Ex 2.

01 Chain of human error in an accident

Part of the following is an extract from an accident report with

thanks to: MINISTRY OF JUSTICE OF THE REPUBLIC OF LITHUANIA TRANSPORT ACCIDENT
AND INCIDENT INVESTIGATION DIVISION.

Look for and evaluate the human factor chain in this accident report:

Synopsis On 2 September 2018, at 13:35, Ro-Pax vessel Regina

Seaways with 335 persons and cargo on board, on her way from Kiel,
Germany to Klaipeda, Lithuania, sustained damage of main engine
No. 2, followed by automatic shutdown of both main engines and
fire in the engine room. Rescue operation was ready to commence,
however crew extinguished fire and successfully started main engine
No. 1 and ship resumed her voyage to Klaipėda using her own power
and 22:07 moored alongside quay in port of Klaipeda.

On 13:35 huge vibration, lasting about 30 seconds, was felt on board.

Both main engines automatically switched off.
13:37 high pressure fresh water firefighting system ‘HI-FOG’ in the
engine room was automatically activated and remained operational
until about 13:57. In the engine room, through video transmission
equipment, thick fumes were observed, heat detected.
13:38 the general alarm activated by the command of the master.
Persons on board notified about fire in engine room from the bridge.
Ship’s crew service instructed to start evacuation of passengers.
13:42 by the command of the master, crew instructed to activate
CO2 fire extinguishing system in the engine room. Crew started to
prepare CO2 fire extinguishing system for activation. Ventilation in
the engine room has been switched off, ventilation openings has
been closed, doors has been verified to be closed and nobody has
left inside the engine room. Oil and fuel supply pumps switched off,
oil and fuel valves closed.
13:52 CO2 fire extinguishing system has been activated by the crew.
14:05 it was determined that the temperature of bulkheads,
adjacent to the engine room, does not rise.
15:11 it was decided by the crew to inspect the engine room.
15:27 after the inspection of the engine room by the crew, no fire
spots were detected.
15:57 two diesel generators started, steam boiler was switched on.
Visual inspection of engine room was carried out by the crew. It was
determined, that main engine No 2 (hereinafter - ME2) has visual
damages, while main engine No 1 (hereinafter - ME1) remained
intact. ME1 crankcase was inspected, no damages were detected.
17:28 ship’s ME1 was started.
17:30 voyage to Klaipėda was resumed by ship‘s own power. Ship‘s
speed was about 13 knots. 17:58 she left Russian Federation’s search
and rescue area.
22:07 arrived to port of Klaipėda and moored alongside quay.
Persons on board sustained no injuries during the voyage.
Damage found:

There were 2 x W12V46 main engines each driving a controllable pitch

propeller through a reduction gear box. Both main engines had an oily
mist detector which shut the engine down, if a higher density than
normal, of oily mist was detected.
Both engines shut down, first the starboard engine, then the port
engine 5 seconds later. Only the starboard (No2) engine was found
damaged.
The damage to the starboard engine was considerable, with engine
parts found outside and inside the engine. Investigation showed that
the damage had come from the failure of “B4” big end bearing. As may
be seen in the pictures, the lower half of “B4” big end bearing keep
had broken in to two pieces. Expert examination showed that there
was a significant material failure. This was a large compressed gas
bubble, which must have been caused in the manufacture of the steel
ingot from which the keep had been forged. This had caused a fatigue
failure and resulted in the damage shown. This developing failure
could probably not have been visible before the accident.

Starboard side of starboard engine

Port side of starboard engine

This accident revealed another fault. Both engines had been stopped
by the oily mist detectors. First the starboard engine then the port
engine 5 seconds later. It was found that the two crankcase ventilation
pipes were joined together and concluded that the port engine had
stopped due to fumes entering its crankcase through the ventilation
pipe.
The International Association of Classification Societies (IACS) rules
include:
M10.5.3 To avoid interconnection between crankcases and the
possible spread of fire following an explosion, crankcase ventilation
pipes and oil drain pipes for each engine are to be independent of any
other engine.

Task:
This accident happily didn’t result in any people being injured
and the fire damage was not too big. This was mostly because
automatic shut downs and the “HI-FOG” automatic system
worked as they should, and the ship’s crew took exactly the right
actions, as they had been trained to do. It could easily have been
much worse.
Therefor:
Explain the chain of human errors that caused this accident to
happen and also the chain of human errors that caused the port
engine to shut down. Explain what defences could and should
now be put in place to stop similar accidents on the same type
of engines. Also explain what defences should be put in place, to
prevent possible accidents, which could happen, due to the
arrangement of the crankcase ventilation pipes.