MAIBInvReport 17 2016 Arco Avon Very Serious Marine

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Extract from,The United Kingdom Merchant Shipping,Accident Reporting and Investigation. Regulations 2012 Regulation 5, The sole objective of the investigation of an accident under the Merchant Shipping Accident. Reporting and Investigation Regulations 2012 shall be the prevention of future accidents. through the ascertainment of its causes and circumstances It shall not be the purpose of an. investigation to determine liability nor except so far as is necessary to achieve its objective. to apportion blame, This report is not written with litigation in mind and pursuant to Regulation 14 14 of the. Merchant Shipping Accident Reporting and Investigation Regulations 2012 shall be. inadmissible in any judicial proceedings whose purpose or one of whose purposes is to. attribute or apportion liability or blame,Crown copyright 2016. You may re use this document publication not including departmental or agency logos free of. charge in any format or medium You must re use it accurately and not in a misleading context. The material must be acknowledged as Crown copyright and you must give the title of the source. publication Where we have identified any third party copyright material you will need to obtain. permission from the copyright holders concerned, All MAIB publications can be found on our website www gov uk maib.
For all enquiries,Marine Accident Investigation Branch. Spring Place,105 Commercial Road,Southampton Email maib dft gsi gov uk. United Kingdom Telephone 44 0 23 8039 5500,SO15 1GH Fax 44 0 23 8023 2459. Press enquiries during office hours 01932 440015,Press enquiries out of hours 020 7944 4292. GLOSSARY OF ABBREVIATIONS AND ACRONYMS,SYNOPSIS 1,SECTION 1 FACTUAL INFORMATION 2.
1 1 Particulars of Arco Avon and accident 2,1 2 Narrative 3. 1 2 1 Pre accident events 3,1 2 2 The accident 5,1 2 3 Post accident events 9. 1 3 Environmental conditions 9,1 4 Vessel equipment and manning 9. 1 4 1 Vessel background 9,1 4 2 Machinery 10,1 4 3 Fuel system 11. 1 4 4 Engine room CO2 fixed fire extinguishing system 11. 1 4 5 Manning 15,1 5 Safety management survey and inspection 16.
1 6 International Maritime Organization initiatives 19. 1 7 Accident site examination 19,1 8 Abrasive wheels 20. 1 9 Personal protective equipment 25,1 10 Other technical investigations 26. 1 11 Medical care 30,1 12 Previous similar accidents 31. 1 13 Voyage data recording 31,SECTION 2 ANALYSIS 32. 2 1 Aim 32,2 2 Overview 32,2 3 Third engineer s actions 32.
2 4 Lone watchkeeping 33,2 5 Source of ignition 34. 2 6 Abrasive wheels and hot work 35,2 7 Personal protective equipment 35. 2 8 Emergency response 36,2 9 Medical treatment 37. 2 10 Maintenance and survey 37,2 11 Safety management system 38. SECTION 3 CONCLUSIONS 39, 3 1 Safety issues relating to the accident that have been addressed or resulted in.
recommendations 39, 3 2 Other safety issues relating to the accident 40. 3 3 Other safety issues that have been addressed or resulted in recommendations 40. 3 4 Other safety issues 40,SECTION 4 ACTIONS TAKEN 41. SECTION 5 RECOMMENDATIONS 42,Figure 1 Chart showing location of accident. Figure 2 Port engine room vent,Figure 3a Engine room main deck access. Figure 3b Engine room tank top,Figure 4 Fuel system.
Figure 5 CO2 cylinder room,Figure 6 CO2 system operating control cabinet. Figure 7a CO2 cylinder valve,Figure 7b CO2 manifold valve. Figure 8a Tools and angle grinder as found, Figure 8b Accident scene with tools and cable reel. Figure 9 Pipe showing leak and partially detached hoop bracket. Figure 10 Defective fuel pipe,Figure 11a Hoop bracket. Figure 11b Hoop bracket wear,Figure 12a Evidence of additional fretting.
Figure 12b Evidence of pipe interference,Figure 13 Pipe support stanchion. Figure 14a CAT scan of angle grinder,Figure 14b CAT scan of angle grinder switch. Figure 15a Spray test,Figure 15b Spray test,Figure 16 Coverall ignition and flame spread test. Annex A HSE Research Report 222,Annex B MSN 1731 M F. GLOSSARY OF ABBREVIATIONS AND ACRONYMS,AB Able Seaman.
ANSI American National Standards Institute,AVR Automatic Voltage Regulator. BA Breathing apparatus,BST British Summer Time,CAT Scan Computerized axial tomography scanner. cm centimetre,CO2 Carbon dioxide, COSWP Code of Safe Working Practices for Merchant Seamen consolidated. edition 20101,DoC Document of Compliance,FR Fire retardant. FRS Fire and Rescue Service,HAML Hanson Aggregates Marine Limited.
HSE Health and Safety Executive,IMO International Maritime Organization. ISM International Safety Management Code,kg kilogramme. kW kilowatt, Mayday A word used internationally as a distress signal in voice radio. communication meaning the prefix to Grave and Imminent Danger. to a Person Ship Aircraft or Other Vehicle Requiring Immediate. Assistance,MCA Maritime and Coastguard Agency,MCR Machinery control room. mg milligramme,MGN Marine Guidance Note,MGO Marine gas oil.
mm millimetre,MSN Merchant Shipping Notice, Replaced with Code of Safe Working Practices for Merchant Seafarers 2015 edition in September 2015. NCN Non conformance note,NFRS Norfolk Fire and Rescue Service. OOW Officer of the watch,PMS Planned maintenance system. PPE Personal protective equipment, PPE 99 The Merchant Shipping and Fishing Vessels Personal Protective. Equipment Regulations 1999,PTO Power take off,PTW Permit to Work.
RNLI Royal National Lifeboat Institution,SCMG Ship Captain s Medical Guide. SMC Safety Management Certificate,SMS Safety management system. STCW International Convention on Standards of Training Certification and. Watchkeeping for Seafarers 1978 as amended,UMS Unmanned machinery space. UTC Universal co ordinated time,VDR Voyage Data Recorder. VHF Very high frequency, TIMES all times used in this report are BST UTC 1 unless otherwise stated.
At 2312 on 18 August 2015 a fire broke out in the engine room. of the dredger Arco Avon while the vessel was loading a sand. cargo approximately 12 miles off Great Yarmouth UK Arco Avon s. third engineer Anthony Jones was badly burned in the fire and. later died as a result of his injuries As a consequence of the fire. which was extinguished following activation of the CO2 smothering. system the vessel lost all power and remained at anchor with its. dredging equipment partially deployed for 9 days until it could be. taken under tow and delivered to a repair facility. The MAIB investigation concluded that, The third engineer was attempting to repair a failed fuel pipe when fuel under. pressure in the pipe ignited, No one else on board was aware of a failed fuel pipe or that the third engineer had. apparently decided to repair it, The third engineer was using a portable angle grinder to access the repair site and. had underestimated the risk of doing so, Possible contributing factors to the third engineer s underestimation of risk were that. he had neither carried out a formal risk assessment nor sought a permit to work prior. to commencing the repair, The Maritime and Coastguard Agency has taken actions to review and update.
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 other 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, The Maritime and Coastguard Agency has been recommended to more widely promulgate. the contents of IMO Circular MSC 1 Circ 1321 i e that owners and operators conduct. periodic inspections of low pressure fuel system components Bureau Veritas has been. recommended to advise its surveyors of the contents of the circular. Hanson Aggregates Marine Limited has been recommended 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,SECTION 1 FACTUAL INFORMATION. 1 1 PARTICULARS OF ARCO AVON AND ACCIDENT,SHIP PARTICULARS. Vessel s name Arco Avon,Flag United Kingdom,Classification society Bureau Veritas. IMO number fishing numbers 8508383,Type Suction dredger.
Registered owner Hanson Aggregates Marine Limited,Manager s Hanson Aggregates Marine Limited. Construction Steel,Year of build 1986,Length overall 98 6m. Registered length 92 74m,Gross tonnage 3474,Minimum safe manning 8. Authorised cargo Dredge spoil,VOYAGE PARTICULARS,Port of departure Dagenham. Port of arrival Dagenham planned,Type of voyage Commercial.
Cargo information Sand,Manning 10,MARINE CASUALTY INFORMATION. Date and time 18 August 2015 2312, Type of marine casualty or incident Very Serious Marine Casualty. Location of incident Approximately 12 miles off Great. Yarmouth UK,Place on board Engine room,Injuries fatalities 1 fatality. Fire damage to engine room power, Damage environmental impact cabling and control systems Smoke. damage throughout engine room,Ship operation Loading dredging.
Voyage segment Mid water, External internal environment Wind F4 sea state moderate. Persons on board 10,1 2 NARRATIVE,1 2 1 Pre accident events. At approximately 1200 on 18 August 2015 Arco Avon left Dagenham and proceeded. along the east coast of the UK to its designated loading area Loading involved. dredging within a defined geographical box designated 240 by The Crown. Estate2 located approximately 12 nautical miles off Great Yarmouth The dredging. operation usually took about 5 hours to complete At 2000 approximately 1 hour. before arrival at the loading area the officer of the watch OOW called the third. engineer to prepare the machinery for loading The third engineer then proceeded. to the engine room and changed the alarm and monitoring system from its remote. unmanned configuration to local control for manned machinery space operations. He then started No 2 generator and transferred the vessel s electrical load from the. shaft alternator on to No 2 generator and prepared the dredging pump which would. be powered by the shaft alternator The normal arrangement for power distribution. during loading operations would have been for No 3 generator to provide power. for the vessel s services with the shaft alternator supplying power for the dredging. pump Due to a defect on No 3 generator s voltage regulator this machine was. unavailable for use Loading commenced at approximately 2124 after which there. was no further communication between the bridge team and the third engineer prior. to the accident, The Crown Estate is a diverse portfolio of UK buildings shoreline seabed forestry agriculture and common. land that generates revenue for the government each year. Reproduced from Admiralty Chart BA 1543 by permission of the Controller of HMSO and the UK Hydrographic Office. Figure 1 Chart showing location of accident,1 2 2 The accident. Loading proceeded as planned until 2312 when a fire detector activated The fire. detection panel on the bridge indicated that the fire was within the engine room. The alarm was reset on the fire detection panel which was situated on the bridge. but it immediately reactivated sounding throughout the accommodation on each. occasion The alarm was then reset again but it activated for a third time alerting. the rest of the crew some of whom had already responded to the initial alarm and. had proceeded to the bridge The remaining crew then mustered rapidly on the. bridge which was the designated emergency station with the exception of the third. engineer who was on watch alone in the engine room and the chief officer who. was asleep following his period of duty, The master looked aft as the crew were mustering and noted smoke coming from.
engine room vents Figure 2 Having established that there was a fire in the. engine room the master immediately made two telephone calls to the engine room. both of which were unanswered Following a discussion with the master the chief. engineer was about to leave for the engine room to investigate further when the third. engineer telephoned the bridge He told the chief engineer that there was a fire in. the vicinity of No 2 generator and that he had been hurt The chief engineer told him. to evacuate the engine room The call had been made from the machinery control. room MCR which meant that the engineer had to re enter the engine room and. exit through the fire as there was no direct escape route from the MCR. Soot residues caused,by smoke prior to the,vents being closed. Figure 2 Port engine room vent, The master ordered the designated fire team to dress in fire suits and breathing. apparatus BA in preparation to fight an engine room fire The team consisted of the. second engineer and an able seaman AB The chief engineer left the bridge and. went aft to assume the role of on scene commander He was accompanied by the. bosun whose role was to shut the engine room ventilation flaps. At approximately 2214 the master began to recover the dredging equipment as. it was essential to raise the dredge pipe off the seabed while the vessel still had. VERY SERIOUS MARINE CASUALTY REPORT NO 17 2016 SEPTEMBER 2016 Report on the investigation of a fire in the engine room on the suction dredger Arco Avon 12 miles off the coast of Great Yarmouth resulting in one fatality on 18 August 2015 Extract from The United Kingdom Merchant Shipping Accident Reporting and Investigation Regulations 2012 Regulation 5 The sole objective of

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