Engine room fire. Two weeks before the fire, the same flange sprayed fuel across the engine.
It was repaired. Tested. Returned to service.
Then it failed again.
On 11 February 2023, Stena Europe was approaching Fishguard when a fire started in the engine room.
Fuel escaped under pressure from ME3.
It reached an exposed exhaust surface above 400°C and ignited.
After the fire, one of the flange's two securing screws was missing. The O-ring was protruding from the joint.
A loose connection appears to be the obvious explanation.
But the flange was only the final failure.
The engine manufacturer had identified this model's fuel system as prone to leakage in 1995. A complete modification was available.
It had been installed on one of the ferry's four main engines. The remaining three were only partially modified.
The leakage was not invisible either.
Engineers had repeatedly entered recurring fuel-system defects in DOCMAP. As the incidents became more frequent, reporting through DOCMAP reduced.
The more familiar the defect became, the less visible it became to management.
Investigators found no evidence that management visits or formal audits had identified the high incidence of reported leaks.
There was another control.
A five-yearly survey of the main engine fuel system sat in the planned maintenance system.
The work order had been delegated to the second engineer, contrary to DNV rules.
At the time of the fire, the engineering officers did not know when the fuel systems had last been surveyed. They were also unclear how that survey should be carried out.
That is a serious assurance gap.
A recurring defect became routine maintenance.
A survey became a work order without shared practical understanding.
Audits saw neither the leakage pattern nor the decline in reporting.
The physical barriers had degraded as well. Protective shielding was missing, damaged or poorly fitted. Every running engine had exposed surfaces above 220°C.
After repairs, spot thermometer readings gave confidence that the hot spots were gone.
A thermographic inspection immediately found exposed surfaces above 220°C on every running engine.
The vessel already carried two thermal imaging cameras. They were kept on the bridge as firefighting equipment, not used for machinery-space hot-spot detection.
For a DPA, the defect report is only the start.
Recurring failures need an escalation threshold that does not depend on somebody reporting the same familiar leak again.
Class-related work orders need defined scope, competent ownership and evidence that can be reviewed ashore.
Audits must test the machinery condition against the records. Not merely confirm that records exist.
What in your PMS is repeatedly closed, while nobody onboard can explain how its condition is actually verified?
#MaritimeSafety #MarineAccidentInvestigation #FireSafety #Maintenance #Auditing
