The Nautical Institute presents an incident where, a liquefied petroleum gas carrier was berthed and preparations were underway to unload the cargo.
he engine room team met for a routine toolbox talk to discuss the jobs for that day. At the end of the meeting the daily duties were assigned; the 3rd engineer was tasked with checking the running of Auxiliary Engine (AE)2 and AE3. The 3rd engineer inquired if he could also clean the AE1 fuel filters. When asked if he needed assistance for that job he declined.
The 3rd engineer decided to clean the AE1 fuel filters as his first task. He undid the two locking screws on the splash shield and removed it from the housing to access the duplex fuel filters. As he was undoing the front right-hand nut of the filter, the fuel pressure (5.5 bar) still present in the system lifted the cover and forced the O-ring seal out of its recess, causing it to split. Marine gas oil sprayed out over a large area, covering the crewmember. The spray also reached the nearby AE2’s turbocharger and exhaust pipework about 1m away. These engine parts were very hot. The fuel ignited almost immediately and thick black smoke began to emanate from the AE2 exhaust insulation.
The engine room fire alarm sounded, which resulted in an immediate emergency shutdown of cargo discharge operations. All crew except the 3rd engineer were quickly accounted for. On the bridge, the Master saw that the fire control panel was indicating a fire in three engine room zones. He then requested firefighting assistance from the port.
In the meantime, the Master was informed that the CO2 fixed firefighting system was ready for release. The Master prohibited the CO2 from being released until the missing 3rd engineer had been found. A vessel search and rescue team wearing breathing apparatus attempted to enter the engine room from the poop deck entrance. A large quantity of smoke and heat was emitted when the team opened the door and their entry was soon aborted because of zero visibility. The search and rescue team attempted a second entry at another location soon afterwards, but they felt unable to proceed due to the intense smoke and having seen flames on the deck above.
Shortly after, a third search party attempt was made via another entry point. Descending the stairs, in thick smoke and with no visibility, the search party followed the starboard walkway aft towards AE3. The AE3 was found still running so it was stopped locally. Through the smoke, the search party could see small flames under the turbocharger at the aft end of AE2. A CO2 fire extinguisher was used to put these out. Soon, the visibility in the ER improved to about 2m. The search party saw flames above AE2 on the auxiliary boiler flat and used the aft port side stairs to access the area. They attempted to extinguish the flames with the same CO2 extinguisher used earlier, but the fire kept reigniting. Then a dry powder extinguisher was used, which initially seemed to extinguish the fire but it soon reignited. They then left the engine room without having sighting of the 3rd engineer.
About 90 minutes after the fire had ignited, a shore-based fire and rescue service team boarded the vessel. They were briefed on the ship’s fire plan and the last known location of the 3rd engineer. They then entered the engine room and descended the stairs to A Platform. Using a thermal imaging camera, they located the victim on the starboard mezzanine walkway.
Upon evacuation of the victim to the cargo control room the medical team observed he was alive but his breathing was laboured. He was evacuated by ambulance to a hospital approximately 20 minutes later. In the meantime, the fire on the vessel was extinguished. The victim had not suffered any burns and was placed in a hospital intensive care unit within two hours of his rescue. He had suffered acute cyanide and carbon monoxide intoxication; although he was initially stable, his condition deteriorated and he died nine days later.
Some of the findings of the official investigation were, among others;
- Of the 59 occasions over 16 months that the fuel filters on all auxiliary engines had been noted as cleaned, no lock out/tag out procedures had been completed for the pressurised fuel system.
- The critical factor for survival of fire victims affected by HCN and CO is rapid extraction from the toxic atmosphere. It is likely that finding and removing the victim from the engine room sooner would have increased his chances of survival. Had the vessel been equipped with a Thermal Imaging Camera, and suitably trained on board fire teams drilled in its use, it is possible the victim could have been found earlier.
Credit: The Nautical Institute
- The victim’s action to remove the AE1 fuel filter elements without first isolating the fuel from the filter assembly was the major contributing factor to this accident. How could this mistake have been avoided? A procedure? A checklist? Better supervision? Teamwork? Better training?
- The shore-based search and rescue team located the victim in the smoke-filled space using a thermal imaging camera. This device could be a valuable addition to shipboard emergency equipment.
- A ship fire is an imposing challenge for crew and drills that replicate the difficulties that may be faced, such as searching in near zero visibility, can pay dividends.