Lessons Learned: Improper Isolation Causes Fire And One Fatality


MAIB provides lessons learnt insights on improper isolation before carrying out any tasks and how it can lead to a series of uncontrolled events dangerous for the safety of vessel and personnel.

Actions: Reviews carried out for risk assessments, work permit and qualification of personnel to perform the assigned tasks. Adequate supervision for junior crew members also taken into account.

 What Happened?

On a regular day, when an LPG vessel was alongside port carrying out discharge operations, there was a fire in engine room, in the generator room, which resulted in the loss of one life and damage to one of the generators.

During the toolbox meeting in the engine room, daily jobs were discussed and designated to the responsible engineers. It was decided that the third engineer would clean the generator fuel filters. Despite being asked by the 4Th engineer and wiper if he needed help, the third engineer proceeded to perform this task, without assistance, meanwhile the others continued their designated jobs.

As the third engineer removed the bolts on the top of the filter cover, the fuel pressure caused the O ring to snap and high pressure diesel oil sprayed out of the filter onto the adjacent generator exhaust. Since the adjacent generator was running and the exhaust gas outlet was hot, the sprayed diesel ignited as it fell on the insulation.

Black smoke began to emanate from the exhaust insulation surface. Almost immediately the fire alarm sounded which resulted in an immediate shutdown of cargo operations. The 4th engineer while rushing to attend the fire alarm saw thick black smoke coming out of the generator room and he used the port side stairs to escape from the engine room. He immediately informed   everyone that it was an actual fire and the master ordered everyone to muster at the muster station.

The search and rescue team which comprised of the fitter and oiler proceeded to engine room, in command from the chief officer, to look for the third engineer.  Two attempts were made to enter the engine room. One from the poop deck and one from the main entrance, however both attempts were aborted due to the large quantity of smoke and flames rising above the Generator no.2 on the boiler platform.

The second team comprised of the second engineer and fitter entered the generator room. One of the Generators were running which the second engineer stopped locally.  The 2E used a local CO2 fire extinguisher to extinguish the flames on Generator No.2. However for the flames rising above Generator No.2 on the boiler flat, neither portable CO2 or DCP were able to extinguish.

Preparations were made to extinguish the fire with water and the fire was brought under control.

Meanwhile the master had informed the DPA and ort authorities of the fire and the shore fire fighting team arrived at the location.

The third engineer was recovered by the shore fire team by the use of thermal imaging camera, as the visibility was restricted. He was recovered from the starboard walkway at the stairs proceeding to the bottom platform.

However, he suffered from Cyanide and Carbon Monoxide intoxication and  9 days later he succumbed to the damages caused to his lungs due to inhaling the toxic vapours.

What Went Wrong

Upon investigation it was revealed that the three way cock isolating the duplex filter was partially open and the  Fuel return line valve was not isolated. The fuel supply valve was closed.

The Oring sealing the filter cover on the surface if the filter holder was split which caused the high pressure Diesel oil to spray out of the filter.

The related paperwork was examined and following discrepancies found-

  • There was no risk assessment in the vessel risk assessment record which would define the hazards associated with the task being performed.
  • A permit had not been prepared prior to the job.
  • 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.
  • There was no record of poor visibility enclosed space drills using EEBDs

There were significant gaps in the exhaust gas pipe insulation which caused the insulation to be exposed and catch fire.

Lessons Learned

 From the above incident, we can conclude that an unnecessary task was performed at a time when the vessel was involved in critical operations of cargo discharge.

Lack of supervision and a causal approach to a task which can be otherwise labelled as a repetitive one, caused an accident which put the safety of vessel and personnel at high risk.

The exposed insulation lagging which caught a fire, was supposed to have been noticed by the crew in their regular rounds and rectified. Such tasks were reported as completed in the vessel PMS however not performed.

The system designed for promotion allowed the user to bypass the tasks to be completed without photographic evidence. Every officer must carry out the tasks assigned to them, with due diligence, and take responsibilities of subsequent ranks only after they have completed the required tasks. Any bypassing such as this, as we can see , has endangered not only the lives of the crew but also put the safety of the s hip at risk.

The designated fire party was unable to perform their task despite regular drills being logged in the system.  However, the fire owing to it’s limited magnitude and prompt actions by the crew was controlled and extinguished.

Every safety drill must be conducted with a serious attitude and every crew member onboard must take not only their own safety but the safety of the ship and  as their responsibility , and carry out drills with diligence.

Actions Taken

  • Reviews of the safety management system carried out and risk assessments reviewed
  • Debriefing conducted with regards to appraisals and considerations of tasks for promotion qualification
  • Adequate supervision of junior team members and discussion of engineering procedures before any task is performed.

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Source: Marine Accident Investigation Branch