Fire Due To Loosened Engine Bolts Triggering an Uncontrolled Fuel Spray Aboard

Summary

On September 7, 2015, about 1133 local time, a fire broke out in the engine room aboard cruise ship Carnival Liberty. At the time, the vessel was alongside the dock in the Port of Charlotte Amalie, St. Thomas, US Virgin Islands. The master ordered the passengers aboard the vessel to evacuate to the dock. The crew used the ship’s water mist- and carbon dioxide (CO2) firefighting systems to extinguish the fire. No one was injured, nor was any environmental damage reported. Fire damage to the ship was estimated at $1.725 million.

The Carnival Liberty in San Juan, Puerto Rico, about 1 week after the accident.

Probable Cause

The National Transportation Safety Board determines that the probable cause of the engine room fire aboard the Carnival Liberty was loosened bolts, likely resulting from improper tightening during prior maintenance and vibration of the piping over time, on a fuel supply inlet flange on diesel generator 4, which triggered an uncontrolled fuel spray from the inlet flange onto a hot surface on the diesel generator.  

Left, location of the fire in the A bank of DG 4. Right, fuel-injection pump for cylinder A2 with suspect flange circled in yellow after the fire.

Findings

1. Comprehensive crew training and familiarity regarding the use and limitations of fixed water-based local application systems in machinery spaces are crucial to safe operations.
2. Preplanned procedures to account for all persons aboard are essential in the event of a mass evacuation of a ship while in port.
3. The source of the fuel spray was loosened bolts on the fuel supply inlet flange to diesel generator 4, likely resulting from improper tightening during prior maintenance and vibration of the piping over time.

Left, the bolt found attached to the housing of the fuel-injection pump for cylinder A2. Discoloration and residue can be seen in some of the threads. Right, the bolt that was found detached.

Recommendations

As a result of its investigation, the National Transportation Safety Board makes the following safety recommendations:

To Carnival Corporation & PLC:

• Implement ship-specific familiarization training regarding the use and limitations of fixed water-based local application systems in machinery spaces.
• Develop and/or improve procedures to manage and account for all persons aboard in the event of a mass evacuation of a ship while in port.

To the Cruise Lines International Association:

• Inform your members about the circumstances of this accident, including the need to plan for accounting for all persons aboard in the event of a mass evacuation of a ship while in port.

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Source: NTSB

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