THE COMMONWEALTH OF THE BAHAMAS
M.v. Splendour of the Seas
IMO Number 9070632
Official Number 9000121
Report of the investigation into the
forward engine room fire which occurred on the
22nd October 2015
THE BAHAMAS MARITIME AUTHORITY
The Bahamas conducts marine safety or other
investigations on ships flying the flag of the
Commonwealth of the Bahamas in accordance with the
obligations set forth in International Conventions to
which The Bahamas is a Party. In accordance with the
IMO Casualty Investigation Code, mandated by the
International Convention for the Safety of Life at Sea
(SOLAS) Regulation XI-1/6, investigations have the
objective of preventing marine casualties and marine
incidents in the future and do not seek to apportion
blame or determine liability.
It should be noted that the Bahamas Merchant
Shipping Act, Para 170 (2) requires officers of a ship
involved in an accident to answer an Inspector’s
questions fully and truly. If the contents of a report
were subsequently submitted as evidence in court
proceedings relating to an accident this could offend
the principle that individuals cannot be required to
give evidence against themselves. The Bahamas
Maritime Authority makes this report available to any
interested individuals, organizations, agencies or
States on the strict understanding that it will not be
used as evidence in any legal proceedings anywhere in
the world.
Date of Issue: 11th May 2017
Bahamas Maritime Authority
120 Old Broad Street
LONDON
EC2N 1AR
United Kingdom
THE BAHAMAS MARITIME AUTHORITY
CONTENTS
1. Glossary of abbreviations and acronyms
2. Summary
3. Details of Involved Vessel(s) and Other Matters
4. Narrative of events
5. Analysis and discussion
6. Conclusions
7. Recommendations
List of Appendices:
I. Wärtsilä Site Survey Conclusions and Recommendations
II. Wärtsilä technical bulletin 4610T002
III. Lucius Pitkin LPI, Inc. Evaluation of Failed Fasteners Conclusions and
Recommendations
THE BAHAMAS MARITIME AUTHORITY
1 GLOSSARY OF ABBREVIATIONS AND
ACRONYMS
AE - Auxiliary Engine
BMA - Bahamas Maritime Authority
°C - Celsius
CCTV - Closed-circuit television
CO2 - Carbon dioxide
DG - Diesel Generator
DMT - Diesel Maintenance Team
DNV-GL - Det Norske Veritas – Germanischer Lloyd
ECR - Engine control room
EEBD - Emergency escape breathing device
EOOW - Engineer officer of the watch
GMT - Greenwich mean time
HFO - Heavy fuel oil
HP - High Pressure
kW - Kilowatt
LP - Low Pressure
LPI, Inc - Lucius Pitkin Incorporated
m - Metre
m3 - Cubic Metre
MARPOL - International Convention for the Prevention of Pollution from
Ships
MGO - Marine Gas Oil
MSC/Circ - Maritime Safety Committee circular
NM - Nautical mile
Nm - Newton Metre
OOW - Officer of the watch
QCV - Quick Closing Valves
SECA - Sulphur Emission Control Area
THE BAHAMAS MARITIME AUTHORITY
SOLAS - International Convention for the Safety of Life at Sea 1974, as
amended
STCW - International Convention for the Standards of Training,
Certification and Watchkeeping for Seafarers 1978, as amended
UHF - Ultra High Frequency
UTC - Universal co-ordinated time
VDR - Voyage Data Recorder
***
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2 SUMMARY
2.1 At 0752 on 22nd October 2015 the Royal Caribbean Cruise Limited vessel
Splendour of the Seas suffered a machinery space fire on diesel generator
number 1 (DG1) in the forward engine room. When the fire broke out the vessel
was on passage from the Greek ports of Mykonos to Argostoli. Due to the
consequences of the fire the vessel diverted directly to Venice under its own
power generated using the aft engine room propulsion units only.
2.2 A few minutes prior to the fire occurring, a large fuel leak was observed from
the hot box on DG1 at the forward, outboard drive end of the engine. DG1 is
located on the starboard side of the forward engine room. There were two
generators in use at the time each operating at 80% load.
2.3 The leakage of fuel was observed to be flowing through gaps of the hot box
covers. Fuel was also spraying onto the rocker covers and was impinging on the
engine exhaust manifold cladding. When the leaking fuel vapours ignited, heat
was intense and smoke propagation was rapid and dense. The engine had been
stopped from the Engine Control Room (ECR), 40 seconds prior to the ignition.
2.4 Within 10 seconds of the fire starting there was an attempted simultaneous
release from the ECR of fixed firefighting installations Ultrafog and flexi fog.
The Ultrafog system, however, did not function due to fire-damaged cables.
CO2 was not deployed. During the firefighting procedures, the tank tops were
smothered with foam from the fixed foam eductor system.
2.5 Code Bravo1 was initiated by the 2nd engineer in charge of the 0400 to 0800
watch resulting in the fire parties mustering at their designated locations. The
initial control point was in the provision area on deck 1 working alleyway (I-
952). This was changed due to the development of smoke to the forward end of
the working alleyway, adjacent to the table tennis area. Finally, the location was
changed to the forward passenger stair landing on deck 2.
2.6 A total of 12 crewmembers were trapped in three workshops on deck 0 in the
forward engine room during the course of the incident. These workshops are
located as follows: mechanical workshop (port side deck 0), electrical workshop
(starboard side forward deck 0) and deck workshop (starboard side aft deck 0).
The electrical workshop is directly adjacent to the seat of the fire. The crew
could not escape due to the intense heat and heavy smoke generated by the fire
and remained trapped inside the respective compartments. Later they all
managed to escape and suffered minor smoke inhalation in the process.
1 Code Bravo is announced over the public-address system to indicate to all crew the presence of a fire
onboard. 2 Colloquial term used to describe the main service corridor running through the vessel forward to aft,
accessible to crew only, named after a large interstate (highway) in the United States of America.
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2.7 Inspection revealed that number 2A fuel pump forward outboard stud was
sheared and that the forward inboard nut was not in place but laying at the
bottom of the hot box. The stud was found to be sheared flush at the engine
frame. Both aft fuel pump securing nuts were in place and secure. The 2A fuel
pump LP fuel supply and return manifold was partially open at the forward end
with an open gap of 2mm. Three manifold securing bolts were sheared and lying
at the bottom of the hot box. The aft lower bolt was in place and secure. The
source of the fuel leak was from the open gap created by the bolts shearing on
the Low Pressure (LP) manifold flange.
2.8 Of the 2626 passengers and crew onboard there were no injuries with the
exception of 25 crew and 2 passengers who were treated for minor smoke
inhalation. The Master determined that it was not necessary to transition to
emergency stations however it did become necessary to activate the crew
responsible for evacuation and crowd management in order to evacuate
passengers and crew from the affected areas as efficiently as possible.
***
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3 DETAILS OF INVOLVED VESSEL(S) AND OTHER MATTERS
3.1 The vessel was constructed in 1996 in the Chantier De L’Atlantique Shipyard,
France and at the time of the incident, was under classification with Det Norske
Veritas - Germanischer Lloyd (DNV-GL). The vessel was owned by Splendour
of the Seas Inc. and operated by Royal Caribbean Cruises Limited. The
following principal particulars were noted:
Official Number 9000121
IMO Number 9070632
Call Sign C6TZ9
Built Chantier De L’Atlantique, St Nazaire, France,
1996
Length Overall 264.26 metre
Breadth 32.00 metre
Draught 7.9 metre
Tonnage 69472 (Gross)
Tonnage 37971 (Net)
Class Entry Passenger Ship
Class Notation DNV +1A1
Propulsion 5 x Wartsila 12V46B, 2 x 21.1 MW propulsion
motors (Diesel Electric)
Brake Shaft Power 58500.00 kW
Complement3 46 (Condition 1)
128 (Condition 2)
Capacity 2,074 passengers, 720 crew
3 Condition 1 is for when the ship operates with no passengers onboard
Condition 2 is for when the ship operates with full complement of passengers onboard.
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Figure 1: Splendour of the Seas general arrangement plan (GA plan of double bottom, tank top, deck 0 and
starboard aspect)
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3.2 The vessel is powered by five diesel-electric engines driving five generators
powering twin fixed pitch propellers at 11,700kW each. Main propulsion is
suplemented by 2 bow thrusters of 1,500kW each and a 1,700kW stern thruster.
3.3 At the time of the incident the vessel was classed with Det Norske Veritas –
Germanischer Lloyd (DNV-GL) and all statutory certificates remained valid.
3.4 All crew carried appropriate documentation as required by the Standards of
Training, Certification and Watchkeeping (STCW). All document holders had
the necessary endorsements provided by the Commonwealth of the Bahamas
and complied with the vessel’s Safe Manning Document.
3.5 The vessel’s fire detection and extinguishing system met the required standards
under the International Convention for the Safety of Life at Sea (SOLAS)
requirements.
3.6 In June 2016 the vessel was sold to Thomson Cruises and renamed the m.v Tui
Discovery. At the same time the vessel changed registration to the flag State of
Malta.
***
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4 NARRATIVE OF EVENTS
4.1 On the 22nd October 2015 the Splendour of the Seas was on passage from
Mykonos to Argostoli in Greece. The vessel departed Mykonos the previous
day at 1529(GMT +3). At the time of the incident the vessel was in position
37˚19´N 20˚50´E on a heading of 325° at a speed of 15 knots with a scheduled
arrival in Argostoli at noon on the 23rd October. The vessel was operating in
Universal Co-ordinated Time (UTC+3) and all references are based upon this
time zone.
4.2 There were two generators in use, DG1 in the forward engine room and DG3
in the aft engine room, each operating at 80% load.
4.3 At 0750 the 1st Electrical Engineer observed a significant fuel leak on DG1 in
the forward engine room. He reported the leakage by phone, located in the
electrical workshop, to the 2nd Engineer on watch in the ECR. The 1st
Electrical Engineer then continued his duties and remained in the electrical
workshop. The 3rd Engineer on watch was instructed to inspect the reported
fuel leak whilst the bridge were informed to decrease speed in order to reduce
engine load by the 2nd Engineer. The fuel leak was described by the 3rd
Engineer as “being like a waterfall flowing from open gaps on the hot box”.
At this point DG2 was prepared for starting. Shortly after an alarm was
registered in the ECR stating the following: [DG1 A BANK FO HP PIPE
LEAKAGE] followed by [DG1 FO INLET LOW PRESSURE] and the stand
by [FO/DO BOOSTER PUMP STARTING]. The bilge alarm for the
[FORWARD ENGINE ROOM STBD AFT BILGE WELL] also activated just
prior to the fuel leakage alarm. The bilge wells are quite small and the high
volume of fuel leaking down the side of the engine to the bilge could account
for this alarm.
4.4 CCTV footage shows fuel spraying in the area between the rocker covers on
unit’s 2A and 3A (see figure 8). The 1st Engineer along with the 3rd Engineer
on watch observed the fuel leak which was leaking heavily out of the hot box
running down the side of the engine to the bilge and instructed the 2nd
Engineer on watch in the ECR to stop the engine immediately. There is no
engine emergency stop located on deck 0; it is located on the local engine
control panel at the drive end of the engine. A fire hose was prepared and laid
out by the 1st Engineer but not charged or used.
4.5 The engine emergency stop button in the ECR was activated and the engine
shut down. The vessel’s power was maintained by DG3 from the aft engine
room. The Officer of the Watch (OOW) was aware that there was only one
generator on load and when his assistant asked him if he should call the Master
he answered “No”, for reasons not determined during the course of the
investigation. The Chief Engineer who was in the technical office adjacent to
the ECR heard the noise of the engine turbo chargers surging caused by
emergency stopping and immediately attended the ECR.
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4.6 Approximately 40 seconds after the engine had been shutdown with the
emergency stop, a fire erupted at 0752 in vicinity of the hot box between
cylinders A2 and A3. Immediately the fixed installation systems were released
however it was later determined that only the Heien-Larssen flexi fog system
activated. The Ultrafog system had a fault due to a fire-damaged cable and did
not deploy.
4.7 Dense smoke generation was rapid and was observed to encompass the
complete engine room within 15 seconds. DG2, which had now started, was
shut down by the emergency stop in the ECR by the Chief Engineer.
4.8 Code Bravo was announced at 0753 from the bridge and fire teams assembled
shortly after. Only three fire teams could be assembled due to the number of
technical crew, made up of firefighters in the event of an emergency, who were
trapped within the workshops located in forward engine room.
4.9 Fuel continued to leak heavily after the emergency stopping of the engine as
the quick closing fuel valves (QCV) had not been closed and the fuel booster
pumps continued to run until 0755, at which point the Staff Chief on attending
the ECR closed the QCV on the ECR panel. The fuel feeder pumps were
stopped at 0758.
4.10 The 1st Electrical Engineer who was the first person to report the fuel leak was
trapped in the electrical workshop with the Engine Foreman. He heard the
noise of a turbo charger barking which would have been the engine shutting
down by the emergency stop. This was followed approximately 1 minute later
with the sound of gushing water, which was the flexi fog being released. When
an attempt to open the workshop door was made the fire was raging outside
preventing their escape. After which smoke entered the workshop through the
vent duct. The vent flap was then closed followed by another attempt to open
the workshop door where there was now thick black smoke but no fire. There
was one EEBD in the electrical workshop but it was reported that the operating
instructions were not easily identified. After an estimated 20 minutes both
crew members wet their overalls with cold water and ran together through the
thick smoke to the working alleyway. They reported to the Environmental
Officer that they had escaped from the electrical workshop prior to making
their way to their respective emergency stations.
4.11 Fire teams equipped with fire suits and breathing apparatus accessed the
forward engine room to fight the fire and commenced boundary cooling. The
activation of the fixed firefighting installation system significantly reduced
further fire precipitation after the initial flare up. The lower level and the tank
top bilges were also on fire and the fixed foam system was activated. The flexi
fog and fixed foam was stopped at some undetermined stage of the
proceedings.
4.12 Initially 12 crewmembers were trapped in the three workshops due to the
intense heat and dense acrid smoke generated by the fire. Once alarms were
activated escape from the workshops located on deck 0 in the forward engine
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room was not possible due to the rapid development of heat and smoke. There
were 2 crew in the electrical workshop who were able to escape, however, 3
crew in the mechanical workshop and 7 crew in the deck workshop remained
stranded in these locations for over 1 hour from the start of the fire. The 3 crew
in the mechanical workshop were the last to escape at 0910 assisted by one of
the fire teams who had a charged fire hose arranged for waterwall protection.
The trapped crew suffered from minor smoke inhalation and were treated on
board in the medical centre. In accordance with the fire control plan there is
only one Emergency Escape Breathing Device (EEBD)4 located in each
workshop.
4.13 The Master made an announcement over the public-address system at 0824
providing an update on the progress of the emergency situation stating that the
fire was under control. He also stated that they were currently dealing with
smoke extraction. This was subsequently broadcast in German, French and
Italian.
4.14 At 0832 the fire was confirmed as being extinguished.
4.15 A decision was made by the Master that due to the fire being contained within
the forward engine room that it was not necessary to activate the ship’s
emergency signal.
4.16 At 0841 smoke eventually spread into crew and passenger accommodation on
decks 1, 2, 3 and 4 necessitating the evacuation of the affected areas by the
evacuation control team.
4.17 At 0851 the fire was reported to have re-established itself. The flexi fog and
fixed foam application activated again. The fire was reported as being
extinguished for the second time at 0931.
4.18 At 1114 the fire teams were instructed to search for hot spots before being
stood down at 1200.
4.19 The vessel aborted the scheduled call to Argostoli and diverted to the port of
Venice using the aft engine room propulsion units only and arrived at 0600 on
Saturday 24th October.
4.20 The appointed Bahamas Maritime Authority marine safety investigator
attended on the vessel’s arrival in Venice and remained on board until the
vessel sailed shortly after 1800. Two DNV-GL surveyors and Port State
Control Inspectors from the Venice station and a salvage surveyor from
Piraeus, RCCL management, technical and safety superintendent were also in
attendance. The technical and safety superintendent sailed with the vessel and
remained on board for the next two cruises.
***
4 EEBDs are designed to provide a minimum of 10-minute supply of air to allow persons time to
escape from compartments.
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5 ANALYSIS AND DISCUSSION
5.1 The marine safety investigation was conducted simultaneously to three other
investigations, namely; mechanical investigation conducted by Wärtsilä the
manufacturer of the engines, material failure specialists Lucius Pitkin Inc.
(LPI, Inc.) 5 instructed on behalf of the Owners to conduct material testing of
the studs and bolts, and the Owners internal investigative team to determine
how the vessel responded overall to the emergency. The analysis conducted
and outlined below benefits from the three independent investigations
conducted acknowledging the source where necessary.
FAILURE MECHANISM
5.2 The fire occurred on the engine as a result of a leaking flange from the high
pressure (HP) fuel oil injection pump supplying cylinder A2, of DG1.
5.3 The fuel oil injection pump attached to the A2 cylinder is retained in place by
4, M24 studs. The manufacturer highly recommends that the 4 studs are pre-
tightened to the final torque of 460Nm in steps of 100Nm6. During the course
of the investigation it was determined that the 4 studs were not pre-tightened
in accordance with document 4610T002 (provided at Annex II) resulting in
the fracture of one stud and as a consequence of increased tension, a second
stud also failed. Once two of the four studs had failed, the injection pump
started to move up and down due to the injection tappet force. As a
consequence, the fuel inlet/return flange screws yielded and the flange started
to leak.
5.4 Analysis undertaken by Lucius Pitkin Inc. (LPI, Inc.) who are independent
material failure specialists determined the following: “injector pump stud 1
failed in the nature of medium to high cycle fatigue as a result of improper
preloading during installation. A fatigue crack initiated at the thread root of
the stud under the influence of cyclic loading at stress levels greater than the
stud’s material fatigue threshold”. The detailed analysis identified the forward
outboard stud was not tensioned sufficiently. The forward inboard stud failed
as a result of subsequent overloading. It was also determined that the stud
specification was in accordance with the designated material requirements and
that the studs had not been over-tensioned.
5 Lucius Pitkin Incorporated specialise in advanced analysis and fitness for service testing, failure of
materials evaluation and non-destructive engineering. 6 Wartsila Technical Bulletin Document 4610T002 Injection Pump Foot Studs (appendix II)
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Figure 2: Fuel pump indicating forward studs, inboard nut had unscrewed (1) and stud had sheared flush (2)
with engine frame. Outboard nut (not visual) had sheared flush with fuel pump flange. Circled (3) indicates fuel manifold flange and source of fuel leak through 2mm gap between flanges.
Figure 3: Three manifold flange broken bolts (3) and two fuel pump stud nuts (2, 1) found loose in hot box
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HOT BOX
5.5 A hot box is designed to contain any fuel leakage within the hot box in order
to avoid fuel in liquid form or fuel vapor coming into contact with a hot
surface. Within the hot box there are splash guard liners which create a
physical barrier between the exhaust manifold and the cylinder liners.
Figure 4: Site survey conducted on 5th November 2015 on DG2 hotbox cover plates indicating (circled) gaps
between the plates – see figure 6 for post incident damage of the same location (4).
5.6 The hot box cover plates which provide additional containment protection
from a fuel leak and are designed to keep unexpected fuel leakage contained
within the hot box to ensure protection against fuel spraying onto the exhaust
manifold. The overall poor condition of the hot box cover plates was
confirmed by a survey conducted by Wärtsilä on the 5th November 2015 and
summarized the condition of the hot box covers as follows: “quite bad
condition and evidently original ones from 1994”. Figure 4 only identifies a
number of air gaps in one location, the survey identified that the condition
depicted above was common throughout the hot box cover plates on all five
engines.
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Figure 5: A gap (circled) in the exhaust and scavenge pipework insulation cladding is a probable source of heat
resulting in ignition
Figure 6: Condition of DG1 hot box plates (4) and hot box A2 (5) post incident
CAUSE OF THE FIRE
5.7 The fire started 40 seconds after the engine had been stopped from the ECR.
The exact source of ignition could not be determined however there are two
probable causes which could be considered as the source of ignition.
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5.8 The flow of leaking fuel from the open low-pressure manifold flange was
reported as being extremely heavy. The manifold fuel pressure is maintained
at 8 bar and a fuel temperature of +/-118ºC when operating on IF380 fuel oil.
The alarm list showed a pressure drop caused by the leaking flange which in
turn prompted the stand by booster pump to start automatically. Significant
amounts of fuel continued therefore to leak from the flange and fill the
surrounding area of A2 both inside and outside the hot box.
5.9 The fuel leakage continued for approximately 5 minutes until the engine fuel
quick closing valves were operated from the remote valve control panel in the
ECR. As a result, leakage continued for another 2 to 3 minutes after the engine
was stopped.
Figure 7: Picture taken two minutes prior to ignition, indicating diesel generators emergency closing of fuel oil valves
5.10 The hot box covers between A2 and A3 cylinders had an air gap which
prevented the hot box from shielding any inadvertent spray and thus rendering
the hot box ineffective. The fuel therefore was able to exit out of the hot box
and potentially reach the exhaust manifold insulation. The source of the
ignition cannot be categorically determined however evidence suggests that an
opening in the exhaust insulation cladding exposing a source of heat from the
exhaust manifold sufficient enough to ignite fuel vapors could be considered
a likely event. Alternatively, fuel vapours leaked from the damaged fuel
injection pump may have ignited on a hotspot generated by friction as a
consequence of the fastening stud failures of the fuel injection pump causing
a sudden explosion within the hot box.
5.11 CCTV footage shows fuel oil spraying from the closing gap on the hot box
cover and impinging on the rocker cover on unit 3A and the exhaust manifold
cladding.
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Figure 8: Fuel oil spraying from the closing gap on the hot box between A2 and A3 cylinders (circled in red) and
coming into contact with the exhaust manifold
5.12 The following sequence of synchronised images from the CCTV recordings
shows the development of the fire for the first 15 seconds. The perspective
from two camera locations represents the rate and extent of fire and smoke
development.
Camera: View fwd of DG1 Camera: View aft of DG2
At the point of ignition the fuel vapours ignited spontaneously
Within one second the intensity reduced momentarily until the liquid heavy fuel ignited
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Two seconds after the initial ignition of vapours the fuel fire has become established
Ten seconds after intial ignition the flexi-fog was released to combat the fire
Fifteen seconds after the initial ignition the forward camera lens has melted, aft camera shows the rapid
generation of acrid smoke across the engine room
5.13 As indicated in the above CCTV frames, the fire erupted and spread both
vertically and horizontally away from DG1, generating thick acrid smoke in
under 15 seconds. The heat generated was so intense the camera looking
forward of DG1 disintegrated. The frame taken at 04:54:39 shows a
dampening effect of the fire, this is believed to be the point where the flexi fog
initiated to combat the effect of the fire by reducing the available oxygen and
flammable vapours.
INSPECTION AND MAINTENANCE
5.14 Wärtsilä attended the vessel from the 31st October until the 6th November to
assess the fire damage to the engine. Their attending technician confirmed that
the fuel pump studs in use were in compliance with the Wärtsilä technical
bulletin 4610T002 issued on the 20th August 2001 (see appendix II). The studs
in place at the time of the incident were the original studs supplied by the
manufacturer of the engine. However, in 2002 the technical bulletin highly
recommended to upgrade the original studs with a later version which had been
modified to the extent where the strength class of 8.8, had been replaced with
a special design, which incorporates better material, rolled threads and zinc
coating (see figure 9). Both versions can still be used without restrictions
however the manufacturer advised to inspect and even exchange the existing
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studs which had been in place for approximately 13 years. The owner placed
an order for 240 replacement fuel pump studs and nuts which were delivered
to the vessel in November 2002 however it is not known the extent to which
the manufacturer’s recommendation had been complied with.
Figure 9: The original stud (top) and the new replacement (below)
5.15 The service history for the engine shows that seven fuel pump maintenance
activities requiring pump removal had occurred since the original studs were
installed in February 2004. Six of these maintenance activities were planned
and one in 2007 was unplanned. The last maintenance activity requiring pump
removal was carried out by the RCCL in house diesel maintenance team
(DMT) in March 2015. The engine running hours when this maintenance was
carried out was 89104 hrs; therefore, the fuel pump and studs have remained
undisturbed for 3179 running hours.
5.16 The fuel injector from unit 2A was removed from the engine to check its
operation post incident. The nozzle opening pressure was 340 bar and the spray
pattern was good. The design operating pressure is 460 bar, however a
reduction of 25% over the service period is not unusual. Checking the injector
break point is important to ensure that no excessive loadings have been
imposed upon the fuel pump studs due to a high opening pressure or restricted
injector nozzle.
5.17 The engine was operating on IF380 fuel oil whilst at sea and ultra-low sulphur
marine gas oil in EU ports. IF380 fuel oil needs to be heated to approximately
120ºC to maintain viscosity at +/-15 centistokes. The viscometer had been
changed over to manual temperature control as the viscosity measurement and
control had malfunctioned. A low fuel temperature will cause a significant
increase in viscosity when operating on heavy fuel, which will subsequently
increase the mechanical loading on the fuel pump and studs. According to
engine operating hours, engine number 1 has significantly more operating
hours than the other engines by 20-30%. This indicates that the engine number
1 is frequently used as the first engine of choice. When operating in EU ports
and in Sulphur Emission Control Areas (SECA) in accordance with
International Convention for the Prevention of Pollution from Ships
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(MARPOL) Annex VI7, fuel will be frequently changed over from HFO to
MGO and vice versa. Without the viscometer in operation it is difficult to
predict the temperature change required during the changeover period. The
fuel temperature had been consistent at 118ºC prior to the incident and
therefore can be discounted as a potential contributory factor.
EMERGENCY PROCEDURES
FIREFIGHTING EFFORT:
5.18 Members of the fire team responded quickly to the Code Bravo announcement,
mustering in accordance with the pre-planned response to a fire located within
the forward engine room.
5.19 A total of 12 technical crew members were trapped within the various
workshops surrounding the seat of the fire (see figure 11) with no means of
escape. The trapped crew reported their predicament to the bridge and engine
control room by phone however it was not fully determined until after the
rescue how many of the crew were trapped. The fire occurred at the start of
the working day at a point where more crew congregated within their
respective workshops in general, compared to any other time of the day. Each
workshop was provided with one EEBD which provided 10 minutes of
breathing air sufficient to enable escape for one crew member only. A sink
dispensing fresh water was also available in each workshop. These two items
provided some level of extra protection.
Seven crew were trapped within the deck workshop who at the time were
conducting repairs to pipework within the space. All seven crew managed to
escape with the help of the arrival of the first fire team. With seven crew
located within the space and only one EEBD, the trapped crew had limited
options but to wait until the arrival of the fire team before making a successful
escape.
5.20 The 3 crew trapped in the mechanical workshop were the last to escape at
0910. Ventilation fans were configured in an attempt to reduce the smoke
ingress to the compartment. Due to the excessive smoke in the workshop the
trapped persons made their way into the adjacent air handling room to try and
escape the smoke that had now propagated into the workshop. After just over
1 hour a fire team approached the workshop and guided them to safety behind
a water wall fire hose. Only one EEBD was installed within the compartment,
the trapped crew relied on respirator masks with filters and wet towels which
provided sufficient protection to make a safe evacuation.
5.21 SOLAS Chapter II-2, Regulation 13 (Means of Escape) does not specify the
requirement to provide adequate means of escape specifically from a
7 Regulations for the prevention of air pollution from ships.
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workshop within a machinery space8. Had a means of escape been provided
within each workshop located within the machinery space, the crew located
within each space would have been able to make their own means of escape
without placing themselves or the firefighters conducting the rescue in
potential danger. Additionally, had adequate fire protection apparatus been
provided such as firefighting suits, breathing apparatus, EEBD’s (in sufficient
quantity for the number of personnel within the space) the risk of exposure to
those trapped may have been reduced.
5.22 In accordance with MSC/Circ.8499 ‘unless personnel are individually
carrying EEBDs, consideration should be given for placing such devices along
the escape routes within the machinery spaces or at the foot of each escape
ladder within the space. In addition, control spaces and workshops located
within the machinery spaces should also be considered for the possible
location of such devices’. Consideration was given as demonstrated with one
EEBD being provided within each workshop, however what was not taken into
consideration was the quantity that may be required in the event of such a
scenario.
Figure 10: Entrance to fan room in the mechanical workshop
8 Regulation 13 was amended by Resolution MSC.365(93) adopted in May 2014. Paragraph 4.1.6 states:
‘For ships constructed on or after 01 January 2016, two means of escape shall be provided from the
main workshop within a machinery space. At least one of these routes shall provide a continuous fire
shelter to a safe position outside the machinery space.’ 9 Guidelines for the performance, location, use and care of emergency escape breathing devices (EEBDs)
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Figure 11: Location of the crew trapped in workshops of deck 0 in proximity to the fire (circled): Mechanical
workshop (1) 3 crew trapped, Electrical workshop (2) 2 crew trapped, Deck workshop (3) 7 crew trapped and 1st Engineers office (4)
5.23 The fuel leak was identified by the 1st Electrical Engineer whilst conducting
routine daily work enroute to the electrical workshop. Initial reaction required
reporting the leak to the Engineer on Watch (EOOW) whose actions involved
calling the 3rd Engineer to confirm visually and to call the 1st Engineer advising
intentions to start DG2. Ninety seconds later the EOOW was ordered to shut
down DG1 and commence preparations to start DG2.
Figure 12: Entrance to electrical workshop
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5.24 Due to the delay in shutting down DG1, fuel continued to accumulate in
vicinity of DG1 which, once ignited, resulted in a flash explosion. From the
time the fuel leak can be seen on CCTV, to visual confirmation, reporting, and
the shutting down of DG1 prior to the activation of the water suppression
system (flexi fog) almost 2 minutes had passed. The immediate activation of
the flexi fog system upon notification of the leak may have prevented the fire
from occurring or as a minimum reduced the presence of fuel vapour in the
vicinity.
5.25 Both the 3rd Engineer and the 1st Engineer were in the forward engine room
before the fire occurred and confirmed the leak on DG1 visually. Both
Engineers at this point could have shut down the engine locally rather than
notifying the Engineer on watch had the local control been in an accessible
location. The location of the local emergency stop of the engines does not
allow for quick access as it is located at the end of an elevated platform
between the tank top and deck 0, inaccessible from either deck.
Figure 13: DG1 local control panel and emergency stop
5.26 The fixed foam system was activated twice in order to smother burning fuel
on the tank top. It is estimated that 150m3 of liquid accumulated in the bilges
during the course of the emergency.
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Figure 14: Fixed foam installation situated on deck 1 (left) and oil mark showing level of oilly water reached in the bilge as a result of the firefighting effort.
5.27 The vessel is fitted with four fixed firefighting applications, CO2, flexi fog,
Ultrafog and fixed foam. The Master decided CO2 was not deemed necessary,
a decision based on the severity of the fire and the speed in which it was
extinguished and the fact that 12 crew where trapped within technical spaces
inside the machinery space. Flexi fog operated successfully and provided the
primary means of containing and extinguishing the fire.
5.28 The third firefighting application, Ultrafog was retro-fitted on board in 2014.
It was determined after the fire that the system had not operated as designed.
Class had attended on the 26th November 2014 and approved the installation
of the system and that it was in accordance with the approved drawings
however at the time of the fire the system had not been commissioned. The
Ultrafog is an additional water mist system fitted in addition to and not in place
of flexi fog. It was determined that the fire had damaged the control cables of
the Ultrafog system preventing it from operating as designed. The control
cables pass through the machinery space and within 2 meters of DG1 which is
in contravention to SOLAS Chapter II-2, Regulation 1010 which states:
‘Pumps, other than those serving the fire main, required for the provision of
water for fire-extinguishing systems required by this chapter, their sources of
power and their controls shall be installed outside the space or spaces
protected by such systems and shall be so arranged that a fire in the space or
spaces protected will not put any such system out of action.’ It cannot be
determined whether this addition fixed application system, had it operated as
designed would have impacted the time taken to extinguish the fire. It could
be considered however that it would have only aided the situation, in all
likelihood reduced the severity of the fire and reduced the time taken to rescue
the trapped crew.
TRAINING
10 Chapter II-2, Regulation 10 Part C Suppression of fire
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THE BAHAMAS MARITIME AUTHORITY
5.28 The last fire drill conducted in the forward engine room was in May 2014,
approximately 18 months prior to the fire. The following drills had been
carried out in technical spaces over the preceding 2 months:
7th September 2015 – Engine control room
3rd September 2015 – Incinerator room
23rd August 2015 – Switchboard room
20th August 2015 – Port separator room
5.29 Despite no drills taking place within the forward engine room since May 2014,
the three fire teams demonstrated a sufficient knowledge and familiarity of
equipment and layout of the space to provide an effective means of protection
during crew evacuation from the technical workshops. This is likely to be
testament of the training delivered on board and professionalism of the
firefighting team members.
SMOKE CONTAINMENT
5.30 The original forward control point was selected in vicinity of I-95 provision
area. As smoke migrated outside of the forward engine room the forward
control area was moved further forward to the end of I-95 before being finally
relocated to the forward guest staircase on deck 2. The decision to relocate the
forward control point was made out of necessity in order to maintain the
function of the forward control point. It proved increasingly difficult to contain
the smoke in the forward engine room as the fire doors remained open to allow
access to the fire teams whilst transiting into and out of the machinery space.
In addition, with 12 crew members trapped within the technical workshops,
ventilation could not be crash stopped. This maintained a positive air pressure
within the machinery space ultimately forcing the smoke outside the space. As
smoke spread throughout the forward section of I-95 and into passenger cabins
on decks 2 and 3 the Command initiated a full evacuation of all cabins on deck
1, 2, 3 and 4.
5.31 The Environmental Officer stated that watertight doors located on I-95 were
closed approximately 10 minutes after the fire started. The accuracy of this
statement cannot be corroborated by the bridge log as there is no record of any
fire or watertight doors being closed remotely from the bridge. All fire and
watertight doors can be closed locally however this does take longer than
closing remotely and as such allows more time for smoke to migrate without
obstruction.
COMMAND AND CONTROL
5.32 The Voyage Data Recorder (VDR) recording on the bridge confirms that the
Master was not informed in the first instance of a fuel leak on DG1 or that the
ECR had requested to shutdown DG1 despite the requirement existing with
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the Captain’s Standing Orders and vessel’s SMS fire procedures. This
ultimately delayed the amount of time the Master had to react to the developing
situation.
5.33 It was clear to those crew members responsible for evacuation and crowd
management that it would only be a matter of time before the emergency signal
would be given and they would be required to not only control the evacuation
of crew and passengers from the affected area (decks 1,2,3 and 4 cabins within
affected fire zone), but to initiate the whole ship emergency evacuation plan.
The emergency signal was not sounded which is a deviation from the vessel’s
SMS, this caused significant confusion for passengers and crew alike who
were being informed to evacuate the affected area and muster at their
respective assembly stations by the evacuation control team. There are no
procedures in place to aid the evacuation control team when attempting to
muster only a proportion of crew and passengers from the affected area. A
controlled muster was hampered further when those passengers and crew went
to their respective assembly stations only to find passengers and crew not
affected by the emergency enjoying the facilities provided for during normal
cruising.
***
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6 CONCLUSIONS
6.1 The primary causal factor which resulted in a fire was the failure of the fuel
pump securing stud, which had not been tensioned correctly during fuel pump
maintenance procedures. The development of this failure could have been
prevented if a follow up procedure was adopted in accordance with the
manufacturers recommended practices which required re-tensioning after
initial fitting and operation of the fuel pump. Had this procedure been in place
the under tensioned stud is likely to have been identified and corrective action
taken to rectify by applying the correct torque of 460Nm.
6.2 The independent survey conducted of the hot box covers confirmed their poor
condition and identified several locations where full containment could not be
achieved. If the hot box covers had been in a condition deemed ‘fit for purpose’
it could be considered highly likely that any fuel leak could be contained
preventing the fuel coming into contact with the exhaust manifold, the only
known heat source. As the source of ignition point cannot be categorically
determined, the catalyst for igniting the fuel may have come from another
source within the vicinity of the fuel pump on A2 cylinder.
6.3 With the frequent need to change fuel grades from heavy fuel to ultra-low
sulphur MGO, the importance of having viscosity control equipment in a
serviceable condition cannot be over emphasised. Running an engine on heavy
fuel with a low fuel temperature significantly increases fuel pump loading,
which is imparted to the securing studs.
6.4 The rapid deployment of the flexi fog system upon discovering the fire stopped
any further development of the fire and reduced the scale of damage sustained
to the forward engine room. Had the flexi fog system been deployed
immediately upon discovering the fuel leak, the probability of ignition would
have been significantly reduced.
6.5 The engine quick closing valves remained open after the engine had been shut
down. The valves are activated independently from the shut down on the
engine. Therefore in order to stop the fuel supply, regardless of the operational
status of the engine, the fuel quick closing valves must be activated. The
delayed response in activating the valves increased the severity of the fire and
the subsequent damage sustained to the forward engine room.
6.6 The location of the engine local emergency stop prevented the operator from
shutting down the engine quickly due to the location of the local control panel.
Although the engine was shut down prior to the fire, as the exact source of
ignition remains unknown, it cannot be determined what impact the delay in
shutting the engine down had moments before ignition.
6.7 When a problem is reported to the engineer in the ECR there are inevitable
delays while appropriate permissions are requested to adjust the machinery
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configuration. The engineer in the ECR advised the Officer of the Watch of
the need to reduce speed due to a mechanical fault with DG1. Procedures are
in place before taking power and ultimately speed away from the bridge in
order that navigational safety can be maintained. However, the EOOW should
communicate the severity of the situation which unless acted on, may result in
catastrophic loss of equipment. Although permission was granted to shut down
DG1, a sense of urgency was not conveyed which may explain why the Master
was not notified immediately.
6.8 An appropriate level of consideration was not given to the safety of crew
working within technical spaces within the forward engine room. The
Splendour of the Seas was not required to provide a means of escape from
these workshops, however, a risk assessment should have identified that in the
event of an engine room fire within the machinery space, adequate safety
equipment should be provided to enable an escape for the total capacity of
persons permitted within each space and reflected on the fire control plan.
Adequate training should be provided on the provision of this equipment. It
was reported that although an insufficient number of EEBD’s were available
for the number of individuals trapped, those that did utilise the EEBD were
not able to get them to work as designed. It is not known whether this was
through inadequate training and understanding of equipment or the EEBD was
faulty. Additionally, it remains unknown whether routine escape drills for
crew members working in the forward engine room were accomplished
regularly.
6.9 Machinery space fire drills were conducted regularly in all but the forward
engine room. Fire drills are designed to not only improve the skills, knowledge
and confidence of the fire teams but also improve the skills required to control,
coordinate and communicate up and down the emergency organisational
structure. The lack of a drill within the forward machinery space may have
contributed to the slow reaction in conducting an immediate emergency
procedure in the event of an engine fire, closing of the quick closing valves.
Closing of the fuel quick closing valves should be second nature, to achieve
this, procedures must be rehearsed robustly.
6.10 The failure to close fire and watertight doors early in the emergency allowed
significant smoke propagation to decks 1, 2, 3 and 4, influencing the location
of the forward control point and increasing demand on the already reduced fire
teams. Further, had the fire spread, it would have become increasingly more
difficult and demanding on the emergency organisation to contain the spread
of the fire.
6.11 In general, the actions of the crew and the tenacity displayed, particularly by
the fire team members in responding to this incident should be commended.
***
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7 RECOMMENDATIONS
Recommendations for the operator11:
7.1 Ensure adherence to manufacturer’s technical bulletin No. 4610T002
specifically in relation to the replacement and tensioning of fuel pump studs.
7.2 Ensure all engine hot box covers are renewed or repaired so that no seal joint
gaps exist.
7.3 Consider installing additional engine emergency stop switches at a suitable
and accessible location.
7.4 Consider scheduling a thermo-graphic survey on all vessels throughout the
fleet to identify any exposed areas where the temperature exceeds 220ºC and
implement a rectification programme as necessary.
7.5 Consider a fleet wide review of emergency escape equipment in sufficient
numbers in all workshops and offices within engine rooms. Provide enhanced
training on the correct operation of emergency equipment in accordance with
SOLAS II/2 Regulation 15 paragraph 2.2.2.
7.6 Consider fleet wide review for the allocation and frequency of emergency fire
and escape drills for crew members onboard.
7.7 Consider implementing a prudent safety enhancement to incorporate the
operation of the quick closing fuel valves with the engine emergency stop
function.
***
11 Recognising that the vessel is no longer operated by Royal Caribbean Cruise Lines some of the
recommendations are directed towards the fleet of existing vessels operated by RCCL.
Recommendations in general are for the benefit of all vessel to incorporate as deemed necessary.
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LIST OF APPENDICES
I. Wärtsilä Site Survey Conclusions and Recommendations
II. Wärtsilä technical bulletin 4610T002
III. Lucius Pitkin LPI, Inc. Evaluation of Failed Fasteners Conclusions
and Recommendations
***
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Appendix I: Wärtsilä Site Survey Conclusions and Recommendations
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Appendix II: Wärtsilä technical bulletin 4610T002
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Appendix III: Lucius Pitkin LPI, Inc. Evaluation of Failed Fasteners Conclusions and
Recommendations
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