Report on the investigation of a marine accident Nordlys LHCW - fire on board during approach to Ålesund 15 September 2011
The Accident Investigation Board Norway (AIBN) has carried out a safety investigation in connection with the fire on board Nordlys 11 September 2011. Two crew members died and two suffered serious injuries during the fire that commenced in the engine room when Nordlys approached Ålesund, Norway. In addition seven crew members suffered minor injuries. Nordlys had 207 passengers on board. They were all evacuated without any physical injuries.
Photo: Thomas Molnes
The investigation concludes that the fire probably started when a diesel leakage was ignited coming into contact with an un-insulated indicator valve on starboard main engine. The most probable cause of the diesel leakage was fatigue fracture in the feed pipes for a fuel injection pump due to the pump being loose. AIBN is of the opinion that insufficient job specification in the shipping company’s maintenance system had contributed to the fuel injection pump not being sufficiently fastened and to the indicator valve not being sufficiently insulated.
The water-based local application fire-extinguishing system was not immediately released because it was set to the manual mode, and the CO2-based main fire-extinguishing system was not released as the master did not have an overview of where all members of the engine crew were located.
Due to limited options of evacuating from the workshop in the engine room, three crew members had to evacuate passing through the area of the fire. They received no protection from the local application fire-extinguishing system as this had not been activated at that time.
Safety-critical tasks, such as shut down of air- and fuel supply, were not attended to in connection with the fire. The AIBN is of the opinion that lack of training to deal with loss of key persons had contributed to that.
The stabiliser fins were not retracted before Nordlys was berthed, and in the impact with the quay the starboard fin was pressed through the hull. Initially, this led to water ingress in cargo hold no 2. Because a watertight sliding door either leaked or was left open, cargo hold no 1 was also flooded. As Nordlys was designed to withstand damages between the main transverse bulkheads only, the flooding became critical and Nordlys came close to capsizing alongside the quay.
After the accident the shipping company has implemented several measures. They have installed a new water-mist system as main fire-extinguishing system. In addition to design alterations of its ships, the company has through management development programs and officers’ conferences focused on attitudes and challenges relating to crew’s compliance with procedures and a cooperation with the University of Bergen has been initiated to map out the level of safety culture on board the company’s ships.
AIBN proposes seven safety recommendations in this report.
Safety recommendation MARINE No 2013/03T
The AIBN's investigation of the fire on board Nordlys shows that un-insulated hot surfaces were a contributory factor to the fire starting. Explicit requirements for insulation of surfaces with temperatures exceeding 220 °C became applicable to Nordlys and its sister ships on 1 July 2003, but the lack of an overview of surfaces that might exceed 220 °C helps to explain why both Nordlys and its two sister ships had several uninsulated surfaces in the engine room.
The AIBN recommends that the Norwegian Maritime Authority propose a requirement for all ships to have prepared an overview of surfaces that must be insulated and to keep such documentation on board at all times.
Safety recommendation MARINE No 2013/04T
The AIBN's investigation of the fire on board Nordlys shows that un-insulated hot surfaces were a contributory factor to the fire starting. The explicit requirement for all surfaces with temperatures exceeding 220 °C to be insulated was applicable to Nordlys with effect from 1 July 2003. Judging by the Norwegian Maritime Authority's checklists, insulation of hot surfaces was not in focus in connection with any of that authority's surveys of Nordlys in 2003, 2005, 2006, 2008 and 2010. Insulation of hot surfaces was a topic during the survey in 2011, the most recent survey prior to the fire, but the inspection was carried out by the shipping company as self-inspection.
The AIBN recommends that the Norwegian Maritime Authority increase its focus on insulation of hot surfaces in connection with inspections of passenger ships.
Safety recommendation MARINE No 2013/05T
Manual release of local application fire-extinguishing systems is permitted in manned engine rooms pursuant to national and international provisions, despite the fact that the length of time that passes before it is released may be decisive for the outcome of the fire. The fire on board Nordlys illustrates clearly that, even if the engine room is manned, automatic release of the fire-extinguishing system may be very important, not least to protect any crew that is present in the engine room.
The AIBN recommends that the Norwegian Maritime Authority propose requirements for automatic release of local application fire-extinguishing systems in engine rooms, regardless of whether or not the engine room is manned.
Safety recommendation MARINE No 2013/06T
The use of CO2 as an extinguishing agent is permitted on ships pursuant to national and international provisions, even though the activation of a CO2 extinguishing system can create a life-threatening atmosphere for anyone who is present in the room where it is released. As a consequence, the fire-extinguishing system may be activated too late or not at all if the situation is unclear, or it may be activated and constitute a threat to human life.
The AIBN recommends that the Norwegian Maritime Authority propose prohibiting the use of extinguishing agents that may threaten the lives of people on board ships.
Safety recommendation MARINE No 2013/07T
The AIBN's investigation of the fire on board Nordlys found inadequacies in the job specifications in Hurtigruten ASA's maintenance system. Insufficient job specifications for replacement of fuel injector pumps, insulation of hot surfaces and maintenance of watertight doors were important organisational factors that help to explain why the fire started and had such serious consequences.
The AIBN recommends that Hurtigruten ASA revise its maintenance system so that the job specifications provide the crew with sufficient support for correct execution of the work.
Safety recommendation MARINE No 2013/08T
When the fire on board Nordlys started, crew members with key functions were put out of action. Stand-ins had been appointed, but no drills had been organised simulating loss of personnel and the assumption of new roles. As a consequence, several safety-critical tasks were not attended to in connection with the fire.
The AIBN recommends that Hurtigruten ASA prepare procedures for training in the loss of key personnel and implement training in this area on board its ships.
Safety recommendation MARINE No 2013/09T
In connection with the berthing of Nordlys during the fire, damage to the hull led to water ingress to cargo hold no 2. However, the water also ingressed to cargo hold no 1, probably through an opening in connection with the watertight door between the cargo holds. Nordlys was not designed to withstand such two-compartment damage and came close to capsizing as a consequence of the flooding.
The AIBN recommends that the shipping company consult with the Norwegian Maritime Authority and implement measures to ensure the watertight integrity of the bulkhead in question.
|Accident category||Misc. accidents|
|Area||Norwegian Territorial Waters|
|Name of vessel||Nordlys|
|Accident type||Fire/Explosion, Fatal Accident, Capsize|
|Vessel type||Passenger Ship - Ferry|
|Register||The Norwegian Ship Register|