Have you thought about how to locate an unconscious crew member in a smoke-filled space? In a new Mars Report, The Nautical Institute describes how an engine room fire cost the life of a crew member. Had the ship been equipped with a thermal imaging camera, the victim might have been found sooner.
The Nautical Institute gathers reports of maritime accidents and near-misses. It then publishes these so-called Mars (Mariners’ Alerting and Reporting Scheme) Reports (anonymously) to prevent other accidents from happening. A summary of this incident:
A liquefied petroleum gas carrier was berthed and preparations were underway to unload the cargo. The 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 third engineer was tasked with checking the running of Auxiliary Engine (AE)2 and AE3. The third engineer inquired if he could also clean the AE1 fuel filters. When asked if he needed assistance for that job he declined.
The third 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 crew member. 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.
Also read: Uninspected engine modifications result in fire
Fire in three engine room zones
The engine room fire alarm sounded, which resulted in an immediate emergency shutdown of cargo discharge operations. All crew except the third 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 third engineer had been found.
Search and rescue
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 2 metres. 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 third engineer.
Also read: Which factors play a role in rising number of ship fires?
Victim found using a thermal imaging camera
About ninety 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 third 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 twenty 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.
Investigation findings
Some of the findings of the official investigation were, among others;
- Of the 59 occasions over sixteen 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.
Also read: Is your fire suppression system connected to the emergency power supply?
Advice from 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.
Mars Reports
This accident was covered in the Mars Reports, originally published as Mars 202407, that are part of Report Number 375. A selection of the Mars Reports are also published in the SWZ|Maritime magazine. The Nautical Institute compiles these reports to help prevent maritime accidents. That is why they are also published (in full) on SWZ|Maritime’s website.
More reports are needed to keep the scheme interesting and informative. All reports are read only by the Mars coordinator and are treated in the strictest confidence. To submit a report, please use the Mars report form.
Also read: ‘Shipping losses hit record low, but jump in fires’
