BSafe Case Study 10 — Fernanda: Two Open Dampers and a Total Loss

A Fire That Started at the Switchboard

The fire detection panel alarmed at 1250 UTC, showing the machinery space and steering room. The master couldn't reset it and sent the bosun to check — heavy smoke on the starboard side of the engine room. The second engineer, returning to the engine room, met the bosun who told him the steering room was on fire; he hadn't heard the alarm himself. As he opened the engine room door and saw heavy smoke, the main engine stopped, causing a blackout. The bosun and a rating donned breathing apparatus, confirmed flames on the starboard side, and the general alarm was sounded.

Closing Down Under Pressure — Not Quite All the Way

The master made the call early to use the ship's fixed halon system. Before releasing it, the crew worked to secure the machinery space — closing dampers, shutting ventilation openings. Two fire dampers were left open when the halon was released, letting air continue feeding the fire and measurably reducing the halon's effectiveness at the exact moment it mattered most.

The situation kept deteriorating despite the halon. The master requested evacuation; the crew donned immersion suits and lifejackets and launched two life rafts in heavy swell, 6 miles offshore. A rescue helicopter had the entire crew off by 1456 UTC — no injuries, but the ship burned for 8 days before final extinguishment and was declared a constructive total loss. The investigation traced the fire's likely origin to the main switchboard.

What the Investigation Found

• The fire likely started in the main switchboard and spread upward through open accesses to the funnel, then to accommodation and the bridge.
• Two fire dampers left open during closedown let air feed the fire and reduced the halon system's effectiveness once released.
• The emergency fire pump was located in the steering gear room — rendered unusable by heavy smoke in the access, and the access hatch itself was too small to enter wearing breathing apparatus.
• Engine room housekeeping, flagged in past inspections, may have contributed to how the fire developed.
• The onboard emergency manual had clear fire prevention/detection measures, but the investigation recommended a full review to ensure they stayed ship-specific and adequate.
• The drill schedule required monthly fire drills but gave the master no guidance on what those drills should actually train — no defined training elements.

Recommended Actions

Direct from the investigation's findings:

1. Closedown for a fixed gas fire-suppression system needs a positive, checked confirmation that every damper and opening is actually closed — not an assumption that it's been done under the pressure of an active fire.
2. Emergency equipment location needs to account for realistic access conditions during the exact emergency it's meant to be used in — a fire pump unreachable through smoke, or an access hatch too small for BA, is a fire pump that doesn't exist when needed.
3. Housekeeping standards in machinery spaces are a fire-prevention control, not just tidiness — recurring inspection findings on this point deserve real follow-through.
4. A fire drill schedule needs defined training objectives, not just a frequency — ‘monthly’ without content guidance leaves masters to decide what's actually being trained, and whether it matches what a real fire like this one demands.

Human Element Analysis

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Related Reading

• BSafe Case Study 32 – another real fire-risk incident where the gap was between procedure and practice