Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2639
Initial Report
The vessel received poor-quality fuel during bunkering, which was not detected in the supplied samples. After departure, the ship lost propulsion in the middle of the night. This occurred because the fuel oil was supplied directly to the fuel oil service tank (FOST/day tank), bypassing the bunker, settling tanks, and purifier.
As a result, several fuel injectors required replacement, and all fuel had to be processed through the purifiers. This caused five hours of downtime during which the vessel was unable to manoeuvre. Fortunately, the vessel had ample sea room and calm conditions; under different circumstances, the situation could have led to serious consequences.
CHIRP Comment
This incident was not primarily a fuel quality issue but a fuel-handling failure. Fuel was delivered directly to the service tank, bypassing the bunker, settling, and purification systems, resulting in a complete loss of propulsion. Several injectors had to be replaced, and all fuel had to be processed through purifiers, causing five hours of downtime. Fortunately, calm conditions and ample sea room prevented more serious consequences. The event highlights the critical importance of following proper fuel-handling procedures, taking representative samples throughout the bunkering process rather than relying solely on supplier-provided samples, and maintaining readiness to respond promptly to engine issues. Even small deviations from standard routines can escalate quickly, underscoring the need for vigilance and strict procedural compliance to ensure safe operations.
Key Issues relating to this report
Human Factors related to this report
Communications – Fuel quality issues were not communicated effectively to relevant personnel. This can vary significantly from port to port, where supplier quality can vary.
Teamwork – Decisions appear to have been made without cross-checking or consultation.
Capability – There was a lack of training for those handling the fuel.
Key Takeaways
Check, comply, communicate—every hand matters for safe fuel at sea.
Regulators – Ensure comprehensive fuel quality checks, standardised procedures, and vigilant oversight of vessel monitoring and risk management systems.
Managers / Operations Leaders – Enforce strict fuel-handling compliance, thoroughly train crews, conduct risk assessments before deviations, and maintain supervision and feedback to prevent unsafe practices.
Crew / Engineers – Follow fuel handling and purification procedures strictly, communicate clearly, double-check work, and report anomalies promptly to prevent operational disruptions and safety risks. Raise a Letter of Protest if the supplied fuel is sub-standard.