MINISTRY OF JUSTICE OF THE REPUBLIC OF TRANSPORT ACCIDENT AND INCIDENT INVESTIGATION DIVISION

Less serious accident on board Lithuanian flag Ro-Pax ferry Regina Seaways IMO 9458535 occurred on 2 October 2018 in the

SAFETY INVESTIGATION REPORT

No. (L-18/17) 1A-136 20 June 2019

Gedimino ave. 30, LT-01104 Vilnius Tel. +370 266 2989 E-mail [email protected] www.tm.lrv.lt/taits

The safety investigation is conducted in accordance with Casualty Investigation Code, adopted by IMO resolution MSC.255(84), Commission Regulation (EU) No. 1286/2011 of 9 December 2011 adopting a common methodology for investigating marine casualties and incidents developed pursuant to Article 5(4) of Directive 2009/18/EC of the European Parliament and of the Council, Article 48 of Maritime Safety Law of the Republic of Lithuania and Description of the procedures for preparation and submission of marine accident and incident investigations, reports and safety recommendations, approved by the Order No. 1R-386 of the Minister of Justice of the Republic of Lithuania on 30 December, 2015. The purpose of the safety investigation is to prevent the occurrence of accidents and incidents in the future, rather than establish blame or liability. The safety investigation is conducted independently of any judicial or administrative proceedings, has no aim to apportion blame or liability, is not related to them, and have no impact thereupon. Each safety investigation shall be concluded with a report in a form appropriate to the type and seriousness of the accident or incident. The report shall contain, where appropriate, safety recommendations, which shall in no case create a presumption of blame or liability for accident or incident. The safety investigation report shall not be used as evidence in a judicial or administrative process seeking to apportion blame or liability, because this was not established in the course of the safety investigation and it is not compatible with the objective of the safety investigation. The information is published to inform the maritime industry and the public of the general circumstances of the accident or incident. Extracts may be published without specific permission providing that the source is duly acknowledged, the material is reproduced accurately and it is not used in a derogatory manner or in a misleading context. This is a courtesy translation by the Transport Accident and Incident Investigation Division of the Safety Investigation Report. As accurate as the translation may be, the original text in Lithuanian is the authentic version and the work of reference. L-18/17

CONTENTS

SUMMARY ...... v Synopsis ...... v Safety Investigation ...... v

1. FACTUAL INFORMATION ...... 1 1.1. Narrative ...... 1 1.1.1. Course of the accident ...... 1 1.1.2. Shore authority involvement and emergency response ...... 2 1.2. Ship’s particulars ...... 3 1.3. Data about the crew ...... 3 1.4. Data about main engines...... 4 1.5. Data about the damages ...... 5 1.6. Survey and examinations of damaged engine components ...... 7 1.6.1. Results of examination ordered by Operator of seagoing ship ...... 7 1.6.2. Results of survey and examination by Engine manufacturer ...... 8 1.7. Quality assurance of production of big end bearing housings ...... 9 1.8. Safety actions after the accident ...... 9

2. ANALYSIS ...... 11 2.1. Cause of main engine breakdown ...... 11 2.2. Cause of fire ...... 11 2.3. Actions taken after the accident...... 11

3. CONCLUSIONS...... 13 Cause of the accident ...... 13

4. SAFETY RECOMMENDATIONS...... 15

iii

L-18/17

SUMMARY

Owner of seagoing ship Grimaldi Holding SPA Operator of seagoing ship DFDS Seaways JSC Building yard of ship Nuovi Canterie Apuani, Italy Name of ship Regina Seaways Type of ship Ro – Ro cargo passenger (Ro-Pax) Flag of ship Republic of Lithuania IMO number 9458535 Place of the accident Baltic Sea 57° 37.4‘ North 019° 18.6‘ East Date and time of the accident 2 October 2018 13:35 (10:35 UTC)1 Injuries/fatalities None Persons on board Crew - 41 Passengers - 244 Truck drivers - 50 Owner of seagoing ship Grimaldi Holding SPA

Synopsis On 2 September 2018, at 13:35, Ro-Pax vessel Regina Seaways with 335 persons and cargo on board, on her way from , to Klaipeda, Lithuania, sustained damage of main engine No. 2, followed by automatic shutdown of both main engines and fire in the engine room. Rescue operation was ready to commence, however crew extinguished fire and successfully started main engine No. 1 and ship resumed her voyage to Klaipėda using her own power and 22:07 moored alongside quay in port of Klaipeda.

Safety Investigation DFDS Seaways JSC designated person immediately after the accident notified Investigator-In-Charge of Maritime Accidents and Incidents about the accident. On the same day, Investigator-In-Charge of Maritime Accidents and Incidents

1 Ship‘s time is used in the report.

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informed German Federal Bureau of Maritime Casualty Investigation (Bundesstelle für Seeunfalluntersuchung) and started a preliminary assessment of the accident. On 9 October 2018, it was decided to start safety investigation of less serious accident.

L-18/17 1 FACTUAL INFORMATION

1.1. Narrative The circumstances of the accident are described on the basis of information, gathered by interviewing ship’s crew members, using data from voyage data recorder (VDR), ship’s log book, engine room log book, engines’ computer and Safe Sea Net system.

1.1.1. Course of the accident Ro-pax ferry Regina Seaways was on scheduled route Kiel – Klaipėda. On 1 October 2018, at 21:00 Regina Seaways departed from port of Kiel, Germany. 13:34 ship was in Baltic Sea, Russian Federation exclusive economic zone (Fig. 1). Both main engines were loaded evenly, at about 65 % rate. Ship’s speed was about 23 knots.

Lithuanian search and rescue area Time and place of the accident 13:35 57°37.4‘N 019°18.6‘E

Regina Seaways alongside Regina Seaways resumes quay in Klaipėda port her voyage 22:07 17:28 57°38.5‘N 019°32.9‘E

Russian Federation search and rescue area

Fig. 1. Ship’s route (Safe Sea Net chart)

On 13:35 huge vibration, lasting about 30 seconds, was felt on board. Both main engines automatically switched off. Deck cadet, who was in the engine room standing close to one of the diesel generators, which was in operation, noticed huge amount of white and black smoke and immediately left the engine room. Later, third engineer visited engine room and confirmed that the engine room is full of white and dense black smoke. He immediately left the engine room as well.

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13:37 high pressure fresh water firefighting system ‘HI-FOG’ in the engine room was automatically activated and remained operational until about 13:57. In the engine room, through video transmission equipment, thick fumes were observed, heat detected. 13:38 the general alarm activated by the command of the master. Persons on board notified about fire in engine room from the bridge. Ship’s crew service instructed to start evacuation of passengers.

13:42 by the command of the master, crew instructed to activate CO2 fire extinguishing system in the engine room. Crew started to prepare CO2 fire extinguishing system for activation. Ventilation in the engine room has been switched off, ventilation openings has been closed, doors has been verified to be closed and nobody has left inside the engine room. Oil and fuel supply pumps switched off, oil and fuel valves closed.

13:52 CO2 fire extinguishing system has been activated by the crew. 14:05 it was determined that the temperature of bulkheads, adjacent to the engine room, does not rise. 15:11 it was decided by the crew to inspect the engine room. 15:27 after the inspection of the engine room by the crew, no fire spots were detected. 15:57 two diesel generators started, steam boiler was switched on. Visual inspection of engine room was carried out by the crew. It was determined, that main engine No 2 (hereinafter - ME2) has visual damages, while main engine No 1 (hereinafter - ME1) remained intact. ME1 crankcase was inspected, no damages were detected. 17:28 ship’s ME1 was started. 17:30 voyage to Klaipėda was resumed by ship‘s own power. Ship‘s speed was about 13 knots. 17:58 she left Russian Federation’s search and rescue area. 22:07 arrived to port of Klaipėda and moored alongside quay. Persons on board sustained no injuries during the voyage.

1.1.2. Shore authority involvement and emergency response 13:40 MAYDAY2 request was given via VHF3, MF/HF4 and INMARSAT5 systems. Notification about fumes and possible fire in the engine room given. 13:41 Klaipėda Maritime Search and Rescue Co-ordination Centre received distress alert from Regina Seaways, informed relevant Lithuanian shore authorities and commenced preparations for rescue operation by directing helicopter and ships for passengers evacuation from the ship. 13:44 Crew established contact with Kaliningrad Maritime Search and Rescue Co-ordination Centre (MRCC Kaliningrad), which was in charge in organising rescue operation until ship left Russian Federation’s search and rescue area. Passengers were instructed by the crew to gather at the reception, pick up necessary items.

2 An emergency procedure word used internationally as a distress signal in voice-procedure radio communications. 3 Very high frequency radio communications. 4 Medium frequency/High frequency radio communications. 5 Two-way data and messaging communication services.

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1.2. Ship’s particulars Particulars of Ro-Pax ferry Regina Seaways (Fig. 2) are provided in Table 1.

Fig. 2. Regina Seaways (Photo DFDS Seaways JSC)

Table 1. Regina Seaways particulars Flag, registration Flag of the Republic of Lithuania. Registered in the Register of Seagoing Ships’ of the Republic of Lithuania. Classification society Registro Italiano Navale (RINA) Identification International Maritime Organisation (IMO) No: 9458535 Call sign: LYTO Maritime Mobile Service Identity (MMSI) number: 277466000 Main characteristics Gross tonnage: 25666 Length: 198,99 m Breadth: 26,6 m Building yard of ship Nuovi Canterie Apuani, Italy Year of build 2010 Minimum safe manning Number of crew, indicated in minimum safe manning document - 18 Cargo allowed Ro-Ro cargo (trailers, lories, cars, etc.)

1.3. Data about the crew Engine room team consisted of chief engineer, second engineer, third engineer, officer in charge of an engineering watch, two motorman and two cadets. During the accident, third engineer was on watch in the engine room central control station and one of the cadets was in the engine room and standing close to the one of the diesel generators, which was in operation.

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1.4. Data about main engines Regina Seaways propulsion system consisted of two main engines (ME1 – port side and ME2 – starboard side), two reductors and two variable-pitch propellers. Each main engine, via reductor, by tail shaft was connected with variable-pitch propeller. ME1 and ME2 were designed to be operated independently from each other. Ship’s speed was regulated by changing the propeller’s pitch position and engines’ revolutions. The engine room was equipped with three diesel generators to supply the vessel with electricity. Ship also had an emergency diesel generator, installed on the platform, arranged between the fourth and fifth decks. Manufacturer of main engines W12V46 – Wärtsilä (hereinafter referred as Engine manufacturer). They are twelve cylinder V-shape non-reversible four stroke turbocharged, fuelled by heavy fuel oil, diesel engines. Nominal power of one engine is rated at 12600 kW, nominal revolutions - 500 rpm. In Instruction manual No. DBAB169064 of engine W12V46 (hereinafter referred as Instruction manual) main components of the engine are shown in Fig. 3. The cylinder units of the engine are numbered by using letter and number combination. Letter means the side (bank) of the engine – A or B bank, and the number means the engine’s cylinder unit number. Crankcases of both main engines were equipped with oil mist detection system, designated to prevent possible explosion by switching off the engine when oil mist is detected. Immediately after the accident oil mist detection system activated automatic shutdown of ME2 and 5 seconds later - ME1, although ME1 remained undamaged. Taking into account that crankcases of both engines (ME1 and ME2) were connected to each other via ventilation pipes, the reason for automatic shutdown of ME1 was explained by oil mist detection system manufacturer Schaller Automation Industrielle Automationstechnik GmbH & Co in the following way: ‘The most likely option is that ME1 was flooded with smoke from ME2 fire. As the oil mist detection system is monitoring the crankcase by light intensity, any opacity will be detected – either by oil mist, blow by or fire smoke.’

Piston Gudgeon pin Cylinder liner Connecting rod, upper part Connecting rod big end bearing housing, upper part Crankshaft Connecting rod big end bearing housing, lower part

Crankcase

Crankshaft counterweight

Fig. 3. Components of main engine W12V46 (Instruction manual)

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Main engines’ connecting rods are a three piece design with hydraulically tightened studs and nuts. They converts the reciprocating motion of the pistons to a rotating motion of the crankshaft. Connecting rod components and piston are shown in Fig. 4. Here 2 – Piston, upper part; 3 – Piston, lower part; 4 – Connecting rod, upper part; 5 – Compression shim; 6 – Big end bearing housing, upper part; 7 – Big end bearing housing, lower part; 8 – Gudgeon pin; 9 – Securing ring; 10 – Connecting rod stud; 11 – Connecting rod nut6; 12 – Big end bearing housing stud; 13 – Big end bearing housing nut.

Fig. 4. Connecting rod and piston of engine W12V46 (Instruction manual)

Big end bearing housing, unit B4, on the day of the accident has run 45473 hrs. Instruction manual provides no limits of running hours nor instructs to carry out fatigue tests or examinations after certain period of operation.

1.5. Data about the damages ME2 damages were located in the section of A4 and B4 cylinder units. Both sides of crankcase were damaged, maintenance covers of both sides were broken from inside, oil was spotted out into the engine room. Some ME2 damaged parts were found in the crankcase (Fig. 5, 6), some in the engine room (Fig. 7). Cylinder liners were broken, connecting rods of A4 and B4 cylinder units were damaged. Crankshaft, engine block and crankcase were damaged. Crankshaft both counter weights of A4 and B4 units were ripped away. Upper parts of the pistons were found separated from the lower parts, which were smashed in pieces. The connecting rod studs of A4 and B4 units were ripped off. No signs of seizure on the upper parts of the pistons and no fretting on the pistons lower part and upper part mating surfaces were observed. Big end bearings of both A4 and B4 units have had normal running surface, no signs of bearing seizure. The contact surface of compression shims, big end bearing housings, upper and lower parts, were in normal condition, no signs of fretting. Gudgeon pins had normal contact surface, no signs of fretting. Surface of crankshaft crankpin had impact damages with no signs of fretting.

6 In the Instruction manual, Fig. 4, the arrow 11 points incorrectly to the stud (should be pointed to the nut, slightly below).

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Broken maintenance cover of the crankcase

Connecting rod, upper part

Counterweight

Fig. 5. ME2 outside damages, starboard side

Fig. 6. ME2 outside damages, port side (trapped A4 big end bearing housing, lower part)

ME2 starboard Connecting rod big end bearing side housing, upper part, B4 unit

Fig. 7. Connecting rod big end bearing housing, upper part, B4 unit, found in vicinity of ME2 on starboard side of the engine room

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Big end bearing housing, lower part, unit B4, was found inside the crankcase, fractured in two pieces (Fig. 8), no excessive external impact damages noticed.

Fig. 8. Fractured big end bearing housing, lower part, B4 unit

Damage caused by the fire to the engine room and to the equipment, adjacent to ME2, was not significant. However, some cleaning and replacement of some equipment, installed in vicinity to the ME2 in the engine room, was required.

1.6. Survey and examinations of damaged engine components

1.6.1. Results of examination ordered by Operator of seagoing ship Operator of seagoing ship ordered examination of B4 unit fractured big end bearing housing, lower part, accompanied with big end bearing shells, compression shims (including compression shim of connecting rod A4), studs, nuts, big end bearing housing, upper part (Fig. 4, 9). Examination was carried out by Force Technology company in Denmark.

A4 and B4 Halves of fractured compression big end bearing Big end bearing Big end bearing Big end shims housing, lower part housing, upper part housing nuts bearing shells

Big end bearing housing studs

Fig. 9. ME2 parts, unit B4 (photo by Force Technology)

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In the Examination report of failed big end bearing housing of 23 November 2018, the following is stated: ‘The purpose of the examination was to determine the cause of failure, applying non-destructive testing only. <…> PMI (Positive Material Identification) was performed on the peculiar looking embedded foreign object and on the fracture surface itself. <…> The examination indicates that the nuts and big end bearing housing, lower part, have not been loose prior to the accident, <…>. <…> The failure of the big end bearing housing, lower part, is caused by fatigue, triggered by a foreign inhomogeneous, not fully molten embedded object in the cast steel. The damage to the other engine parts are collateral damage.’ A close-up view of fatigue fracture surface of failed B4 big end bearing housing is provided in Fig. 10.

Fig. 10. Close up view of fatigue fracture (photo by Force Technology)

1.6.2. Results of survey and examination by Engine manufacturer On 11 October 2018, the draft Engine breakdown site survey report was released by Engine manufacturer. Among others, the following conclusions were provided in the report: ‘Possible cause for the breakdown is big end bearing housing failure of B4 unit. <…>. No excessive external impact damages on the bearing housing are visible.’ Engine manufacturer also carried out examination of components, provided in Fig. 9, in Finland. Cut out samples of fracture surface of failed big end bearing housing were examined using scanning electron microscope and energy dispersive spectrometry (SEM/EDS) analysis methodology. In examination report of 20 December 2018, is stated:

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‘In EDS analysis of the surface no strange elements noted. Some slightly increased amount of Al7 and Si8 and only marginal amount of oxygen indicating a void in solid material instead of open defect to surface. The defect surface is likely created in solidification phase when some voids had been formed in material. <…> The big end bearing housing B4 had cracked in the middle of the lower part of the housing. The fracture had started in multiple places from a large defect and propagated sideways and inwards by fatigue, reaching gradually the bearing bore before the final failure. The split surface of housing halves and the support surface towards connecting rod showed no signs of poor tightening of housing or connecting rod screws, indicating that the tightening had been adequate. The large defect in material was void, formed during manufacturing process of the raw steel bar (ingot). During the forging process the void had been deformed, but the void surfaces were still separated to each other. Due to limited oxidation of void surfaces the defect has been a closed space even though reaching nearly to the surface. No particular slack inclusions was noted in material. Material structure is normal tempered martesite/bainite with no changes in near- by areas of the defect. Material hardness and related tensile strength fulfils the specification and have therefore not contributed to the failure. Material analysis inspected with XRF9 analyser corresponds to the specified material type with adequate accuracy.’

1.7. Quality assurance of production of big end bearing housings On 14 March 2019, Engine manufacturer informed about the following: ‘Production of the concerned BEBHs10 has been carried out in accordance with the QI11 in force at the time and approved by the classification societies. <…> Manufacturing of components was made in accordance with to the industry standards used at the time. The raw material has been produced by casting process and the process variables contributing to the quality are monitored, followed by NDT (Non-Destructive Testing) sample testing. However, due to the incident there is a reason to suspect that this specific casting batch in concern may contain units not fully meeting the requirements, described in QI in force at the time.’

1.8. Safety actions after the accident On 8 March 2019, Operator of seagoing ship informed that Engine manufacturer carried out main engines’ big end bearing housings’ PAUT12 and MT13 inspections on Regina Seaways and her sistership Victoria Seaways. After the inspections, Engine manufacturer recommended to replace one big end bearing housing on Regina Seaways’ main engine and two big end bearing housings on Victoria Seaways’ main engine. Operator of seagoing ship followed the Engine manufacturer’s recommendations.

7 Aluminium 8 Siliceous 9 X-ray-Fluorescence 10 Big end bearing housings 11 Quality instruction 12 Phased Array Ultrasonic Test 13 Magnetic Testing

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In addition, Operator of seagoing ship informed, that it is planned to inspect big end bearing housings of main engines of other sister ship Athena Seaways. On 14 March 2019, Engine manufacturer informed about the following: ‘After the incident Wärtsilä has conducted PAUT for the remaining BEBHs on the concerned vessel Regina Seaways and on the sister vessel Victoria Seaways to ensure the integrity of components. Wärtsilä has identified the BEBHs belonging to the same casting batch and will commence a PAUT inspection campaign to minimize the risk for similar accidents and will be in direct contact to the customers in concern. For new engines production Wärtsilä has introduced an automated PAUT inspection for 100% of the BEBHs in 2017.’

L-18/17 2 ANALYSIS

2.1. Cause of main engine breakdown As the moving contact surfaces of pistons, connecting rod big end bearings, gudgeon pins, crankshaft pin had no signs of fretting, ME2 breakdown was not caused by improper lubrication of relevant components of A4/B4 units. Taking into account the results of performed examinations, and that the relevant mating surfaces of B4 big end bearing housing parts (6 and 7 components, Fig. 4) and compression shim (5, Fig. 4) were found in normal condition, with no signs of fretting, it can be stated that the tightening of relevant connecting rod nuts, unit B4, was adequate. Engine manufacturer provided no instructions regarding the limits of running hours of connecting rod big end bearing housing nor instructed to carry out tests or examinations after certain period of operation. Taking into account the above statements, the breakdown of the engine was not related to its maintenance or operation. Big end bearing housing, lower part, unit B4, was found fractured in two pieces (Fig. 8). As no excessive external impact damages on the halves of the housing were visible, two examinations, independent from each other, were carried out. Both examinations concluded, that the B4 big end bearing housing, lower part, failure was caused by fatigue. The fatigue crack was initiated due to the large defect in material, which was formed during the production process. The failure of big end bearing housing, lower part, unit B4, was a direct cause of the ME2 breakdown. Damage of other parts of the engine was a collateral damage.

2.2. Cause of fire Failure of components of A4 and B4 units resulted in the breakdown of both sides of the crankcase in A4/B4 unit area. Some components of A4 and B4 units were thrown away from the crankcase to the engine room. Certain amount of lubricating oil escaped to the engine room and ignited. It was the reason of fire in the engine room. As rescue operations, due to the fire on board, were not commenced, actions, related to preparation to the rescue operation were not analysed.

2.3. Actions taken after the accident In order to eliminate the risk of similar occurrences on its ships, Operator of seagoing ship initiated and carried out inspections of big end bearing housings of main engines on Regina Seaways and her sister ship Victoria Seaways, and

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replaced them as was recommended by Engine manufacturer after the inspection. Engine manufacturer informed, that it has identified the big end bearing housings belonging to the same casting batch and will commence a PAUT examination campaign to minimize the risk for similar accidents and will be in direct contact to the customers in concern. However, it is still unclear, when such inspection campaign is planned to be launched and when it is planned to finish, which engines in service are at such risk and how such campaign will be organised, including allocation of necessary recourses. The following Safety Recommendation is therefore made: SR-2019-L-01 Engine manufacturer Wärtsilä is recommended to identify ships with installed engines with connecting rod big end bearing housings at risk, propose and implement measures to eliminate such risk. As since 2017 Engine manufacturer has introduced automated PAUT inspections for all big end bearing housings, the possible risk of reliability of newly manufactured big end bearing housings, according to Engine manufacturer, is under control.

L-18/17 3 CONCLUSIONS

Cause of the accident The cause of the main engine breakdown was the failure of connecting rod big end bearing housing, lower part. The failure occurred due to fatigue crack in connecting rod big end bearing housing, lower part, which was initiated due to the large defect in material, which was formed during the production process. Damage of other parts of the engine as well as the cause of the fire in the engine room was a result of the failure of connecting rod big end bearing housing. The breakdown of the engine was not related to its maintenance or operation.

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L-18/17 4 SAFETY RECOMMENDATIONS

Safety recommendation means a proposal of a safety investigation authority, based on information derived from a safety investigation or other sources such as safety studies, made with the intention of preventing accidents and incidents Safety recommendations shall in no case create a presumption of blame or liability for an accident or incident. SR-2019-L-01 Engine manufacturer Wärtsilä is recommended to identify ships with installed engines with connecting rod big end bearing housings at risk, propose and implement measures to eliminate such risk.

15 Corrigendum of Safety investigation report L-18/17

Corrigendum Safety investigation report No. (L-18/17) 1A-136, page 2 Corrigendum date: 17 June 2020 Explanation: In page 2 of the original published report, definitions of MAYDAY, VHF, MF/HF, INMARSAT were explained incorrectly in the footnotes. The current report contains corrected explanations (footnotes) of theses definitions. This corrigendum corrects a detail in factual reporting and does not change the analysis within the report.