Back in my armchair.
There’s two parts to this incident; the way the emergency of lost propulsion was handled and secondly how the engine room was managed on a routine basis. The way the lube oil was managed doesn’t seem to follow good engineering practice
Apparently nobody ashore or aboard knew what the correct oil levels in the DG sump tanks should be and apparently no one was concerned about it.
Instead of managing according to oil levels they were going solely by the TBN (Total Base Number).
The cost of exchanging lube oil due to low TBN alone – when oil samples were otherwise ok – was mentioned as a source of annoyance.
The NSIA was also informed that maintaining an oil level higher than strictly necessary would be to run an unnecessary economic risk as there is always a possibility that the complete volume of oil in a tank had to be discarded, e.g. in the case of a water leakage or other contamination.
Lube oil was added based on an assumption about the rate of consumption.
Both engine crew and technical shore staff have reported that this was a concern as the TBN fell below the recommended minimum level faster than expected. This would trigger the exchange of part of the volume of oil in the subject tank to increase the TBN. It was common practice to discard a certain volume of oil and refill a somewhat larger volume to compensate for presumed oil consumption.
Problem was, the rate of consumption was based on an incorrect assumption.
The general impression of both crew and technical shore staff was that the engines – still being new and of a modern design – consumed very little oil, although no one knew or would estimate the actual consumption when asked.
As shown in section 1.8.7.1, the nominal consumption specified by the engine manufacturer was 467 litres/week and 635 litres/week for the small and large engines, respectively. Both on board and shore based technical staff found this surprisingly high when confronted with this number.
The investigation has not been able to establish the exact oil consumption of the engines, but data samples indicate that the actual consumption is likely in the range of the nominal consumption specified by the engine manufacturer.
So what this would imply, if my understanding is correct is that the ship presumably came out of the shipyard with the correct amount of lube oil in the DG lube oil sump tank.
Then over time, with each partial oil change to adjust the TBN, the lube oil levels would become lower
Meanwhile the engineers (somewhat justifiably) ignored the low-level alarms except to compensate by adjusting the low level alarms limits yet lower from time to time.
If that’s correct that having DGs trip out on low lube oil was just a mater of time, and a time would be when the ship hit bad weather.
Hard to understand how an engine room would be managed that way.