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Workaround method to restart main engine led to March 2017 catastrophic failure of machinery aboard Atlantic Destiny near Halifax, Nova Scotia

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Dartmouth, Nova Scotia, February 26, 2018 – In its investigation report (M17A0039) released today, the Transportation Safety Board of Canada (TSB) found that a workaround method of bypassing engine controls to restart the engine led to the March 2017 catastrophic failure of machinery aboard the fishing vessel Atlantic Destiny near Halifax, Nova Scotia.

On 14 March 2017, the fishing vessel Atlantic Destiny, with 31 people on board, sustained a breakdown of its main engine, as well as damage to its shaft alternators and machinery spaces, 200 nautical miles southwest of Halifax. The fishing vessel Atlantic Preserver towed the disabled fishing vessel to Shelburne, Nova Scotia. No injuries or pollution were reported.

Multiple unexpected engine shutdowns had occurred on the Atlantic Destiny's previous trips over the last few years. On the day of the occurrence, as on previous occasions, the main engine was restarted by using a rope and wrench to bypass the governor, thereby disabling all engine speed controls. While the engineer was in the control room resetting various systems, a deckhand, who had no experience or training in the engine room but who had been assisting with the workaround, inadvertently set the fuel injection to 80% instead of 0%. Once the engine started again, attempts to reduce the engine speed at the local control panel were unsuccessful because of the disabled engine controls.

The investigation found that the main engine overspeed protection was also compromised by speed sensors that were either installed incorrectly or functioning intermittently due to electrical shorting, and that the engine emergency stop mechanism was inoperable due to wear and resistance. Consequently, the engine emergency stop mechanism could not shut down the engine, and the gearbox fluid couplings failed in an instantaneous overstress rupture due to excessive rotational speed.

In addition, the investigation determined that the company did not ensure that engine crews were performing periodic testing of engine safety systems. If engine safety systems are not periodically tested in accordance with manufacturers' recommended schedules and repaired accordingly, there is a risk that engine safety systems will not operate as intended when a malfunction occurs. As well, if untrained personnel are placed in an unfamiliar work environment, there is a risk that they will perform tasks incorrectly, which could lead to an accident or an injury.

Following this occurrence, the vessel owner installed shielding around the fluid couplings and replaced the aluminum floor plates above the fluid couplings with stronger ones.

of bypassing engine controls to restart the engine led to the March 2017 catastrophic failure of machinery aboard the fishing vessel Atlantic Destiny near Halifax, Nova Scotia.

On 14 March 2017, the fishing vessel Atlantic Destiny, with 31 people on board, sustained a breakdown of its main engine, as well as damage to its shaft alternators and machinery spaces, 200 nautical miles southwest of Halifax. The fishing vessel Atlantic Preserver towed the disabled fishing vessel to Shelburne, Nova Scotia. No injuries or pollution were reported.

Multiple unexpected engine shutdowns had occurred on the Atlantic Destiny's previous trips over the last few years. On the day of the occurrence, as on previous occasions, the main engine was restarted by using a rope and wrench to bypass the governor, thereby disabling all engine speed controls. While the engineer was in the control room resetting various systems, a deckhand, who had no experience or training in the engine room but who had been assisting with the workaround, inadvertently set the fuel injection to 80% instead of 0%. Once the engine started again, attempts to reduce the engine speed at the local control panel were unsuccessful because of the disabled engine controls.

The investigation found that the main engine overspeed protection was also compromised by speed sensors that were either installed incorrectly or functioning intermittently due to electrical shorting, and that the engine emergency stop mechanism was inoperable due to wear and resistance. Consequently, the engine emergency stop mechanism could not shut down the engine, and the gearbox fluid couplings failed in an instantaneous overstress rupture due to excessive rotational speed.

In addition, the investigation determined that the company did not ensure that engine crews were performing periodic testing of engine safety systems. If engine safety systems are not periodically tested in accordance with manufacturers' recommended schedules and repaired accordingly, there is a risk that engine safety systems will not operate as intended when a malfunction occurs. As well, if untrained personnel are placed in an unfamiliar work environment, there is a risk that they will perform tasks incorrectly, which could lead to an accident or an injury.

Following this occurrence, the vessel owner installed shielding around the fluid couplings and replaced the aluminum floor plates above the fluid couplings with stronger ones.

TSB

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