How an engine room fire ended up costing $1.2 million

A fire onboard the 600-foot-long chemical tanker ship Endo Breeze while the vessel was transiting outbound from Linden, New Jersey was extinguished by the crew, but the main damage was still to come.

Operation at sea, far from assistance, can add a different dimension to engineering: one of self-reliance. Ship crews are not always able to send components back to a manufacturer when they are at sea, and are used to improvisation, and solving problems on the fly.

This is a necessary way to act and solves many more problems than it causes. But on occasion, not following established procedures can lead to issues.

What happened onboard the Endo Breeze?

Endo Breeze, a chemical tanker flying the flag of Malta, was making its way to Raritan Bay, New York, preparing to depart for the upper New York Bay for bunkering fuel, when something unnerving happened. The vessel’s second and fourth engineers noticed a smell of fuel oil, getting increasingly more pronounced. On closer inspection, they found fuel everywhere.

As the second engineer opened the cover on the no.1 injector, oil sprayed across the engine room. Stemming the spray with a rag, they saw that the spray was originating from the banjo tube on the side of the injector (a pipe component connected through hollow bolts, the banjo tube is designed to allow oil to pass through).

The crew moved quickly to shut down the engine, but not quickly enough. At 7:13pm, the chief engineer called the captain to tell him to shut down the starboard engine; but less than a minute into this call, the situation escalated.

The oil burst into flames, which followed the track of spilled oil across the engine room floor and toward the second engineer. “Fire in the engine room, we need to stop the engines, zero pitch now,” the chief engineer told the captain, and pressed each engine’s emergency stop button.

Shortly after the crew had evacuated the engine room space and control room, the vessel lost electrical power. A diesel generator started up, bringing emergency power online.

Eight minutes later, at 7:21pm, the chief engineer activated the fire extinguishing system, filling the engine room with CO2. Around 40 minutes later, the New York Fire Department arrived at the vessel’s emergency anchorage, fixed their pumps to Endo Breeze’s fire main, and proceeded to fight the fire until 3pm the next day.

Reassembly procedures not followed

Subsequent investigation by the National Transportation Safety Board (NTSB) discovered that the fire was caused when fuel oil spraying from the starboard engine’s no.1 injector contacted the hot surface of the engine’s exhaust manifold and was carried across the engine room by trails of oil on the deck.

Recent engine diagnostics had identified unusual discrepancies in the exhaust gas temperature in 1 and 7 cylinders, and in maintenance operations the day before, the second engineer replaced the injectors as per protocol.

But it was discovered by the NTSB that during this time, the second engineer had not properly reattached the banjo tube, and that there was a substantial crack in the piping.

Although he told investigators he had followed the manufacturer’s procedures, the NTSB determined that: “It is likely that the engineer did not correctly follow the manufacturer’s reassembly procedure for the fuel injector pump.”

Fastening the bolts in the wrong order, the banjo tube was reattached diagonally, rather than straight. This led to a fracture in the tubing, and this, NTSB determined, was from where the spraying oil had originated.

When the second engineer ran the engine for testing purposes, the no-load condition didn’t generate sufficient pressure for a leak to show up. “But when the main engine was fully loaded with a full-ahead order, the expanding stresses (due to heat) caused the banjo tube to fracture,” NTSB clarified.

An expensive mistake

Ultimately, the incorrect reattachment of this piece of tubing, costing less than $100, led to $1.2m in damage to the vessel.

The engineer who fastened the bolts had worked on ships for some 17 years and had spent years maintaining medium-speed ship engines.

It would be reasonable to expect that during this time he had encountered various situations not covered in textbooks and would have had to make decisions based on initiative, and improvisation.

Yet faced with repeating a procedure he had doubtless executed many times before, for reasons unknown the instructions were not followed.

“Due to the high risk of fire associated with pressurised fuel, when working with diesel engine components, it’s critical to carefully follow manufacturer assembly procedures and review manufacturer manuals and guidance on a regular basis to ensure familiarity with correct maintenance procedures,” NTSB noted.

However much we may have mastered the task at hand, none of us are above needing to reread the manual.

Main image: A tanker loading fuel in Linden, New Jersey; credit: Shutterstock