Transport Malta’s Marine Safety Investigation Unit (MSIU) issued an investigation report, concerning an engine explosion on board a passenger vessel, that caused severe burn injuries to two persons, on May 2016. The purpose of the report is to determine the circumstances of the accident, as a basis for making recommendations, in order to prevent further incidents from occurring in the future.
The incident
Two motor mechanics, from the Company’s workshop were sent on board MV Delfini, to investigate an engine problem reported by the vessel’s skipper and engine driver. Work was necessary on the port main engine to identify and eliminate the exhaust white smoke, which was being emitted by the engine under load conditions.
The mechanics dismantled the port main engine turbocharger and exhaust manifold as they suspected that the problem was caused by faulty injector(s) on either one or more of the units. To troubleshoot the faulty fuel injector valve(s), the engine was started on idle speed with these parts removed.
In the process, one of the two mechanics suffered severe burns to his face, hands and chest, while his colleague sustained a superficial injury to his forehead, caused by the explosion and fire that escaped from the engine exhaust ports.
Conclusions
- When the engine was stopped for the night, the faulty fuel injector(s) may have leaked minute droplets of fuel onto the piston crown.
- When the engine was started, the following morning (with the exhaust manifold and turbocharger removed), the fuel late ignition escaped through the exhaust ports, producing an afterburning flame that injured the mechanic.
- There was no planned preventive maintenance system for the engine room machinery.
- The Company did not provide Cummins engine specific training courses to its mechanics.
- The operation and maintenance manual for the Cummins main engines was not available on board Delfini.
- While working in the engine-room, the younger mechanic had taken off his top, thereby compromising his protection.
- No responsible person had been designated in charge of the maintenance work that was to be performed on the port main engine.
- No risk assessment was carried out to identify any risks that could be encountered during the work on the port main engine.
- The dismantling of the exhaust manifold to identify an offending fuel injector was not a new procedure to the Company.
- The risks associated with the actual actions taken by the two shore-based maintenance personnel were either accepted or not understood.
- The shutting down of each cylinder was not deemed to be possible from a practical perspective, given that the necessary equipment / resources were either not available or not made available to the shore-based maintenance personnel working on board.
- The personnel involved were convinced that the removal of the exhaust manifold would have provided an immediate indication as to which was the offending fuel injector.
- The decision to overhaul the exhaust manifold was therefore based on a rational decision and was seen as a reasonable option to solve the problem with the main engine.
Recommendations
MSIU advises Supreme Travel, the owner company of MV Delfini to adopt and implement:
- 10/2017_R1 a planned maintenance regime on all Company operated vessels, in accordance with recommended maintenance schedules.
- 10/2017_R2 a health and safety policy to ensure that all Company employees implement relevant procedures.
Further information may be found by reading the full report:
