Marine Safety Investigation Unit

MARINE SAFETY INVESTIGATION REPORT

Safety investigation into the engine-room fire on board

the Maltese registered supply vessel

GSP PERSEU

at GSP Shipyards, Agigea, Constanta, Romania

on 29 September 2014

201409/035

MARINE SAFETY INVESTIGATION REPORT NO. 24/2015

FINAL

ii

Investigations into marine casualties are conducted under the provisions of the Merchant

Shipping (Accident and Incident Safety Investigation) Regulations, 2011 and therefore in

accordance with Regulation XI-I/6 of the International Convention for the Safety of Life at

Sea (SOLAS), and Directive 2009/18/EC of the European Parliament and of the Council of 23

April 2009, establishing the fundamental principles governing the investigation of accidents

in the maritime transport sector and amending Council Directive 1999/35/EC and Directive

2002/59/EC of the European Parliament and of the Council.

This safety investigation report is not written, in terms of content and style, with litigation in

mind and pursuant to Regulation 13(7) of the Merchant Shipping (Accident and Incident

Safety Investigation) Regulations, 2011, shall be inadmissible in any judicial proceedings

whose purpose or one of whose purposes is to attribute or apportion liability or blame, unless,

under prescribed conditions, a Court determines otherwise.

The objective of this safety investigation report is precautionary and seeks to avoid a repeat

occurrence through an understanding of the events of 29 September 2014. Its sole purpose is

confined to the promulgation of safety lessons and therefore may be misleading if used for

other purposes.

The findings of the safety investigation are not binding on any party and the conclusions

reached and recommendations made shall in no case create a presumption of liability

(criminal and/or civil) or blame. It should be therefore noted that the content of this safety

investigation report does not constitute legal advice in any way and should not be construed

as such.

© Copyright TM, 2015.

This document/publication (excluding the logos) may be re-used free of charge in any format

or medium for education purposes. It may be only re-used accurately and not in a misleading

context. The material must be acknowledged as TM copyright.

The document/publication shall be cited and properly referenced. Where the MSIU would

have identified any third party copyright, permission must be obtained from the copyright

holders concerned.

MARINE SAFETY INVESTIGATION UNIT

Malta Transport Centre

Marsa MRS 1917

Malta

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CONTENTS

LIST OF REFERENCES AND SOURCES OF INFOMRATION .......................................... iv

GLOSSARY OF TERMS AND ABBREVIATIONS ................................................................v

SUMMARY ............................................................................................................................. vi

1 FACTUAL INFORMATION .............................................................................................1 1.1 Vessel, Voyage and Marine Casualty Particulars .......................................................1 1.2 Description of Vessel .................................................................................................2 1.3 Crew Members and Watchkeeping Arrangements .....................................................3

1.3.1 Crew members ........................................................................................................3 1.3.2 Watchkeeping arrangements in the shipyard ..........................................................4

1.4 Fire-Fighting Equipment in the Engine-Room ...........................................................4 1.5 Environment ...............................................................................................................6 1.6 Location of Steelworks ...............................................................................................6 1.7 Narrative .....................................................................................................................8 1.8 Damages ...................................................................................................................11 1.9 Safety Management System Documentation ............................................................13

2 ANALYSIS .......................................................................................................................15 2.1 Purpose .....................................................................................................................15 2.2 The LEV System ......................................................................................................15 2.3 Cause of Fire.............................................................................................................17 2.4 Fire Patrol and Fire Watches ....................................................................................19

3 CONCLUSIONS ...............................................................................................................22 3.1 Immediate Safety Factor ...........................................................................................22 3.2 Latent Conditions and other Safety Factors .............................................................22 3.3 Other Findings ..........................................................................................................22

4 ACTIONS TAKEN ...........................................................................................................23 4.1 Safety Actions Taken During the Course of the Safety Investigation ......................23

LIST OF ANNEXES ................................................................................................................25

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LIST OF REFERENCES AND SOURCES OF INFORMATION

Crew members MV GSP Perseu

Health and Safety Authority. (2014). Local exhaust ventilation (LEV) guidance.

Retrieved from www.hsa.ie on 06 February 2015

Managers MV GSP Perseu

Occupational Safety and Health Administration. (2009). Shipyard industry standards.

Retrieved from www.osha.gov on 06 February 2015

v

GLOSSARY OF TERMS AND ABBREVIATIONS

AB Able Seaman

BHP Brake Horse Power

BV Bureau Veritas

CO2 Carbon Dioxide

DG Compartment Diesel Generators Compartment

DPA Designated Person Ashore

GST Grup Servicii Petroliere S. A.

EEBDs Emergency Escape Breathing Devices

gt Gross Tonnage

HSEQ Health, Safety, Environmental Quality

LEV Local Exhaust Ventilation

LT Local Time

m Metres

m2 Square metres

mm Millimetres

MP Compartment Main Engine-room

mt Metric Tonnes

OOW Officer of the Watch

PC Compartment Power Control Compartment

Rpm Revolutions Per Minutes

SMS Safety Management System

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SUMMARY

At 20301 on 29 September 2014, a fire broke out in the engine-room of the supply

vessel GSP Perseu, which was under repairs at GSP Shipyards, at Agigea, Constanta,

Romania.

The safety investigation concluded that the fire was a result of possible hot works

(steel cuttings) being carried out by shipyard‟s workers in way of bilge tank located

aft of the engine room compartments during the night shift on 29 September 2014.

The fire broke out in the main engine-room, aft port side and was first noticed by the

engine-room watchman who initially tried to put out the fire on his own, by means of

a portable CO2 fire extinguisher. The fire was eventually extinguished during the

early hours of 30 September following the release of the fixed CO2 system of the

vessel into the main engine-room.

In view of the safety actions taken by the Company during the course of the safety

investigation, no recommendations have been issued.

1 Vessel‟s time is GMT+3.

2 During MSIU‟s visit on board, the CO2 bottles were ashore for refilling.

1

1 FACTUAL INFORMATION

1.1 Vessel, Voyage and Marine Casualty Particulars

Name GSP Perseu

Flag Malta

Classification Society Bureau Veritas

IMO Number 9083160

Type Supply vessel

Registered Owner GSP Perseu Ltd

Managers Grup Servicii Petroliere S.A.

Construction Steel (Double bottom)

Length overall 60.92 m

Registered Length 56.37 m

Gross Tonnage 1289

Minimum Safe Manning 11

Authorised Cargo Solid

Port of Departure Not Applicable

Port of Arrival Constanta, Romania

Type of Voyage Not Applicable

Cargo Information Not Applicable

Manning 14

Date and Time 29 September 2014 at 2030 (LT)

Type of Marine Casualty Serious Marine Casualty

Place on Board Ship – Engine-room

Injuries/Fatalities None

Damage/Environmental Impact None

Ship Operation In Shipyard

Voyage Segment Alongside

External & Internal Environment Clear skies with a Southerly Force 3 winds. Air

temperature was recorded at 15°C.

Persons on Board Six excluding shipyard workers

2

1.2 Description of Vessel

GSP Perseu (Figure 1) is a 1,289 gt supply vessel built at Braila Shipyards, Romania,

in 1992. The vessel is owned by GSP Perseu Limited, managed by Grup Servicii

Petroliere S. A. (GSP) of Romania and classed with Bureau Veritas (BV).

Figure 1: MV GSP Perseu

GSP Perseu has a length overall of 60.92 m, her moulded breadth is 13.59 m and her

moulded depth is 5.45 m. The deck cargo area, which measured 210 m2, has a

carrying capacity of 460 mt. Being a supply boat, the vessel is equipped with

numerous deck machinery, including tugger winches, capstans and mooring winches.

Propulsive power is provided by two 12V251F Alco Resita four stroke, single acting

diesel engines (Vee configuration), each developing 2,465 bhp at 1000 rpm. Each

engine drives a single, four-bladed fixed pitch propeller (in nozzle), 2410 mm in

diameter. GSP Perseu has a service speed of 11 knots.

The vessel‟s engine-room comprises of three compartments, i.e., the Power Control

Compartment (PC Compartment), located forward of the Diesel Generators

Compartment (DG Compartment), where three diesel generators and other auxiliary

equipment of the vessel are fitted, and the Main Engine-room (MP Compartment).

The main engines are fitted in the MP Compartment below the main deck (Figure 2).

3

Figure 2: GSP Perseu engine-room arrangement

Several bunker tanks are fitted aft of the MP Compartment (Figure 2 in red), which

also extend to the port and starboard sides of the MP Compartment. On either side of

the centreline, aft of the MP Compartment, is a void space. Four lubrication oil

storage tanks are fitted in the forward part of the void space (Figure 2 in yellow). In

the aft part, a bilge tank (Figure 2 green shading) is fitted. This configuration creates

an „H‟ shape in the void space. The bulkhead separating the void space and the MP

Compartment is continuous but has two manholes, which may be used to enter the

space from the MP Compartment. The manholes are usually kept closed.

1.3 Crew Members and Watchkeeping Arrangements

GSP Perseu‟s Minimum Safe Manning Certificate required a crew of 11, i.e. a master,

a chief mate and a navigational officer of the watch (OOW), one chief engineer, a

second engineer and an engineering OOW, three deck hands and two engine ratings.

At the time of the accident, the vessel was at the shipyard undergoing a general refit

and she had a crew complement of 14, i.e. a deck officer, a chief engineer, two

engineers, one electrician, the bosun, three ABs, two motormen, one cook and two

deck cadets. All crew members were Romanian nationals. The working language on

board was English, although the spoken language was Romanian.

1.3.1 Crew members

The deck officer on duty at the time of the accident had been at sea for about 15 years.

He had been working for this Company since 2008, always as a deck officer.

Normally, while the vessel was in port, he worked during day time, supervising the

maintenance of the deck and other related items. On the day of the accident, the deck

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officer signed on board during the morning and remained on the vessel after the day

work hours until after the accident.

The chief engineer had been at sea for about 34 years. He served as a chief engineer

for 14 years. He had been working as chief engineer with the Company since 2005.

While in port, he normally worked during day time, overseeing the maintenance of the

main engines and other machinery. During this particular refit, the chief engineer was

overseeing the maintenance and overhauling of the starboard side main engine. On

the day of the accident, he signed on the vessel during the morning and remained on

board after the working hours being present during the accident.

The second engineer had been at sea for about 16 years. He had been a second

engineer for about eight months. He had been working for this Company since 2011

as a second engineer. In port, the second engineer was normally on day work,

overseeing the maintenance of the main engines and other machinery. During this

particular refit, he was tasked to assist the chief engineer with the maintenance and

overhauling of the starboard side main engine.

1.3.2 Watchkeeping arrangements in the shipyard

Evidence suggested that since the vessel‟s entry into the shipyard, all crew members

were working during daytime, mainly on the deck and in the engine-room. At the end

of the daytime hours, a deck watch was maintained by one of the ABs. The AB used

to stay near the accommodation ladder, controlling the access to the ship. His deck

watch also included rounds on the vessel, and the accommodation block. Watches

were maintained on a 24-hour basis. The engine-room watch was kept by an engineer

officer and one motorman who had to remain on board to carry out random safety

tours in the machinery spaces throughout the night.

1.4 Fire-Fighting Equipment in the Engine-Room

The main fire-fighting equipment fitted in the engine-room is a fixed CO2 system,

comprising of a battery of 27 CO2 bottles (Figure 3). The CO2 system was last

inspected by an authorised firm on 20 March 2014. The CO2 battery is fitted in the

CO2 room, located on the aft port side of the accommodation block with direct access

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to the main deck. The release of the CO2 is operated from inside the CO2 room. The

CO2 battery had been released during the fire-fighting operations2.

Figure 3: CO2 fixed fire-fighting system (following the refilling after the accident)

In addition to the above, the engine-room space is equipped with a number of portable

dry powder and CO2 fire extinguishers. These were last inspected / tested by an

authorised firm on 20 March 2014. The engine-room space is also provided with two

high expansion foam fire-fighting systems, each fitted in every engine-room

compartment and each consisting of two bottles filled with 45 litres of foam. The

installation was last tested / certified by an authorised firm on 25 February 2014.

The vessel is also provided with a fixed water system with fire hoses and relevant

fittings at various locations around the vessel in accordance with the onboard fire

plan. There are two main fire pumps driven by electric motors, in separate engine-

2 During MSIU‟s visit on board, the CO2 bottles were ashore for refilling.

6

room compartments, and an emergency fire pump, which is located remotely from the

engine-room.

The vessel is protected by a fire detection system, which is provided with various

smoke detectors and manual call points, located at various positions around the vessel,

including the engine-room and heat detectors in the DG Compartment. At the time of

the accident, this system was not working since it had been deactivated some days

before.

GSP Perseu has two complete sets of firemen‟s outfits in accordance with the relevant

requirements of the SOLAS Convention. One of the outfit is located in the

wheelhouse and the other one is on the main deck in close proximity of the entrance

to the engine-room. A total of six Emergency Escape Breathing Devices (EEBDs) are

available on board, located at various places around the vessel, including the engine

control room.

1.5 Environment

The weather conditions on the day of the incident were normal with clear skies and

Southerly Force 3 winds. Air temperature was recorded at 15°C.

1.6 Location of Steelworks

The shipyard workers were carrying out steelworks in way of tank nos. 2.7 and 6.1.

As indicated in Figure 4, tank no. 6.1 is situated within the „H‟ shape cofferdam. In

the forward ends (port / starboard sides) of the cofferdam, there are manholes which

are further connecting the cofferdam to the MP Compartment. The covers of these

manholes were open during the hot works in way of tank no. 6.1, while a Local

Exhaust Ventilation (LEV) system was in rigged in place to ensure adequate

ventilation to the shipyard workers during the hot works.

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Figure 4: Tank plan showing the ventilation duct (red line) as arranged by the shipyard workers

The fitted LEV system comprised of plastic ducting and an electric exhaust fan. The

entry hood for hot works residues / smoke suction of the flexible ventilation duct was

placed inside tank no. 6.1, with the flexible ventilation duct running across the

cofferdam, passing the MP Compartment, through the port side manhole and ending

at an electric extraction fan, which was placed near the port side emergency exit door

to discharge the exhaust air from inside tank no. 6.1.

In addition to the above arrangement, the deck was cut right above tank no. 6.1 in

order to provide natural ventilation of the working space and access to the space

(Figure 5).

Figure 5: Access to tank no. 61 from the deck

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1.7 Narrative

On the day of the accident, the vessel was stern moored at the shipyard, located in

Constanta South, Agigea port, Romania. The vessel had been berthed at the same

position since 11 September 2014. The work by the shipyard workers in the area of

the fire (near the bilge tank no. 6.1), commenced on 25 September 2014. The work

mostly involved the renewal of steel. The deck crew was engaged with various

maintenance works in way of the deck fittings while the engine-room crew was

engaged with various works in the engine room and particularly with the overhauling

of the starboard side main engine.

On the day of the accident, both the master and the chief mate were not on board since

they were engaged on another vessel owned by the same Company. Six new crew

members signed on board, i.e. one deck officer, the chief engineer, two ABs, one

motorman and the cook, bringing the total crew onboard to 14 persons; one deck

officer, the chief engineer, two engineers, the electrician, the bosun and three ABs,

two motormen, one cook and two deck cadets.

During daytime, the work on board progressed uneventful, including the work carried

out by the shipyard workers. Late in the afternoon, at around 1800, the shipyard

repair team left the vessel after terminating their day of work.

Since the majority of vessel's crew members had just joined the ship, they remained

on board with the officers doing some paperwork. One of the two ABs stood watch at

the access ladder of the vessel, whilst the motorman stood watch in the engine-room.

The engine-room watch was also carrying out random safety rounds, especially after

the shipyard workers had left.

Later during the afternoon, at approximately 1900, another team of shipyard workers

arrived on board in order to continue with the work being carried out by the previous

team. The chief engineer recalled that since they did not carry the necessary

documentation and given that he was not informed of this work which was due to be

carried out during the night shift, he did not authorise the workers to resume their

work. The chief engineer, however, acceded to their request to access the area where

the steel works were being carried out to collect the tools.

9

At approximately 2030, the engine-room watchman noticed smoke coming from the

MP Compartment. Upon seeing this, he requested the shipyard workers to leave the

vessel. Soon after, he saw flames coming out of the aft part of the main engine-room

in the level of the floor plates on the port side (Figure 6). He recalled grabbing one of

the portable CO2 fire extinguishers and tried to extinguish the fire on his own.

Figure 6: Area where the fire was first observed

Seeing that he was unsuccessful, he subsequently notified the deck watchman in order

to warn the rest of the crew members of the fire. The deck watchman proceeded to

the accommodation to warn the rest of the crew. He then ran to the wheelhouse and

activated the fire alarm.

When the chief engineer arrived in the machinery space, he could not see any open

flames but only black smoke. He ordered the crew to isolate the electric power, close

the ventilators to the engine-room and to start the fire pump. Together with the

motorman, he then entered the engine-room with a fire hose; however, they were

forced to abandon the attempt as the smoke was too dense.

Following that attempt, they both donned a breathing apparatus set and entered again

the engine-room in order to locate the seat of the fire. By that time, the engine-room

10

compartments had been engulfed in black smoke and the chief engineer and the

motorman had to leave again, closing behind them the watertight door to isolate the

space.

At about 2130, the chief engineer called the Company‟s Designated Person Ashore

(DPA) and advised him of his intention to activate the fixed CO2 system to extinguish

the fire. However, at that time, the local fire brigade arrived near the vessel and the

person in charge requested the chief engineer not to activate the CO2 system but to

open / ventilate the engine-room for the firemen to access the space, evaluate the

situation and try to extinguish the fire. Moreover, the crew members were requested

to proceed ashore.

Indeed, the ventilation was opened and the firemen entered the engine-room with fire

hoses, water and foam. However, the black smoke had intensified again and after a

number of attempts to extinguish the fire and reduce the smoke, the firemen exited

from the machinery space. With the assistance of the crew, the machinery spaces

were sealed again. The CO2 system was eventually released at approximately 2330.

Another vessel, which was stern moored nearby, the MV GSP Licorn, provided

boundary cooling on the deck and port side of GSP Perseu.

The firemen waited for about two hours whereupon together with the chief engineer,

they went down to the DG Compartment. They observed that there was no smoke

coming out of the watertight door. The firemen entered the space and started cooling

down the space with their fire hoses.

At around 0200 (30 September 2014), the firemen confirmed that the fire was

extinguished and subsequently left the vessel.

The crew proceeded with the ventilation of the space and continuous watch in the

engine-room spaces until the following morning.

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1.8 Damages

A damage survey was carried out by the BV Surveyor on 01 October 2014. The

following damage was identified:

electrical cables under the main deck affected by the fire and required

replacement;

electrical junction boxes affected by the fire and required replacement;

one electrical panel and monitoring devices affected by the fire and required

renewal;

light fittings affected by the fire and required replacement;

forward seal on the port side tailshaft required replacement; and

smoke damage in various areas of the engine-room.

The damage was localised in the main engine area (Figures 7 and 8) and overhead

cables and insulation (Figure 9).

Figure 7: Fire damage in way of one of the main engines

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Figure 8: Remaining supporting wire for the LEV ducting

Figure 9: Fire and smoke damages

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1.9 Safety Management System Documentation

In accordance with the Company's Safety Management System Manual (SMS

Manual), a written agreement was required between the Company and the Shipyard to

address mutual responsibilities related to safety procedures (Figure 10). Evidence

collected during the course of the safety investigation suggested that these relevant

agreements were not in place. However, the following documents had been issued:

Hot Work Certificate (issued on 25 September 2014) [Annex A]; and

Work Permits for 25, 26, 27 and 29 September 2014 [Annex B].

Figure 10: Extract from the Company’s SMS Manual

The Hot Work Certificate only covered the relevant works being carried out in

designated tanks nos. 2.7 and 6.1. Moreover, the work permit (issued on a daily

basis) provided a general description / location of the work, namely “works in tanks”,

and which were supposed to start at either 0700 or 0800 and were valid for up to

maximum of 12 hours. According to this document, the permission to start the works

on board had to be obtained from the second engineer who was signing these

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documents. The work permit valid for the date of the accident envisaged

commencement of relevant works at 0700, for a duration (permit validity) of 12 hours,

i.e. until 1900. The document was signed by the second engineer.

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2 ANALYSIS

2.1 Purpose

The purpose of a marine safety investigation is to determine the circumstances and

safety factors of the accident as a basis for making recommendations, to prevent

further marine casualties or incidents from occurring in the future.

2.2 The LEV System

The scope of fitting LEV systems is to capture airborne contaminants at the point of

generation, preventing inhalation by workers in the vicinity. Choosing the proper

type of ventilation is critical in effectively protecting workers from hazardous

airborne contaminants that are normally generated by the various hot work operations

performed during the repairs of vessels. Adequate and safe ventilation may be

achieved with the support of mechanical ventilation (natural ventilation alone would

not suffice to provide efficient means of ventilation in confined spaces as the one

under review). The method is based on the principle that air moves from an area of

high pressure to an area of low pressure. The difference in pressure is created by a

fan that draws or sucks air through the ventilation system.

Mechanical ventilation provided by GSP Shipyards was of the LEV type. LEV is, in

fact, the recommended ventilation method when there is a risk for workers to be

exposed to hazardous chemicals and / or when a large amount of dust and welding

fumes are generated.

For welding, cutting and heating processes, an LEV system would include freely

movable hoods placed by the welder or burner as close as possible to where the work

is being performed in order to „trap‟ the contaminants generated by the hot works and

before they can be released into the work area. The flexible ventilation ducting also

has to be of the right specifications vis-à-vis type / material / length. The ducting

leads to an exhaust fan, which provides the suction power and also to discharge the

collected air / contaminants from the space. Hazards may be created if the material

used for the flexible ventilation ducting is not fit for the purpose.

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There are a number of considerations which need to be made before an LEV system is

put in place:

1. the ventilation ducting must be flexible but rigid so that it does not collapse

under negative pressure. Usually, the LEV flexible ducting is supported by a

spring-wound frame covered by a fire-retardant material to form the duct.

Ducts made of ordinary polyethylene or other non fire-retardant plastics are

not fit for hot work since the tubing can melt if slag or sparks are drawn inside

and flammable debris is transferred with the hot air flow. Although usually

this type of ducting maintains shape allowing maximum airflow, sharp bends

should be avoided as otherwise the flow of air can be blocked. While a

blocked duct can be dangerous to the workers in the space, it may result in a

serious fire hazard;

2. the length of the flexible ventilation ducting may also be an issue to ensure the

greatest amount of air flow. The hose or ductwork should not be excessive so

as not to affect the efficiency of volume of air being drawn from the space;

and

3. the correct positioning of the exhaust fan is essential. If the fan is incorrectly

placed so that a major section of the ducting is under positive pressure, the

effectiveness of the system is impaired. Poor selection of the exhaust point

may cause the contaminants to be captured by the air supply system; for

instance, instead of being exhausted and diluted, the exhaust air may encounter

a downdraught coming from the open air and re-enter the workplace.

The evidence collected by the MSIU revealed that the LEV fitted by the shipyard had

the following safety issues:

The flexible ventilation ducting used was not made of a fire-retardant material;

The way the flexible ventilation ducting was laid through the various spaces

may have potentially created an obstruction to the flow of exhaust air due to

the various sharp bends in way of the engine room entrance;

The overall length of the flexible ventilation ducting, running from the entry

hood to the exhaust fan was approximately 12 m. This length may have

reduced the efficiency of the system for the extraction of the air flow; and

17

The installation of the exhaust fan within the MP Compartment may have

prevented the efficient expulsion of the exhaust air, given that the exhaust air

outlet was placed within the MP Compartment, albeit close to the open door of

the MP Compartment Emergency Exit.

2.3 Cause of Fire

The safety investigation concluded that in all probability, the fire started from the

plastic flexible ventilation ducting which was used for the LEV system. The flexible

ventilation ducting was running from the cofferdam all the way to the MP

Compartment. Of particular importance was a sharp double loop of the plastic

flexible ventilation ducting, which was located within the cofferdam / engine-room

opening. The double loop was arranged as such to secure the flexible ventilation

ducting (Figure 11).

As indicated in Figure 11, the flexile ducting had a downward bend immediately after

exiting the cofferdam to pass behind two metal pipes and then looped again to pass

above the metal pipes and then continued running on the floor of the engine-room

until its connection to the exhaust fan placed near to the emergency exit of the MP

Compartment.

Figure 11: Representation of how the ducting was routed through the spaces

18

It was not excluded that the double bend created airflow resistance of hot air and hot

work particles, eventually leading to the flexible ventilation ducting catching fire

(Figure 12).

Figure 12: Seat of fire - the double bend of the ducting material

The fire from the burning flexible ventilation ducting then spread to the electric cables

on the deckhead to the port forward side of the cofferdam and the aft port side of the

MP Compartment from where it was further propagated to the forward and starboard

side of the main engine-room as well as to several other areas3.

This scenario raised one question. The MSIU had been informed that the first team

had stopped working at about 1800, which was a normal practice. Thus, if the fire

had started in the LEV system ducting due to the issue discussed above, it meant that

hotwork was actually being carried out at the time.

As indicated elsewhere in this safety investigation report, a second team from the

shipyard came on board to continue the work in the area at about 1900. The MSIU is

aware that at the time of the fire, the second team had not yet left the ship. Their

whereabouts were not controlled by the crew members. However, it was not excluded

that work in the space had resumed by the shore workers until the fire was actually

detected by the duty crew member.

3 Vide sub-section 1.8 for a list of damages.

19

2.4 Fire Patrol and Fire Watches

The fire detection system had been deactivated for a number of days. Consequently,

the crew members were unaware that there was a fire on board, until the duty crew

member observed the smoke during his visit to the engine-room spaces. The safety

investigation could not determine when the fire had actually started. However, by the

time it was discovered, there was already significant smoke in the MP Compartment.

It may be stated that since the fire detection system had been deactivated, fire patrols

and fire watches should have been more frequent. It was claimed, in fact, that the

frequency of fire patrols had been increased. It has to be noted, however, that

notwithstanding the increase in frequency of fire patrols, none of the crew members

reported that the second team had resumed the steel work.

It is a concern that a number of accidents which occurred in shipyards and have been

investigated by the MSIU, point to a situation where the crew members on board are

not necessarily fully aware of the work being carried out by the shipyard workers and

for various reasons, communication is not effective4.

Moreover, risk assessments had not been carried out by the vessel given that the work

was being coordinated and affected by the shipyard workers. A risk assessment

document (issued by the shipyard) in Romanian was made available to the MSIU.

The document was dated 29 September 2014. The document made reference to the

availability of fire extinguishers and fire blankets when hot work was to be carried

out. The document also specified that the use of open flames was not allowed unless

the fire protection requirements specified in the document were fulfilled. The

shipyard risk assessment document also specified that entrance into spaces, which

contained flammable or toxic gases was prohibited without gas free and hot work

certificates being first issued.

The risk assessment document, however, made no reference to the type of flexible

ventilation ducting material that had to be used when hot work was being carried out.

Per se, that may be suggestive that the risk of the material catching fire was either not

anticipated (and assessed), or was missed altogether.

4 Vide Safety Investigation Reports 04/2012 and 17/2015.

20

It was observed, however, that after the fire, the flexible ventilation ducting brought

on board was made of fire retardant material and the exhaust fan was placed on the

main deck (Figure 13).

Figure 13: Flexible ducting made of fire retardant material used after the accident

21

THE FOLLOWING CONCLUSIONS AND SAFETY

ACTIONS SHALL IN NO CASE CREATE A

PRESUMPTION OF BLAME OR LIABILITY.

NEITHER ARE THEY LISTED IN ANY ORDER OF

PRIORITY.

22

3 CONCLUSIONS

Findings and safety factors are not listed in any order of priority.

3.1 Immediate Safety Factor

.1 In all probability, the fire started at a sharp double loop on the plastic flexible

ventilation ducting which was used for the LEV system. It was not excluded

that the double bend created airflow resistance of hot air and hot work

particles, eventually leading to the flexible ventilation ducting material

catching fire.

3.2 Latent Conditions and other Safety Factors

.1 The flexible ventilation ducting was not made of a fire-retardant material;

.2 The way the flexible ventilation ducting was laid through the various spaces

may have potentially created an obstruction to the flow of exhaust air due to

the various sharp bends in way of the engine room entrance;

.3 The overall length of the flexible ventilation ducting may have reduced the

efficiency of the system for the extraction of exhaust air;

.4 It was not excluded that work in the space had resumed by the shore workers

without the crew members being aware;

.5 The risk assessment document made no reference to the type of flexible

ducting material which had to be used when hot work was being carried out.

Per se, that may be suggestive that either the risk of the material catching fore

was not anticipated (and assessed), or was missed altogether.

3.3 Other Findings

.1 The installation of the exhaust fan within the MP Compartment may have

prevented the efficient expulsion of the exhaust air;

.2 The fire detection system had been deactivated for a number of days.

Consequently, the crew members were unaware that there was a fire on board,

until the duty crew member observed the smoke during his visit to the engine-

room spaces;

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.3 At the time of the fire, the space where steel work was being carried out was

not covered by a hot work permit.

4 ACTIONS TAKEN

4.1 Safety Actions Taken During the Course of the Safety Investigation

During the course of the safety investigation, the Company has taken the following

safety actions:

1. All vessels and operational/technical departments have been instructed to

ensure that prior commencing hot work on board any vessel within the fleet,

approval from the Health, Safety, Environmental Quality (HSEQ) Department

is requested and received. Without the approval, hot work can neither be

carried out on board by the crew members nor by the contractor personnel;

2. The „Stop Work Policy‟ on board all vessels as well as within the shore team

has been reinforced so that any on board activity that is considered unsafe is

immediately addressed;

3. The requirement for a written agreement between the Vessel Technical

Operators and the shipyard (addressing all aspects concerning responsibilities

of safety procedures) has been reinforced and adequately implemented within

the Company. Confirmation of compliance from Technical Department is a

Company requirement;

4. All vessels and the Technical Superintendents have been instructed to ensure

that the Fire Detection System on board each vessel is kept operational during

shipyard/dry-docking repairs as required;

5. No work shall be allowed to commence on board by any subcontractor unless

approved by the on board responsible officer and the work is adequately

monitored by a vessel assigned competent crew member. Moreover, the

responsible officer shall check if all the necessary safety precautions have

been taken into account prior to approve the commencement of the work;

6. Whenever a vessel enters in dry-dock/shipyard for major repairs, a technical

superintendent shall be dispatched on board to supervise the planning and

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execution of such repairs, including checking/ensuring the availability and use

of adequate equipment by the contracted repair team for the task at hand;

7. As the executing shipyard belongs to the same Group, Corporate HSEQ

Director has taken the lead to evaluate and audit the HSEQ aspects of the

activity within the GSP Shipyard in order to evaluate its compliance with the

required safety precautions and requirements; and

8. Basic Safety Training and Advance Safety Training, which is part of the

Company Safety Induction process applicable to all offshore going personnel,

has been revised in order to put a strong emphasis on the Hot Work Procedure

and Task Risk Assessments, in line with Company procedures and

requirements.

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LIST OF ANNEXES

Annex A Hot Work Certificate (issued on 25 September 2014)

Annex B Work Permits for 25, 26, 27 and 29 September 2014

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Annex A Hot Work Certificate (issued on 25 September 2014)

27

28

29

30

Annex B Work Permits for 25, 26, 27 and 29 September 2014

31

32

33