MARINE INVESTIGATION REPORT M07C0034 ENGINE ROOM FIRE SAIL TRAINING VESSEL FAIR JEANNE OFF AMHERST ISLAND, LAKE ONTARIO, ONTARIO 13 JULY 2007 The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability. Marine Investigation Report Engine Room Fire Sail Training Vessel Fair Jeanne Off Amherst Island, Lake Ontario, Ontario 13 July 2007 Report Number M07C0034 Summary On 13 July 2007 at approximately 1600 eastern daylight time, a fire broke out near the auxiliary propulsion engine of the sail training vessel Fair Jeanne off Amherst Island near Kingston, Ontario. After initial firefighting attempts, the 20 sea cadets on board, along with several crew members and two naval personnel, were evacuated. Volunteer firefighters extinguished the fire. The vessel was towed to Kingston to assess the damage. One cadet received minor injuries. Ce rapport est également disponible en français. - 2 - Other Factual Information Particulars of the Vessel Name Fair Jeanne Official Number 391893 Port of Registry Ottawa, Ontario Flag Canada Type Sail training vessel (registered as a pleasure craft) Gross Tonnage 138.36 Length 1 20.57 m Draught Forward: 1.7 m Aft: 1.7 m Built 1981 Propulsion Sail and motor — Detroit diesel, model GM 6-71 marine diesel engine, 147 BHP Cargo N/A Crew and others 9 crew members, 2 naval personnel, and 20 sea cadets Registered Owner Private owner Operator Bytown Brigantine Inc. Description of the Vessel The sail training vessel Fair Jeanne is an auxiliary brigantine constructed of steel and fibreglass with 418 m² of sail area and a retractable keel. Navigational instruments on board include radar, fixed and handheld GPS, an echo sounder, magnetic compass, and two VHF radiotelephones, one of which is handheld. The Fair Jeanne’s auxiliary propulsion is provided by a single diesel engine connected to a reduction gear and propeller. The engine’s water-jacketed exhaust manifold runs along Photo 1. Fair Jeanne the starboard side of the engine, which is connected to a dry-exhaust pipe. This section of pipe runs aft, down toward and along the bilge, and then back up and aft, out of the engine room. 1 Units of measurement in this report conform to International Maritime Organization (IMO) standards or, where there is no such standard, are expressed in the International System of units. - 3 - The vessel was equipped with a 30-kilowatt (kW) Northern Lights generator fitted longitudinally in a rectangular box over the engine. In addition, a 21.5 kW Onan generator was fitted in a rectangular box athwart ships against the aft bulkhead of the engine room. Neither generator was in use at the time of the occurrence. History of the Voyage The Fair Jeanne was chartered by the Department of National Defence (DND) as an introductory sail training vessel for sea cadets. Prior to the contract being finalized, DND conducted an inspection of the vessel to verify that it met their requirements for training and safety. On 12 July 2007, the Fair Jeanne, using its engine, departed anchorage for the Royal Military College of Canada (RMC) in Kingston, Ontario. As the vessel was under way, a petty officer informed the master that a routine safety check in the engine room had revealed a stream of oil coming from the housing of the transmission’s hydraulic oil filter. The housing was subsequently looked at and, although oil residue was visible, the source of any leak was not apparent. Once the vessel was alongside its berth at RMC, the master called the vessel’s regular mechanic in Ottawa. With his advice, the source of the leak was found. The oil filter was removed from the housing and attempts were made to purchase a new filter and O-ring in Kingston. A new filter was found, but the O-ring was not the correct size for the housing. The filter was reassembled that evening and the old O-ring, which had been cleaned, was put back in place using high-pressure and high-temperature Teflon sealant. The master judged this repair acceptable to allow the vessel’s departure. At 0600 2 on 13 July 2007, the Fair Jeanne departed RMC using the engine. On board were nine crew, two naval personnel and 20 sea cadets aged 14 and 15 years old. The master requested that, in addition to the rounds to be made every 30 minutes, particular attention be paid to monitoring the filter in the engine room for leaks. At 1000, the Fair Jeanne set sail and shut down the engine. Sail was reduced around 1500 due to strong winds and adverse weather conditions. The engine was started and, as most of the cadets were seasick, the vessel headed for a calm anchorage for the evening. At 1615, the Fair Jeanne was proceeding toward Prinyer’s Cove, Ontario, via the Upper Gap off the Bay of Quinte, Lake Ontario, when a ship’s petty officer notified the master of thick smoke in the engine room. The master proceeded to the engine room and saw flames along the dry-exhaust pipe. The master extinguished the flames using a CO extinguisher at the entrance of the engine room. 2 At this point, the smoke and CO forced the master to leave the engine room. The master 2 dogged the door, verbally raised the alarm, and shut down the main engine. 2 All times in this report are eastern daylight time (Coordinated Universal Time minus four hours). - 4 - All hands promptly mustered on the main deck and were accounted for. Hatches were closed, the vessel’s position was plotted on the paper chart in use 3, and the chart was brought on deck. Handheld radios and the ship’s cellular telephone were also retrieved to ensure communications. The engine room remote fuel shut-off valve was activated and access to accommodations below decks was sealed off. Two fire pumps were started and a team composed of cadets and crew members began a chain of fire buckets to provide boundary cooling for the deck. Around 1630, the master reported the situation to the Prescott Coast Guard radio and a Mayday relay was broadcast on VHF channel 16. With heavy smoke still escaping the closed engine room hatch cover, the engine room’s fixed CO firefighting system was activated from the deck. Buckets were used to continuously cool 2 the deck near the engine room, a hose sprayed water into the engine room via a vent in the hatch, and the smoke began to diminish. At 1730, the Canadian Coast Guard (CCG) search-and-rescue (SAR) cutter Cape Hearne arrived and sent two crew members to assess the situation on the Fair Jeanne. One cadet, who had received a minor head injury, was transferred to the Cape Hearne and later sent by MEDEVAC to Kingston for further assessment. The cadet was released from hospital that evening. The cadets, wearing lifejackets, were evacuated by the CCG cutter’s fast-rescue craft (FRC) to the Cape Hearne, along with three crew members and the two naval personnel. This left six senior crew members and one CCG crew member on board. With minimal smoke now coming from the engine room, the pumps were temporarily shut off. Approximately 5 to 10 minutes later, however, smoke again began billowing from the engine room and, with the fire apparently re-igniting, both pumps were re-started. Water was pumped into the engine room via the forward vent in the hatch and the fire buckets were again used to cool the deck above. 3 Canadian Hydrographic Service chart No. 2064 - 5 - Subsequent Firefighting Activities By about 1830, eight vessels were on scene, including the fire boat Last Chance, from Clayton, New York, U.S.A., as well as a helicopter and a Hercules SAR aircraft from Trenton, Ontario. As firefighters from the Last Chance approached the Fair Jeanne, they noted grey smoke billowing from the vessel (see Photo 4). Upon request, four volunteer firefighters boarded the Fair Jeanne. Two of them donned self-contained breathing apparatuses (SCBAs) to fight the fire in the Photo 2. Front windows of the deckhouse broken by engine room, while the other two assisted firefighters (to ventilate the accommodation with equipment on deck. No international area) shore connections were fitted, nor were they required. The hoses and pumps from the Fair Jeanne were used, as the fire-hose couplings from the Last Chance did not match the onboard fittings. When the firefighters first opened the main cabin door, dense heavy smoke billowed out, reducing visibility inside to zero. Firefighters therefore requested that the fire-support team on the main deck break windows to ventilate (see Photo 2). This improved visibility and allowed firefighters to make their way down to the engine room door. When this door was opened, extremely hot, heavy, black smoke billowed out, and a large amount of flame rising one metre above the engine room floor was observed on the starboard side of the auxiliary engine. After extinguishing the engine room fire, firefighters noted a small amount of smoke still issuing from the engine room. Further investigation disclosed that the fire had spread into the insulation between the engine room deck head and the main deck floor. The insulation was removed and this secondary fire was extinguished. Due to an accumulation of firefighting water, vessel stability became a concern; the Fair Jeanne’s portable gasoline-powered pumps were used to remove an estimated one-metre depth of water from the crew’s quarters, most of it on the starboard side. After striking the remaining sails, the Cape Hearne towed the Fair Jeanne toward Kingston, where arrangements had been made to meet with a local tow boat, the Windigo. Under tow of the Windigo, the Fair Jeanne arrived at RMC at 0230 on 14 July 2007. Photo 3. Collapsed shelf in engine room where flammable goods were stored - 6 - Damage to the Vessel The vessel’s engine room had extensive heat, smoke, and water damage. An inspection of an engine room shelf that had collapsed revealed damage patterns indicative of localized hot spots 4 (see Photo 3) and the remains of burned/melted plastic containers were found on the shelf. It was discovered afterwards that flammable goods had likely been stored openly on a shelf in the engine room, thus contributing to the fire. Photo 4. Photo courtesy of Clayton Fire Several deckhouse windows were broken for Department ventilation and the accommodation had extensive smoke and water damage. Onboard Firefighting Equipment Firefighting equipment on board the Fair Jeanne included two portable gas-powered pumps, buckets, axes, extinguishers, and hoses. In addition, the engine room was equipped with a fixed CO firefighting system. The equipment did not include protective firefighter coats or SCBAs, 2 nor were these required. 4 TSB Engineering Laboratory report LP 095/07 (available upon request) - 7 - Post-Occurrence Testing Transmission Oil Filter Post-occurrence testing 5 of the hydraulic filter showed that the seal provided by the O-ring and Teflon sealant was ineffective. This caused a small leakage of a few drops of oil per minute. Furthermore, the location of the filter unit at the time was such that any leakage dropped onto the dry exhaust below. Transmission Oil Hose Post-occurrence testing revealed that, when the engine was running, transmission oil sprayed from a leak in the transmission hose onto the hot section of the dry-exhaust pipe. Further investigation found that the hose had a small slit, which likely pre-dated the fire. In addition, when the engine was shut down, the transmission oil level was checked and the sump was almost empty. The investigation revealed that the hose was worn and Photo 5. General view of layout of the may have been part of the original equipment installed auxiliary engine on board in 1981. An examination of other hoses and lines in the engine room did not reveal any components that may have broken or failed prior to the fire. Photo 6. Starboard wall showing the transmission Photo 7. Outboard face of the transmission oil oil hose placed where it had been hose showing the large wear mark (5), mounted. A small hole was found in the holes (6 to 8) and slit (9) in the outer cover hose, facing down and aft, toward the dry exhaust section 5 See footnote 4 - 8 - Battery Storage Arrangement A post-occurrence inspection of the engine room’s electrical wiring revealed that the compartment housing the main house-and-electronic battery bank was located within an accommodation space— on the lower deck in the after port side stateroom/cabin. Ventilation was intended to be provided by a plastic hose connected to the compartment (see arrow in Photo 8). This hose ran under the sole and up through a closet to a vent on the main deck. The vent, however, was found sealed and painted over. Crew Training and Certification Photo 8. Floor compartment housing the main house-and-electronic battery bank The certificates held by the master were a Master 500-tonne Near Coastal and a First Mate Intermediate Voyage. This was the master’s fifth season in command of the vessel. The mate held a Watchkeeping Mate certificate and had previously served three seasons as a petty officer. This was his first season as a mate. The remaining seven crew members held no certificates of competency or marine emergency duties (MED) certificates, but had sailed on the vessel for various lengths of time over the previous seasons. According to the vessel’s letter of compliance (for sail training vessels in Transport Canada’s Ontario Region) the Fair Jeanne is required to carry one certificated master (350-tonne minimum), one certificated mate (Watchkeeping Mate certificate minimum) and five deckhands (each with MED training in courses A2, B1, and B2). By comparison, the United States Coast Guard Marine Safety Manual, Volume III, Marine Industry Personnel, provides information and program interpretations on statutory and regulatory issues relating to the manning of sailing school vessels operated by the U.S. Merchant Marine and state Maritime Academies. In addition to taking into consideration the vessel’s route and specific characteristics, vessels equipped with one or more masts must carry a seaman (able seaman or deckhand, as appropriate) for each mast and an additional able seaman for each square-rigged mast. Standards for Sail Training Vessels At present, no mandatory standards address sail training vessels in Canada. TP 13313, Standards Relating to the Design, Construction and Operational Safety of Sail Training Vessels, is a reference document developed in 1999. Compliance is voluntary. - 9 - A number of issues have arisen as a result, including:  Registration: This is inconsistent across Canada, as some sail training vessels are registered as pleasure craft;  Crewing: Sail training vessels registered as pleasure craft are not subject to the requirements of the Marine Personnel Regulations and are not required to carry master, mate, and certificated engineers;  Letter of Compliance (LOC): Voluntary inspections leading to LOCs are issued to sail training vessels by Transport Canada (TC) in Ontario. However, TC inspectors have limited guidance regarding the requirements for issuing such a letter;  Age of trainees: As part of a sail training vessel’s requirements, the active participation of trainees—some of whom are as young as 13—are often considered by an operator to be essential to the efficient operation of the sailing vessel. This effectively makes them crew members. The Marine Personnel Regulations, however, set a minimum age of 16 for persons employed, engaged, or working on a Canadian vessel 6;  Passengers: Some sail training vessels offer cruises and carry passengers other than trainees as a way of raising funds. However, they are not built, inspected, or certified as passenger vessels; and  Foreign sail training vessels sailing between Canadian ports: Foreign vessels applying for a coasting license are inspected to Canadian standards prior to being granted a permit. However, there are no applicable Canadian standards addressing sail training vessels. Safety Management The company operating the Fair Jeanne did not have a formal safety management system (SMS) in place, nor was an SMS required. Although there were some written policies and procedures available on board, these did not provide guidance to the crew for routine and preventative maintenance, or when operating the vessel under routine or emergency circumstances. There are particular risks associated with sail training operations, such as the dangers of working with heavy sails and rigging under strain, working aloft, the isolated environment, and the number of inexperienced trainees/cadets who may not be available to assist in times of emergency. Effective safety management requires all organizations, large or small, to be cognizant of these operational risks, to be competent to manage those risks, and to be committed to operating safely. However, there is no regulatory requirement in Canada for operators of sail training vessels to practice safety management. 6 Marine Personnel Regulations, section 302