BSafe Case Study 30 — The CO2 System Was Meant to Save Them. The Wire Had Parted.

An Old Ship's Real Limitations

Built in 1943, the ship predated many safety features now mandatory: the main engine couldn't be stopped from the bridge, only locally or by closing fuel valves. Fuel supply lines had no spray shielding against a containment failure. Small fuel leaks on the supply and return lines were considered routine, temporarily fixed as they appeared without deeper investigation of why they kept happening. The engine room skylight, opened for ventilation along with some portholes and fire doors secured open, could only be closed via a remote winch control located inside the engine control room itself — or manually, from inside the space.

Flames, a Missed Alarm, and a System That Didn't Fire

At 2159, flames were spotted at the top of the main engine during routine rounds. The duty engineer couldn't reach the control room through the flames and heat, evacuated, and manually raised the alarm. Crew mustered — except the second engineer, who had slept through it. The emergency generator started, ventilation fans stopped, and by 2209 the chief engineer activated the quick-closing fuel valves and started the emergency fire pump. The skylight and some portholes remained open — heat and smoke made manual closure impossible, and the remote control sat unreachable inside the engine room itself.

The master ordered the fixed CO2 system activated as the primary means of fighting the fire. It failed to operate as designed — the release wires had parted, never opening the gas cylinders. A local release attempt from inside the CO2 room itself followed; as the room began filling with CO2, the chief engineer had to evacuate before completing it. Separately, the emergency fire pump was confirmed running with good discharge pressure — but no water was reaching the fire main, and initial troubleshooting couldn't identify why. The engine stopped at 2217; anchors were dropped. By 2231 smoke was visibly reducing, and by 2328, none was observed.

What This Illustrates

• Small fuel leaks treated as routine, repeatedly patched rather than investigated, are exactly the kind of normalised deviation that can seed a larger fire.
• A remote CO2 release mechanism is only as reliable as its physical release wire — a mechanical component that can fail silently until the moment it's actually needed.
• Critical remote controls (the skylight winch) located inside the very space they're meant to control during an emergency become unusable exactly when needed most.
• An emergency fire pump reporting normal operation and pressure gave false reassurance while water genuinely wasn't reaching the fire main — a fault the crew couldn't diagnose in real time.