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Precis File
SHIP NAME: NARIVA KEY: NUM. ENTRIES: 2
source FSI
type A
volume
material
dead
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When the vessel was underway, vessel engineers drained a deck hydraulic line to an engine room storage tank by way of a reservoir/expansion tank. During this evolution, the vessels was on a ballast passage and trimmed three meters down by the stern. As the large deck line was draining, the vent to the expansion tank filled and overflowed just above the main engine turbocharger. The falling oil contacted hot surfaces, vaporized and ignited. About 40 minutes passed until CO2 was released which successfully extinguished the fire. The ship's engineers were able to restore electrical power but not propulsion and the vessel require a tow.

The hydraulic oil piping system was inadequately designed in that its reservoir/expansion tank venting arrangements failed to be suitable for all levels of trim. In the condition of trim at the time of the casualty, the tank's vent was lower than sections of the piping being drained.

Vessel operators and shipboard employees may be incorrect to assume that an installed system is adequate for all aspects of operation. Shipboard engineering systems, their design and installation although approved to various standards may be in certain instances found inadequate and lead to unintended and unfavorable circumstances. The investigation revealed that the engine room escape terminated near an area that shares access to the engine room doors.

Although the drain back process of overflowing and emptying the reservoir/expansion tank to the storage tank appeared innocuous, the individual overseeing the process should have recognized the potential risk for problems occurring in the engine room. Defenses could have been established by assigning an individual to continually observe the levels in both the tanks.


source CTX
type C
volume
material
dead
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The emphasis in the above entry is CTX's.

After correctly identifying the cause of the fire as a dangerous design fault, the IMO summary of the Bahamian investigation report goes on to castigate the crew for assuming the piping was properly designed. The option of placing liability on the shipyard or Class is not mentioned. (I doubt if it ever occured to the investigators; but, since the actual Bahamanian investigation report is not public, we cannot be sure.) Unless the yards are held accountable for bad design, bad design will continue.

The investigation also discovered that the ER emergency escape route design was defective. But once again there is no suggestion of yard/Class liability, just an example of why the crew cannot assume safe design.