MARINE Reports - 2003 - M03W0073

1.0 Factual Information

1.1 Particulars of the Vessel

"QUEEN OF SURREY"
Official Number	396048
Port of Registry	Victoria, British Columbia
Flag	Canada
Type	Double-ended, roll-on/roll-off passenger and vehicle ferry
Gross Tonnage	6968.91
Length1	139.35 m
Draught2	Forward: 5.25 m	Aft: 5.35 m
Year Built	1981
Propulsion	Two MaK diesel engines, type 12 M551 AK, 11 860 BHP, driving two controllable-pitch propellers (one at each end of the vessel)
Cargo	Passengers and vehicles (capacity: 360 vehicles and 1442 passengers and crew)
Passengers	318
Crew Members	28
Vehicles	137
Owner	British Columbia Ferry Corporation (BCFC)3, Victoria

1.1.1 Description of the Vessel

The Queen of Surrey is a double-ended vessel, having a wheelhouse, propeller and rudder at each end, with the engine room being at midships. The two ends are almost identical and, for the purposes of identification, are numbered "1" and "2." This establishes the port and starboard sides of the vessel and the numbering system of the machinery in the engine room (see Figure 1).

There are three car decks: the upper car deck, the middle gallery deck, and the lower main car deck. The upper and main car decks are accessed from ashore by way of the terminal's ramp systems, while the gallery deck is accessed through ramps from the main car deck.

There are two narrow, vertical casings that extend fore and aft over 60 per cent of the length of the car decks. Each casing is positioned about mid-distance between each side of the ship and the centreline, dividing the upper and main car decks into three continuous roll-on/roll-off (ro-ro) vehicle zones. The enclosed casings provide passengers with sheltered access from car decks to upper recreational areas and passenger service decks. They also provide for the routing of engine exhaust uptakes, the distribution of piping, ventilation and electrical systems, crew access to machinery spaces and operational areas of the vessel, and emergency escape routes.

The engine room contains two main diesel-fuelled propulsion engines, three auxiliary engines for electrical power generation and the associated machinery and equipment. Two propeller/intermediate shafts and reduction gears connect the main engines to the propellers. The shafts are enclosed in "shaft spaces," which can be isolated from the engine room by means of automatic watertight doors.

An engine control room (ECR) is located within the engine room at its starboard⁴ side. It contains the main electric switchboard and the means of remotely starting, stopping and monitoring the main engines and associated machinery. The inboard side of the ECR is fitted with glass windows for viewing various parts of the engine room. The No. 2 main engine, which is closest to the ECR, is clearly visible, although not in its entirety.

The engine room has two entrances from the main car deck; one from within each of the port and starboard casings. The starboard engine room entrance and passageway passes very close to the No. 2 main engine. The ECR can be entered from the starboard side aft by way of the engineers' workshop, as well as from a forward entrance that opens into the engine crew's "day room," where an overhead emergency escape hatch leads directly into the starboard casing on the main car deck.

1.2 History of the Voyage

1.2.1 Fire in the Engine Room

At 0620 Pacific daylight time⁵ on 12 May 2003, the Queen of Surrey started its scheduled run between its base at Langdale and Horseshoe Bay. A single crossing of the distance of 9.8 nautical miles (nm) takes 40 minutes, and the ferry made three crossings without incident.

At 0923, the vessel departed Horseshoe Bay in clear and calm conditions, on its fourth trip of the day. It had a total of 318 passengers, 137 vehicles and 28 crew on board. There was no marine traffic in the immediate area and, after the engines were set to "Full Away," the master handed over the conduct of the vessel to the chief officer and went down to his office.

At 0932, the third engineer was in the process of carrying out his round of the engine room and, as he approached the No. 2 main engine from its turbocharger end, a spray of liquid was observed shooting upwards and ricocheting off the deckhead and onto the turbocharger casing and engine exhaust. Shortly thereafter, the cloud of spray erupted into flames.

The fire alarm on the smoke detector panel in the wheelhouse sounded, and the bridge was notified that thick black smoke was billowing out of the aft engine room entrance on the main car deck. The master returned to the wheelhouse to take command and sounded the general alarm. The crew members then mustered at their fire stations and the chief officer directed the deck fire party. Passengers were ushered into a safe area, the fire doors in the passenger lounges were closed, and the ventilation system was shut down. Marine Communications and Traffic Services (MCTS), the Canadian Coast Guard, and the Horseshoe Bay and Langdale ferry terminals were advised of the fire.

Meanwhile, as the flames in the engine room grew rapidly, the fire became intense. Observing the scene from the ECR window, the chief engineer immediately alerted the wheelhouse, shut down the main propulsion engines, generators and ventilation fans, and ordered the engine room evacuated. The time was then 0937, just five minutes after the fire was first noticed.

Due to the intense heat around the No. 2 main engine, both engineers left the ECR using the emergency escape hatch to the main deck. Smoke restricted visibility on the main deck, and portable very high frequency (VHF) radios were used for communication between the master in the wheelhouse and other officers on board.

At approximately 0943, following consultation between the chief engineer and the master, a decision was made to flood the engine room with carbon dioxide (CO2) gas from the fixed fire-smothering system. The fuel supply valves to the engines and the ventilation dampers were closed from their remote locations and, with the engine room cleared of personnel and effectively sealed off, the release of the CO2 was activated from the starboard side remote station.

By that time, the heat from the engine room could be felt on the main car deck directly above and the sprinkler system was activated to prevent secondary fires from starting in the parked cars.

1.2.2 Release of CO2

The remote release station for CO2 is located beside the starboard engine room entrance on the main deck and above the CO2 compartment, where the cylinders of compressed gas and their discharge control mechanism are located. A watertight hatch on the main deck provides vertical access to the CO2 compartment below.

As the remote release handles were pulled, a loud bang was heard from the CO2 compartment and the manhole cover over the hatch burst open. (Investigation later revealed that it had been insufficiently dogged down.) It was seen from above that the CO2 distribution manifold had fractured and, as a result, some of the contents of the CO2 cylinders had discharged into the CO2 compartment itself.

Some sprinkler system water vaporized as it sprayed onto the hot main car deck, particularly in way of the No. 2 main engine. However, as the evaporation ceased, it became evident that sufficient gas had made its way into the engine room to extinguish the fire.

1.2.3 Return to Langdale

At 0939, MCTS was requested to arrange tug assistance for the vessel. Accordingly, the Rescue Co-ordination Centre tasked the ferry Queen of Capilano, together with the tugs Seaspan Cavalier and Seaspan Crusader, to assist.

With no propulsive power, the Queen of Surrey lost speed and started to drift towards Finisterre Island, approximately three miles from the Horseshoe Bay terminal (see Appendix A). Anchors were prepared for immediate deployment, if required. The Queen of Capilano arrived on the scene at 1001, and a line was secured between the two vessels.

The Seaspan Cavalier arrived at 1110 and was secured to the Queen of Surrey. The second tug, Seaspan Crusader, arrived at 1138 and the tow to Langdale commenced.

During the tow, the boundaries of the engine room were monitored and no increases in temperature were noted.

At 1339, the vessel docked at the Langdale terminal. After all the passengers disembarked, members of the Langdale fire department, along with two of the ship's engineers, entered the engine room to ensure that the fire had been extinguished. Passengers who had vehicles on board were then permitted to reboard the ferry and drive them off.

1.3 Exhaust and Fuel Oil Systems of the Main Engine

Each vee-type main engine has 12 cylinders arranged in two banks (A and B) of six cylinders each. The exhaust manifolds from each bank are situated inside the recess formed by the vee, leading to two turbochargers located at the free end. The exhaust pipes are designed to be covered by fire-retardant lagging, with the entire arrangement enclosed under a thermal heat shield.

A daily service tank provides each engine with diesel fuel oil, which is piped through an independent electrically driven booster pump and led, through filters, to a low-pressure fuel rail. Branch pipes from the fuel rail lead to individual jerk-type fuel pumps for high-pressure feed to the fuel injectors.

The low-pressure fuel rail of mild steel pipe has various gauges connected to it by way of tubing of appropriate material with threaded compression connections to steel "bosses" welded to the fuel rail. The fuel oil pressure gauge connection is located at the engine's turbocharger end and is fitted with a shut-off cock at the pressure gauge.

After the fire, an inspection revealed the following:

• the fuel oil pressure gauge pipe, attached to the compression fitting on the A bank, was made of copper and had fractured;
• the high-pressure fuel pipes were jacketed, whereas the low-pressure fuel rail was not;⁶
• the thermal heat shields, which should have been arranged on top of the exhaust manifold of the main engine, were missing;
• the exhaust pipes were inadequately lagged.

1.4 CO2 Smothering System

The vessel is fitted with a fixed, total gas flooding installation for extinguishing engine room fires, the firefighting medium being CO2. Requirements for the construction, inspection and testing of such a CO2 system are specified in the Fire Detection and Extinguishing Equipment Regulations made pursuant to the Canada Shipping Act (CSA).

1.4.1 CO2 Storage Compartment

The CO2 compartment, aft of the engine room below the starboard side main deck casing, contains 53 steel cylinders or "bottles" of pressurized CO2. Access to the compartment is through a circular hatchway on the main deck, which can be sealed off by means of a quick closing weathertight hatch cover. The hatch is normally kept closed.

The compartment has two ventilation trunks: a forced draft exhaust and a supply. Each trunk is fitted with three flap-type dampers (two fusible-link type and one manually operated), the closing of any one of which enables the CO2 compartment to be isolated. A fusible-link damper in the supply trunking was found to be closed, the link having been broken at some indeterminate time in the past.

1.4.2 CO2 Distribution Manifold

The CO2 cylinders were arranged in three banks, rigidly clamped to the outboard, forward and inboard bulkheads of the CO2 compartment. Each cylinder was connected to a distribution manifold by means of a flexible, reinforced, braided neoprene hose, which formed an inverted U between the top of the cylinder and the piping. The distribution manifold was made up in sections of sub-manifolds and branches, all constructed out of threaded, galvanized, schedule 40 steel pipe (or schedule 80, depending upon its diameter). An overhanging arrangement of steel frames and brackets was welded to the bulkheads, and it held the distribution piping by means of U clamps, which were passed around the pipes and bolted to the brackets (see Photo 2).

The arrangement of CO2 cylinders was comprised of four master cylinders and 49 slave cylinders, each containing about 45 kg of liquid CO2 at a pressure of 6300 kPa (at 24ºC). Two of the master cylinders were fitted with manually operated valves, which could be opened from either within the CO2 compartment or from remote CO2 release stations (see Appendix B).

The slave cylinders were fitted with non-return check valves, which were opened by the action of spring-loaded plungers. These, in turn, were depressed by the back pressure of the CO2 when it was released into the discharge manifold from the master cylinders.⁷ A stop valve separated the master and slave cylinders and effectively isolated them from each other. This valve had a similar pull-cable arrangement to the master cylinders, and it too could be operated either remotely or locally from within the CO2 compartment.

A time-delay unit was also built into the master side of the system and its function was to delay the release of CO2 for 25 to 30 seconds, to allow personnel time to evacuate the engine room safely. Automatic audio alarms to alert the crew to an impending discharge, electrical stop switches for shutting down fuel oil pumps, and vent fans were also incorporated into the system via pressure transducers attached to the time-delay unit.

1.4.2.1 Condition of the Distribution Manifold

The condition of the CO2 distribution manifold at the time of the occurrence was as follows:

• various stub pipe sections showed strong evidence of having been "chewed" into by a pipe-tightening wrench;
• some sections were misaligned at their couplings;
• at other places, the threads on some couplings were broken; and
• the hoses were bent into many different radii.

1.5 Requirements for Structural Fire Protection

The Hull Construction Regulations, Part III, of the CSA, define the degree of fire-retardant insulation required on the bulkheads and decks of different compartments aboard a vessel, and/or the utilization of sprinkler systems as a means of managing the fire risk inherent in these compartments. These regulations were introduced in 1958 and were based on the 1948 International Convention for the Safety of Life at Sea (SOLAS). Subsequent SOLAS conventions and amendments further improved the requirements for structural fire protection, but the Hull Construction Regulations have not been amended to reflect these improvements.

In 1979, Transport Canada (TC) published TP 2237, Equivalent Standards for Fire Protection of Passenger Ships, to reflect modern concepts in structural fire protection and include the latest requirements of the SOLAS at that time. The Board of Steamship Inspection considered these standards to provide a level of protection equivalent to the provisions of the Hull Construction Regulations, Part III. Shipowners were therefore given the option of having their vessels constructed in accordance with either the existing regulations or the equivalent standards. TC is currently reviewing the regulations under the regulatory reform agenda.

1.5.1 Structural Fire Protection Around the Engine Room

On the Queen of Surrey, the deckhead of the engine room (which formed part of the semi-enclosed main car deck) was of non-insulated bare steel. A sprinkler system fitted over the deck above was the means of limiting the propagation of the fire.

1.6 Safety Management System

Although not required to comply with the requirements of the International Management Code for the Safe Operation of Ships and for Pollution Prevention (ISM Code), BCFC had voluntarily elected to obtain a Document of Compliance for its fleet and a Safety Management Certificate for the Queen of Surrey.

In accordance with the ISM Code, the company had developed a Safety Management System (SMS) for the Queen of Surrey. This SMS, among other things, required vessel inspection and planned maintenance routines to be drawn up and implemented, as well as contingency plans and procedures for dealing with various potential shipboard emergency situations. A program of drills and exercises, to enable the vessel's crew to efficiently deal with such situations, had also been developed. These procedures were all maintained in the vessel's ship-specific manual and the operations/current orders manuals.

1.6.1 Inspection, Planned Maintenance, and Repair Procedures

An inspection of the engine room, main and auxiliary engines, was required to be done periodically by engine room watchkeepers. The items to be checked and the nature of the checks were specified in checklists drafted pursuant to the ship's SMS. Recognizing that checklists for engine room operations could not enumerate every detail, the watchkeeping staff was also required to use their experience, knowledge and training to advantage.

The planned maintenance routines for the main engines required them to be dismantled and overhauled on the basis of "running hours," and different routines had been established for different components. Depending on the extent of the work involved, these were done either by ship- or shore-based workshop staff.

Additionally, defects of the running machinery noticed during inspection rounds were brought to the chief engineer's attention, who, after evaluation, noted them in an engine room daily defect sheet. Defects that could not be rectified during the operational time of the vessel were attended to by the night maintenance shift while the vessel was alongside. Descriptions of the work done and significant events noted during a shift were entered in a computerized fleet-wide planned maintenance database called Maximo. These were supplemented by a verbal exchange of information between adjacent outgoing and incoming shifts. The comments in the defect sheet and Maximo also served to provide a feedback loop between the person rectifying the defect and the person noting it.

The leaking pressure gauge connection on the No. 2 main engine had first been identified on May 10, two days before the occurrence. It was tightened by the engineers on the morning shift and, when that did not prove effective, it was noted in the defect sheet for attention by the night-shift staff. Along with the request for repair, a notation was also made that the connection "did not feel right" when it was being tightened.

Further, the entire CO2 storage, distribution and activation system was required to be routinely inspected by the ship's staff. However, such inspections were not conducted on a regular basis.

1.6.2 Training of Ship's Staff and Supervision of Maintenance Tasks

All of the vessel's crew members held the appropriate TC certificates of competency for their rank. BCFC had also developed a training program for its officers and crew whereby, depending on their rank and the type of vessel, they were trained in various subjects, including the ISM Code. The senior engineers were also required to attend a course in "supervisory safety." This training course was designed to increase occupational safety awareness and safe work practices, and its syllabus covered subjects such as safety responsibilities and duties, industrial hygiene, machinery and plant inspections.

The vessel's senior engineers were required to train and instruct their juniors in good engineering and safe working practices, but BCFC had not developed any formal on-the-job training programs to this end. The expectation was that these would be imparted to the juniors by the senior engineers in their supervisory role, during the day-to-day operation and maintenance aboard the vessel.

The first engineer was responsible for the direct supervision of maintenance tasks carried out during his shift. While the first engineers on the morning and afternoon shifts reported to the senior/chief engineers, the night maintenance shift did not have a chief engineer. The first engineer was responsible for this shift and all the work carried out during it. The first engineers met and could discuss events during the change-over from one shift to the next. (The chief engineers, having staggered watch timings, arrived later and, consequently, did not meet the first engineers coming off the night shift.)

1.6.3 Emergency Preparedness Aboard the Vessel

The company had developed procedures for effectively dealing with various identified emergency and safety-critical situations aboard the vessel. However, no plans had been developed for the safe evacuation of passengers and non-essential crew when the vessel, in a state of emergency, was alongside.

1.6.4 Passenger Safety

In this instance, when the fire alarm was sounded and soon after arriving back in the wheelhouse, the master, in consultation with the senior officers aboard, made occurrence-specific plans to safeguard the vessel, its passengers and crew against the different identifiable contingencies, with reference being made to appropriate manuals.

The passengers were mustered in a lounge area, away from the scene of the fire, and were kept informed of the situation. Lifejackets were also prepared for issue to the passengers, to be used under instruction and only if required.

Before the vessel docked at Langdale, there was discussion with the terminal about the correct disembarkation protocol to adopt, considering that the vehicles contained substantial quantities of gasoline, which presented a risk of fire and explosion. An evacuation plan was prepared for the passengers, and arrangements were also made for the local volunteer fire department, paramedics and ambulance services. Tow trucks and police were to be present when the ferry docked.

1.6.5 Analysis of Accidents and Non-Conformities

The ISM Code requires that the SMS incorporate procedures for the master to report accidents, hazardous occurrences and non-conformities to the designated person ashore. These are then required to be investigated and analysed, and suitable corrective action has to be taken to prevent their recurrence.

BCFC had accordingly developed such procedures and defined different levels of severity for ship-board incidents. Masters were required to report them to the appropriate person representing the company's shore-based management, depending on the operational division of the fleet to which the vessel belonged. Depending on the level of severity of the occurrence, it would then be investigated by a panel of suitable senior managers.

The chairperson of the investigating panel was required to produce an inquiry report, including recommendations to avoid a recurrence. This would be distributed to all the managers and superintendents in the fleet.

1.6.6 Role of the Designated Person

To ensure that the SMS was effectively implemented, audited and periodically reviewed, BCFC had appointed a designated person (DP), as per the ISM Code. The DP's responsibilities included:

• reviewing the findings of internal investigations into accidents and making recommendations for corrective action required;
• ensuring the monitoring and "close out" of corrective action requests; and
• auditing for continued compliance.

1.6.7 Corrective Action Procedures

Recommendations arising out of investigations and inquiries required appropriate corrective action to be taken within a specified time frame. The corrective action required was implemented by a designated "office of primary interest," which had the responsibility of ensuring the completion of the necessary work, while progress was tracked and monitored by the operational safety superintendent.

1.6.8 British Columbia Ferry Corporation's Investigation into the Engine Room Fire and Recommendations

An internal inquiry held on 13 May 2003 issued 14 recommendations, 13 of which had fleet-wide relevance, and their implementation was assigned to different offices of primary interest. As required by the SMS, the Operational Safety Superintendent produced a recommendation tracking document that maintained the 30-, 60- and 90-day status of the recommendations.

The DP was not part of the investigative process, and the ensuing recommendations were not made into corrective action requests, per BCFC's SMS.

1.7 Regulatory Surveys and Inspections

The Queen of Surrey was required to undergo annual hull and machinery surveys by its classification society, Lloyd's Register of Shipping (Lloyd's), as well as statutory annual safety equipment and safety construction surveys by TC. Under the system in use at the time of the accident, TC and Lloyd's carried out joint annual and continuous surveys, while TC carried out the statutory surveys. Under TC's and Lloyd's continuous machinery survey program, the No. 2 main engine was required to be surveyed once every five years.

The Fire Detection and Extinguishing Equipment Regulations, made pursuant to the CSA, and SOLAS's International Code for Fire Safety Systems specify the requirements for the national and international construction, inspection and testing of a CO2 smothering system and distribution manifold. However, being a non-Convention ship, the Queen of Surrey did not have to comply with the SOLAS requirements. The complete installation is required to undergo an annual inspection, at which time the operating gear, gas distribution system and all audible alarms are to be examined and tested by TC inspectors. However, authorized third-party subcontractors.could also perform this function and carry out the necessary repairs, with their reports being accepted by TC. On the Queen of Surrey, several different subcontractors had been given this responsibility over the years.

1.8 Previous Similar Occurrences

The Transportation Safety Board of Canada (TSB) has investigated other instances of engine room fires caused as a result of diesel oil spraying onto hot engine exhaust manifolds,⁸ and TC has issued two Ship Safety Bulletins (SSB 13/1985 and SSB 08/2000) in this regard. These bulletins are distributed to the marine community at large, through a voluntary distribution list, and they serve to alert the end users to issues TC considers significant. The SSBs are also circulated among TC inspectors for their instruction and guidance, and are available on the TC Web site.

Both SSB 13/1985 and SSB 08/2000 strongly recommend that attention be given to the following:

• the integrity, vulnerability to damage, and wall thickness of fittings, during inspection of fuel, lubricating and hydraulic oil piping installations;
• the possibility of fitting shields at connections, to contain or deflect oil spray in the case of breakage and drainage of any leakage to a drip tray;
• the fitting of sheathing around lagging if there is a possibility of it being subjected to oil leaks from any source;
• the frequent checking of the condition of lagging, oil pipework and fittings; and
• any maintenance or replacement of fuel and lubrication oil pipework or components is to be accomplished with due regard to the potential hazards involved and using replacement parts that comply with the specifications for the systems or the components.

1.8.1 Action Taken by British Columbia Ferry Corporation Upon Receipt of Ship Safety Bulletins

The SSBs are received by either the library or the documentation control department at BCFC's management headquarters in Victoria. Photocopies of these are sent to the company's various local management offices, with two copies provided to every vessel in the fleet. One each is sent to the wheelhouse and the engine room, and a signed acknowledgement of receipt form is then sent back to management at headquarters.

BCFC has not developed any formal follow-up procedures in this regard and any action taken (or expected), subsequent to the receipt of the SSB, is left to the discretion of the fleet superintendents or the vessel's senior staff. Aboard the vessels, the SSBs are received by the senior master and senior chief engineer, who may then choose to disseminate the information contained therein to the other ship staff and also take such appropriate action as may be relevant to their vessel.

1.9 Damage

1.9.1 Engine Room and No.2 Engine

There was considerable fire and heat damage to the electrical cables that were laid out along the engine room deckhead, and large sections of these had to be renewed (see Photo 3).

1.9.1 Engine Room and No. 2 Engine

There was considerable fire and heat damage to the electrical cables that were laid out along the engine room deckhead, and large sections of these had to be renewed (see Photo 3).

The outboard air cooler on the No. 2 main engine was badly damaged such that the collapse of the tubes allowed sea water ingress into the cylinders, and the entire engine had to be overhauled.

The engine room and No. 2 main engine suffered from soot deposit. They required extensive cleaning and had to be repainted.

1.9.2 CO2 Compartment and Distribution Manifold

There was some localized buckling of the deck and deckhead of the CO2 compartment, and some of the welded seams on the stringers and frames separated from the deck plates.

Examination of the CO2 distribution manifold revealed that:

• the free ends of the flexible hoses had flailed around and caused some impact damage to the insulation on the after bulkhead of the CO2 compartment; and
• manifold segments had fractured and sheared off at five different points (see Photo 4).

The fractured pipe segments were sent to the TSB Engineering Laboratory for analysis.⁹ The examination under a scanning electron microscope confirmed that failure was due to fatigue pre-cracking, initiated at the thread root and probably as a result of excessive vibrations.

1.9.3 Main Car Deck

There was some buckling of the starboard side of the main car deck in way of the engine room.

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