decision was made by the Master that due to the fire being contained within

the forward engine room that it was not necessary to activate the ship’s

emergency signal.

4.16 At 0841 smoke eventually spread into crew and passenger accommodation on

decks 1, 2, 3 and 4 necessitating the evacuation of the affected areas by the

evacuation control team.

4.17 At 0851 the fire was reported to have re-established itself. The flexi fog and

fixed foam application activated again. The fire was reported as being

extinguished for the second time at 0931.

4.18 At 1114 the fire teams were instructed to search for hot spots before being

stood down at 1200.

4.19 The vessel aborted the scheduled call to Argostoli and diverted to the port of

Venice using the aft engine room propulsion units only and arrived at 0600 on

Saturday 24th October.

4.20 The appointed Bahamas Maritime Authority marine safety investigator

attended on the vessel’s arrival in Venice and remained on board until the

vessel sailed shortly after 1800. Two DNV-GL surveyors and Port State

Control Inspectors from the Venice station and a salvage surveyor from

Piraeus, RCCL management, technical and safety superintendent were also in

attendance. The technical and safety superintendent sailed with the vessel and

remained on board for the next two cruises.

***

4 EEBDs are designed to provide a minimum of 10-minute supply of air to allow persons time to

escape from compartments.

9


5 ANALYSIS AND DISCUSSION

5.1 The marine safety investigation was conducted simultaneously to three other

investigations, namely; mechanical investigation conducted by Wärtsilä the

manufacturer of the engines, material failure specialists Lucius Pitkin Inc.

(LPI, Inc.) 5 instructed on behalf of the Owners to conduct material testing of

the studs and bolts, and the Owners internal investigative team to determine

how the vessel responded overall to the emergency. The analysis conducted

and outlined below benefits from the three independent investigations

conducted acknowledging the source where necessary.

FAILURE MECHANISM

5.2 The fire occurred on the engine as a result of a leaking flange from the high

pressure (HP) fuel oil injection pump supplying cylinder A2, of DG1.

5.3 The fuel oil injection pump attached to the A2 cylinder is retained in place by

4, M24 studs. The manufacturer highly recommends that the 4 studs are pre-

tightened to the final torque of 460Nm in steps of 100Nm6. During the course

of the investigation it was determined that the 4 studs were not pre-tightened

in accordance with document 4610T002 (provided at Annex II) resulting in

the fracture of one stud and as a consequence of increased tension, a second

stud also failed. Once two of the four studs had failed, the injection pump

started to move up and down due to the injection tappet force. As a

consequence, the fuel inlet/return flange screws yielded and the flange started

to leak.

5.4 Analysis undertaken by Lucius Pitkin Inc. (LPI, Inc.) who are independent

material failure specialists determined the following: “injector pump stud 1

failed in the nature of medium to high cycle fatigue as a result of improper

preloading during installation. A fatigue crack initiated at the thread root of

the stud under the influence of cyclic loading at stress levels greater than the

stud’s material fatigue threshold”. The detailed analysis identified the forward

outboard stud was not tensioned sufficiently. The forward inboard stud failed

as a result of subsequent overloading. It was also determined that the stud

specification was in accordance with the designated material requirements and

that the studs had not been over-tensioned.

5 Lucius Pitkin Incorporated specialise in advanced analysis and fitness for service testing, failure of

materials evaluation and non-destructive engineering. 6 Wartsila Technical Bulletin Document 4610T002 Injection Pump Foot Studs (appendix II)

10


Figure 2: Fuel pump indicating forward studs, inboard nut had unscrewed (1) and stud had sheared flush (2)

with engine frame. Outboard nut (not visual) had sheared flush with fuel pump flange. Circled (3) indicates fuel manifold flange and source of fuel leak through 2mm gap between flanges.

Figure 3: Three manifold flange broken bolts (3) and two fuel pump stud nuts (2, 1) found loose in hot box

11


HOT BOX

5.5 A hot box is designed to contain any fuel leakage within the hot box in order

to avoid fuel in liquid form or fuel vapor coming into contact with a hot

surface. Within the hot box there are splash guard liners which create a

physical barrier between the exhaust manifold and the cylinder liners.

Figure 4: Site survey conducted on 5th November 2015 on DG2 hotbox cover plates indicating (circled) gaps

between the plates – see figure 6 for post incident damage of the same location (4).

5.6 The hot box cover plates which provide additional containment protection

from a fuel leak and are designed to keep unexpected fuel leakage contained

within the hot box to ensure protection against fuel spraying onto the exhaust

manifold. The overall poor condition of the hot box cover plates was

confirmed by a survey conducted by Wärtsilä on the 5th November 2015 and

summarized the condition of the hot box covers as follows: “quite bad

condition and evidently original ones from 1994”. Figure 4 only identifies a

number of air gaps in one location, the survey identified that the condition

depicted above was common throughout the hot box cover plates on all five

engines.

12


Figure 5: A gap (circled) in the exhaust and scavenge pipework insulation cladding is a probable source of heat

resulting in ignition

Figure 6: Condition of DG1 hot box plates (4) and hot box A2 (5) post incident

CAUSE OF THE FIRE

5.7 The fire started 40 seconds after the engine had been stopped from the ECR.

The exact source of ignition could not be determined however there are two

probable causes which could be considered as the source of ignition.

13


5.8 The flow of leaking fuel from the open low-pressure manifold flange was

reported as being extremely heavy. The manifold fuel pressure is maintained

at 8 bar and a fuel temperature of +/-118ºC when operating on IF380 fuel oil.

The alarm list showed a pressure drop caused by the leaking flange which in

turn prompted the stand by booster pump to start automatically. Significant

amounts of fuel continued therefore to leak from the flange and fill the

surrounding area of A2 both inside and outside the hot box.

5.9 The fuel leakage continued for approximately 5 minutes until the engine fuel

quick closing valves were operated from the remote valve control panel in the

ECR. As a result, leakage continued for another 2 to 3 minutes after the engine

was stopped.

Figure 7: Picture taken two minutes prior to ignition, indicating diesel generators emergency closing of fuel oil valves

5.10 The hot box covers between A2 and A3 cylinders had an air gap which

prevented the hot box from shielding any inadvertent spray and thus rendering

the hot box ineffective. The fuel therefore was able to exit out of the hot box

and potentially reach the exhaust manifold insulation. The source of the

ignition cannot be categorically determined however evidence suggests that an

opening in the exhaust insulation cladding exposing a source of heat from the

exhaust manifold sufficient enough to ignite fuel vapors could be considered

a likely event. Alternatively, fuel vapours leaked from the damaged fuel

injection pump may have ignited on a hotspot generated by friction as a

consequence of the fastening stud failures of the fuel injection pump causing

a sudden explosion within the hot box.

5.11 CCTV footage shows fuel oil spraying from the closing gap on the hot box

cover and impinging on the rocker cover on unit 3A and the exhaust manifold

cladding.

14


Figure 8: Fuel oil spraying from the closing gap on the hot box between A2 and A3 cylinders (circled in red) and

coming into contact with the exhaust manifold

5.12 The following sequence of synchronised images from the CCTV recordings

shows the development of the fire for the first 15 seconds. The perspective

from two camera locations represents the rate and extent of fire and smoke

development.

Camera: View fwd of DG1 Camera: View aft of DG2

At the point of ignition the fuel vapours ignited spontaneously

Within one second the intensity reduced momentarily until the liquid heavy fuel ignited

15


Two seconds after the initial ignition of vapours the fuel fire has become established

Ten seconds after intial ignition the flexi-fog was released to combat the fire

Fifteen seconds after the initial ignition the forward camera lens has melted, aft camera shows the rapid

generation of acrid smoke across the engine room

5.13 As indicated in the above CCTV frames, the fire erupted and spread both

vertically and horizontally away from DG1, generating thick acrid smoke in

under 15 seconds. The heat generated was so intense the camera looking

forward of DG1 disintegrated. The frame taken at 04:54:39 shows a

dampening effect of the fire, this is believed to be the point where the flexi fog

initiated to combat the effect of the fire by reducing the available oxygen and

flammable vapours.

INSPECTION AND MAINTENANCE

5.14 Wärtsilä attended the vessel from the 31st October until the 6th November to

assess the fire damage to the engine. Their attending technician confirmed that

the fuel pump studs in use were in compliance with the Wärtsilä technical

bulletin 4610T002 issued on the 20th August 2001 (see appendix II). The studs

in place at the time of the incident were the original studs supplied by the

manufacturer of the engine. However, in 2002 the technical bulletin highly

recommended to upgrade the original studs with a later version which had been

modified to the extent where the strength class of 8.8, had been replaced with

a special design, which incorporates better material, rolled threads and zinc

coating (see figure 9). Both versions can still be used without restrictions

however the manufacturer advised to inspect and even exchange the existing

16


studs which had been in place for approximately 13 years. The owner placed

an order for 240 replacement fuel pump studs and nuts which were delivered

to the vessel in November 2002 however it is not known the extent to which

the manufacturer’s recommendation had been complied with.

Figure 9: The original stud (top) and the new replacement (below)

5.15 The service history for the engine shows that seven fuel pump maintenance

activities requiring pump removal had occurred since the original studs were

installed in February 2004. Six of these maintenance activities were planned

and one in 2007 was unplanned. The last maintenance activity requiring pump

removal was carried out by the RCCL in house diesel maintenance team

(DMT) in March 2015. The engine running hours when this maintenance was

carried out was 89104 hrs; therefore, the fuel pump and studs have remained

undisturbed for 3179 running hours.

5.16 The fuel injector from unit 2A was removed from the engine to check its

operation post incident. The nozzle opening pressure was 340 bar and the spray

pattern was good. The design operating pressure is 460 bar, however a

reduction of 25% over the service period is not unusual. Checking the injector

break point is important to ensure that no excessive loadings have been

imposed upon the fuel pump studs due to a high opening pressure or restricted

injector nozzle.

5.17 The engine was operating on IF380 fuel oil whilst at sea and ultra-low sulphur

marine gas oil in EU ports. IF380 fuel oil needs to be heated to approximately

120ºC to maintain viscosity at +/-15 centistokes. The viscometer had been

changed over to manual temperature control as the viscosity measurement and

control had malfunctioned. A low fuel temperature will cause a significant

increase in viscosity when operating on heavy fuel, which will subsequently

increase the mechanical loading on the fuel pump and studs. According to

engine operating hours, engine number 1 has significantly more operating

hours than the other engines by 20-30%. This indicates that the engine number

1 is frequently used as the first engine of choice. When operating in EU ports

and in Sulphur Emission Control Areas (SECA) in accordance with

International Convention for the Prevention of Pollution from Ships

17


(MARPOL) Annex VI7, fuel will be frequently changed over from HFO to

MGO and vice versa. Without the viscometer in operation it is difficult to

predict the temperature change required during the changeover period. The

fuel temperature had been consistent at 118ºC prior to the incident and

therefore can be discounted as a potential contributory factor.

EMERGENCY PROCEDURES

FIREFIGHTING EFFORT:

5.18 Members of the fire team responded quickly to the Code Bravo announcement,

mustering in accordance with the pre-planned response to a fire located within

the forward engine room.

5.19 A total of 12 technical crew members were trapped within the various

workshops surrounding the seat of the fire (see figure 11) with no means of

escape. The trapped crew reported their predicament to the bridge and engine

control room by phone however it was not fully determined until after the

rescue how many of the crew were trapped. The fire occurred at the start of

the working day at a point where more crew congregated within their

respective workshops in general, compared to any other time of the day. Each

workshop was provided with one EEBD which provided 10 minutes of

breathing air sufficient to enable escape for one crew member only. A sink

dispensing fresh water was also available in each workshop. These two items

provided some level of extra protection.

Seven crew were trapped within the deck workshop who at the time were

conducting repairs to pipework within the space. All seven crew managed to

escape with the help of the arrival of the first fire team. With seven crew

located within the space and only one EEBD, the trapped crew had limited

options but to wait until the arrival of the fire team before making a successful

escape.

5.20 The 3 crew trapped in the mechanical workshop were the last to escape at

0910. Ventilation fans were configured in an attempt to reduce the smoke

ingress to the compartment. Due to the excessive smoke in the workshop the

trapped persons made their way into the adjacent air handling room to try and

escape the smoke that had now propagated into the workshop. After just over

1 hour a fire team approached the workshop and guided them to safety behind

a water wall fire hose. Only one EEBD was installed within the compartment,

the trapped crew relied on respirator masks with filters and wet towels which

provided sufficient protection to make a safe evacuation.

5.21 SOLAS Chapter II-2, Regulation 13 (Means of Escape) does not specify the

requirement to provide adequate means of escape specifically from a

7 Regulations for the prevention of air pollution from ships.

18


workshop within a machinery space8. Had a means of escape been provided

within each workshop located within the machinery space, the crew located

within each space would have been able to make their own means of escape

without placing themselves or the firefighters conducting the rescue in

potential danger. Additionally, had adequate fire protection apparatus been

provided such as firefighting suits, breathing apparatus, EEBD’s (in sufficient

quantity for the number of personnel within the space) the risk of exposure to

those trapped may have been reduced.

5.22 In accordance with MSC/Circ.8499 ‘unless personnel are individually

carrying EEBDs, consideration should be given for placing such devices along

the escape routes within the machinery spaces or at the foot of each escape

ladder within the space. In addition, control spaces and workshops located

within the machinery spaces should also be considered for the possible

location of such devices’. Consideration was given as demonstrated with one

EEBD being provided within each workshop, however what was not taken into

consideration was the quantity that may be required in the event of such a

scenario.

Figure 10: Entrance to fan room in the mechanical workshop

8 Regulation 13 was amended by Resolution MSC.365(93) adopted in May 2014. Paragraph 4.1.6 states:

‘For ships constructed on or after 01 January 2016, two means of escape shall be provided from the

main workshop within a machinery space. At least one of these routes shall provide a continuous fire

shelter to a safe position outside the machinery space.’ 9 Guidelines for the performance, location, use and care of emergency escape breathing devices (EEBDs)

19


Figure 11: Location of the crew trapped in workshops of deck 0 in proximity to the fire (circled): Mechanical

workshop (1) 3 crew trapped, Electrical workshop (2) 2 crew trapped, Deck workshop (3) 7 crew trapped and 1st Engineers office (4)

5.23 The fuel leak was identified by the 1st Electrical Engineer whilst conducting

routine daily work enroute to the electrical workshop. Initial reaction required

reporting the leak to the Engineer on Watch (EOOW) whose actions involved

calling the 3rd Engineer to confirm visually and to call the 1st Engineer advising

intentions to start DG2. Ninety seconds later the EOOW was ordered to shut

down DG1 and commence preparations to start DG2.

Figure 12: Entrance to electrical workshop

20


5.24 Due to the delay in shutting down DG1, fuel continued to accumulate in

vicinity of DG1 which, once ignited, resulted in a flash explosion. From the

time the fuel leak can be seen on CCTV, to visual confirmation, reporting, and

the shutting down of DG1 prior to the activation of the water suppression

system (flexi fog) almost 2 minutes had passed. The immediate activation of

the flexi fog system upon notification of the leak may have prevented the fire

from occurring or as a minimum reduced the presence of fuel vapour in the

vicinity.

5.25 Both the 3rd Engineer and the 1st Engineer were in the forward engine room

before the fire occurred and confirmed the leak on DG1 visually. Both

Engineers at this point could have shut down the engine locally rather than

notifying the Engineer on watch had the local control been in an accessible

location. The location of the local emergency stop of the engines does not

allow for quick access as it is located at the end of an elevated platform

between the tank top and deck 0, inaccessible from either deck.

Figure 13: DG1 local control panel and emergency stop

5.26 The fixed foam system was activated twice in order to smother burning fuel

on the tank top. It is estimated that 150m3 of liquid accumulated in the bilges

during the course of the emergency.

21


Figure 14: Fixed foam installation situated on deck 1 (left) and oil mark showing level of oilly water reached in the bilge as a result of the firefighting effort.

5.27 The vessel is fitted with four fixed firefighting applications, CO2, flexi fog,

Ultrafog and fixed foam. The Master decided CO2 was not deemed necessary,

a decision based on the severity of the fire and the speed in which it was

extinguished and the fact that 12 crew where trapped within technical spaces

inside the machinery space. Flexi fog operated successfully and provided the

primary means of containing and extinguishing the fire.

5.28 The third firefighting application, Ultrafog was retro-fitted on board in 2014.

It was determined after the fire that the system had not operated as designed.

Class had attended on the 26th November 2014 and approved the installation

of the system and that it was in accordance with the approved drawings

however at the time of the fire the system had not been commissioned. The

Ultrafog is an additional water mist system fitted in addition to and not in place

of flexi fog. It was determined that the fire had damaged the control cables of

the Ultrafog system preventing it from operating as designed. The control

cables pass through the machinery space and within 2 meters of DG1 which is

in contravention to SOLAS Chapter II-2, Regulation 1010 which states:

‘Pumps, other than those serving the fire main, required for the provision of

water for fire-extinguishing systems required by this chapter, their sources of

power and their controls shall be installed outside the space or spaces

protected by such systems and shall be so arranged that a fire in the space or

spaces protected will not put any such system out of action.’ It cannot be

determined whether this addition fixed application system, had it operated as

designed would have impacted the time taken to extinguish the fire. It could

be considered however that it would have only aided the situation, in all

likelihood reduced the severity of the fire and reduced the time taken to rescue

the trapped crew.

TRAINING

10 Chapter II-2, Regulation 10 Part C Suppression of fire

22


5.28 The last fire drill conducted in the forward engine room was in May 2014,

approximately 18 months prior to the fire. The following drills had been

carried out in technical spaces over the preceding 2 months:

7th September 2015 – Engine control room

3rd September 2015 – Incinerator room

23rd August 2015 – Switchboard room

20th August 2015 – Port separator room

5.29 Despite no drills taking place within the forward engine room since May 2014,

the three fire teams demonstrated a sufficient knowledge and familiarity of

equipment and layout of the space to provide an effective means of protection

during crew evacuation from the technical workshops. This is likely to be

testament of the training delivered on board and professionalism of the

firefighting team members.

SMOKE CONTAINMENT

5.30 The original forward control point was selected in vicinity of I-95 provision

area. As smoke migrated outside of the forward engine room the forward

control area was moved further forward to the end of I-95 before being finally

relocated to the forward guest staircase on deck 2. The decision to relocate the

forward control point was made out of necessity in order to maintain the

function of the forward control point. It proved increasingly difficult to contain

the smoke in the forward engine room as the fire doors remained open to allow

access to the fire teams whilst transiting into and out of the machinery space.

In addition, with 12 crew members trapped within the technical workshops,

ventilation could not be crash stopped. This maintained a positive air pressure

within the machinery space ultimately forcing the smoke outside the space. As

smoke spread throughout the forward section of I-95 and into passenger cabins

on decks 2 and 3 the Command initiated a full evacuation of all cabins on deck

1, 2, 3 and 4.

5.31 The Environmental Officer stated that watertight doors located on I-95 were

closed approximately 10 minutes after the fire started. The accuracy of this

statement cannot be corroborated by the bridge log as there is no record of any

fire or watertight doors being closed remotely from the bridge. All fire and

watertight doors can be closed locally however this does take longer than

closing remotely and as such allows more time for smoke to migrate without

obstruction.

COMMAND AND CONTROL

5.32 The Voyage Data Recorder (VDR) recording on the bridge confirms that the

Master was not informed in the first instance of a fuel leak on DG1 or that the

ECR had requested to shutdown DG1 despite the requirement existing with

23


the Captain’s Standing Orders and vessel’s SMS fire procedures. This

ultimately delayed the amount of time the Master had to react to the developing

situation.

5.33 It was clear to those crew members responsible for evacuation and crowd

management that it would only be a matter of time before the emergency signal

would be given and they would be required to not only control the evacuation

of crew and passengers from the affected area (decks 1,2,3 and 4 cabins within

affected fire zone), but to initiate the whole ship emergency evacuation plan.

The emergency signal was not sounded which is a deviation from the vessel’s

SMS, this caused significant confusion for passengers and crew alike who

were being informed to evacuate the affected area and muster at their

respective assembly stations by the evacuation control team. There are no

procedures in place to aid the evacuation control team when attempting to

muster only a proportion of crew and passengers from the affected area. A

controlled muster was hampered further when those passengers and crew went

to their respective assembly stations only to find passengers and crew not

affected by the emergency enjoying the facilities provided for during normal

cruising.

***

24


6 CONCLUSIONS

6.1 The primary causal factor which resulted in a fire was the failure of the fuel

pump securing stud, which had not been tensioned correctly during fuel pump

maintenance procedures. The development of this failure could have been

prevented if a follow up procedure was adopted in accordance with the

manufacturers recommended practices which required re-tensioning after

initial fitting and operation of the fuel pump. Had this procedure been in place

the under tensioned stud is likely to have been identified and corrective action

taken to rectify by applying the correct torque of 460Nm.

6.2 The independent survey conducted of the hot box covers confirmed their poor

condition and identified several locations where full containment could not be

achieved. If the hot box covers had been in a condition deemed ‘fit for purpose’

it could be considered highly likely that any fuel leak could be contained

preventing the fuel coming into contact with the exhaust manifold, the only

known heat source. As the source of ignition point cannot be categorically

determined, the catalyst for igniting the fuel may have come from another

source within the vicinity of the fuel pump on A2 cylinder.

6.3 With the frequent need to change fuel grades from heavy fuel to ultra-low

sulphur MGO, the importance of having viscosity control equipment in a

serviceable condition cannot be over emphasised. Running an engine on heavy

fuel with a low fuel temperature significantly increases fuel pump loading,

which is imparted to the securing studs.

6.4 The rapid deployment of the flexi fog system upon discovering the fire stopped

any further development of the fire and reduced the scale of damage sustained

to the forward engine room. Had the flexi fog system been deployed

immediately upon discovering the fuel leak, the probability of ignition would

have been significantly reduced.

6.5 The engine quick closing valves remained open after the engine had been shut

down. The valves are activated independently from the shut down on the

engine. Therefore in order to stop the fuel supply, regardless of the operational

status of the engine, the fuel quick closing valves must be activated. The

delayed response in activating the valves increased the severity of the fire and

the subsequent damage sustained to the forward engine room.

6.6 The location of the engine local emergency stop prevented the operator from

shutting down the engine quickly due to the location of the local control panel.

Although the engine was shut down prior to the fire, as the exact source of

ignition remains unknown, it cannot be determined what impact the delay in

shutting the engine down had moments before ignition.

6.7 When a problem is reported to the engineer in the ECR there are inevitable

delays while appropriate permissions are requested to adjust the machinery

25


configuration. The engineer in the ECR advised the Officer of the Watch of

the need to reduce speed due to a mechanical fault with DG1. Procedures are

in place before taking power and ultimately speed away from the bridge in

order that navigational safety can be maintained. However, the EOOW should

communicate the severity of the situation which unless acted on, may result in

catastrophic loss of equipment. Although permission was granted to shut down

DG1, a sense of urgency was not conveyed which may explain why the Master

was not notified immediately.

6.8 An appropriate level of consideration was not given to the safety of crew

working within technical spaces within the forward engine room. The

Splendour of the Seas was not required to provide a means of escape from

these workshops, however, a risk assessment should have identified that in the

event of an engine room fire within the machinery space, adequate safety

equipment should be provided to enable an escape for the total capacity of

persons permitted within each space and reflected on the fire control plan.

Adequate training should be provided on the provision of this equipment. It

was reported that although an insufficient number of EEBD’s were available

for the number of individuals trapped, those that did utilise the EEBD were

not able to get them to work as designed. It is not known whether this was

through inadequate training and understanding of equipment or the EEBD was

faulty. Additionally, it remains unknown whether routine escape drills for

crew members working in the forward engine room were accomplished

regularly.

6.9 Machinery space fire drills were conducted regularly in all but the forward

engine room. Fire drills are designed to not only improve the skills, knowledge

and confidence of the fire teams but also improve the skills required to control,

coordinate and communicate up and down the emergency organisational

structure. The lack of a drill within the forward machinery space may have

contributed to the slow reaction in conducting an immediate emergency

procedure in the event of an engine fire, closing of the quick closing valves.

Closing of the fuel quick closing valves should be second nature, to achieve

this, procedures must be rehearsed robustly.

6.10 The failure to close fire and watertight doors early in the emergency allowed

significant smoke propagation to decks 1, 2, 3 and 4, influencing the location

of the forward control point and increasing demand on the already reduced fire

teams. Further, had the fire spread, it would have become increasingly more

difficult and demanding on the emergency organisation to contain the spread

of the fire.

6.11 In general, the actions of the crew and the tenacity displayed, particularly by

the fire team members in responding to this incident should be commended.

***

26


7 RECOMMENDATIONS

Recommendations for the operator11:

7.1 Ensure adherence to manufacturer’s technical bulletin No. 4610T002

specifically in relation to the replacement and tensioning of fuel pump studs.

7.2 Ensure all engine hot box covers are renewed or repaired so that no seal joint

gaps exist.

7.3 Consider installing additional engine emergency stop switches at a suitable

and accessible location.

7.4 Consider scheduling a thermo-graphic survey on all vessels throughout the

fleet to identify any exposed areas where the temperature exceeds 220ºC and

implement a rectification programme as necessary.

7.5 Consider a fleet wide review of emergency escape equipment in sufficient

numbers in all workshops and offices within engine rooms. Provide enhanced

training on the correct operation of emergency equipment in accordance with

SOLAS II/2 Regulation 15 paragraph 2.2.2.

7.6 Consider fleet wide review for the allocation and frequency of emergency fire

and escape drills for crew members onboard.

7.7 Consider implementing a prudent safety enhancement to incorporate the

operation of the quick closing fuel valves with the engine emergency stop

function.

***

11 Recognising that the vessel is no longer operated by Royal Caribbean Cruise Lines some of the

recommendations are directed towards the fleet of existing vessels operated by RCCL.

Recommendations in general are for the benefit of all vessel to incorporate as deemed necessary.

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LIST OF APPENDICES

I. Wärtsilä Site Survey Conclusions and Recommendations

II. Wärtsilä technical bulletin 4610T002

III. Lucius Pitkin LPI, Inc. Evaluation of Failed Fasteners Conclusions

and Recommendations

***

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Appendix I: Wärtsilä Site Survey Conclusions and Recommendations

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Appendix II: Wärtsilä technical bulletin 4610T002

30


Appendix III: Lucius Pitkin LPI, Inc. Evaluation of Failed Fasteners Conclusions and

Recommendations

31


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