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MINISTRY OF JUSTICE OF THE REPUBLIC OF LITHUANIA
TRANSPORT ACCIDENT AND INCIDENT INVESTIGATION DIVISION
Less serious accident on board Lithuanian flag
Ro-Pax ferry Regina Seaways
IMO 9458535
occurred on 2 October 2018
in the Baltic Sea
SAFETY INVESTIGATION REPORT
No. (L-18/17) 1A-136
20 June 2019
Gedimino ave. 30,
LT-01104 Vilnius
Tel. +370 266 2989
E-mail [email protected]
www.tm.lrv.lt/taits
http://www.tm.lrv.lt/taits
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The safety investigation is conducted in accordance with
Casualty Investigation Code, adopted by IMO resolution MSC.255(84),
Commission Regulation (EU) No. 1286/2011 of 9 December 2011
adopting a common methodology for investigating marine casualties
and incidents developed pursuant to Article 5(4) of Directive
2009/18/EC of the European Parliament and of the Council, Article
48 of Maritime Safety Law of the Republic of Lithuania and
Description of the procedures for preparation and submission of
marine accident and incident investigations, reports and safety
recommendations, approved by the Order No. 1R-386 of the Minister
of Justice of the Republic of Lithuania on 30 December, 2015.
The purpose of the safety investigation is to prevent the
occurrence of accidents and
incidents in the future, rather than establish blame or
liability. The safety investigation is
conducted independently of any judicial or administrative
proceedings, has no aim to
apportion blame or liability, is not related to them, and have
no impact thereupon.
Each safety investigation shall be concluded with a report in a
form appropriate to the type and seriousness of the accident or
incident. The report shall contain, where appropriate, safety
recommendations, which shall in no case create a presumption of
blame or liability for accident or incident.
The safety investigation report shall not be used as evidence in
a judicial or administrative process seeking to apportion blame or
liability, because this was not established in the course of the
safety investigation and it is not compatible with the objective of
the safety investigation.
The information is published to inform the maritime industry and
the public of the general circumstances of the accident or
incident. Extracts may be published without specific permission
providing that the source is duly acknowledged, the material is
reproduced accurately and it is not used in a derogatory manner or
in a misleading context.
This is a courtesy translation by the Transport Accident and
Incident Investigation Division of the Safety Investigation Report.
As accurate as the translation may be, the original text in
Lithuanian is the authentic version and the work of reference.
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CONTENTS
SUMMARY
............................................................................................................
v
Synopsis
......................................................................................................................
v
Safety Investigation
......................................................................................................
v
1. FACTUAL INFORMATION
................................................................................
1
1.1. Narrative
...............................................................................................................
1
1.1.1. Course of the accident
...............................................................................
1
1.1.2. Shore authority involvement and emergency response
.............................. 2
1.2. Ship’s particulars
...................................................................................................
3
1.3. Data about the crew
..............................................................................................
3
1.4. Data about main
engines.......................................................................................
4
1.5. Data about the damages
.......................................................................................
5
1.6. Survey and examinations of damaged engine components
................................... 7
1.6.1. Results of examination ordered by Operator of seagoing
ship ................... 7
1.6.2. Results of survey and examination by Engine manufacturer
...................... 8
1.7. Quality assurance of production of big end bearing housings
................................ 9
1.8. Safety actions after the accident
............................................................................
9
2. ANALYSIS
.......................................................................................................
11
2.1. Cause of main engine breakdown
.......................................................................
11
2.2. Cause of fire
........................................................................................................
11
2.3. Actions taken after the
accident...........................................................................
11
3.
CONCLUSIONS...............................................................................................
13
Cause of the accident
................................................................................................
13
4. SAFETY
RECOMMENDATIONS.....................................................................
15
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SUMMARY
Owner of seagoing ship Grimaldi Holding SPA
Operator of seagoing ship DFDS Seaways JSC
Building yard of ship Nuovi Canterie Apuani,
Italy
Name of ship Regina Seaways
Type of ship Ro – Ro cargo passenger (Ro-Pax)
Flag of ship Republic of Lithuania
IMO number 9458535
Place of the accident Baltic Sea
57° 37.4‘ North
019° 18.6‘ East
Date and time of the accident 2 October 2018
13:35 (10:35 UTC)1
Injuries/fatalities None
Persons on board Crew - 41
Passengers - 244
Truck drivers - 50
Owner of seagoing ship Grimaldi Holding SPA
Synopsis
On 2 September 2018, at 13:35, Ro-Pax vessel Regina Seaways with
335 persons and cargo on board, on her way from Kiel, Germany to
Klaipeda, Lithuania, sustained damage of main engine No. 2,
followed by automatic shutdown of both main engines and fire in the
engine room. Rescue operation was ready to commence, however crew
extinguished fire and successfully started main engine No. 1 and
ship resumed her voyage to Klaipėda using her own power and 22:07
moored alongside quay in port of Klaipeda.
Safety Investigation
DFDS Seaways JSC designated person immediately after the
accident notified Investigator-In-Charge of Maritime Accidents and
Incidents about the accident. On the same day,
Investigator-In-Charge of Maritime Accidents and Incidents
1 Ship‘s time is used in the report.
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informed German Federal Bureau of Maritime Casualty
Investigation (Bundesstelle für Seeunfalluntersuchung) and started
a preliminary assessment of the accident.
On 9 October 2018, it was decided to start safety investigation
of less serious accident.
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1 FACTUAL INFORMATION
1.1. Narrative
The circumstances of the accident are described on the basis of
information, gathered by interviewing ship’s crew members, using
data from voyage data recorder (VDR), ship’s log book, engine room
log book, engines’ computer and Safe Sea Net system.
1.1.1. Course of the accident
Ro-pax ferry Regina Seaways was on scheduled route Kiel –
Klaipėda. On 1 October 2018, at 21:00 Regina Seaways departed from
port of Kiel, Germany.
13:34 ship was in Baltic Sea, Russian Federation exclusive
economic zone (Fig. 1). Both main engines were loaded evenly, at
about 65 % rate. Ship’s speed was about 23 knots.
Fig. 1. Ship’s route (Safe Sea Net chart)
On 13:35 huge vibration, lasting about 30 seconds, was felt on
board. Both main engines automatically switched off. Deck cadet,
who was in the engine room standing close to one of the diesel
generators, which was in operation, noticed huge amount of white
and black smoke and immediately left the engine room. Later, third
engineer visited engine room and confirmed that the engine room is
full of white and dense black smoke. He immediately left the engine
room as well.
Lithuanian search and rescue area
Regina Seaways resumes her voyage 17:28 57°38.5‘N 019°32.9‘E
Russian Federation search
and rescue area
Time and place of the accident 13:35 57°37.4‘N 019°18.6‘E
Regina Seaways alongside quay in Klaipėda port 22:07
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13:37 high pressure fresh water firefighting system ‘HI-FOG’ in
the engine room was automatically activated and remained
operational until about 13:57. In the engine room, through video
transmission equipment, thick fumes were observed, heat
detected.
13:38 the general alarm activated by the command of the master.
Persons on board notified about fire in engine room from the
bridge. Ship’s crew service instructed to start evacuation of
passengers.
13:42 by the command of the master, crew instructed to activate
CO2 fire extinguishing system in the engine room. Crew started to
prepare CO2 fire extinguishing system for activation. Ventilation
in the engine room has been switched off, ventilation openings has
been closed, doors has been verified to be closed and nobody has
left inside the engine room. Oil and fuel supply pumps switched
off, oil and fuel valves closed.
13:52 CO2 fire extinguishing system has been activated by the
crew.
14:05 it was determined that the temperature of bulkheads,
adjacent to the engine room, does not rise.
15:11 it was decided by the crew to inspect the engine room.
15:27 after the inspection of the engine room by the crew, no
fire spots were detected.
15:57 two diesel generators started, steam boiler was switched
on. Visual inspection of engine room was carried out by the crew.
It was determined, that main engine No 2 (hereinafter - ME2) has
visual damages, while main engine No 1 (hereinafter - ME1) remained
intact. ME1 crankcase was inspected, no damages were detected.
17:28 ship’s ME1 was started.
17:30 voyage to Klaipėda was resumed by ship‘s own power. Ship‘s
speed was about 13 knots.
17:58 she left Russian Federation’s search and rescue area.
22:07 arrived to port of Klaipėda and moored alongside quay.
Persons on board sustained no injuries during the voyage.
1.1.2. Shore authority involvement and emergency response
13:40 MAYDAY2 request was given via VHF3, MF/HF4 and INMARSAT5
systems. Notification about fumes and possible fire in the engine
room given.
13:41 Klaipėda Maritime Search and Rescue Co-ordination Centre
received distress alert from Regina Seaways, informed relevant
Lithuanian shore authorities and commenced preparations for rescue
operation by directing helicopter and ships for passengers
evacuation from the ship.
13:44 Crew established contact with Kaliningrad Maritime Search
and Rescue Co-ordination Centre (MRCC Kaliningrad), which was in
charge in organising rescue operation until ship left Russian
Federation’s search and rescue area. Passengers were instructed by
the crew to gather at the reception, pick up necessary items.
2 Very high frequency radio communications. 3 Medium
frequency/High frequency radio communications. 4 Two-way data and
messaging communication services. 5 An emergency procedure word
used internationally as a distress signal in voice-procedure radio
communications.
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1.2. Ship’s particulars
Particulars of Ro-Pax ferry Regina Seaways (Fig. 2) are provided
in Table 1.
Fig. 2. Regina Seaways (Photo DFDS Seaways JSC)
Table 1. Regina Seaways particulars
Flag, registration Flag of the Republic of Lithuania. Registered
in the Register of Seagoing Ships’ of the Republic of
Lithuania.
Classification society Registro Italiano Navale (RINA)
Identification International Maritime Organisation (IMO) No:
9458535
Call sign: LYTO
Maritime Mobile Service Identity (MMSI) number: 277466000
Main characteristics Gross tonnage: 25666
Length: 198,99 m
Breadth: 26,6 m
Building yard of ship Nuovi Canterie Apuani,
Italy
Year of build 2010
Minimum safe manning Number of crew, indicated in minimum safe
manning document - 18
Cargo allowed Ro-Ro cargo (trailers, lories, cars, etc.)
1.3. Data about the crew
Engine room team consisted of chief engineer, second engineer,
third engineer, officer in charge of an engineering watch, two
motorman and two cadets. During the accident, third engineer was on
watch in the engine room central control station and one of the
cadets was in the engine room and standing close to the one of the
diesel generators, which was in operation.
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1.4. Data about main engines
Regina Seaways propulsion system consisted of two main engines
(ME1 – port side and ME2 – starboard side), two reductors and two
variable-pitch propellers. Each main engine, via reductor, by tail
shaft was connected with variable-pitch propeller. ME1 and ME2 were
designed to be operated independently from each other. Ship’s speed
was regulated by changing the propeller’s pitch position and
engines’ revolutions. The engine room was equipped with three
diesel generators to supply the vessel with electricity. Ship also
had an emergency diesel generator, installed on the platform,
arranged between the fourth and fifth decks.
Manufacturer of main engines W12V46 – Wärtsilä (hereinafter
referred as Engine manufacturer). They are twelve cylinder V-shape
non-reversible four stroke turbocharged, fuelled by heavy fuel oil,
diesel engines. Nominal power of one engine is rated at 12600 kW,
nominal revolutions - 500 rpm. In Instruction manual No. DBAB169064
of engine W12V46 (hereinafter referred as Instruction manual) main
components of the engine are shown in Fig. 3. The cylinder units of
the engine are numbered by using letter and number combination.
Letter means the side (bank) of the engine – A or B bank, and the
number means the engine’s cylinder unit number.
Crankcases of both main engines were equipped with oil mist
detection system, designated to prevent possible explosion by
switching off the engine when oil mist is detected. Immediately
after the accident oil mist detection system activated automatic
shutdown of ME2 and 5 seconds later - ME1, although ME1 remained
undamaged. Taking into account that crankcases of both engines (ME1
and ME2) were connected to each other via ventilation pipes, the
reason for automatic shutdown of ME1 was explained by oil mist
detection system manufacturer Schaller Automation Industrielle
Automationstechnik GmbH & Co in the following way:
‘The most likely option is that ME1 was flooded with smoke from
ME2 fire. As
the oil mist detection system is monitoring the crankcase by
light intensity, any
opacity will be detected – either by oil mist, blow by or fire
smoke.’
Fig. 3. Components of main engine W12V46 (Instruction
manual)
Piston
Gudgeon pin
Cylinder liner
Connecting rod, upper part
Connecting rod big end
bearing housing, upper
part
Crankshaft
Connecting rod big end
bearing housing, lower part
Crankcase
Crankshaft counterweight
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Main engines’ connecting rods are a three piece design with
hydraulically tightened studs and nuts. They converts the
reciprocating motion of the pistons to a rotating motion of the
crankshaft. Connecting rod components and piston are shown in Fig.
4. Here 2 – Piston, upper part; 3 – Piston, lower part; 4 –
Connecting rod, upper part; 5 – Compression shim; 6 – Big end
bearing housing, upper part; 7 – Big end bearing housing, lower
part; 8 – Gudgeon pin; 9 – Securing ring; 10 – Connecting rod stud;
11 – Connecting rod nut6; 12 – Big end bearing housing stud; 13 –
Big end bearing housing nut.
Fig. 4. Connecting rod and piston of engine W12V46 (Instruction
manual)
Big end bearing housing, unit B4, on the day of the accident has
run 45473 hrs. Instruction manual provides no limits of running
hours nor instructs to carry out fatigue tests or examinations
after certain period of operation.
1.5. Data about the damages
ME2 damages were located in the section of A4 and B4 cylinder
units. Both sides of crankcase were damaged, maintenance covers of
both sides were broken from inside, oil was spotted out into the
engine room. Some ME2 damaged parts were found in the crankcase
(Fig. 5, 6), some in the engine room (Fig. 7).
Cylinder liners were broken, connecting rods of A4 and B4
cylinder units were damaged. Crankshaft, engine block and crankcase
were damaged. Crankshaft both counter weights of A4 and B4 units
were ripped away. Upper parts of the pistons were found separated
from the lower parts, which were smashed in pieces. The connecting
rod studs of A4 and B4 units were ripped off.
No signs of seizure on the upper parts of the pistons and no
fretting on the pistons lower part and upper part mating surfaces
were observed. Big end bearings of both A4 and B4 units have had
normal running surface, no signs of bearing seizure. The contact
surface of compression shims, big end bearing housings, upper and
lower parts, were in normal condition, no signs of fretting.
Gudgeon pins had normal contact surface, no signs of fretting.
Surface of crankshaft crankpin had impact damages with no signs of
fretting.
6 In the Instruction manual, Fig. 4, the arrow 11 points
incorrectly to the stud (should be pointed to the nut, slightly
below).
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Safety investigation report
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Fig. 5. ME2 outside damages, starboard side
Fig. 6. ME2 outside damages, port side (trapped A4 big end
bearing housing, lower part)
Fig. 7. Connecting rod big end bearing housing, upper part, B4
unit, found in vicinity of ME2 on starboard side of the engine
room
Broken maintenance cover of the crankcase
Connecting rod, upper part
Counterweight
ME2 starboard side
Connecting rod big end bearing housing, upper part, B4 unit
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Big end bearing housing, lower part, unit B4, was found inside
the crankcase, fractured in two pieces (Fig. 8), no excessive
external impact damages noticed.
Fig. 8. Fractured big end bearing housing, lower part, B4
unit
Damage caused by the fire to the engine room and to the
equipment, adjacent to ME2, was not significant. However, some
cleaning and replacement of some equipment, installed in vicinity
to the ME2 in the engine room, was required.
1.6. Survey and examinations of damaged engine components
1.6.1. Results of examination ordered by Operator of seagoing
ship
Operator of seagoing ship ordered examination of B4 unit
fractured big end bearing housing, lower part, accompanied with big
end bearing shells, compression shims (including compression shim
of connecting rod A4), studs, nuts, big end bearing housing, upper
part (Fig. 4, 9). Examination was carried out by Force Technology
company in Denmark.
Fig. 9. ME2 parts, unit B4 (photo by Force Technology)
Halves of fractured big end bearing housing, lower part
Big end bearing housing, upper part
A4 and B4 compression shims
Big end bearing shells
Big end bearing housing nuts
Big end bearing housing studs
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In the Examination report of failed big end bearing housing of
23 November 2018, the following is stated:
‘The purpose of the examination was to determine the cause of
failure, applying
non-destructive testing only.
PMI (Positive Material Identification) was performed on the
peculiar looking
embedded foreign object and on the fracture surface itself.
The examination indicates that the nuts and big end bearing
housing, lower part,
have not been loose prior to the accident, .
The failure of the big end bearing housing, lower part, is
caused by fatigue,
triggered by a foreign inhomogeneous, not fully molten embedded
object in the
cast steel. The damage to the other engine parts are collateral
damage.’
A close-up view of fatigue fracture surface of failed B4 big end
bearing housing is provided in Fig. 10.
Fig. 10. Close up view of fatigue fracture (photo by Force
Technology)
1.6.2. Results of survey and examination by Engine
manufacturer
On 11 October 2018, the draft Engine breakdown site survey
report was released by Engine manufacturer. Among others, the
following conclusions were provided in the report:
‘Possible cause for the breakdown is big end bearing housing
failure of B4 unit.
. No excessive external impact damages on the bearing housing
are
visible.’
Engine manufacturer also carried out examination of components,
provided in Fig. 9, in Finland. Cut out samples of fracture surface
of failed big end bearing housing were examined using scanning
electron microscope and energy dispersive spectrometry (SEM/EDS)
analysis methodology. In examination report of 20 December 2018, is
stated:
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‘In EDS analysis of the surface no strange elements noted. Some
slightly
increased amount of Al7 and Si8 and only marginal amount of
oxygen indicating
a void in solid material instead of open defect to surface. The
defect surface is
likely created in solidification phase when some voids had been
formed in
material.
The big end bearing housing B4 had cracked in the middle of the
lower part of
the housing. The fracture had started in multiple places from a
large defect and
propagated sideways and inwards by fatigue, reaching gradually
the bearing
bore before the final failure. The split surface of housing
halves and the support
surface towards connecting rod showed no signs of poor
tightening of housing
or connecting rod screws, indicating that the tightening had
been adequate.
The large defect in material was void, formed during
manufacturing process of
the raw steel bar (ingot). During the forging process the void
had been deformed,
but the void surfaces were still separated to each other. Due to
limited oxidation
of void surfaces the defect has been a closed space even though
reaching nearly
to the surface. No particular slack inclusions was noted in
material.
Material structure is normal tempered martesite/bainite with no
changes in near-
by areas of the defect. Material hardness and related tensile
strength fulfils the
specification and have therefore not contributed to the failure.
Material analysis
inspected with XRF9 analyser corresponds to the specified
material type with
adequate accuracy.’
1.7. Quality assurance of production of big end bearing
housings
On 14 March 2019, Engine manufacturer informed about the
following:
‘Production of the concerned BEBHs10 has been carried out in
accordance with
the QI11 in force at the time and approved by the classification
societies.
Manufacturing of components was made in accordance with to the
industry
standards used at the time. The raw material has been produced
by casting
process and the process variables contributing to the quality
are monitored,
followed by NDT (Non-Destructive Testing) sample testing.
However, due to the
incident there is a reason to suspect that this specific casting
batch in concern
may contain units not fully meeting the requirements, described
in QI in force at
the time.’
1.8. Safety actions after the accident
On 8 March 2019, Operator of seagoing ship informed that Engine
manufacturer carried out main engines’ big end bearing housings’
PAUT12 and MT13 inspections on Regina Seaways and her sistership
Victoria Seaways. After the inspections, Engine manufacturer
recommended to replace one big end bearing housing on Regina
Seaways’ main engine and two big end bearing housings on Victoria
Seaways’ main engine. Operator of seagoing ship followed the Engine
manufacturer’s recommendations.
7 Aluminium 8 Siliceous 9 X-ray-Fluorescence 10 Big end bearing
housings 11 Quality instruction 12 Phased Array Ultrasonic Test 13
Magnetic Testing
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In addition, Operator of seagoing ship informed, that it is
planned to inspect big end bearing housings of main engines of
other sister ship Athena Seaways.
On 14 March 2019, Engine manufacturer informed about the
following:
‘After the incident Wärtsilä has conducted PAUT for the
remaining BEBHs on
the concerned vessel Regina Seaways and on the sister vessel
Victoria
Seaways to ensure the integrity of components. Wärtsilä has
identified the
BEBHs belonging to the same casting batch and will commence a
PAUT
inspection campaign to minimize the risk for similar accidents
and will be in direct
contact to the customers in concern. For new engines production
Wärtsilä has
introduced an automated PAUT inspection for 100% of the BEBHs in
2017.’
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2 ANALYSIS
2.1. Cause of main engine breakdown
As the moving contact surfaces of pistons, connecting rod big
end bearings, gudgeon pins, crankshaft pin had no signs of
fretting, ME2 breakdown was not caused by improper lubrication of
relevant components of A4/B4 units.
Taking into account the results of performed examinations, and
that the relevant mating surfaces of B4 big end bearing housing
parts (6 and 7 components, Fig. 4) and compression shim (5, Fig. 4)
were found in normal condition, with no signs of fretting, it can
be stated that the tightening of relevant connecting rod nuts, unit
B4, was adequate.
Engine manufacturer provided no instructions regarding the
limits of running hours of connecting rod big end bearing housing
nor instructed to carry out tests or examinations after certain
period of operation. Taking into account the above statements, the
breakdown of the engine was not related to its maintenance or
operation.
Big end bearing housing, lower part, unit B4, was found
fractured in two pieces (Fig. 8). As no excessive external impact
damages on the halves of the housing were visible, two
examinations, independent from each other, were carried out. Both
examinations concluded, that the B4 big end bearing housing, lower
part, failure was caused by fatigue. The fatigue crack was
initiated due to the large defect in material, which was formed
during the production process. The failure of big end bearing
housing, lower part, unit B4, was a direct cause of the ME2
breakdown. Damage of other parts of the engine was a collateral
damage.
2.2. Cause of fire
Failure of components of A4 and B4 units resulted in the
breakdown of both sides of the crankcase in A4/B4 unit area. Some
components of A4 and B4 units were thrown away from the crankcase
to the engine room. Certain amount of lubricating oil escaped to
the engine room and ignited. It was the reason of fire in the
engine room.
As rescue operations, due to the fire on board, were not
commenced, actions, related to preparation to the rescue operation
were not analysed.
2.3. Actions taken after the accident
In order to eliminate the risk of similar occurrences on its
ships, Operator of seagoing ship initiated and carried out
inspections of big end bearing housings of main engines on Regina
Seaways and her sister ship Victoria Seaways, and
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12
replaced them as was recommended by Engine manufacturer after
the inspection.
Engine manufacturer informed, that it has identified the big end
bearing housings belonging to the same casting batch and will
commence a PAUT examination campaign to minimize the risk for
similar accidents and will be in direct contact to the customers in
concern. However, it is still unclear, when such inspection
campaign is planned to be launched and when it is planned to
finish, which engines in service are at such risk and how such
campaign will be organised, including allocation of necessary
recourses.
The following Safety Recommendation is therefore made:
SR-2019-L-01
Engine manufacturer Wärtsilä is recommended to identify ships
with installed
engines with connecting rod big end bearing housings at risk,
propose and
implement measures to eliminate such risk.
As since 2017 Engine manufacturer has introduced automated PAUT
inspections for all big end bearing housings, the possible risk of
reliability of newly manufactured big end bearing housings,
according to Engine manufacturer, is under control.
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3 CONCLUSIONS
Cause of the accident
The cause of the main engine breakdown was the failure of
connecting rod big end bearing housing, lower part. The failure
occurred due to fatigue crack in connecting rod big end bearing
housing, lower part, which was initiated due to the large defect in
material, which was formed during the production process. Damage of
other parts of the engine as well as the cause of the fire in the
engine room was a result of the failure of connecting rod big end
bearing housing. The breakdown of the engine was not related to its
maintenance or operation.
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4 SAFETY RECOMMENDATIONS
Safety recommendation means a proposal of a safety investigation
authority, based on information derived from a safety investigation
or other sources such as safety studies, made with the intention of
preventing accidents and incidents
Safety recommendations shall in no case create a presumption of
blame or liability for an accident or incident.
SR-2019-L-01
Engine manufacturer Wärtsilä is recommended to identify ships
with installed
engines with connecting rod big end bearing housings at risk,
propose and
implement measures to eliminate such risk.
