Marine Report 236, Independent investigation into the engine room ...

In this case the engine manufacturer provided no guidance on the maintenance and
replacement of the flexible fuel hoses. While the crew has an important role in
managing the safety of the ship, it must be supported by the ship’s managers, the
classification society and the Flag State. The evidence indicates that Baltimar
Boreas’s generator fuel hoses were not in compliance with applicable regulations
and guidelines to reduce the fire risk. Even after the fire, the grounding and the
repairs and surveys after each incident, no irregularities appear to have been noted
by LR or the ship’s managers. In such a situation, particularly over long periods of
time, it is likely that if readily apparent hazards are overlooked, higher risks become
acceptable and poor practices become the norm for the ship’s crew.
Evidence of wear, similar to that found on the failed fuel hoses, was evident on
other generator fuel hoses. The condition of the failed hoses, their unnecessary
length, poor arrangement and the condition of other fuel hoses together with a lack
of documentary evidence, indicated that there was no planned maintenance or other
systematic regime on board Baltimar Boreas to effectively maintain these hoses.
2.4 Shipboard emergency response
The fire was extinguished because it was detected quickly and the initial response
of the crew was rapid and effective. Fortunately, circumstances that could have
adversely affected the outcome did not eventuate.
It is likely that the smoke detector about one metre away from number three
generator activated first, setting off the fire alarm at 0250 on 9 February. Less than
two minutes later, the second engineer was at the scene of the fire. Soon after, when
he realised that the fire was too large to fight locally, he stopped the engine room
ventilation fans. Leaking fuel did not accumulate because the fire probably started
shortly after the hose failure. About seven minutes after the fire started, the chief
engineer operated the engine room oil tank quick closing valve system. With no
fuel and the fans stopped, the fire was being starved.
At 0305, about fifteen minutes after the fire started, the Halon system was operated
and the gas probably extinguished the already starved fire very quickly. The Halon
nozzle located above number three generator (Figure 8) ensured that some of the
gas was released immediately above the seat of the fire and would have quickly
started to inhibit the combustion process. The fire dampers for the funnel vents
could not be closed. Some Halon would have risen with the smoke and escaped
from the open vents, particularly as the funnel casing lay immediately abaft the seat
of the fire.
Once cooling of the engine room boundary was started, preparations for entry into
the space were made. The Halon system’s instruction book on board the ship
contained the following caution:
For deep seated fire hazards, the hazard space should be kept tightly closed for 30
to 60 minutes after discharge of the Halon 1301 agent. Be sure fire is completely
extinguished before ventilating area. Before permitting anyone to enter the space,
ventilate area thoroughly or ensure self-contained breathing apparatus is being
used.
At about 0320, just 15 minutes after the release of the Halon, the engine room entry
was premature. The presence of spot fires on entry suggests that the hold time was
insufficient. Not allowing sufficient hold time for the engine room to cool increased
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