Case Study 5 Engine Room Case
A laden bulk carrier was on passage between two ports in Europe. In anticipation of a larger electrical
load due to cleaning of the cargo holds, auxiliary engines (A/E) Nos. 1 and 2 were on a parallel load-
sharing configuration. All the engine officers were present in the engine control room (ECR). A safety
meeting was held to emphasise the importance of carrying out risk assessments, toolbox meetings and
to discuss the lessons learnt from a recent incident onboard one of the sister vessels. During the safety
meeting, the engine ratings were carrying out their assigned tasks. One of these tasks was the renewal
and cleaning of lube and fuel oil filters. As the engineer officers were busy in their meeting, the ratings
were not supervised in their work. Suddenly, flames were seen between the two running generator
engines. The fire alarm system sounded and the officers called the bridge in order to clarify if they could
stop engines. Engineers then tripped the main supply breakers on the switchboard, stopped the auxiliary
engines and all other running machinery whilst the emergency generator came on load. Now, thick black
smoke reduced the visibility in the engine room, forcing all staff to evacuate the machinery space. While
the crew mustered, the ventilation trips, flaps and quick closing valves were operated, to seal and isolate
the engine room. The onboard fire team entered the space wearing heat protecting suits and Self-
Contained Breathing Apparatus (SCBA) and extinguished the fire with portable and semi-portable
extinguishers. The crew continued to monitor the space for any other outbreaks of fire. A few hours
later, they re-entered the machinery space to verify that the fire was completely extinguished.
Subsequently, after carrying out all the appropriate operational safety checks, Aux. engine #3, (located
on the lower platform), main engine and other machinery were restarted and the vessel resumed her
passage. In the evaluation and investigation after the incident, it was discovered that a sudden shearing
of one of the three bolts that secures the lubricating oil filter of A/E #2 had displaced the cover. Lube oil
under pressure splashed onto various hot components on both generators and ignited. It was also
discovered that the lube oil primer pumps had continued to operate after shutdown of engines and
generators, because of power being restored by emergency power source. This resulted in the spill of all
the lube oil in the sump of the A/E #2 engine – which fed the fire. It was also found out that the filter
cover bolts were improperly tightened and there was a lack of proper inspection routines. Regular
inspection is important as it is known that these fittings could be subject to excessive wear or loosen due
to vibration / internal pressure. Spray shields and extra securing arrangements for cover bolts were not
manufactured and fitted for lube oil pipes and filters for the auxiliary engines on board; and that had
severe consequences for this vessel. If you have any questions or comments please contact Gard’s Loss
Prevention team at Case study for onboard safety meeting Engine room fire Please read the
below story of an incident. Keep our company’s standards and procedures in mind while reading to
compare with the actions of the crew below as we will discuss the factors which led to the incident
occurring. 1 What factors contributed to the incident in the above case? How to improve by lessons
learnt Based on the case and the keywords below, you should now perform an onboard risk assessment
of the incident and the factors which led to it. Bear in mind the company’s SMS procedures when
answering the questions. Please also discuss the following questions in order to increase awareness;
Keywords for discussion: • Leadership, supervision and delegation. A clear understanding among officers
of which tasks can be delegated to ratings and which cannot. • Familiarisation of air control; are we
familiar with all the openings to the engine room that may need to be closed in a fire situation? • Fire
hazards and combustible oil (fuel oil, lubricating oil and hydraulic oil). What makes them flammable? •
A laden bulk carrier was on passage between two ports in Europe. In anticipation of a larger electrical
load due to cleaning of the cargo holds, auxiliary engines (A/E) Nos. 1 and 2 were on a parallel load-
sharing configuration. All the engine officers were present in the engine control room (ECR). A safety
meeting was held to emphasise the importance of carrying out risk assessments, toolbox meetings and
to discuss the lessons learnt from a recent incident onboard one of the sister vessels. During the safety
meeting, the engine ratings were carrying out their assigned tasks. One of these tasks was the renewal
and cleaning of lube and fuel oil filters. As the engineer officers were busy in their meeting, the ratings
were not supervised in their work. Suddenly, flames were seen between the two running generator
engines. The fire alarm system sounded and the officers called the bridge in order to clarify if they could
stop engines. Engineers then tripped the main supply breakers on the switchboard, stopped the auxiliary
engines and all other running machinery whilst the emergency generator came on load. Now, thick black
smoke reduced the visibility in the engine room, forcing all staff to evacuate the machinery space. While
the crew mustered, the ventilation trips, flaps and quick closing valves were operated, to seal and isolate
the engine room. The onboard fire team entered the space wearing heat protecting suits and Self-
Contained Breathing Apparatus (SCBA) and extinguished the fire with portable and semi-portable
extinguishers. The crew continued to monitor the space for any other outbreaks of fire. A few hours
later, they re-entered the machinery space to verify that the fire was completely extinguished.
Subsequently, after carrying out all the appropriate operational safety checks, Aux. engine #3, (located
on the lower platform), main engine and other machinery were restarted and the vessel resumed her
passage. In the evaluation and investigation after the incident, it was discovered that a sudden shearing
of one of the three bolts that secures the lubricating oil filter of A/E #2 had displaced the cover. Lube oil
under pressure splashed onto various hot components on both generators and ignited. It was also
discovered that the lube oil primer pumps had continued to operate after shutdown of engines and
generators, because of power being restored by emergency power source. This resulted in the spill of all
the lube oil in the sump of the A/E #2 engine – which fed the fire. It was also found out that the filter
cover bolts were improperly tightened and there was a lack of proper inspection routines. Regular
inspection is important as it is known that these fittings could be subject to excessive wear or loosen due
to vibration / internal pressure. Spray shields and extra securing arrangements for cover bolts were not
manufactured and fitted for lube oil pipes and filters for the auxiliary engines on board; and that had
severe consequences for this vessel. If you have any questions or comments please contact Gard’s Loss
Prevention team at Case study for onboard safety meeting Engine room fire Please read the
below story of an incident. Keep our company’s standards and procedures in mind while reading to
compare with the actions of the crew below as we will discuss the factors which led to the incident
occurring. 1 What factors contributed to the incident in the above case? How to improve by lessons
learnt Based on the case and the keywords below, you should now perform an onboard risk assessment
of the incident and the factors which led to it. Bear in mind the company’s SMS procedures when
answering the questions. Please also discuss the following questions in order to increase awareness;
Keywords for discussion: • Leadership, supervision and delegation. A clear understanding among officers
of which tasks can be delegated to ratings and which cannot. • Familiarisation of air control; are we
familiar with all the openings to the engine room that may need to be closed in a fire situation? • Fire
hazards and combustible oil (fuel oil, lubricating oil and hydraulic oil). What makes them flammable? •
