Repairing Fuel Pipe with Fuel Under Pressure Kills Crew

Summary

This reports the MAIB’s investigation into a fire in the engine room of the dredger Arco Avon while the vessel was loading a sand cargo approximately 12 miles off Great Yarmouth, UK. The fire claimed the life of the vessel’s third engineer, who was attempting to repair a failed fuel pipe when fuel, under pressure in the pipe, ignited.

Statement from the Chief Inspector of Marine Accidents

The sad death of an experienced officer serving on a UK registered ship serves as a salient reminder of the risks that crews can be exposed to when policies and procedures designed to mitigate such risks are not followed, and recognised safe systems of work are allowed to lapse. Robust risk assessments and safe systems of work are important barriers that prevent marine accidents. Everyone, from the individual seafarer to the senior company executive ashore, needs to develop shared company safety cultures that make the use of risk assessments and safe systems of work an unquestioned part of life when working on board UK registered vessels.

Safety Issues

• The third engineer’s decision to act autonomously without informing either the OOW or CEO was contrary to the documented standing orders but was commensurate with the onboard culture of regular lone working.
• The fact that sparks generated by using fixed and portable angle grinders produce a hot work hazard is not currently acknowledged in marine industry guidance.
• The contents of International Maritime Organization (IMO) circular MSC. 1/Circ.1321, which recommends a 6 monthly inspection of fuel system pipework to be included in a vessel’s SMS, had not been formally promulgated to the UK shipping industry.
• Merchant Shipping Notices relating to personal protective equipment in engine rooms are inadequate, suggesting that cotton garments could provide fire protection.
• The Ship Captain’s medical guide gave confusing and inconsistent advice on the treatment of serious burns.

Actions Taken

• The Code of Safe Working Practices for Merchant Seafarers to address the hot work hazard of sparks generated by the use of fixed and portable angle grinders.
• Merchant Shipping Notice 1870 (M+F) to introduce an appropriate standard for overalls for work in engine rooms or any area where there is a risk of fire.
• The Ship Captain’s Medical Guide to provide clear guidance on the appropriate medical treatment for serious burns.
• Fleet Directive E363 detailing amendments to personal protective equipment requirements on its vessels.
• Fleet Directive M33 requiring fleet-wide inspection of fuel systems.
• Fleet Directive M34 requiring fleet-wide inspection of high temperature surface insulation and spray shields.

Conclusions

1. Although required by Arco Avon’s chief engineer’s standing orders and elsewhere in the vessel’s SMS, the third engineer informed neither the chief engineer nor the bridge OOW of a fuel leak and his apparent intended action to repair it. His reason for not doing so is likely to have been influenced by the onboard culture of routine lone working and absence of regular and frequent communication.
2. The UMS patrol alarm was deemed on board Arco Avon to be an impractical tool to cover the periods when the engine room was manned by a lone watchkeeper.
3. Given the routine, rather than exceptional, practice of not using the patrol alarm, the vessel’s SMS requirement to communicate with the bridge OOW at not more than 15-minute intervals had been allowed to lapse.
4. Arco Avon’s chief engineer’s standing orders requiring the duty engineer to progress routine duties and conduct planned maintenance while on watch, effectively condoned lone working and was not consistent with the guidance provided in section 15.9.1 of COSWP or with similar guidance now provided in the Code of Safe Working Practices for Merchant Seafarers 2015 edition.
5. From the results of fuel pipe testing following the accident and the findings of HSE Research Report 222, it is concluded that high energy sparks from the portable angle grinder were the probable source of ignition for the fire.
6. The fact that sparks generated by using fixed and portable angle grinders produce a hot work hazard is not currently acknowledged in marine industry guidance.
7. The presence of atomised fuel coupled with the wicking effect of a diesel-saturated coverall, regardless of the fact that the third engineer was not wearing a coverall of 100% cotton, resulted in an extremely flammable garment that could be readily ignited.
8. A combination of vibration and fuel pipe support bracket material loss through corrosion had resulted in loosening of the brackets in service and consequent fretting of the pipework. The fretting had resulted in a hole in a low pressure fuel pipe located below the engine room floor plates.
9. The contents of IMO circular MSC.1/Circ.1321, which recommends a 6-monthly inspection of all low pressure fuel system components to be included in the vessel’s SMS, had not been promulgated by the MCA to the shipping industry.
10. The lack of a requirement in HAML’s PMS for fuel system pipework inspections to form part of the vessel’s routine maintenance was compounded by the discretionary nature of BV’s survey of fuel system pipework, and allowed defective pipework below the engine room floor plates to go undetected.
11. While HAML’s SMS provided a tool to support vessels in operating in a safe and consistent manner, operational inconsistencies on board Arco Avon were not detected by the vessel’s shore management team.

Recommendations

The Maritime and Coastguard Agency has been recommended (2016/136) to more widely promulgate the contents of IMO Circular MSC.1/Circ.1321 and Bureau Veritas has been recommended (2016/138) to advise its surveyors of the contents of the circular.

Hanson Aggregates Marine Limited has been recommended (2016/137) to review and, as appropriate, amend its safety management system to ensure, inter alia, that manning levels, watchkeeping duties and communication procedures provide for safe engine room operations at all times.

Source: GOV.UK