Belgium’s FEBIMA issued an investigation report on a fire onboard the Trail Suction Hopper Dredger ‘UILENSPIEGEL’ while moored at Lisnave shipyard, Portugal, in January 2021. Investigation established that insulation panels contaminated with oil were installed during the re-assembly of the main engine after dry-dock.
The incident
On January 26th, 2021, Trail Suction Hopper Dredger UILENSPIEGEL was moored at pier 0 at Lisnave shipyard, Setubal, Portugal. The vessel was refloated again after a period in dry dock where maintenance had been carried out, including an overhaul of the vessel’s main engines.
During the running-in of PS main engine, smoke appeared and fire broke out at the exhaust of PS main engine. The engine was stopped and the fire emergency response plan was activated. The shipboard fire team observed the situation under command of the Master and the chief engineer.
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The fixed fire extinguishing system was not to be activated. When flames were no longer visible and normal operating temperatures were measured; controlled ventilation of the engine room was started. After starting the fans and measuring of the oxygen level, the engine room was given free entrance again.
Nobody was injured during this incident and the damage was limited to some carbon deposits inside the engine room and fire damage at the exhaust of PS main engine.
Probable causes
- The fire was caused because insulation panels contaminated with oil were installed during the re-assembly of the main engine.
- Insufficient control measures were in place to verify the condition of the insulation before installation.
- The oil ignited when the temperature in the exhaust line increased during the running-in of the engine.
- The contamination with oil happened when the insulation was stored unprotected under a thermal oil line.
- During maintenance of the oil line, an oil spill occurred and contaminated the insulation. The maintenance on the thermal oil line was not properly prepared and thus contributed to the accident.
- It was not communicated that the spilled oil had contaminated the insulation panels. The lack of communication about the spilled oil is also considered as a contributing factor to the incident
Safety issues
The communication between the ship’s personnel and personnel of the shipyard was insufficient and not all operational procedures as prescribed by the vessel’s management system were followed by the personnel of the shipyard:
- During maintenance of a thermal oil line by personnel of the shipyard, oil was spilled, and the panels were contaminated with the spilled oil. The maintenance of the thermal oil line was not scheduled for the day it was executed. The required “Permit to work on pressurized systems” when working on a system that is under pressure during normal operations was not available.
- No action had been taken to preserve the condition of the insulation before commencing the maintenance of the oil line. It was not reported that the panels were contaminated during the spill.
- During the assembly of the engine, the contaminated insulation panels were installed at the exhaust line by personnel of the shipyard. The condition of the panels had not been reported before or during installation.
Actions taken
A Root Cause Analysis, RCA, was made by the company, involving personnel from the vessel’s team, including the chief engineer, personnel from the technical support team and personnel from the QHSE department. The RCA resulted in following safety improvements:
1.The communication between yard, service engineers, crew and docking team should be improved:
- All jobs that are planned during the day, need to be discussed during the daily meeting; o Tracks of minutes of meetings have to be signed by parties involved;
- Prior to start a job, a work permit needs to be issued and to be signed by the yard and the owners representative(s);
- Prior to start any job on board, the crew needs to be informed; o After an incident, take the time and go on the spot with all people involved to assess the complete damage in detail.
2. The condition of the insulation should be checked (if possible) prior to re-installing:
- The inspection of the condition of the exhaust insulation before reinstallation had been added to the company’s quality card for tasks during the overhaul of a main engine.
3. Care has to be taken of proper storage & protection of disassembled equipment (e.g. insulation) and store it away from the working area.
4. Improve the work preparation:
- Stick to the planning of the day discussed during the daily meetings with different stakeholders.
- Shipyard supervisors need to be on the spot during the start-up of the job and regular inspections are needed during the execution of the job.
The results of the RCA were discussed and distributed among all vessel managers, which are engaged in major repairs. The RCA was also distributed to higher management and to QHSE & Marine Operations department. A summary of the RCA will form part of the info shared in the 6 monthly Technical Department Maintenance newsflash.
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