The Britannia Steamship Insurance Association Limited

Workshop Maritime Casualty

Victoria Dittmann

Captain Shajed Khan

Captain John Leach

Agenda

Introduction

Overview

Work Group Discussion

Group Feedback

Summary and Conclusion

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

If you were the 3rd Engineer

What would your next step be?

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

▪ The 3E was working below the deck plates in direct line of the fuel oil leak

.

▪ 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

Smoke is seen from

exiting the ER vents

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

MAIB Incident

Conclusions

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

Thank you for your attention

Questions?

The Britannia Steamship Insurance Association Limited