NTSB: Critical Maintenance Error Leads to Engine Room Fire That Claimed Two

The 7x11” cut out in the vent piping is wild. I can’t think of a reason for that to exist. I wish there was a little more investigation into why it was there, especially after being discovered on four of eight ships in the fleet.

Is it common on smaller vessels to have a common vent pipe for all fuel tanks? I’ve not really seen that.

On the fire response side, anyone have any opinions on the CG requesting CO2 release three and half hours after a team entering the space found the fire to be out? It doesn’t mention whether they had any reason to believe the fire may have relit or still been burning, but just as a precaution.

Report: https://www.ntsb.gov/investigations/AccidentReports/Reports/MIR2505.pdf

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At some unknown time in the vessel’s 26-year history, a 7-inch-by-11-inch section of pipe had been cut into the top of a horizontal section of the 12-inch vent pipe on the D deck (see figure 9 and figure 10). The vent pipe ran from the lower engine room up to the compass deck. There were no records of this alteration and no records of approvals, nor were there any records of inspections of this unauthorized alteration. The cut out section of pipe had been replaced with a flexible sealant and then wrapped in tape

My guess? It rusted out due to being horizontal. Was cut and soft patch put on, thinking no fuel ever gets up here anyway

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Essentially no issues with their conclusion. I’m aware of at least one ship that combined vent and overflow into a single system and some tanks are grouped so multiple main deck vents but the vent line where manifolded is self draining to the overflow tank.

Agree with you @tengineer1 but with a twist. Corrosion yes but the photos look like the opening is on the top of the pipe (page 18 shows looking down at the remaining accumulated diesel oil at the bottom of the pipe). So instead of it simply rotting through being the cause of the cut it could be that (since those photos also show the position of the window near a 90 elbow up) cutting the window may have been an effort to allow clearing scale from the vent line. Not unheard of but the repair plan is turned out to be a foolish act.

Also on my mind is not so much grouping the tank vents - provided the flow areas complied with class or flag rules and that an overflow tank was incorporated in the design of the vent/overflow line to prevent inadvertent transfers - but how about having the atmospheric vent terminus at 125 feet above the tank top? These are usually what 30” above the freeboard deck. 125 feet would be a head pressure of about 46 psi in the tank if it ever did overflow out the vent terminal of course and it would be less differential in the water. Hard to imagine that was the tank design pressure. Sure wouldn’t hydro the tank to that. Just makes this arrangement strange from yet another perspective. But back to the location of the vent terminus - what’s the thought process there? Better to give the superstructure a shower and out multiple deck suppers over the side than into a single vent containment on main deck?

The small section of the FO Diagram suggests what to me appears top be a really cheapo way to approach FO filling and transfer system design. Yes a single line to/from the tank but usually a manifold approach to provide fill valves (stop) and suction valves (stop-check). Old timey cast manifolds too expensive these days?Would be nice to see the complete diagram if we might learn something more.

Since the guy who ordered the valve was not the guy aboard another lesson might be better check the work orders in progress and look over the job/materials before assigning the work. Even though we all assume our reliefs do it right too. Apparently the assistants who installed the valve were not looking too deeply at the work/materials in hand either. Guy paid with his life, then again absence of alarms and level indication monitoring was all on the crew aboard. Pretty sad and so unnecessary.

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Makes sense that they wanted to clean scale but for what reason? Was there a scale blockage? That seems unreasonable with that size vent pipe. Regardless it is evident that the repairs done were not properly documented and reported to class. Another example of a seemingly minor repair causing a major problem.

Another disaster with loss of life. Some thoughts. I think the NTSB report does not go deep enough.
Hydrocarbon tanks arrangements in the engine room.
Not uncommon to have all the fuel DB tanks tied to a common vent. This vent is NOT an overflow. There is a distinction between the two. Typically, the vent will originate from the overflow tank and other vents will be tied or manifolded to this line. The overflow tank will have a separate overflow line terminating on the main deck (or A deck) with the required spill containment with a capacity of 1 bbl. So, the max hydro pressure that any of the other tanks would experience is the hydro head from the main deck (or maybe the A deck).
Any overflow from the DB hydrocarbon tanks will first overflow to the overflow tank. Overflow tank level alarm is generally set at 10% and HH at 25%. No mention of the levels in this tank in the report. Really strange in that the diesel went up the vent line all the way to the D deck. So, is this 12” vent line from the overflow tank blocked (not likely) or valved in an unauthorized mod (also not likely). Possible there is a spade blank on a flange close to the overflow tank (upstream of the tie-ins from the other tanks) – possibly inserted for tank testing or left over from the yard.

Semantics
In spite of English being the ‘unofficial’ medium of communication, some terms are unique to US. In this case ‘Check valve’. This is called a non-return valve rest of world. This term is understood in the US – but I think ‘check valve’ is not well understood in most places. Maybe the reason for the error in the order for the spare valve. Not intercepted by the technical staff and straight to procurement.
Another one – although no bearing on this incident. Cast iron. Valve ordered is cast iron. The valve standard referred to and in the rest of the world it actually means ductile cast iron. In the US cast iron is exactly what is says – not allowed on vessels for valves. (had an incident with a CI butterfly skin valve installed in the pump room – spec was from American water works (AWWS) - almost flooded the space.

CO2 total flooding – as info.
Fire fighters requesting CO2 discharge comes from NFPA. Thought process is fires could be ‘deep seated’ such as electrical switchboard fires and flooding/blanketing the space with CO2 for an extended period is from NFPA. Also the rate of discharge and required concentrations of CO2 in NFPA is different than the IMO requirements.

7x11 window
Pure conjecture. I think the crew might have placed some rags to absorb any moisture/water coming down from the goose neck and running down to the fuel tanks.

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Work/Rest hour violations contributing to crew fatigue is a real problem. Chief Engineers, Masters and especially office management very well understand that stacking port operations on top of one another is a problem. Maneuvering, Cargo Operations, stores, audits, inspections, vetting, vendor repairs … We will continue to have things like this happen until we start putting the proper emphasis on proper rest for our crews. It is getting better but if safety is first, we all need to put safety first. Even if fatigue didn’t contribute in this case because the fuel spill started a short time after starting bunkers, it would have been an issue here at some point because the time required for Bunkers would have almost certainly resulted in a violation.

This event offers an opportunity to demonstrate a simple timeline of what happens every day in every port.

Shipping is different from tugs or work boats regarding arrivals, maneuvering and less so Bunker Operations. It doesn’t mean these vessels do not have similar, equally important hazards in their operations. This applies to the entire maritime industry.

Many of my timelines are based on a knowledgeable Engine crew and them being very efficient. Times will be longer, not shorter.

They arrive dockside at 16:30. It doesn’t say what time they are All Fast so we will assume it is arrival, dockside. Maybe the entire crew is efficient and the Bridge doesn’t delay in communicating with the ECR and they call Finished With Engines at 16:30.

It’s been a while since I’ve been into Baytown so I may be off but maneuvering inbound would be about six hours from Arrival with another hour to tie up.

The CE would be up for maneuvering beginning at 09:30. Add a half hour call-out to prepare for maneuvering to shut down the evaporator, shift to the high sea chest, standby generator, gear/astern testing he’s downstairs by 09:00. VLSFO is sub 1.0 sulfur so time for Fuel changeover is not a consideration.

Again anticipating efficiency, a 30 minute for 09:00 call out for the CE starts his day if he is not up already. At least two licensed engineers will be in the Engine Room for maneuvering, possibly more.

The report said after arrival he and the 2AE did tank soundings. Call it 30 min to complete these and say he knocked off at 17:00. He would have to do his maneuvering reports and bunker plan based on his soundings which will take an hour even if he had his VPS paperwork pre-filled out. Add another two hours until he gets showered and to bed.

Down at 19:00, Up at 01:30 when the Bunker Barge shows up. That’s 6 hours uninterrupted sleep by Watch-keeper. He’s taking 1,180 MT bunkers at 100 MT an hour. They’re not taking both at the same time so that’s 12 hours bunker time not including paperwork, hose connections and disconnects, slow downs while shifting tanks, samples, post-bunker soundings, post paperwork with the barge and everything else. Call it all 14 hours. Then he has to complete his bunker paperwork after bunkers.

It is likely everything took longer than what I outlined and he was almost certainly in violation at the onset of bunker operations. He honestly only had 30 minutes leeway and that doesn’t take into consideration his rest prior to the day of arrival. As vessel management we try to manage our hours but those in the office who are scheduling our port visits need to take into consideration that our days begin long before we catch that first line. Same goes with after departure. We can do better…

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Wonder if NTSB reads any of these subject threads. Maybe good tutorials for them - and also free!