Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2319
Initial Report
After a period of maintenance in dry dock, a motor yacht was moved to a repair berth. Shore power was unavailable, and one of the yacht’s generators was started. The captain was not made aware that shore power was lacking, nor told that the generator had been started.
During a pre-sail survey, the engine room (ER) ventilation dampers had been shut by the contractors. In the haste to move out of the dry-dock, the crew did not have enough time to fully check the condition of these, so failed to notice that they were still closed. This raised the temperature in the ER, and an emergency escape hatch was opened to improve ventilation. A while later, the ER fire alarm sounded. The captain briefly checked the ER, observed haziness but no strong odour or visible fire source, and closed the door.
The engineer and deckhand donned breathing apparatus and entered the ER. They discovered smoke near the running generator, which was shut down to minimise fire risk. However, this left the vessel without power. The emergency hatch was also closed.
While attempting to respond to the incident, several issues were discovered: the emergency fire pump was difficult to operate, the emergency generator was inoperative, smoke detectors and atmosphere testing equipment were unavailable, and the fire system’s uninterruptible power supply battery had failed. Unable to monitor the ER, the master activated the CO2 system, which did not operate properly because it had been incorrectly configured. The captain and crew were unaware that the CO2 cylinder valves had to be held open until they were fully discharged.
The local emergency services intervened and made the space safe for re-entry. Subsequent investigation revealed that hot exhaust gas leaking from a malfunctioning exhaust valve caused the fire, which was made worse because the closed ventilation dampers limited air circulation in the compartment.
CHIRP Comment
Taking vessels into and out of dry dock is a complex and high-risk operation that requires very clear communications between contractors, dockyards, and vessel crews. This is particularly true when the responsibility for maintaining or operating the vessel, its fixtures, and other equipment is transferred.
It is essential that the schedule for bringing a vessel out of dry dock allows sufficient time for the crew to conduct thorough inspections of their assigned equipment and spaces. They must also be able to re-check systems if external surveyors make modifications, as with the ventilation dampers.
While owners may prefer to prioritise hotel services, safety systems must take precedence. Beneath the polished exterior of a large superyacht, it remains a seagoing vessel where safety is paramount. A significant cultural shift in management is needed to ensure safety is consistently the top priority.
Time is also needed for the crew to become familiar with the operation and maintenance of the equipment and to become proficient in routine and emergency modes of operation.
Equally important, they need time to learn how to function as a team. The fact that the captain was not informed of the power issues or the running of the generator suggests that they had not had the opportunity to work as a single, efficient crew. This includes reviewing (or developing) suitable risk assessments for every stage of the vessel’s emergence from dry dock and return to seagoing operations.
Key Issues relating to this report
Capability— After any maintenance period, the crew need time to identify emergent defects, ensure that equipment is configured correctly, and they are correctly trained to operate it safety.
Communications— Defects and changes in operational readiness must be reported to the captain.
Teamwork– Teams need time to gel as a coherent and effective unit. Management should plan so that the drydock crew have sufficient time to establish good teamwork.
Alerting- Given the situation on board with non-operational essential safety appliances, would you have alerted your head of department.