The UK Marine Accident Investigation Branch (MAIB) has published its investigation report into the fatal engine room fire on board Moritz Schulte on 4 August 2020.
The incident
On 4 August 2020, a fire broke out in the engine room of the liquefied petroleum gas/ethylene carrier Moritz Schulte when the recently promoted third engineer opened an auxiliary engine’s pressurised fuel filter allowing marine gas oil to spray onto an adjacent auxiliary engine’s hot exhaust.
The third engineer attempted to stop the fuel leak and tried unsuccessfully to escape from the toxic smoke-filled engine room. He was found an hour later by a shore fire and rescue team but did not recover consciousness and died 9 days later in hospital.
Investigation
The investigation found that, despite the vessel having a full range of safe systems of work in place, the third engineer, who had worked for the company for over 5 years, died while attempting an unnecessary job conducted in an unsafe way at an inappropriate time, without a risk assessment and in the absence of any direct supervision of the task.
Analysis of the third engineer‘s training programme activity log found that only two of the 65 rank-specific tasks he was required to undertake before his promotion to third engineer had been completed with the requisite evidence. It also found that the training system permitted line management to confirm that training had been completed without evidence being provided. This facilitated his promotion twice when he was not ready.
Other findinigs included a lack of any evidence of poor visibility enclosed space rescue drills or escape drills using Emergency Escape Breathing Devices. The company’s investigation identified 32 actions relating to: communication, crew and competence management, safety management and technical management. The company has since equipped its four vessels that were built before July 2003 with additional Emergency Escape Breathing Devices.
Safety Issues
- fire and fatality due to unintended release of fuel onto an ignition source
- crew training scheme weaknesses that enabled the crew member to bypass requirements and gain promotion twice when he was not ready
- inadequate crew fire training, affecting the potential for a successful escape and recovery of a crew member from a smoke-filled environment
