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U.S. Coast Guard cites loose bolts, escape-route issues in fatal fire

Jul 29, 2015 01:03 PM

Unfamiliarity with escape routes was a contributing factor in the death of one crewmember and two contractors in an engine-room fire aboard a cruise ship in the Caribbean.

The engine-room fire occurred when a bolted flange parted, resulting in a fuel oil spray from an operating engine’s fuel supply line, according to a U.S. Coast Guard Marine Safety Alert about the Dec. 11 fire on board the 684-passenger cruise ship Insignia

The fuel ignited when it sprayed onto the engine’s exhaust piping or turbocharger components.

The fire occurred while the ship was in port at St. Lucia, part of a 10-day cruise that originated in San Juan, Puerto Rico, on Dec. 7.

The fine mist system automatically went on and put out the primary fire. Fuel pumps and shutoff valves were secured, but the fire ignited cable bundles, which filled the machinery space with smoke. 

The ongoing investigation showed that a fuel line supply flange parted after three bolts loosened and the remaining bolt fractured, according to the safety alert. The bolts may have loosened due to engine vibrations. Other bolts in the engine’s hot box were found broken. It is not known when the piping was last removed or reinstalled and whether the bolts were properly torqued.

In the alert, the Coast Guard advises engineers to pay attention to engine technical bulletins and take action on them. Engineers should frequently perform detailed inspections of engines, systems and other equipment.

The Coast Guard cites lack of knowledge of escape routes as a problem. On Insignia, after the engine room filled with smoke, the three men were unable to leave the engine room and died there. One other crewmember was hospitalized but returned to the ship Dec. 12. 

“Machinery spaces on board cruise ships and other large vessels are complex spaces where an unfamiliar person can become quite disoriented, particularly during emergencies,” the safety alert stated. Smoke and power loss makes escape even harder.

The safety alert was prepared by the Coast Guard’s Office of Investigations and Casualty Analysis in Washington and by Sector San Juan’s Prevention Division. It recommends that service vendors, technicians, crewmembers or anyone working in machinery spaces understand escape routes and emergency equipment. They should know how to locate and use emergency escape breathing devices and they should carry a good flashlight.

In general, this kind of training is routine, said Brad Schoenwald, senior marine inspector at the Coast Guard Cruise Ship National Center of Expertise. “All contractors reporting on board are given indoctrination training, specific to where they are working,” he said. When it comes to engine-room spaces “they are given specific training on emergency escape routes as well as basic safety instructions.” Schoenwald could not speak to the details of the Insignia fire because it a foreign-flag investigation.

Insignia is a Marshall Islands-flagged vessel. Laura Sherman, spokeswoman for International Registries Inc., said the investigation is not finished. She would not comment on the incident. International Registries does administrative and technical work for the Republic of the Marshall Islands.

Capt. D. Peter Boucher, a former master mariner and cruise ship safety officer, said engine-room safety protocols are not always followed. “All too often, there is not clear instruction to the subcontractors when they board a vessel, in spite of what the USCG thinks happens,” he said. He said the staff chief engineer is responsible for informing subcontractors of engine-room safety standards. 

“One gets the impression that engineering departments presume that the subcontractors, being a supposed specialist in the equipment being worked on, are familiar with shipboard engine-room protocols,” Boucher said. “However, these subcontractors work in shipyard or manufacturing workshops with completely different protocols.”

At least one engineering officer should be assigned to work with subcontractors. “Past experience has shown that when subcontractors are working on board, the accident/fire risk tends to rise,” Boucher said.

The safety alert recommended that all engineering crew know how to do comprehensive inspections in order to detect problems in systems and equipment. 

“Identifying discrepancies such as loosening bolts, leaking piping and flanges, excessive oil loss through poor seals and gaskets, failing pump seals, loosening of pipe brackets, inadequate lubricant levels, etc., are typical issues found when thorough inspection rounds are conducted,” the safety alert stated. Each operating engine should be examined several times a watch to check for potential problems.

The safety alert cited a June 2014 document prepared by the Oil Companies International Marine Forum (OCIMF) noting that widespread machinery automation has created a problem in vessel operation. “The extensive use of computers, monitoring tools and equipment has increased the volume and accuracy of data to the extent that there is a risk that the responsible officer may become insulated from the actual machinery status and performance,” the OCIMF wrote. 

The paper highlights the importance of regular inspections of machinery spaces “with the aim of addressing the perceived lack of appreciation for traditional hands-on working practices.”

Boucher said an extra officer is often needed when contract work is being done, but in his experience, this does not happen.

When asked whether cruise ships have enough engineers on board, John Sedlak, assistant chief at the Coast Guard Foreign and Offshore Compliance Division, said they do. “Most of the operations I have seen usually have more engine-room staff than required by the flag state,” he said.

Fuel and oil leaks were on the Coast Guard list of the top 10 cruise ship deficiencies in 2014. “Numerous deficiencies were found in engine room spaces,” stated the report. Most of them “were due to excessive oil leaks around the main engines, leaks in the oil purifier room and shaft seal leaks.” Of the 329 deficiencies cited in 2014, problems in engine room spaces ranked 10th, with seven occurrences. The top problem, fire screen doors not operating properly, had 31 occurrences.

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