Marine Transportation Safety Information Letter 03/23

May 05, 2023

Director General, Marine Safety and Security
Transport Canada
Ottawa, ON K1A 0N5

Subject :

Marine Transportation Safety Information Letter 03/23 (occurrence M22A0258)
Installed location of CO2 pilot cartridges and access to manual release levers

On 22 July 2022, a fire started in the engine room of the roll-on/roll-off ferry Holiday Island during its approach to Woods Islands, Prince Edward Island. All passengers and crew were safely evacuated. The fire continued to burn until the next day and the vessel began to take on water. The vessel was seriously damaged and removed from service.  The Transportation Safety Board of Canada investigation into this occurrence (M22A0258) is ongoing.

Investigation M22A0258 has identified potential issues regarding the installation of the CO2 smothering system onboard the Holiday Island, which may be present onboard other vessels. During the course of an investigation, the TSB may communicate safety issues before an investigation is complete. This communication is undertaken to ensure that those best able to take remedial action and effect change are made aware of the identified safety issues in a timely manner. As the TSB is not a regulator, the identified issue is related to safety and not necessarily to regulatory compliance. The identification of these issues is not intended to indicate they contributed to the occurrence.

The smothering system onboard the Holiday Island was changed to a Kidde manufactured system in 2016. A review of the onboard installation identified that the smothering system was designed to be activated (or emptied) into the protected space by the use of pilot cylinders. When opened, the pilot cylinders would then in turn activate the bank of cylinders to the protected spaces. The pilot cylinders could be activated either by pulling a cable remotely from the bridge, or by locally opening the manual release levers on each pilot cylinder.

The TSB observed that the manual release lever on at least 1 pilot cylinder was obstructed from being opened manually. The obstruction was caused by the location of a delay cylinder (Figure 1).

Figure 1. The pilot cylinder manual release levers (A and B) should open fully. Some opened fully (A) but 1 manual release lever (B) was obstructed by a discharge delay cylinder (C) (Source: TSB)
Image
The pilot cylinder manual release levers (A and B) should open fully. Some opened fully (A) but 1 manual release lever (B) was obstructed by a discharge delay cylinder (C) (Source: TSB)

The proper functioning and operation of a smothering system is critical in responding to an emergency. Installation contractors, service providers, inspection bodies, owners, operators, and vessel crews have an opportunity to inspect, identify irregularities, and propose corrective actions to these systems when they exist.

The foregoing is provided for whatever follow-up action is deemed appropriate. The TSB would appreciate being advised of any action that is taken in this regard.

Upon completion of investigation M22A0258, the Board will release its report into the occurrence.

Yours sincerely,

Original letter signed by

Clifford Harvey
Director, Marine Investigations

CC.

  • Vice-President, Marine Operations, NFL
  • Acting Regional Director, Programs, Transport Canada
  • Associate Director, Product Management, Kidde Fire Systems
  • President, DBCAN, Don Breton’s Fire Protection
  • Senior Surveyor in Charge, Lloyd’s Register Canada Ltd.