MARINE Reports - 2003 - M03W0073

Table of Contents

1. 1.0 Factual Information
   1. 1.1 Particulars of the Vessel
   2. 1.1.1 Description of the Vessel
   3. 1.2 History of the Voyage
   4. 1.2.1 Fire in the Engine Room
   5. 1.2.2 Release of CO2
   6. 1.2.3 Return to Langdale
   7. 1.3 Exhaust and Fuel Oil Systems of the Main Engine
   8. 1.4 CO2 Smothering System
   9. 1.4.1 CO2 Storage Compartment
   10. 1.4.2 CO2 Distribution Manifold
   11. 1.4.2.1 Condition of the Distribution Manifold
   12. 1.5 Requirements for Structural Fire Protection
   13. 1.5.1 Structural Fire Protection Around the Engine Room
   14. 1.6 Safety Management System
   15. 1.6.1 Inspection, Planned Maintenance, and Repair Procedures
   16. 1.6.2 Training of Ship's Staff and Supervision of Maintenance Tasks
   17. 1.6.3 Emergency Preparedness Aboard the Vessel
   18. 1.6.4 Passenger Safety
   19. 1.6.5 Analysis of Accidents and Non-Conformities
   20. 1.6.6 Role of the Designated Person
   21. 1.6.7 Corrective Action Procedures
   22. 1.6.8 British Columbia Ferry Corporation's Investigation into the Engine Room Fire and Recommendations
   23. 1.7 Regulatory Surveys and Inspections
   24. 1.8 Previous Similar Occurrences
   25. 1.8.1 Action Taken by British Columbia Ferry Corporation Upon Receipt of Ship Safety Bulletins
   26. 1.9 Damage
   27. 1.9.1 Engine Room and No. 2 Engine
   28. 1.9.2 CO2 Compartment and Distribution Manifold
   29. 1.9.3 Main Car Deck
2. 2.0 Analysis
   1. 2.1 Cause of Fire
   2. 2.1.1 Failure of the Fuel Oil Pressure Gauge Pipe at No. 2 Main Engine
   3. 2.1.2 Fuel Oil Pressure Gauge Connection
   4. 2.1.3 Fire on No. 2 Main Engine
   5. 2.2 Structural Fire Protection Around the Engine Room
   6. 2.2.1 Engine Room Deckhead
   7. 2.3 Release of CO2 and Failure of the Distribution Manifold
   8. 2.4 Adequacy of Standards for Construction and Testing of CO2 Systems
   9. 2.4.1 Design of the CO2 Distribution Manifold
   10. 2.4.2 Method of Design, Fabrication, and Approval of the CO2 Distribution Manifold
   11. 2.4.3 Inspection and Testing of the CO2 Distribution Manifold
   12. 2.5 Adequacy of the Queen of Surrey's Safety Management System
   13. 2.5.1 Internal Communications
   14. 2.5.2 Responsibilities for Maintenance and Repair
   15. 2.5.3 Shipboard Inspection Procedures
   16. 2.5.3.1 No. 2 Main Engine
   17. 2.5.3.2 CO2 Storage Compartment
   18. 2.5.4 Emergency Preparedness
   19. 2.5.5 Analysis of Accidents, Tracking and Closing of Recommendations
   20. 2.5.6 Continued Validity of the Safety Management System
   21. 2.5.7 Action Taken by British Columbia Ferry Corporation Upon Receipt of Ship Safety Bulletins
   22. 2.6 Adequacy of Regulatory Surveys and Inspections
3. 3.0 Conclusions
   1. 3.1 Findings as to Causes and Contributing Factors
   2. 3.2 Findings as to Risk
4. 4.0 Safety Action
   1. 4.1 Action Taken
   2. 4.2 Action Required
   3. 4.2.1 Design, Inspection, and Testing of the CO2 System
   4. 4.2.2 Structural Fire Protection
   5. 4.3 Safety Concerns
   6. 4.3.1 Adequacy of Regulatory Inspection
   7. 4.3.2 Adequacy of British Columbia Ferry Corporation's Safety Management System
5. Appendices
   1. Appendix A - Sketch of the Area of Occurrence
   2. Appendix B - Diagram of the CO2 Distribution Manifold
   3. Appendix C - List of Supporting Reports
   4. Appendix D - Glossary
6. Figures
   1. Figure 1 - General Arrangement of Compartments at Midships
7. Photos
   1. Photo 1 - Ro-Ro Passenger Ferry Queen of Surrey Under Tow to Langdale Ferry Terminal
   2. Photo 2 - Bank of CO2 Cylinders and Distribution Manifold
   3. Photo 3 - Damage to Engine Room and Electrical Cables
   4. Photo 4 - A Fractured Manifold Pipe Segment
   5. Photo 5 - Spatial Orientation of the Fuel Oil Pressure Gauge Connection
   6. Photo 6 - Section Through a Schedule 40 Pipe

Previous | Next