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MARINE INCIDENT REPORT NO 16/2018 SEPTEMBER 2018

Report on the investigation of

unintentional release of carbon dioxide

Eddystone

in the Red Sea on 8 June 2016

and

Red Eagle

in Southampton Water on 17 July 2017

Extract from

The United Kingdom Merchant Shipping

(Accident Reporting and Investigation)

Regulations 2012 – Regulation 5:

“The sole objective of the investigation of an accident under the Merchant Shipping (Accident

Reporting and Investigation) Regulations 2012 shall be the prevention of future accidents

through the ascertainment of its causes and circumstances. It shall not be the purpose of an

investigation to determine liability nor, except so far as is necessary to achieve its objective,

to apportion blame.”

NOTE

This report is not written with litigation in mind and, pursuant to Regulation 14(14) of the

Merchant Shipping (Accident Reporting and Investigation) Regulations 2012, shall be

inadmissible in any judicial proceedings whose purpose, or one of whose purposes is to

attribute or apportion liability or blame.

© Crown copyright, 2018

You may re-use this document/publication (not including departmental or agency logos) free of charge in any format or medium. You must re-use it accurately and not in a misleading context. The material must be acknowledged as Crown copyright and you must give the title of the source publication. Where we have identified any third party copyright material you will need to obtain permission from the copyright holders concerned.

All MAIB publications can be found on our website: www.gov.uk/maib

For all enquiries:Marine Accident Investigation BranchFirst Floor, Spring Place105 Commercial RoadSouthampton Email: maib@dft.gov.ukUnited Kingdom Telephone: +44 (0) 23 8039 5500SO15 1GH Fax: +44 (0) 23 8023 2459

Press enquiries during office hours: 01932 440015Press enquiries out of hours: 020 7944 4292

CONTENTS

GLOSSARY OF ABBREVIATIONS AND ACRONYMS

GLOSSARY OF TECHNICAL TERMS

SYNOPSIS 1

SECTION 1 - BACKGROUND 2

1.1 Fixedfire-extinguishingsystems 21.2 Carbondioxide(CO2)asafire-extinguishingmedium 2

1.2.1 PropertiesofCO2 21.2.2 EffectofCO2onhumanphysiology 2

SECTION 2 - FACTUAL INFORMATION: EDDYSTONE 4

2.1 ParticularsofEddystone andincident 42.2 Narrative 5

2.2.1 Incident 52.2.2 Systemreinstatement 7

2.3 Company,vesselandcrew 82.3.1 Companyandvessel 82.3.2 Crewandotherpersonnel 8

2.4 Fire-extinguishingsystemdescription 82.4.1 Configuration 82.4.2 Protection 82.4.3 Cylindervalves 10

2.5 Inspectionandmaintenance 11

SECTION 3 - FACTUAL INFORMATION: RED EAGLE 12

3.1 ParticularsofRed Eagleandincident 123.2 Narrative 13

3.2.1 Incident 133.2.2 Systemreinstatement 13

3.3 Company,vesselandcrew 153.3.1 Company 153.3.2 Vesselandcrew 15

3.4 Fire-extinguishingsystemdescription 153.4.1 Configuration 153.4.2 Protection 173.4.3 Cylindervalves 17

3.5 Inspectionandmaintenance 193.6 Testscarriedout 19

3.6.1 Cylindervalves’leaktest 193.6.2 Pressureswitchtest 20

SECTION 4 - COMMON TOPICS 22

4.1 SaferalternativestoCO2 224.2 Regulationsandguidance 22

4.2.1 Internationalrequirements 224.2.2 Cylindervalves 22

4.2.3 Systemtesting 234.2.4 Land-basedinstallations:requirementsforCO2cylindersandcylinder valves 244.2.5 Approvalofservicesuppliers 25

4.3 Previousaccidents 254.3.1 Publishedreports 254.3.2 CasesinvolvingsistervesselstoEddystone 264.3.3 CasesfromMariners’AlertingandReportingScheme 274.3.4 UnitedStatesCoastGuardreports 274.3.5 ResearchonCO2relatedaccidents 27

SECTION 5 - ANALYSIS 29

5.1 Aim 295.2 Overview 295.3 MechanismofCO2release 29

5.3.1 Eddystone 295.3.2 Red Eagle 30

5.4 Cylindervalveleakage 305.4.1 Eddystone 305.4.2 Red Eagle 315.4.3 Maintenance 31

5.5 Useofship’sserviceair 315.6 ProtectionSystems 31

5.6.1 Ventvalves 315.6.2 Leakagealarms 32

5.7 Ambiguityofguidance 325.7.1 Hydrostatictestingofhighpressurecylinders 325.7.2 Cylindervalvetesting,inspectionandmaintenance 335.7.3 Summary 34

5.8 Servicesuppliers 34

SECTION 6 - CONCLUSIONS 36

6.1 Safetyissuesdirectlycontributingtotheaccidentthathavebeenaddressedorresultedinrecommendations 36

SECTION 7 - ACTION TAKEN 37

7.1 Actionstakenbyotherorganisations 37

SECTION 8 - RECOMMENDATIONS 38

FIGURES

Figure 1 - CO2cylinderpressureandtemperaturerelationship

Figure 2 - Eddystone’sCO2room:bankA

Figure 3 - Schmölecylindervalve

Figure 4 - Eddystone’sCO2room:bankB

Figure 5 - Bulginginouterskinofrubberhoses

Figure 6 - Eddystonesystemdrawing(inset:non-returnvalveinsitu)

Figure 7 - Non-returnvalve(A)andcheckvalve(B)

Figure 8 - DensewhitecloudinCO2room(inset:cylindervalveactuationhead)

Figure 9 - Red Eaglesystemdrawingshowingpressureswitch

Figure 10 - Triggerline

Figure 11 - DABD109631/2”CO2cylindervalveswithD10964manual/pneumaticactuatorwithdetent

Figure 12a - LeakingDABvalve97056

Figure 12b - Evidenceofcorrosion

Figure 12c - Evidenceofcleaningwithwirewheel

Figure 12d - Brassparticlesembeddedinseatingface

TABLES

Table 1 - EffectofCO2onhumanphysiology

ANNEXES

Annex A - DABInspectionReport–Red Eagle–31stJuly2017

Annex B - IMOcircular-MSC.1/Circ.1318

Annex C - FireIndustryAssociationguidancenote

Annex D - URZ17-ProceduralRequirementsforServiceSuppliers

Annex E - MCASafetyBulletinNo.12

GLOSSARY OF ABBREVIATIONS AND ACRONYMS

ADR - EuropeanAgreementConcerningtheInternationalCarriageofDangerousGoodsbyRoad

Barber - BarberBrothersLimited

BS - BritishStandard

CO2 - Carbondioxide

DAB - DABFireEngineeringCompanyLtd

EN - NormesEuropéennes(EuropeanStandard)

DNVGL - DetNorskeVeritas–GermanisherLloyd

EPA - EnvironmentalProtectionAgency

FIA - FireIndustryAssociation

FSSCode - InternationalCodeforFireSafetySystems

GFT - GriffinFire&TrainingLimited

HSE - HealthandSafetyExecutive

IACS - InternationalAssociationofClassificationSocieties

IMO - InternationalMaritimeOrganization

ISO - InternationalOrganizationforStandardization

kg - kilogram

LR - Lloyd’sRegister

MARS - Mariners’AlertingandReportingScheme

MCA - MaritimeandCoastguardAgency

MOD - UK’sMinistryofDefence

MSC - MaritimeSafetyCommittee

MSIS - MerchantShipsInstructionstoSurveyors

Nm - Newtonmetres

OceanSafety - OceanSafetyLimited

RESMAR - RESMARLimited

Ro-ro - Rollon,rolloff

SOLAS - InternationalConventionfortheSafetyofLifeatSea1974,asamended

UR - UnifiedRequirement

USCG - UnitedStatesCoastGuard

GLOSSARY OF TECHNICAL TERMS

CO2cylinder - ContainerforstoringCO2underpressure

Cylindervalve - Thevalvefittedonacylinder,whichisopenedeithermanuallyorthroughtheactionofgaswhenCO2isrequiredforextinguishingfire

Bank - ThesetofCO2cylindersdesignatedforreleaseintoaspace

Bustingdisc - Adiaphragmthatisdesignedtoruptureatapre-determinedpressure

Checkvalve - Avalvethatrestrictstheflowofthemediumtoonedirection.Forthepurposeofthisreport,checkvalvesarenotspring-loaded

Mastercylinder - Acylinderthatisactivatedfirst,causingtheCO2gastoenterthetriggerlinetodischargetheremainingdesignatedcylinders

Non-returnvalve - Avalvethatrestrictstheflowofthemediuminonedirection.Forthepurposeofthisreport,non-returnvalvesarespring-loaded

Pilotcylinder - Acylindercontaininggas(usuallyCO2ornitrogen)andstoredinanenclosureseparateandremotefromthemainCO2cylinders

Pilotline - Thepipingsystemthatleadsthegasfromthepilotcylinder(s)totheCO2cylinderbank

Remoterelease - ThemeanstodischargeCO2intoacompartmentonfirethatislocatedawayfromtheroomcontainingtheCO2cylinders

Triggerline - ThepipingsystemthatleadsCO2fromthemastercylinder(s)toactivatetheremainingcylindersinthebank

TIMES: alltimesusedinthisreportareship’stime(UKsummertimeUTC+1forRed EagleandUTC+3forEddystone)

Eddystone

Red Eagle

1

SYNOPSIS

On8June2016,therollon,rolloffcargovesselEddystoneexperiencedanunintentionalreleaseofcarbondioxidefromitsfixedfire-extinguishingsystemwhileonpassageintheSouthernRedSea.Asimilarincidenttookplaceon17July2017onboardtherollon,rolloffpassengerferryRed Eagle whileonpassagefromtheIsleofWighttoSouthampton.Inbothcases,theengineroomdistributionvalveforthecarbondioxidegasremainedclosedandgasleakedoutintothecompartmentwherethecarbondioxidecylinderswerestored.Fortunately,noonewasharmedineitheroftheseincidents.However,areportissuedbytheUKHealthandSafetyExecutivestatedthattheunintendedreleaseofcarbondioxidefromfire-extinguishingsystemscaused72deathsand145injuries,mainlyinthemarineindustry,between1975and2000.

Inbothincidents,thereleaseofcarbondioxidewasfoundtobetheresultofmalfunctioningcylindervalves.TheMAIBinvestigationrevealedthatmaintenanceofthefire-extinguishingsystemshadbeeninadequate,andthattheavailableguidanceforthemarineindustryonthemaintenanceandinspectionofcarbondioxidefixedfire-extinguishingsystemswasinsufficient.

TheMaritimeandCoastguardAgencyhasissuedasafetybulletintotheoperatorsofallUKregisteredvesselsregardingtheappropriatemaintenanceofcarbondioxidefixedfire-extinguishingsystems.ThisbulletinclarifiestheUKadministration’spositionwithrespecttotheapplicationoftheinternationalrequirementsforthetestingofgascylinders.

AWShipManagement(Eddystone’smanager)andRedFunnel(Red Eagle’sowner/manager)havereplacedthecomponentsthatcontributedtotheseincidentsonthesistervesselsintheirfleets.

Recommendationshavebeenmadeto:

• TheMaritimeandCoastguardAgency,toseekclarificationfromtheInternationalMaritimeOrganizationofthemaximumpermittedperiodicitybetweenhydrostatictestingofindividualhighpressurecylinders(MSC.1/Circ.1318);and,toensurethatallsafetydevicesfittedtocarbondioxidefixedfire-extinguishingsystemsaremaintainedandsurveyedappropriately.

• DetNorskeVeritas–GermanischerLloydandLloyd’sRegister,toraisewiththeInternationalAssociationofClassificationSocietiestheissueofthequalityofserviceprovidedbyapprovedservicesuppliersinthemaintenanceofcarbondioxidefixedfire-extinguishingsystems.

• TheownersofRed Eagle, toreviewthedesignofthecarbondioxidefire-extinguishingsystemsfittedtotheirvesselswheretheleakageofasinglecylindervalvecausestheentiresystemtodischarge.

2

SECTION 1 - BACKGROUND

1.1 FIXED FIRE-EXTINGUISHING SYSTEMS

TheInternationalConventionfortheSafetyofLifeatSea1974,asamended(SOLAS)requiredmachineryspacesofcategoryA1tobeprotectedbyapermanentlyinstalledfixedfire-extinguishingsystemthatusesoneofthefollowingastheextinguishingmedium:

a. Gasb. Highexpansionfoamc. Water-spray.

Carbondioxide(CO2)isaninexpensive,widelyavailable,effectivefire-extinguishingmediumandisusedformostmarineapplicationswheregasisthechosenmedium.

1.2 CARBON DIOXIDE (CO2) AS A FIRE-EXTINGUISHING MEDIUM

1.2.1 Properties of CO2

CO2isodourless,colourlessandexistsingaseousformatatmosphericpressuresandtemperatures.

CO2hasahighrateofexpansion,enablinglargeareastobefloodedquickly.Itisnon-flammableanddoesnotsupportcombustion.Whenreleasedintoaconfinedspace,aconcentrationof20%ormoreCO2issufficienttodisplacethelighteroxygenmolecules,smotheringanyfire.However,itprovidesalmostnocoolingeffectandthereisariskofre-ignitionifthespaceissubsequentlyventedbeforeithashadsufficienttimetocool.

Abovethecriticaltemperatureof31.1°C,CO2cannotbeliquifiedbytheapplicationofpressure.Atypicalfire-extinguishingsystemcylinderat20°Cwillhaveavapourpressureofapproximately57bar;thiswillriseto74baratthecriticaltemperature.Furtherincreaseintemperaturewillleadtoincreasedpressurewithinthecylinder(Figure 1).

CO2willpermeatethroughrubberatapproximatelyfivetimestherateofair2.

1.2.2 Effect of CO2 on human physiology

ThemaindrawbackofCO2asafire-extinguishingmediumisthattheamountrequiredtosuppressafireishigherthantheamountrequiredtocauseharmtohumanbeings.Aboveaconcentrationof10%itcausesunconsciousness,followedbydeath.Atconcentrationsof17%andabove,survivaltimeislessthanaminute(Table 1).

1 MachineryspacesofcategoryAarethosespacesandtrunkstosuchspacesthatcontaineither:1.internalcombustionmachineryusedformainpropulsion;2.internalcombustionmachineryusedforpurposesotherthanmainpropulsionwheresuchmachineryhasintheaggregateatotalpoweroutputofnotlessthan375kW;or3.anyoil-firedboileroroilfuelunit,oranyoil-firedequipmentotherthanboilers,suchasinertgasgenerators,incinerators,etc.

2 J.D.Edward&S.F.Pickering,1920, Permeability of rubber to gases.

3

3 Shortnessofbreath

Imagecourtesyofhttps://www.epa.gov/snap/carbon-dioxide-fire-suppressant-examining-risks

Table 1: EffectofCO2onhumanphysiology

Figure 1: CO2cylinderpressureandtemperaturerelationship

4

SECTION 2 - FACTUAL INFORMATION: EDDYSTONE

2.1 PARTICULARS OF EDDYSTONE AND INCIDENT

SHIP PARTICULARS

Vessel’sname Eddystone

Flag UK

Classificationsociety Lloyd’sRegister

IMOnumber 9234070

Type Ro-rocargo

Registeredowner ForelandShippingLimited

Manager(s) AWShipManagementLimited

Construction Steel

Yearofbuild 2002

Lengthoverall 193.0m

Grosstonnage 23235

Authorisedcargo Militaryequipment

VOYAGE PARTICULARS

Portofdeparture Jeddah,SaudiArabia

Portofarrival Duqm,Oman

Typeofvoyage International

Cargoinformation Militaryequipment

Manning 21

MARINE CASUALTY INFORMATION

Dateandtime 8June2016at1625

Typeofmarinecasualtyorincident Marineincident

Locationofincident 1328.4N;04237.4E,SouthernRedSea

Placeonboard CO2room

Injuries/fatalities None

Damage/environmentalimpact None

Shipoperation Normalservice

Voyagesegment Transit

Internalandexternalenvironment Ambientairtemperature32°C,calmsea

Personsonboard 30

5

2.2 NARRATIVE

2.2.1 Incident

At1625on8June2016,whiletherollon,rolloff(ro-ro)cargovesselEddystone wasintheSouthernRedSeaonpassagetoDuqm,Oman,thefixedfire-extinguishingsystem’sCO2releasealarmsounded.Theengineroomhadbeenchangedovertounmannedmachineryspacewatchkeepingmodebutthesecondengineer,whowasondutythatday,wasintheengineroomatthetime,attendingtoapurifieralarm.Hetelephonedthechiefengineertoapprisehimofthesituationandremainedintheenginecontrolroom,whichwasseparatedfromtheengineroom.Themainengine,generatorsandengineroomventfansallcontinuedtooperatenormally.

ThechiefengineerandtheelectrotechnicalofficerinspectedtheremoteCO2releasestationandsawthatitwasundisturbed.TheythenwenttothedooroftheCO2room,wheretheyheardaloudhissingnoisefromwithin.Thechiefengineerinformedthemaster,whosentthechiefofficertoassistthem.

ThechiefengineerandchiefofficerdonnedbreathingapparatusandenteredtheupperleveloftheCO2room,whichcontainedthe65CO2cylindersthatcomprisedbankA4ofthevessel’sfixedfire-extinguishingsystem(Figure 2).Awhitecloudwasseenformingatthefarcornerofthecompartmentandallthecylindervalves(Figure 3)wereintheopenposition.Theythenwentdowntothelowerlevel,wherethereservesetof65CO2cylinderscomprisingbankB(Figure 4)werelocated.AllofbankB’scylindervalveswereintheclosedposition.

4 Eddystone’sCO2cylinderswerestoredastwoindependentbanks,AandB.

Figure 2: Eddystone'sCO2room:bankA

Safetypin Triggerline

TobankB

RubberCO2 outlethose

CO2manifold

6

Figure 3: Schmölecylindervalve

OvercentrelinkageSetscrew

Valvespindle

Valvelid

OvercentrelinkageSetscrew

Burstingdisc

Actuatorplunger

Pilot/triggerline

Tomanifold

Valveinclosedposition Valveinopenposition

7

TopreventthereleaseofCO2frombankB,thechiefengineerdisconnectedthepilotactivationlinestobothbanksofcylindersandleftbankBinthemanualactivationmode,allowingittobeactivatedfromwithintheCO2roomifrequired.CO2gasfrombankAcontinuedtoleakfromafewfailedcylinderoutletrubberhosesoverthenext4days,duringwhichtimemostoftherubberhosesinbankAdevelopedbulgesintheirouterskin(Figure 5).

2.2.2 System reinstatement

On19June,whenEddystone calledatBahrain,afterDuqm,aCO2fire-extinguishingsystemspecialistattendedthevessel.AllfourpilotcylindersandthecylindersofbankBwereweighedtoconfirmtheycontainedthefullchargeofgas.Aftercarryingoutvisualchecksonallthecomponents,thepilotcylinderswerereconnectedandthesystemwasputbackinservicewithbankAisolated.ThevesselthencontinueditsplannedvoyagetoMarchwood,UK.

WhenEddystonereachedMarchwood,RESMARLimited(RESMAR),thecompanycontractedbythemanagersofEddystonetocarryouttheannualinspectionandmaintenanceoftheCO2fire-extinguishingsystemsonthevesselsintheirfleet,attendedthevesselwithitssubcontractor,BarberBrothersLimited(Barber).AllthecylindersfrombankAweretransportedtoBarber’sfacilityinBirmingham,refilledandreturnedtothevessel.Between28Julyand2AugustRESMARreplacedeightcheckvalvesandonenon-returnvalvethathadbeenidentifiedtobeleaking,andrenewedalltherubberhosesinbothbanks.

Figure 4: Eddystone'sCO2room:bankB

Engineroomdistributionvalve

Figure 5: Bulginginouterskinofrubberhoses

Bulgingouterskin

8

2.3 COMPANY, VESSEL AND CREW

2.3.1 Company and vessel

Eddystonewasoneofsixsistervesselsbuiltforthetransportofmilitarycargoesandvehicles.EddystoneandthreeothersistervesselswereownedbyForelandShippingLimitedandmanagedontheirbehalfbyAWShipManagementLimited.AllthevesselswereonchartertotheUK’sMinistryofDefence(MOD)andpliedregularlybetweenMarchwood,UK,andportsintheMiddleEast.

2.3.2 Crew and other personnel

Atthetimeoftheincident,therewere21crewmembersandninemilitarypersonnelonboardEddystone.AllwereUKnationals.ThemanningonboardexceededtheMCA’sminimumsafemanningrequirements.

2.4 FIRE-EXTINGUISHING SYSTEM DESCRIPTION

2.4.1 Configuration

TheMODrequiredafullyredundantfixedfire-extinguishingsystemfortheengineroom,soallsixsistervesselshadbeenfittedwithanadditionalbankofCO2 cylinders.Eddystone’ssystemhadbeensuppliedbyTycoEngineeringServices,andcomprisedtwobanks,AandB,eachof65cylindersincludingtwomastercylinders.Therewerealsotworemotereleasestations,eachcontainingtwopilotcylindersandcapableofoperatingeitherbank (Figure 6).

Inoperation,thegasfromthepilotcylinderswasroutedthroughtwoindependentlines:oneforopeningtheengineroomdistributionvalveandtheotherforactivatingthemastercylindersofthechosenbank.TheCO2fromthemastercylindersreleasedintothemanifoldthroughaspring-loadednon-returnvalveattheendofthecylinderrubberoutlethose.Atthecylinderendofthenon-returnvalve,aT-branchwasfittedthroughwhichthegaswasled,viathetriggerline,tothereleasemechanismtotriggertheremainingcylindersinthebank.Everytenthcylinderineachbankhadasimilararrangementtomaintainthetriggerlinepressure.Thegasfromeachoftheremainingcylinderswasreleasedtothemanifoldthroughacheckvalve,whichconsistedofaballvalvemaintainingthesealbytheweightoftheball.Checkvalveswerenotspring-loaded(Figure 7).

2.4.2 Protection

TopreventanaccidentalreleaseofCO2,thepilotlineswerefittedwithventvalvessettoremainopennormallyandtocloseifthepressureexceeded1.5bar.Intheeventofleakagethroughthepilotcylinders’valves,theventvalveswouldpreventgradualpressurebuild-upinthepilotlinesthatmightotherwiseleadtothecylindervalvesbeingtriggered.

Themanifoldwasfittedwithapressureswitchdesignedtotriggeranalarmifminorleaksfromthecylindervalvescausedthepressureinthemanifoldtorise.Thispressureswitchwasnotshowninthesystemdrawing.DuringavisittothevesselbyMAIBinspectorson24August2017,thechiefengineerremovedthepressureswitch,whichhadastatedrangeof0to10bar,andtestedit;itwasfoundtobesetat12bar.

ToprotectthemainCO2manifoldfromextremeoverpressure,themanifoldwasalsofittedwithapressurereliefvalvesettoopenat120bar.

9

Fig

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6:

Edd

ysto

nesystemdrawing(in

set:non-returnvalveinsitu)

Vent

valve

Checkvalve

Non-returnvalve

Key

Pilotline

MainCO2

manifold

Trigger

line

BankA

BankB

Relief

valve

10

2.4.3 Cylinder valves

Thesystem’smainCO2cylinderswereallfittedwithSchmöle5K85-50cylindervalves(Figure 3).Theinternalmechanismofthesevalvesconsistedofavalvespindleandvalvelidsealingagainsttheseat.TheseatsealingsurfacewasmadeofpolyetheretherketoneorPEEK,asyntheticmaterialwithhighresistancetothermal,chemicalandaqueousdegradation.Thevalvewaskeptclosedbyanover-centrelinkagetensionedbyasetscrewactingonthetopofthevalvespindle.Toensurethatthevalvesremainedclosedirrespectiveoftheambienttemperatureandtheassociatedvariationofcylinderpressure,themanufacturerrequiredthissetscrewtobetightenedtobetween10Nmand11Nmatinstallation.Thesevalvesalsoprovidedaburstingdiscdiaphragmtoprotectthecylinderagainstextremeoverpressure.

5 NowownedbyVTIVentilTechnikGmbH.

A

B

Figure 7: Non-returnvalve(A)andcheckvalve(B)

11

TheSchmölevalvesweredesignedtobeoperatedeithermanually,usingtheoperatinglever,orremotely,viatheapplicationofaminimumpneumaticpressureof20barthroughthepilotortriggerlinetothevalvesactivationplungermechanism.Thetighteningtorqueofthevalvebodytothecylinderwasrequiredtobebetween160Nmand180Nm.

Themanufacturer’sinstructionmanualstatedthatthevalvesdidnothaveanydesign-relatedrestrictionsregardingtheirservicelife,andwerefitfor100releases.

2.5 INSPECTION AND MAINTENANCE

Beforetheincident,between2and5October2015,RESMARcarriedouttheannualinspectionandmaintenanceofEddystone’sfixedfire-extinguishingsystem.InDecember2015,italsoreplacedeightcylinderswithpressuretestedcylindersincompliancewiththegenerallyunderstoodrequirementtohydrostaticallypressuretest10%ofcylindersevery10years.

Duringtheannualinspectionandmaintenance,theship’sserviceair,supplieddirectlyfromthemainairreceiverthroughareductionvalvesettoapproximately7bar,wasusedtoblowthroughthesystemandpressuretestthemainmanifold.Thecylindervalveswerevisuallyinspected,andallgascylinderswerecheckedwithliquidleveldetectorstoensuretheycontainedtheirfullchargeofCO2.

WhenMAIBinspectorsvisitedEddystoneinAugust2017,RESMARtechniciansworkingonboardreportedthattheserviceairpressurewasinsufficienttotriggertheleakagealarmpressureswitch.

NeitherBarbernorRESMARwereabletoprovideanydocumentaryevidencetoconfirmthatthevalvesetscrewshadbeensettotherequiredtorqueatanytimebeforeoraftertheincident.

12

SECTION 3 - FACTUAL INFORMATION: RED EAGLE

3.1 PARTICULARS OF RED EAGLE AND INCIDENT

SHIP PARTICULARS

Vessel’sname Red Eagle

Flag UKClassificationsociety NotapplicableIMOnumber 9117337Type Ro-rocargoferry

RegisteredownerSouthamptonIsleofWight&SouthofEnglandRoyalMailSteamPacketCompanyLimited(knownasRedFunnel)

Manager(s) SouthamptonIsleofWight&SouthofEnglandRoyalMailSteamPacketCompanyLimited

Construction SteelYearofbuild 1996Lengthoverall 93.22mGrosstonnage 4075Authorisedcargo Passengersandvehicles

VOYAGE PARTICULARS

Portofdeparture EastCowesPortofarrival SouthamptonTypeofvoyage InternalwatersCargoinformation 57passengers,34vehiclesManning 8crewmembers

MARINE CASUALTY INFORMATION

Dateandtime 17July2017atapproximately0435Typeofmarinecasualtyorincident MarineincidentLocationofincident Solent(offBrambleBanks)Placeonboard CO2roomInjuries/fatalities NoneDamage/environmentalimpact NoneShipoperation NormalserviceVoyagesegment TransitInternalandexternalenvironment CO2roomtemperature18°C,calmseaPersonsonboard 65

13

3.2 NARRATIVE

3.2.1 Incident

At0420on17July2017,thero-roferryRed EagledepartedEastCowes,IsleofWight,boundforSouthampton.Approximately15minutesafterdeparting,theCO2 releasealarmsoundedintheengineroom.Thechiefengineerandmechanic,whowereintheenginecontrolroomatthetime,ranoutofthespace,exitingontothevehicledeckimmediatelyabove.TheCO2roomanditsremotereleasestationwerelocatedonoppositesidesofthisdeck.

ThechiefengineerinspectedtheremoteCO2releasestationandsawthatitwasundisturbed.HethenwenttothedooroftheCO2room,whereheheardaloudhissingsoundfromwithin.Heopenedthedoortotheroomslightly,andthroughaverysmallopeningsawadensewhitecloudinside(Figure 8).

Thechiefengineertelephonedthebridgeanddiscussedthesituationwiththemaster.TheyconcludedthatnoemergencyresponsewasrequiredotherthanensuringthatnooneenteredeithertheCO2roomortheengineroom.ThemasterthentelephonedGriffinFire&TrainingLimited(GFT),whowerecontractedtomaintaintheCO2fire-extinguishingsystemsonthecompany’sro-roferries,andaskedthemtoattendthevesselassoonaspossible.Healsoinformedthevessel’sowners,whointurnnotifiedtheMCA.Red Eagleberthedat0515and,afterdisembarkingthepassengersandtheirvehicles,movedtoalaybyberthnearby.ThevesselwastakenoutofservicependingtherestorationoftheCO2system.

AGFTtechnicianarrivedonboardat0630and,havingdonnedbreathingapparatus,wentinsidetheCO2roomtoinvestigate.Hecouldhearseveralofthecylindervalvesrattlingduetothebackpressureintheoutletmanifold,andCO2stillleakingintotheroomfromsomeofthecylinderoutlethosetomanifoldconnections(Figure 8). Topreventfurtherdischargeofgas,thetechnicianremovedallthecylindervalveactuationheads(Figure 8 inset).

AnMCAsurveyorarrivedonboardlaterthatmorning.Attherequestofthesurveyor,theGFTtechnicianprovedthatneithertheremotenorlocalreleasemechanismfortheCO2systemhadbeenactivatedtocausethecylinderstodischarge.

3.2.2 System reinstatement

All26ofthesystem’sCO2maincylindersandthepilotcylinderweresenttoOceanSafetyLimited(OceanSafety),subcontractorstoGFT.OceanSafetyestablishedthatthetwomastercylindersandthepilotcylindercontainedtheirfullcharge;sixcylindershadcompletelydischargedandtheremainingcylinderswerepartiallydischarged.Theywereunabletoestablishwhichcylindervalvehadleaked,causingthesystemtodischarge.

OceanSafetyemptiedandpressuretestedalltheCO2cylinders,examiningandrefurbishingthecylindervalvesasrequired.ItwasduringtheprocessofrefillingthecylindersthattheMCAaskedthevessel’sownerstoreplaceallthecylindervalvesasthevalvethathadcausedtheleakagecouldnotbeidentified.OceanSafetythenordered26newcylindervalvesfromDABFireEngineeringLtd(DAB)inYork.Thefilledcylinderswereemptiedandrefilledwiththenewvalvesfitted,andthevesselreturnedtonormalserviceon21Julyafterthesystemhadbeenreinstated.

14

ThefinalreportbyGFTfollowingitsreinstatementoftheCO2systemstated:

A new 10-370 bar latching pressure switch was fitted to the manifold. This was tested and witnessed by the MCA representative.

TheMAIBsubsequentlypointedoutthatthepurposeofthispressureswitchwastoraiseanalarmintheeventofthemanifoldbecomingpressurisedto1barasaresultofleakagepastcylindervalves.Thenewpressureswitchwasnotinaccordancewiththesystemdrawingandcouldnotraisethealarmbeforethesystemwas

Figure 8: DensewhitecloudinCO2room(inset:cylindervalveactuationhead)

Frostedunionofcheckvalve

15

triggered.GFTrespondedthattheydidnothavethesystemdrawingsforRed Eagle. GFTlaterreportedthattheywereunabletofindapressureswitchoftherightspecificationandwasdirectedbytheMAIBtoreportthemattertotheMCA.GFTwassubsequentlyinformedbytheCO2systemmanufacturerthattheoriginalpressureswitchhadbeenunavailablesince2013andthatthepressureswitchGFThadfittedwascorrect.

3.3 COMPANY, VESSEL AND CREW

3.3.1 Company

Red EaglewasownedandoperatedbyTheSouthamptonIsleofWightandSouthofEnglandRoyalMailSteamPacketCompanyLimited,commonlyknownasRedFunnel.Red EaglewasoneofthreeRaptorclasssistervesselsemployedonaregularpassenger,vehicleandfreighttransportationservicebetweentheIsleofWightandSouthampton.RedFunnelalsooperatedafootpassengeronlyservicebetweentheIsleofWightandSouthamptonwithfourhighspeedcatamarans.

3.3.2 Vessel and crew

Between2003and2005,thethreeRaptorclassvesselsintheRedFunnelfleetwerelengthenedatRemontowashipyardinGdansk,Poland.Red Eaglewasthelastvesseltobeextended.Duetotheincreasedvolumeoftheengineroomresultingfromtheextensionwork,thefixedfire-extinguishingsystemneededanadditionalsixCO2cylinderstobeaddedtotheexisting20.Followingthiswork,themainCO2 manifolduptotheengineroomdistributionvalvewaspressuretestedto122barasrequiredbyLloyd’sRegister(LR),theclassificationsocietythatwitnessedandsurveyedthework.

Thevessel’screwcomprisingthemaster,mate,engineer,mechanicandfourdeckratingssatisfiedtheMCA’ssafemanningrequirements.

3.4 FIRE-EXTINGUISHING SYSTEM DESCRIPTION

3.4.1 Configuration

Red Eagle’sfixedfire-extinguishingsystemwassuppliedbyWormaldEngineering(laterpartofTycoEngineeringServices)andcomprised26cylinders,includingtwomastercylinders.Theremotereleasestation,whichcontainedthepilotCO2cylinder,waslocatedonvehicledeckE,thedeckabovetheengineroom.

Inoperation,thepilotgaswasroutedthroughtwoindependentlines:oneforopeningtheengineroomdistributionvalveandtheotherforactivatingthemastercylinders.TheCO2fromthemastercylindersreleasedintothemanifoldthroughcheckvalvesattheendofthecylinderoutlethoses(Figure 9).Fromtheendofthemanifold,gaswasledviathetriggerlinetothereleasemechanismofeachcylindervalveinturn,causingthemtoopenandreleaseintothemanifoldthroughacheckvalve(Figure 10).ThetriggerlinewasnotseparatedfromthemanifoldasinthesystemonEddystone.

16

Fig

ure

9:

Red

Eag

lesystemdrawingshow

ingpressureswitch

Checkvalve

Key

17

3.4.2 Protection

Nopartofthesystemwasfittedwithaventvalvetoprotectfromgradualpressurebuild-upcausedbyleakingcylindervalves.

ThemanifoldwasfittedwithawidelyavailableDanfossKPS33pressureswitch,designedtotriggertheCO2releasealarmintheeventofminorleaksfromthecylindervalvesaswellasactasaCO2dischargealarm.Thispressureswitchhadastatedrangeof0to3.5barandwastobesettobreakat1barrising(Figure 9).

ToprotectthemainCO2manifoldfromextremeoverpressure,themanifoldwasalsofittedwithaburstingdiscdesignedtoruptureat190bar.

3.4.3 Cylinder valves

Thesystem’smainCO2cylinderswereallfittedwithDABD109631/2”CO2cylindervalves(Figure 11),eachofwhichhadaD10964manual/pneumaticactuatorwithdetentfittedontop.Whenactivatedbypilotgaspressureorthemanualreleasemechanism,theservopistonwaspusheddown,causingthefiringpintopushthepilotseatdown,openingthepilotvalve.Thisallowedcylinderpressuretoenterthetopofthevalveseat(madeofasyntheticmaterialcalledNylon6),pushingit

Figure 10: Triggerline

Triggerline

CO2manifold

Checkvalve

18

Fig

ure

11:

DAB

D109631/2"CO2cylindervalveswithD10964manual/pneum

aticactuatorw

ithdetent

Balancecham

ber

Burstingdisc

Pilotseat

Servopiston

CO2cylinderp

ressure

Firingpin

Valveseat

Valve

Valve

Actuatorhead

19

furtherdownuntilthedetentontheactuatorlocked,keepingthevalveopen.Thesevalvesalsoprovidedaburstingdiscdiaphragmtoprotectthecylinderfromextremeoverpressure.

Asmallholehadbeendrilledintothesideoftheservopiston,allowingtheescapeofanygasthatmighthavebecometrappedwithinit.Arestrictorwireinsertedintothisholeservedtoreducethecross-sectionalareaoftheholetotherequiredaperture.InDABvalvesmanufacturedbefore2000,thisrestrictorwirewasmadeofcopper.Withtheexceptionofthevalveseat,allotherinternalcomponentsandthebodyofthevalvesweremadeofbrassandstainlesssteel.

Theactuatorsfittedtothetopofthevalvesweredesignedtobeoperatedeithermanually,usingtheoperatinglever,orremotely,viatheapplicationofpneumaticpressurethroughthepilotortriggerlinetotheactuator.TheinstructionsfortheDABactuatorstatedthataminimumpneumaticpressureof31barwasrequiredtoopenit,whenthecylinderpressurewasbetween45and50bar.DuringthetestscarriedoutatDAB,itwasobservedthatanactivationpressureof4.1barwassufficienttoactivatethevalvewithacylinderpressureof50bar(simulatedwithnitrogengas).

Althoughthevalvesweredesignedtobeserviced,themanufacturer’sinstructionmanualstated:‘DAB do not recommend that CO2 valves be serviced or refurbished in the field’.

3.5 INSPECTION AND MAINTENANCE

On9June2016,GFTreplacedthreecylinderswithpressuretestedcylindersincompliancewiththegenerallyunderstoodrequirementtohydrostaticallypressuretest10%ofcylindersevery10years.On19December2016,GFTcompletedtheannualinspectionandmaintenanceofRed Eagle’sfixedfire-extinguishingsystem.Followingavisualinspectionofthecylindervalves,whichdidnotraiseanyconcern,allthecylindervalveactuatorswereremovedandprovedtobeworkingbypressurisingthemainmanifoldwithdrycompressedair.Thesystem’spressureswitchactivatedwhenthemanifoldwaspressurised.Thepressureswitchsetpointwasnotcheckedatthetime.

PriortotheincidentonRed Eagle,OceanSafetybelievedthatDABhadceasedtrading,andsorefurbishedcylindervalvesonthethreeRaptorclassvesselswithsparepartsheldatitsworkshop.Norecordsweremaintainedoftheserefurbishments.

3.6 TESTS CARRIED OUT

3.6.1 Cylinder valves’ leak test

FollowingtheaccidentalreleaseofCO2,DABtestedall26cylindervalvesfromRed Eagle.TheMAIBwitnessedthesetests.Nitrogenat50barwasappliedtothecylindersideofthevalvesandtheoutletsweremonitoredforleakageusingsoapsolution.Ofthe26valvestested,two(serialnumbers37017and97056)werefoundtobeleaking.

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Theleakagefromvalve97056wasverysmall.Thebubbleformedinthesoapsolutionduringtestingtookafewsecondstoburst(Figure 12a).Ondismantlingthisvalve,evidenceofcorrosionwasapparent(Figure 12b) andtheDABreportofthetests(Annex A)stated:

When valve 97056 was disassembled, it was noted that the outlet side of the valve was heavily discoloured internally and rust had formed in the outlet. As the valve is manufactured from brass and stainless steel it was surmised that the rust had come from the discharge hose fitting which are normally manufactured from zinc plated steel. [sic]

Thereportalsonotedthatthe bonnet assembly showed signs of pitting associated with being cleaned with a wire wheel, or similar. The valve had obviously been disassembled previously during its service life (Figure 12c).

Withregardtothesourceoftheleak,theseatingareaofthevalveseatwasfoundtohavesmallparticles,subsequentlyidentifiedasbrass,embeddedinit(Figure 12d). TheDABreportstated:

From experience, this brass swarf was the most likely cause of the leak. The leak however, was so slight that it would have taken many months if not longer for the leak to build up pressure inside the manifold and discharge the system.

Thereportconcluded:

Onceapressureof60PSI6isachievedinthemanifoldthefirstofthevalveswouldstarttoopencausingacascadeeffectintherestofthesystemopeningtheremaining25valves.

Theleakagefromvalve37017wassevereand,whenthevalvewasdismantled,apieceofthecopperrestrictorwirefromtheservopistonwasfoundtohavelodgedopenthepilotconeofthevalveseat.TheDABreportstatedthatthiscouldonlyhaveoccurredwhenthesystemwasactivated.

DABconfirmedthat,basedontheserialnumbersofthecylindervalves,20hadbeensuppliedbeforetheyear2000andsixadditionalvalvesweresuppliedin2006whenthevesselwasextended.

3.6.2 Pressure switch test

TheDanfossKPS33pressureswitchfittedtotheCO2manifoldwasexaminedbyalocalcompanyspecialisinginpressureswitchcalibration.Itfoundthat:

● Theswitchwassettoopenat0barrising

● Uponapplicationofpressureupto4bar,theswitchdidnotoperate

● Thelowerdiaphragmappearedtobecontorted

● Theupperplatethatthemechanismattachedtowasbentupwards.

6 60PSI=4.14bar.

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Figure 12a: LeakingDABvalve97056

Figure 12c: Evidenceofcleaningwithwirewheel

Figure 12d: Brassparticlesembeddedinseatingface

Brassparticlesembeddedinseatingface

Figure 12b: Evidenceofcorrosion

Corrosion

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SECTION 4 - COMMON TOPICS

4.1 SAFER ALTERNATIVES TO CO2

Fixedfire-extinguishingsystemsthatuseCO2poseasignificantrisktohumanlifeifusedwithinaconfinedspace.Safer,alternativesystemshavethereforebeendeveloped,andshore-basedfixedfire-extinguishingsystemsareincreasinglyusing:Argogen(IG55),Argonite(IG55),Inergen(IG541),FM200andNOVEC1230.

Thedocumententitled‘FireprotectionstandardforUKpowernetworksoperationalsites’waspublishedinJanuary2016byUKPowerNetworks.Itsetouttoprovide guidance on the broad fire safety legislative responsibilities and current fire safety standards as well as maintaining best practice from previous documentation concerningfireprotectionofUKpowernetworks’operationalsites.Itstated:

Where gaseous fixed fire extinguishing systems are installed it is preferred that Carbon Dioxide is not used.

4.2 REGULATIONS AND GUIDANCE

4.2.1 International requirements

SOLASreferstotheInternationalCodeforFireSafetySystems(FSSCode)forthetechnicalrequirementsoffixedgasfire-extinguishingsystems.TheFSSCoderequiresallgas-basedfixedfire-extinguishingsystemstobefittedwithanaudibleandvisualwarningofthereleaseofgasintospaceswherepersonnelnormallyworkorhaveaccess.FormachineryspacesprotectedbyCO2systems,theFSSCoderequiresthat85%oftheCO2shallbedischargedwithin2minutes,tocover35%7 ofthegrossvolumeofthelargestmachineryspaceprotected,includingtheenginecasing.

Red EaglewascategorisedasaClassIVpassengershipengagedonlyonvoyagesininlandwaters.ClassIVvesselswererequiredtocomplywithStatutoryInstrument(SI)1998No.1011,TheMerchantShipping(FireProtection:SmallShips)Regulations1998.TherequirementsforfixedgassystemswerecontainedinMSN1666,TheMerchantShipping(FireProtection)Regulations1998,whichformedanintegralpartofSI1998No.1011.TherequirementssetoutinMSN1666didnotincludemaintenanceandtestingroutinesastheMCAdeferredtotheInternationalMaritimeOrganization’scircularMSC.1/Circ13188 (Annex B),publishedinJune2009,forguidanceonthissubject.

4.2.2 Cylinder valves

MSC.1/Circ.1318aimedtoprovide the minimum recommended level of maintenance and inspections for fixed carbon dioxide fire-extinguishing systems on all ships, and are intended to demonstrate that the system is kept in good working order as specified in SOLAS regulation II-2/14.2.1.2.Itlistedtherequirementsandprovidedchecklistsforusebyservicesupplierstomaintainarecordoftheirinspectionsandmaintenance.MSC.1/Circ.1318statedthatmaintenanceandinspectionsshouldbecarriedoutinaccordancewiththemanufacturer’sinstructions,andlistedmonthly

7 or40%ofthegrossvolumeexcludingcasingsasdefinedinsection2.2.1.3ofFSSCode,whicheverislarger.8 MSC.1/Circ.1318,‘Guidelinesforthemaintenanceandinspectionsoffixedcarbondioxideandfire-

extinguishingsystems’.

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andannualchecksthatshouldbeconducted.Itfurtherstatedthatbienniallyforpassengershipsandatintermediate,periodicorrenewalsurveysofallothershiptypes,thefollowingmaintenance,interalia,shouldbecarriedout:

● The hydrostatic test date of all storage containers should be checked.

● High pressure cylinders should be subjected to periodical tests at intervals not exceeding 10 years. At the 10-year inspection, at least 10% of the total number provided should be subjected to an internal inspection and hydrostatic test**

TheasterisksinthequoteaboverefertoafootnotetotheInternationalOrganizationforStandardization(ISO)Standard,Gas cylinders – Seamless steel gas cylinders – Periodic inspection and testing,ISO6406.Thestandardstatesthatifavalveistobereintroducedontoacylinder,itshallbeinspectedandmaintainedtoensureoptimalperformance.Arecommendedmaintenanceplanisthenoutlinedinanannextothestandard,andincludesthefollowing:

Maintenance of the valve should include general cleaning, together with replacement of elastomers and worn or damaged components, packing and safety devices, where necessary.

However,ISO6406referstoEN14189Transportable gas cylinders. Inspection and maintenance of cylinder valves at time of periodic inspection of gas cylinders,nowreplacedbyBSENISO22434:2011,Transportable gas cylinders – Inspection and maintenance of cylinder valves.Thisstandardprovidesfurtherguidanceonexternalexaminationwiththecylindervalvebothinsituandremovedfromthecylinder.Itstatesthatifexternalexaminationrevealsnodefectsoranomalies,thevalvesmaybereintroducedintoservice.

TheMCA’sMerchantShipsInstructionstoSurveyors(MSIS)stated:

If the fixed CO2 cylinders are found to be in a very good condition at the 10 year interval, then the MCA will accept the hydrostatic test requirements specified in MSC/Circular 1318 paragraph 6.1.2, provided that all cylinders are tested within a 20 year maximum period.

4.2.3 System testing

MSC.1/Circ.1318undertheheadingMinimum recommended maintenancestates:the discharge piping and nozzles should be tested to verify that they are not blocked. The test should be performed by isolating the discharge piping from the system and flowing dry air or nitrogen from test cylinders or suitable means through the piping.

ItalsostatesunderExample Service Charts: Manifold tested for leakage, by applying dry working air.

DetNorskeVeritas–GermanischerLloyd(DNVGL)ClassGuidelinesCG-0058re-iteratetheserequirementsunderMaintenance of safety equipment,whichstatethatCO2linesandnozzlesshouldbeblownthroughwithdryairornitrogentoconfirmthattheyarenotblocked.

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Land-basedguidancealsorequirestheuseofnitrogenorasuitablealternativeinBritishStandardBS5306-4Fire-extinguishing installations and equipment on premises – Part 4: Specification for carbon dioxide systemswhichprovidesthefollowingguidance:

After assembly, the system shall be thoroughly blown through with nitrogen or suitable alternative …

4.2.4 Land-based installations: requirements for CO2 cylinders and cylinder valves

InNovember2015theUnitedKingdomFireIndustryAssociation(FIA)publishedGuidance on the periodic testing of transportable gas containers used in fire-extinguishing systems (Annex C).Thisguidancegaverecommendationsonhowfire-extinguishingsystemcontainersshouldbetreated.WithintheUK,thedesign,manufacture,inspectionandtest,andtransportofdangerousgoods,includingtransportablepressureequipment,isgovernedbytheCarriageofDangerousGoodsandUseofTransportablePressureEquipmentRegulations.TheseregulationsimplementtheEuropeanTransportablePressureEquipmentDirectiveandtheEuropeanAgreementConcerningtheInternationalCarriageofDangerousGoodsbyRoad(ADR).FIA’sguidancereferstoinstructionP200ofADR,whichspecificallyrequiresCO2cylinderstobepressuretestedat10-yearlyintervalsto190-250bar.TheUnitedStatesNationalFireProtectionAgencyimposestherequirementforhydrostatictestingofallcylinderswhicharedischargedafter5yearsofthelasttestandimposesamaximumlimitof12yearsbetweenhydrostatictests.

Oncylindervalves,theFIAguidancestates:

For safety reasons container [cylinder] valves should not be reused after removal from containers unless the following conditions are met:

● The valve has been refurbished in accordance with manufacturer’s recommendations

● The connection thread to the container and discharge hose are inspected to ensure they are within tolerance and undamaged.

Theguidancenotesthat,wherecylindervalveshaveataperthread,theyareoftenfoundtobeunfitforreuseafter a single fitment and removalduetothedistortionofthebrassthreadwhentightenedagainstthesteelcylinder.

ISO6183,Fire protection equipment -- Carbon dioxide extinguishing systems for use on premises -- Design and installation,statesthatCO2isnolongerrecommendedforuseinnormallyoccupiedspaces.Similarly,theNationalFireProtectionAgencyoftheUnitedStatesofAmericarecommendsthatCO2shouldnotbeusedinnewtotalfloodingsystemsforspacesthatarenormallyoccupied.

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4.2.5 Approval of service suppliers

TheInternationalAssociationofClassificationSocieties(IACS)providesguidancefortheapprovalofservicesuppliersinUnifiedRequirement(UR)Z17,Procedural Requirements for Service Suppliers (Annex D).URZ17definesaservicesupplieras:

A person or company, … provides services for a ship or a mobile offshore drilling unit such as measurements, tests or maintenance of safety systems and equipment, the results of which are used by surveyors in making decisions affecting classification or statutory certification and services.

URZ17definesasubcontractoras:

A Person or Company providing services to a Manufacturer or approved/recognized service supplier, with a formal contract defining the assumption of the obligations of the service supplier.

URZ17hasdetailedrequirementsonthetraining,personnelandqualitysystemsoftheservicesupplier,whicharealsoapplicabletotheirsubcontractors(exceptthoseonlyprovidingequipment).Italsorequirestheclassificationsocietythatisprovidingtheapprovaltoaudittheservicesupplierevery5years.Firmsengagedinservicingfixedfire-extinguishingsystemsarenotrequiredtobeapprovedbythesystem’smanufacturer,butneedtodemonstrateanunderstandingoftheprinciplesinvolvedwithgas,foam,deluge,sprinklerandwatermistsystems,asrelevantfortheapprovalbeingsought.Accesstosystemdrawings,manufacturers’instructionmanualsandbulletinsisrequiredfortheservicesupplierandnominatedsubcontractors.

Theservicesupplierapprovalcertificates(fortheinspectionandmaintenanceofportablefireextinguishers,andgasandfoamtypefixedfire-extinguishingsystems)wereissuedtoRESMARbyLloyd’sRegister(LR),andtoGFTbyDNVGL.

EddystonehadbeenservicedbyGFTfromSeptember2010toOctober2013andbyRESMARfrom2014onwards.GFThadbeenRed Eagle’sservicesuppliersincethevesselenteredservice.

4.3 PREVIOUS ACCIDENTS

4.3.1 Published reports

ThereareseveralpublishedreportsconcerningthereleaseofCO2fromfixedfire-extinguishingsystems.

In2004,thereleaseof5tonnesofCO2onboardtheHongKongregisteredcontainershipYM People9killedthevessel’smaster,chiefengineer,chiefofficerandthirdengineer.AllthedeceasedwereintheCO2roomatthetimeandwereattemptingtoventthemanifoldintowhichCO2hadinadvertentlyreleasedwhilethechiefengineerwaspreparingthesystemforinspectionandmaintenance.

9 ImproperreleaseofcarbondioxideonboardM.V.”YM People”on27.9.2004causingfourfatalities (https://www.mardep.gov.hk/en/publication/pdf/mai040927.pdf).

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In2010,theoffshoresupportvesselMarsol Pride10experiencedadischargeofCO2 intothemanifoldduetoaleakingSchmölecylindervalve.Subsequently,themainengineroomdistributionvalvedevelopedaleak,whichresultedintheengineroombeingfloodedwithCO2.Fortunately,therewerenocasualties.

In2011,ashore-basedserviceengineerwasseriouslyinjuredonboardthetugSD Nimble11whensixcylindersofCO2wereaccidentallydischargedshortlyafterthetughadslippedfromitsberth.Theengineerhadbeentestingcomponentsofthevessel’sfixedCO2fire-extinguishingsystem,intheCO2room,withoutfirstdisconnectingthesystem’sactivationpilotline.Theengineerlostconsciousness,butwasairliftedtoalocalhospitalandrecoveredfollowingalongperiodofrecuperationandtherapy.

4.3.2 Cases involving sister vessels to Eddystone

AccidentsonboardtwoofEddystone’ssistervesselswerereportedtotheMAIB.ThesereportsdidnotresultininvestigationsbytheMAIB,butthecircumstancesoftheaccidentsasreportedareoutlinedbelow:

Sister vessel 1 of Eddystone

InJune2017,techniciansworkingontheCO2fire-extinguishingsystemdecidedtopressuretestthemanifoldaftertheynoticedacorrodedsectiononit.Whentheyappliedserviceairpressuretothemanifold,all65cylindersinbankBofthesystemdischargedintothemanifoldandleakedoutthroughvariousunionsbetweenthecylinderoutlethosesandthemanifold.Therewerenoinjuries.

Thesubsequentinvestigationcarriedoutbythechiefengineerfoundthaton124of130cylinders,thesetscrewsoncylindervalveswerenottorquedto11nmasrequiredbytheinstructionmanualforSchmölevalves.

Theservicesupplier,basedinBarcelona,alsocarriedoutaninvestigationandreportedasfollows:

CAUSES OF THE ACCIDENTAL RELEASE

1. One of the Check valves from Master Cylinder was not working properly.2. The pilot loops from manifold check valves were not disconnected before apply

compressed air.3. The bolts for calibrating the CO2 valves of many cylinders were untightened (less

than 11 Nm). Because that even the valves were secured by safety pin some of them were partially released. [sic]

10 Report10-203:Marsol Pride,uncontrolledreleaseoffire-extinguishinggasintoengineroom,Tuioilandgasfield,27May2010 (https://taic.org.nz/sites/default/files/inquiry/documents/10-203%20Final%20Published.pdf).

11 ReportontheinvestigationoftheaccidentaldischargeofcarbondioxideonboardSD Nimble,resultinginseriousinjurytoashore-basedserviceengineeratHerMajesty’sNavalBaseFaslane23August2011(https://www.gov.uk/maib-reports/accidental-discharge-of-carbon-dioxide-when-testing-the-fixed-co2-fire-extinguishing-system-on-tug-sd-nimble-at-hm-naval-base-faslane-scotland-with-1-person-injured).

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Sister vessel 2 of Eddystone

InJanuary2013,whilethechiefengineerwasputtingtheCO2systembackintoserviceattheendofthedrydockingperiod,CO2dischargedfrom14cylinderswhosesafetypinshadalreadybeenremoved.Theengineroomdistributionvalve,whichwaslockedshut,preventedthereleaseofCO2intotheengineroom.ThecauseofleakagewassubsequentlydeterminedtobeleakagefromaSchmölecylindervalve.

4.3.3 Cases from Mariners’ Alerting and Reporting Scheme

TheMariners’AlertingandReportingScheme(MARS)wasaconfidentialreportingsystemrunbyTheNauticalInstitutetoallowfullreportingofaccidentsandnearmissesonboardvessels,withoutfearofidentificationorlitigation.AnonymousMARSreportsbasedontheseaccidentsandincidentswereheldinapublicly-accessibledatabaseasafreeservicetotheindustry.

MARS201311reportedonaninadvertentreleaseofCO2from11cylindersintothemanifold,whichsubsequentlyleakedintotheCO2roomofavessel.Thesubsequentinvestigationestablishedthatacylindervalvesetscrewhadnotbeentightenedtothecorrecttorque,resultinginthevalveopeningwhentheambienttemperatureintheCO2roomreached50°C.

MARS201120,reportedthefailureofaCO2extinguishingsystemtoreleaseduringanengineroomfire.Thiswasfoundtohavebeenduetoseveraldeficienciesinthemaintenanceofthesystem.Theseincludedleakingconnections,faileddistributionvalves,failureofpilotcylinderstorelease,andwateraccumulationandcorrosioninsidethepipelines.Thesystemhadbeeninspectedandservicedbyanauthorisedservicesuppliershortlybeforetheincident.

4.3.4 United States Coast Guard reports

InJuly2017,theUSCGpublishedSafetyAlert07-17,titledCO2HazardsareNothingNew.But we’d like to remind you of what not to do!ThealertreportedanearfatalaccidentduetotheunintentionalreleaseofCO2whilecoastguardofficerswereinspectingavessel.TechniciansworkingonthesystemwereresponsibleforreleasingtheCO2.

4.3.5 Research on CO2 related accidents

Inapaper12exploringtherisksofCO2asafire-suppressant,146deathswerefoundtobeassociatedwiththeuseofCO2intheperiod1940to1998.Thedataexcludeddeathscausedbyfires,andconcluded:

These deaths point to a need for additional safety measures when using CO2. A large proportion (68%) of the post-1975 incidents was marine-related. Examination of the causes of the incidents indicated that only a limited number of crewmembers had the training and authority to activate the systems. Those crewmembers without training may not have had a true appreciation of the dangers that surround exposure to high CO2. Consequently, additional safety measures might be warranted for marine applications.

12 S.R.SkaggsatHalonOptionsTechnicalWorkingConference(May1998):ExaminingtherisksofCO2asafiresuppressant.

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Thisdatawasfurthercorroboratedinaseparatestudy13bytheUSEnvironmentalProtectionAgency(EPA),whichconcluded:

Examination of the accident records shows that a disproportionately large number of accidents involving carbon dioxide have occurred on marine vessels.

And:

Maritime regulations (46 CFR Part 76.1514 and SOLAS) do not provide detailed requirements to ensure safety of personnel. These maritime regulations can be contrasted with the NFPA15 standard that has more specific suggestions to protect personnel against the adverse effect of carbon dioxide.

Thereportwentontorecommend:

Improvement of maritime regulations would at least provide specific requirements that would presumably help reduce the accidental exposures that occur in marine applications.

TheUK’sHealth&SafetyExecutive(HSE)drawsuponthedatafromtheUSEPAstudyinamajorpaper16andstates:

From 1975 to 2000, a total of 51 incident records were located that reported a total of 72 deaths and 145 injuries resulting from accidents involving the discharge of CO2 from fire extinguishing systems. The review indicates that the majority of reported incidents occurred during maintenance on or around the CO2 fire protection system itself.

13 U.S.EnvironmentalProtectionAgency,February2000:CarbonDioxideasaFireSuppressant:ExaminingtheRisks.

14 U.S.domesticregulation.15 TheNationalFireProtectionAssociation(NFPA)isaU.S.tradeassociation.16 PeterHarperHSE:Assessmentofthemajorhazardpotentialofcarbondioxide(CO2).

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SECTION 5 - ANALYSIS

5.1 AIM

Thepurposeoftheanalysisistodeterminethecontributorycausesandcircumstancesoftheaccidentasabasisformakingrecommendationstopreventsimilaraccidentsoccurringinthefuture.

5.2 OVERVIEW

TheconcentrationofCO2requiredtobereleasedintoaspacetoextinguishafireismorethandoublethatrequiredtokillahumanbeingwithinaminute.Therefore,anyaccidentalreleaseofCO2can,andoftendoes,havefatalconsequences.

Ashore,theuseofCO2isdiscouragedinspaceswherepeoplemaybepresent.ThedatacollatedbytheEPAonfatalaccidentsandinjuriesfrom1975to2000mostlikelyinfluencedthismoveagainsttheuseofCO2.Severalsaferalternativeshavebeendeveloped,andthemoveawayfromusingCO2asanextinguishingagenthasimprovedthesafetyofland-basedsystems.Themarineindustry’sreluctancetoadoptasimilarapproachislikelytocostmorelivesinthefuture.

ThetwoincidentsinvestigatedforthisreportwerebothcausedbyleakageofCO2 throughcylindervalves.UnliketheMarsol Prideincident,inbothofthesecasesthedistributionvalvesheld,protectingship’sstafffromexposuretoCO2,reducingthepotentialforinjuryorlossoflife.Itislikelythatinbothcasestheleakageofthecylindervalves,andthefailureofthealarmsdesignedtowarnofsuchleakage,wasattributabletotheworkofapprovedservicesuppliersoperatingwithintheambiguousandlimitedinternationalrequirementsregardingthesesystemsandtheirmaintenance.

5.3 MECHANISM OF CO2 RELEASE

5.3.1 Eddystone

ImmediatelyaftertheincidentonboardEddystone,thechiefengineerobservedthatall65cylindervalvesinbankAhadopened,andthatthemanualandremotereleasesremainedundisturbed.Inorderforthistohaveoccurred,oneormorecylindervalvesmusthaveleaked,pressurisingthemanifold.Thisledtothepressurisationofthetriggerline,throughthenon-returnvalvethatwassubsequentlyfoundtobeleaking,andthedischargeofallthecylindersinbankA.

Itwasnotpossibletoidentifywhichcylindervalvehadinitiatedthedischarge,andtherewerenoavailablerecordsforthetorquesettingsoftheSchmölevalvesetscrewsforeitherbankofcylindersfrombeforeoraftertheincident.

ThedesignofSchmölevalveswassuchthatiftheirsetscrewswereinadequatelytorqued,thelikelihoodofthevalveleakingwouldrisesignificantlywithincreasedcylinderpressure.Atthetimeoftheunintendedrelease,EddystonehadjustenteredtheSouthernRedSea,andtheambienttemperatureoftheCO2roomhadrisenaboveCO2’scriticaltemperature.Thefilldensityofthecylinderswasnotrecordedbut,inanyevent,giventheminimumpermissiblefilldensity,thistemperaturerisewouldhavecausedthepressurewithintheCO2cylinderstoriserapidlytoover76

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barat32°C(Figure 1).Therefore,itisconsideredalmostcertainthattheleakageonEddystone wastheresultofoneormoreincorrectlytorquedSchmölevalvesetscrews.

ThereisahistoryofsimilarincidentsinvolvingSchmöletypecylindervalvesleakingasaresultofincorrecttorqueshavingbeenappliedtotheirsetscrewsatinstallationorservice.TheseincludetheMARS201311reportandthetwoincidentsonEddystone’ssistervessels,whereonewasfoundtohavehadalmostallofitsSchmölevalvesetscrewsincorrectlytorqued.

5.3.2 Red Eagle

FollowingtheincidentonRed Eagle,itwasestablishedthatallbutthetwomastercylindershadbeenreleased,despitethemanualandremotereleasesremainingundisturbed.Red Eagle’sfixedfire-extinguishingsystemwasdesignedsuchthatpressurisationofthemanifold,normallyfromthemastercylinders,wouldleadtothereleaseofalltheremainingcylindersthroughadirectconnectionbetweenthemanifoldtothetriggerline(Figure 10).Theunintendedreleasewascausedbyone,ormore,ofthecylinders(otherthanamastercylinder)leakingintothemanifolduntiltheactivationpressurewasreachedinthetriggerline,whentheremainingcylindersstartedbeingactivated.Bothmastercylindersremainedundischargedbecausetheirtriggerlineswerenotconnectedtothemainmanifold.

DuringtestscarriedoutatDAB’sfacilitiesitwasestablishedthattheactuatorswouldstartopeningcylindervalvesatatriggerpressureof4.14bar.Cylindervalves97056and37017werealsoidentifiedtobeleakingduringthesetests.However,theleakagefromvalve37017wasconsideredtohaveresultedfromtheincident.

ThelocalisedfrostingoftheunionbetweenthecheckvalveandthecylinderoutlethosevisibleinFigure 8,takenimmediatelyaftertheincident,wasaresultofcoolingcausedbytherapidexpansionofCO2asitescaped.Thisindicatedthatthiswasalikelysourceofleakagefromthesystemfollowingtheunintendedrelease.Therefore,assumingthecheckvalveswereingoodworkingorderandthatthemanifoldwascompletelygastightatlowpressure,itispossiblethattheslowleakfoundinvalve97056ledtoagradualbuild-upofpressure.However,thiswouldhavetakenseveralweekstoreachthe4.14barneededtotriggerthedischarge.Itisalsopossiblethatthevalvethatleaked,causingthesystemtodischarge,hadsubsequentlyre-seatedandheldpressureduringtestsconductedatDAB.

5.4 CYLINDER VALVE LEAKAGE

5.4.1 Eddystone

Schmölevalves,suchasthosefittedonboardEddystone,weredesignedtooperate100timesbeforetheyneededtobereplaced,andtheycouldnotberefurbished.However,itwascriticalthatthecorrecttorquewasappliedtotheirsetscrewsatinstallation,andcheckedduringtheannualinspectionandmaintenance.

Intheabsenceofanyrecordofthesetscrewtorqueshavingbeensetorchecked,itislikelythatthiswasnotdoneduringthesystem’slastinspection8monthsbeforetheincident.Thesettingandcheckingofthesetscrews’torquearespecifictoSchmölevalves,sodonotappearinanyofthegeneralguidanceorrequirementsforannualinspectionandmaintenance.Itshould,however,formpartofthevessel-specificworklistdevelopedbytheservicesupplier.

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5.4.2 Red Eagle

TheCO2cylindersfittedonRed EaglewereequippedwithDABvalves.Therewasnowrittenguidanceconcerningtheservicelifeofthesevalves,althoughaftertheincidentDABstatedthattheyshouldbereplacedevery10years.Thevalvesweredesignedtobeserviced,butthemanufacturer’smaintenanceinstructionsstatedthattheywerenottoberefurbishedbytheend-user,exceptinanemergency.

TheleakingvalvethatledtotheunintendedreleaseofCO2onboardRed Eagle couldnotbeidentifiedwithcertainty.Therefore,thespecificcauseoftheleakagecannotbeknown.However,thevalvesshowedevidenceofrefurbishmentbyservicesuppliers,includingtheuseofawirewheelorsimilartocleantheinternalcomponents.Thisiscontrarytothemanufacturer’sinstructionsandledtotheentrapmentofbrassparticlesonthesealingsurfaceofonevalve,causingittoleak.

5.4.3 Maintenance

GiventhepotentiallyfatalconsequencesofunintentionaldischargeofCO2fromfixedfire-extinguishingsystems,thecurrent‘fitandforget’approachtocylindervalvesisunsafe.Regularinspectionandmaintenanceinlinewiththemanufacturer’sinstructionsisofparamountimportanceinensuringthesafetyofthesesystems.

5.5 USE OF SHIP’S SERVICE AIR

Ship’sserviceairistypicallytakendirectlyfromtheairreceiverand,asaresult,containsbothmoistureandoil.Unlikecontrolair,serviceairisnotdriedorfiltered.Therefore,applyingserviceairtoCO2systemsintroducesmoisture,leadingnotonlytointernalcorrosionofpipeworkandfittings,butalsototheriskofblockagescausedbyinternalicingwhenCO2isreleased.ItisforthesereasonsthatMSC.1/Circ.1318requirestheuseofnitrogenordryair.

TheannualinspectionandmaintenanceofEddystone’sCO2systemwascarriedoutinOctober2015.WhenthesystemwasbeingreinstatedfollowingtheincidentinJuly2016,eightcheckvalvesandonenon-returnvalvewerefoundtobeleaking.Itislikelythatthepracticeofusingship’sserviceaircontributedtotheprematurefailureofthesefittings.

5.6 PROTECTION SYSTEMS

5.6.1 Vent valves

Fixedfire-extinguishingsystemdesignerswereawareofthepotentialforcylindervalvestoleakduringtheirservicelife.Tomitigatetheriskofunintentionalsystemdischargeposedbysuchleakage,manysystemswerefittedwithventvalves.Theseweredesignedtopreventpressurebuild-upbyventingCO2leakagetoatmosphere,typicallyuptoapressureofabout1.5bar.Toensurenormaloperationwhenactivated,thesevalveswouldclosewhenthesystemwassubjectedtooperationalpressure.However,ventvalveswerenotmandatoryforCO2fixedfire-extinguishingsystems.

Eddystone’ssystemwasfittedwithventvalvesinitspilotlines.However,theleakageoccurredintothemanifoldandthetriggerline,anddidnotaffectthepilotlines.

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5.6.2 Leakage alarms

TheleakagealarmsfittedtobothvesselsactivatedonlyoncethecylindersreleasedCO2intothemanifolds.Thealarmsetpointswereoutsidetherangeoftherespectivepressureswitches,anditwasfortunatethattheytriggeredthealarm.Hadthedistributionvalvesbeenopen(orfailedasaresultoftheshockloading),allowingCO2toreleaseintotheenginerooms,itispossiblethatnoalarmwouldhavesoundedsincethemanifoldpressurewouldhavebeensignificantlylower.

Leakagealarmswerenotrequiredbynationalorinternationalregulations.Therefore,theywerenotmentionedintheExample Service ChartforhighpressureCO2 systemsincludedinMSC.1/Circ.1318(Annex B)asitonlyincludedchecksoncomponentsrequiredbytheFSSCode.Asaresult,theirpurposeandfunctionwerenotunderstoodbytheservicesuppliersorsurveyorsinvolved,andtheyhadbeensubjectedtoinappropriatetests.

RESMARtechniciansrecognisedthatthe7barpressureavailablefromtheship’sserviceaironEddystone wasinsufficienttotriggerthealarm.Hadtheyunderstoodthepurposeofthealarm,itwouldhavebeenclearthatitshouldhavebeensettotriggeratthelowestpressurepossible.

ThepressureswitchforthealarmfittedtoRed Eaglewasfoundtohavebeenadjustedtotriggerat0barasitwasprobablydamagedbytheapplicationofcompressedairatapressureaboveitsmaximumratedpressure.Itislikelythatatsometimeinthepast,thesettingofthepressureswitchwasadjusteduntilthealarmwastriggeredduringannualpressuretestingofthemanifold.Withoutreferencetothesystemdrawing,therange,setpointandpurposeofthealarmweremisunderstood.Thiswasfurtherdemonstratedbythefittingofaswitchwitharangeof10-370barwhenre-instatingthesystemfollowingtheCO2release.ThatthisswitchwasacceptedbytheMCAsurveyorandJohnsonControlsInternationaldemonstratestheneedforimprovedguidanceonthemaintenanceandoperationofthesesystems.Thisisespeciallytrueinthecaseoflegacysystems,whentherationalebehindthedesignfeaturesoftheoriginalsystembecomeslostorismisunderstoodfollowingachangeofcompanyownership.

5.7 AMBIGUITY OF GUIDANCE

5.7.1 Hydrostatic testing of high pressure cylinders

MSC.1/Circ.1318section6providesrecommendedminimummaintenanceforfixedCO2fire-extinguishingsystems.Withrespecttohydrostatictesting,sub-section6.1.2initiallystatesthatthehydrostatictestdateofallstoragecontainersshouldbechecked.Itisnotimmediatelyclearwhatthepurposeofcheckingthedatesis,althoughthetextthatimmediatelyfollowsit:High pressure cylinders should be subjected to periodical tests at intervals not exceeding 10 years,couldimplythathydrostatictestingshouldnotexceeda10-yearperiodicity.However,thesubsequentsentence,furtherreinforcedbypoint19ofExampleServiceChartsintheAppendix,statesthatatthe10-yearinspection,atleast10%ofthetotalnumberprovidedshouldbesubjectedtoaninternalinspectionandhydrostatictest.Thiscanresultintheinterpretationthatthesame10%ofcylindersmaybehydrostaticallytestedevery10years,withtheresultthat90%ofavessel’scylinderscouldremainuntestedthroughoutitsservicelife.

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Manyadministrationshavechosentointerprettheaboverequirementfortestingperiodicityasmeaningthatonly10%ofcylindersneedtobehydrostaticallytestedevery10years.IntheUK,thisinterpretationisnegatedbytheMCA’sguidancetosurveyorsthatstipulatesthatallCO2cylindersshouldbetestedwithin20years.Inthiscontext,itisnoteworthythatthemaintenancerequirementsforland-basedsystemsmakeitmandatorythatallCO2 cylindersbehydrostaticallytestedwithina10-yearperiod(12yearsintheUSA).ThedivergenceinapproachbetweenlandandmarineorganisationstothesafetyofCO2systemsishardtoreconcile,especiallyasamalfunctioningCO2installationonanocean-goingvesselhasthepotentialtoleavethevesselwithoutafixedfire-extinguishingsystemuntilitarrivesataportwherethesystemcanbereinstated.

Giventhatthemarineindustry,unlikeshore-basedindustries,isnotmakingthetransitiontosaferalternativestoCO2,thereisanurgentneedfortheInternationalMaritimeOrganization(IMO)toclarifyMSC.1/Circ.1318section6toremoveanyambiguityabouttherequirementsforhydrostatictestingofhighpressurecylinders.

5.7.2 Cylinder valve testing, inspection and maintenance

MSC.1/Circ.1318providesnoguidanceonthetestingandmaintenanceofcylindervalves,beyondrecommendinganannualvisualinspectionandstatingthatanymaintenanceshouldbecarriedoutaccordingtothesystemmanufacturer’sinstructions.Itdoesrefer,however,inafootnote,toISO6406,whichinturnreferstoEN14189(nowsupersededbyBSENISO22434:2011).

ISO6406providessomeguidanceonvalvemaintenance,recommendinggeneralcleaning,togetherwithreplacementofelastomersandwornordamagedcomponents,withoutspecifyingtheneedtorefertomanufacturer’sinstructions.BSENISO22434:2011permitsvalvestobere-usedwithoutmaintenanceifanexternalinspectionrevealsnodefectsoranomalies.

Inpractice,duetotheambiguityinMSC.1/Circ.1318outlinedin5.7.1above,theonlytestcarriedoutoncylindervalvesisaleaktestwhenthecylindersarerefilledfollowinghydrostatictesting.Itisthereforepossiblefor90%ofavessel’sCO2 cylindervalvestoremainuntestedforthelifeofthevessel.SinceitisnotpossibletoestablishbyvisualinspectionthatthesetscrewonaSchmöletypevalveiscorrectlytorqued,90%ofthesecouldalsoremainincorrectlysetforthelifeofavessel,oruntiltheyleak.

IntheincidentinvolvingRed Eagle,itispossiblethatCO2leakedthroughasealcontaminatedwithbrassparticlesthathadresultedfromtheservicesupplierusingawirewheelorsimilarwhilerefurbishingtheDABvalve.Thisrefurbishmentwasnotinaccordancewithmanufacturer’sinstructions(see5.4.2),butwaslikelyaconsequenceoftheservicesupplierbelievingDABwasnolongertrading.

Finally,FIAguidance(see4.2.4)recommendsthatcylindervalveswithtaperedthreads,themostcommontypesusedinthemarineindustry,arereplacedwhenremovedafterasingleconstructionduetolikelihoodthatthebrassthreadwillhavedistortedupontighteningintoasteelcylinder.ThisguidanceisnotreplicatedinMSC.1/Circ.1318.

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Fromtheabove,itcanbeconcludedthatambiguityexistsovertheappropriateservicingstandardstobeappliedtocylindervalves,andthatthegenericguidanceavailabletotheindustryvariesinquality.TheambiguityisfurthercompoundedbytheuncertainrequirementsforhydrostatictestingofCO2cylindersasdescribedintheprevioussection.

5.7.3 Summary

GiventhehazardthatCO2posestohumanhealth,thereisaneedfortheIMOtoclarifyMSC.1/Circ.1318section6toremoveanyambiguityabouttherequirementsforhydrostatictestingofhighpressurecylinders.[5.7.1]

Itcanbeconcludedthatambiguityexistsovertheappropriateservicingstandardstobeappliedtocylindervalves,andthatthegenericguidanceavailabletotheindustryvariesinquality.[5.7.2]

5.8 SERVICE SUPPLIERS

CO2basedfixedfire-extinguishingsystemsareentirelyreliantontheabilityofships’stafftoreleasetherequiredquantityofCO2intotheappropriatespaceintheeventofanemergency.Flagadministrations,classificationsocieties,ships’owners,operatorsandcrewallrelyonapprovedservicesupplierstoensurethatthesesystemsareinacontinuousstateofreadiness,bymeansofregularmaintenanceandtesting.

Servicesuppliersareoftencalledupontoattendunfamiliarvesselswhentheycallintoport.Itisacceptedthatworkingonanunfamiliarsystemwithintheconstraintsofavessel’sbusyscheduleinportcouldbechallenging.However,bothEddystoneandRed Eagle werevesselsknowntotheirrespectiveservicesupplier.

Theinvestigationsintotheincidentsdescribedinthisreportfoundsignificantdeficienciesintheinspectionandmaintenanceprovidedbyservicesuppliers.Theseincluded:

● Refurbishingofcylindervalvescontrarytothemanufacturer’sguidance.

● Notmaintainingrecordswhencylindervalveswererefurbished.

● BlowingthroughorpressurisingEddystone'ssystemwithship’sserviceairinsteadofdryairornitrogen.

● Workingonsystemswithoutadequatedocumentationsuchassystemdrawings.

● Fittinganinappropriatepressureswitch.

● Settingpressureswitchesoutsidetheiroperatingrange.

● Nottestingpressureswitches.

● Notmaintainingcontrolandoversightoversubcontractedthirdparties.

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Manypastincidentshaveoccurredduringmaintenance,andasaresultofpoormaintenanceofsystemcomponents.TheincidentsonSD Nimble andsistervessel1ofEddystone;thecasesreportedinMARS201311;andtheUSCGreportcitingseveralseriousdeficienciesobservedimmediatelyafterasystemservice,demonstratethatsuchdeficienciesarewidespread.ThisisfurthersupportedbythefindingsoftheUKHSEandtheUSEPA.

TheProcedural Requirements for Service Suppliers,URZ17(Annex D),describesrequirementsplacedbytheclassificationsocietiesonthoseapprovedtomaintainsafetysystemsandequipment.However,itisapparentfromthefindingsofthisreport,thatthelevelofservicegivenbysomeapprovedservicesuppliersregularlyfailstomaintainthesafetyofCO2basedfixedfire-extinguishingsystemsonboardships.

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SECTION 6 - CONCLUSIONS

6.1 SAFETY ISSUES DIRECTLY CONTRIBUTING TO THE ACCIDENT THAT HAVE BEEN ADDRESSED OR RESULTED IN RECOMMENDATIONS

1. ItisalmostcertainthattheCO2fire-extinguishingsystemonEddystone dischargedbecauseofoneormoreincorrectlytorquedSchmölecylindervalvesetscrews.[5.3.1]

2. TheunintendedreleaseofCO2onRed Eagle wascausedbyoneormorecylindervalvesleakingintothemanifold,causingthesystemtodischarge.[5.3.2]

3. Red Eagle’sfixedfire-extinguishingsystemwasdesignedsuchthatpressurisationofthemanifoldwouldleadtothereleaseofalltheremainingcylinders.[5.3.2]

4. ItislikelythatthetorqueonEddystone’sSchmölevalvesetscrewshadnotbeencheckedduringthesystem’slastinspection8monthsearlier.[5.4.1]

5. Red Eagle’scylindervalvesshowedevidenceofrefurbishmentbyservicesuppliers,whichledtotheentrapmentofbrassparticlesonthesealingsurfaceofonevalve,causingittoleak.[5.4.2]

6. RegularinspectionandmaintenanceofCO2cylindervalvesinlinewiththemanufacturer’sinstructionsisofparamountimportanceinensuringthesafetyofthesesystems.[5.4.3]

7. Thepracticeofusingships’serviceairtoblowthroughCO2systemsislikelytohavecontributedtotheprematurefailureoffittingsonthesesystems.[5.5]

8. Thepurposeandfunctionofleakagealarmswitcheswasnotunderstoodbytheservicesuppliersorsurveyorsinvolved,resultinginthembeingincorrectlysetandsubjectedtoinappropriatetests.[5.6.2]

9. GiventhehazardthatCO2posestohumanhealth,thereisaneedfortheIMOtoclarifyMSC.1/Circ.1318section6toremoveanyambiguityabouttherequirementsforhydrostatictestingofhighpressurecylinders.[5.7]

10. Itcanbeconcludedthatambiguityexistsovertheappropriateservicingstandardstobeappliedtocylindervalves,andthatthegenericguidanceavailabletotheindustryvariesinquality.[5.7.2]

11. Flagadministrations,classificationsocieties,ship’sowners,operatorsandcrewallrelyonapprovedservicesupplierstoensurethatCO2fixedfire-extinguishingsystemsareinacontinuousstateofreadiness,bymeansofregularmaintenanceandtesting.[5.8]

12. ThelevelofservicegivenbyapprovedservicesuppliersregularlyfailstomaintainthesafetyofCO2basedfixedfire-extinguishingsystemsonboardships.[5.8]

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SECTION 7 - ACTION TAKEN

7.1 ACTIONS TAKEN BY OTHER ORGANISATIONS

TheMaritime and Coastguard Agency has:

IssuedasafetybulletintotheoperatorsofallUKregisteredvesselsclarifyingtheambiguityofMSC.1/Circ.1318regardingthehydrostatictestingperiodicityforCO2 cylindersandtheappropriatemaintenanceofCO2fixedfire-extinguishingsystemsandtheircomponents(Annex E).

Red Funnelhas:

ReplacedtheCO2cylindervalvesonalltheRaptorclassvesselsinitsfleet.

AW Ship Management Limited has:

Replacedthenon-returnandcheckvalvesonallthesistervesselsofEddystone.

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SECTION 8 - RECOMMENDATIONS

TheMaritime and Coastguard Agencyisrecommendedto:

2018/123 EnsurethatsurveyscheckthatallsafetydevicesfittedtoCO2fixedfire-extinguishingsystemsareappropriatelymaintainedandsurveyed.

2018/124 SeekclarificationfromtheIMOofthemaximumpermittedperiodicitybetweenhydrostatictestsofindividualhighpressurecylinders,asdetailedinMSC.1/Circ.1318ANNEXB6.1.2.

Det Norske Veritas – Germanischer LloydandLloyd’s Registerarerecommendedto:

2018/125 ProposetotheInternationalAssociationofClassificationSocietiesthataninvestigationbecarriedoutintotheapplicationofProceduralRequirementsforServiceSuppliers,URZ17.Thisshouldtakeintoconsiderationthefindingofthisreport,thatthelevelofserviceprovidedbyapprovedservicesuppliersregularlyfailstomaintainthesafetyofCO2basedfixedfire-extinguishingsystemsonships.

Red Funnelisrecommendedto:

2018/126 ReviewthedesignoftheCO2fixedfire-extinguishingsystemsfittedtoitsvesselswheretheleakageofasinglecylindervalvecausestheentiresystemtodischarge.

Safetyrecommendationsshallinnocasecreateapresumptionofblameorliability

Marin

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