Annex A
Laboratory report - Examination of a Hyundai generator and associated exhaust system from the recreational craft Arniston
Page 4 of 42 Client: MAIB, Southampton SO15 2JU & Cumbria Constabulary, Cumbria LA14 2LE Job reference: T31033 ARNISTON
Figure 7: Detail of figure 6, showing generator labelling.
Figure 8: Generator as received and viewed from the electrical panel end.
Page 5 of 42 Client: MAIB, Southampton SO15 2JU & Cumbria Constabulary, Cumbria LA14 2LE Job reference: T31033 ARNISTON
Figure 9: Generator as received and viewed from the exhaust end, and showing the short stub of the owners supplement exhaust pipework still attached to the engine exhaust.
Figure 10: Straight copper fitting to integral engine exhaust pipe end, showing attachment by screws.
Page 6 of 42 Client: MAIB, Southampton SO15 2JU & Cumbria Constabulary, Cumbria LA14 2LE Job reference: T31033 ARNISTON
Figure 11: As figure 10, viewed from a different camera angle.
Figure 12: As figure 10, viewed from a different camera angle.
Page 7 of 42 Client: MAIB, Southampton SO15 2JU & Cumbria Constabulary, Cumbria LA14 2LE Job reference: T31033 ARNISTON
Figure 13: As figure 10, viewed from a different camera angle.
Figure 14: Straight copper fitting to engine exhaust joint, showing TTH joint match marking prior to disassembly.
Page 8 of 42 Client: MAIB, Southampton SO15 2JU & Cumbria Constabulary, Cumbria LA14 2LE Job reference: T31033 ARNISTON
Figure 15: Integral generator exhaust pipe end, showing three fully penetrating holes through which the screw fixings had fitted.
Figure 16: Screw fixings from the copper pipe to engine exhaust pipe connection (approximate joint clock positions shown in brackets) and showing sooting at the tip ends.
Page 9 of 42 Client: MAIB, Southampton SO15 2JU & Cumbria Constabulary, Cumbria LA14 2LE Job reference: T31033 ARNISTON
Figure 17: End casing of the generator after removal of the copper pipe and showing local condensate corrosion.
Figure 18: Lower, as installed side of the copper fitting, showing condensate rust staining at this side of the copper fitting.
Page 11 of 42 Client: MAIB, Southampton SO15 2JU & Cumbria Constabulary, Cumbria LA14 2LE Job reference: T31033 ARNISTON
Figure 21: Copper fitting and 45º copper elbow to short copper pipe piece joints, viewed from the side of the joints.
Figure 22: Copper fitting and 45º copper elbow to short copper pipe piece joints, viewed from the underside of the joints.
Page 16 of 42 Client: MAIB, Southampton SO15 2JU & Cumbria Constabulary, Cumbria LA14 2LE Job reference: T31033 ARNISTON
outlet end
inlet end
Figure 31: As figure 30, viewed from the opposite face of the silencer box.
Figure 32: detail of the screw in the silencer box drain hole.
Page 17 of 42 Client: MAIB, Southampton SO15 2JU & Cumbria Constabulary, Cumbria LA14 2LE Job reference: T31033 ARNISTON
Figure 33: Parted joint and migrated copper pipe piece to 45º elbow joint, showing evidence of suitable prior wetting.
Figure 34: As figure 33.
Page 19 of 42 Client: MAIB, Southampton SO15 2JU & Cumbria Constabulary, Cumbria LA14 2LE Job reference: T31033 ARNISTON
Figure 37: Copper elbow to silencer joint, showing securing screw and joint sealant.
Figure 38: Copper elbow to silencer joint, showing joint sealant.
Page 20 of 42 Client: MAIB, Southampton SO15 2JU & Cumbria Constabulary, Cumbria LA14 2LE Job reference: T31033 ARNISTON
Figure 39: Silencer side of the parted joint, showing sooting in the tube bore.
Figure 40: Outlet from the silencer, showing mild sooting of the bore.
Page 25 of 42 Client: MAIB, Southampton SO15 2JU & Cumbria Constabulary, Cumbria LA14 2LE Job reference: T31033 ARNISTON
Figure 49: As figure 48.
Figure 50: Detail of the untightened jubilee pipe clip at the silencer box end of the flexible hose.
Page 27 of 42 Client: MAIB, Southampton SO15 2JU & Cumbria Constabulary, Cumbria LA14 2LE Job reference: T31033 ARNISTON
Figure 53: Vessel hull piercing end of the flexible hose, showing a loose untightened jubilee pipe clip.
Figure 54: Vessel hull piercing end of the flexible hose, showing a loose untightened jubilee clip and silver foil insulation over the “worm” part of the clip.
Page 28 of 42 Client: MAIB, Southampton SO15 2JU & Cumbria Constabulary, Cumbria LA14 2LE Job reference: T31033 ARNISTON
Figure 55: Vessel hull piercing end of the flexible hose, showing silver foil insulation over the “worm” part of the clip.
Figure 56: As figure 55.
Page 29 of 42 Client: MAIB, Southampton SO15 2JU & Cumbria Constabulary, Cumbria LA14 2LE Job reference: T31033 ARNISTON
Figure 57: Vessel hull piercing end of the flexible hose, showing only traces of exhaust sooting of the bore.
Figure 58: Removal location of laboratory specimen M1 from the parted soldered joint.
Page 36 of 42 Client: MAIB, Southampton SO15 2JU & Cumbria Constabulary, Cumbria LA14 2LE Job reference: T31033 ARNISTON
Figure 71: Micrograph (original image captured at X100), specimen unetched. Detail of figure 70, showing the fillet region.
Figure 72: Micrograph (original image captured at X200), specimen unetched. Detail of figure 70, showing the intact capillary region.
Page 37 of 42 Client: MAIB, Southampton SO15 2JU & Cumbria Constabulary, Cumbria LA14 2LE Job reference: T31033 ARNISTON
Figure 73: Micrograph (original image captured at X200), specimen unetched. Specimen M1, showing a good solder bond to the copper fitting in the parted region of the joint.
Figure 74: Micrograph (original image captured at X25), specimen unetched. Specimen M2 showing an intact solder fillet and well run capillary region.
Page 38 of 42 Client: MAIB, Southampton SO15 2JU & Cumbria Constabulary, Cumbria LA14 2LE Job reference: T31033 ARNISTON
Figure 75: Micrograph (original image captured at X100), specimen unetched. Detail of figure 74, showing the fillet region.
Figure 76: Micrograph (original image captured at X200), specimen unetched. Detail of figure 74, showing small volumes of intruded copper and porosity in the capillary region of the joint.
Page 39 of 42 Client: MAIB, Southampton SO15 2JU & Cumbria Constabulary, Cumbria LA14 2LE Job reference: T31033 ARNISTON
Figure 77: Micrograph (original image captured at X12.5), specimen unetched. Specimen M2 showing second side of the joint and melted out fillet.
Figure 78: Micrograph (original image captured at X200), specimen unetched. Detail of figure 77, showing well wetted second capillary region of the joint.
Page 40 of 42 Client: MAIB, Southampton SO15 2JU & Cumbria Constabulary, Cumbria LA14 2LE Job reference: T31033 ARNISTON
Figure 79: Micrograph (original image captured at X500), specimen unetched. Detail of de-wetted region in specimen M2 and showing a continuous lead-tin-copper intermetallic layer at the solder to copper interface, consistent with suitable wetting having been achieved.
Figure 80: FTIR Spectrum characterising the elbow to silencer box joint sealant.
Page 41 of 42 Client: MAIB, Southampton SO15 2JU & Cumbria Constabulary, Cumbria LA14 2LE Job reference: T31033 ARNISTON
Figure 81: FTIR Spectrum for the joint sealant (top of field) and library spectrum for silicone resin (bottom of field).
Figure 82: SEM Back scattered electron image, showing EDX analysis fields EDX 1 and EDX 2 in a sample of sealant removed from the copper elbow to silencer box joint – EDX spectra shown in figures 83 and 84.
Page 42 of 42 Client: MAIB, Southampton SO15 2JU & Cumbria Constabulary, Cumbria LA14 2LE Job reference: T31033 ARNISTON
Figure 83: SEM-EDX Spectrum from field EDX 1 shown earlier in figure 82.
Figure 84: SEM-EDX Spectrum from field EDX 2 shown earlier in figure 82.
T31033: APPENDIX 3 LEAD-TIN EQUILIBRIUM DIAGRAM SHOWING PLOT OF AVERAGE ANALYSIS FROM THE FILLET AND DE-WETTED CAPILLARY REGIONS OF SPECIMEN M1 (Equilibrium diagram from http://www.physicsforums.com)
259
Alpha phase + liquid 183
solid Alpha + Beta phase
Annex B
Incident report- Windermere. Report of the reconstruction findings from Corgi Technical Services Ltd (appendix 2 omitted)
Appendix 1. CO Concentrations ‐ Doors Open 1 Engine compartment % 2At the Head of the Deceased (Aft Cabin) ppm Date 25/09/2013 3CO detector in Aft Cabin ppm Start 9.02 4 Survivor & Co detector at table (Galley) ppm Finish 11.02 5 Engine Compartment Temperature (C o) Mins 120 123456CO Activation Range 1 0.07 13.0 6.0 7.0 24.8 2 0.10 15.0 7.0 7.0 3 0.13 12.0 8.0 7.0 4 0.24 14.0 7.0 6.0 5 0.35 13.0 7.0 7.0 Exhaust became detached (4m,54sec) 6 0.57 14.0 7.0 7.0 7 0.67 14.0 7.0 7.0 8 0.78 13.0 6.0 7.0 9 0.85 23.0 9.0 10.0 10 0.81 39.0 13.0 11.0 11 0.82 75.0 14.0 14.0 12 0.85 121.0 15.0 15.0 13 0.86 155.0 20.0 19.0 14 0.87 214.0 23.0 25.0 15 0.89 268.0 30.0 31.0 16 0.90 277.0 37.0 37.0 17 0.91 270.0 51.0 40.0 18 0.91 311.0 57.0 47.0 19 0.91 329.0 59.0 53.0 39.0 20 0.92 338.0 61.0 55.0 21 0.92 355.0 68.0 61.0 22 0.93 346.0 77.0 66.0 23 0.93 393.0 85.0 78.0 24 0.93 411.0 88.0 83.0 25 0.92 425.0 105.0 89.0 UK Standard; 100 ppm (10‐40mins) 26 0.91 484.0 115.0 85.0 27 0.91 555.0 116.0 99.0 28 0.91 559.0 120.0 100.0 UK Standard; 100 ppm (10‐40mins) 29 0.91 603.0 130.0 108.0 30 0.92 606.0 138.0 108.0 31 0.87 613.0 142.0 116.0 45.0 32 0.90 596.0 140.0 112.0 33 0.89 621.0 135.0 118.0 34 0.90 627.0 138.0 121.0 35 0.91 632.0 152.0 127.0 36 0.87 613.0 146.0 124.0 37 0.89 624.0 141.0 124.0 38 0.93 609.0 151.0 125.0 USA Standard; 150ppm (10‐50mins) 39 0.94 601.0 155.0 141.0 40 0.92 591.0 155.0 137.0 41 0.94 640.0 158.0 142.0 42 0.92 612.0 157.0 141.0 56.0 43 0.94 543.0 164.0 153.0 USA Standard; 150 ppm (10‐50 mins) 44 0.95 600.0 172.0 160.0 45 0.94 687.0 172.0 157.0 46 0.95 640.0 184.0 164.0 47 0.94 687.0 175.0 165.0 48 0.94 609.0 184.0 178.0 49 0.96 580.0 193.0 185.0 Probe 123456CO Activation Range 50 0.95 532.0 195.0 182.0 51 0.96 611.0 204.0 196.0 52 0.96 656.0 215.0 212.0 59.0 53 0.96 618.0 228.0 225.0 54 0.96 616.0 250.0 244.0 55 0.98 672.0 256.0 235.0 56 0.97 657.0 269.0 258.0 57 0.94 667.0 270.0 261.0 58 0.95 655.0 285.0 273.0 59 0.97 749.0 293.0 279.0 Max 60 0.98 710.0 314.0 273.0 UK Standard; 300 ppm (0‐3 mins) 61 0.95 798.0 308.0 287.0 62 0.93 710.0 314.0 284.0 63 0.96 709.0 317.0 295.0 64 0.96 710.0 318.0 292.0 59.0 65 0.97 697.0 324.0 307.0 UK Standard; 300 ppm (0‐3 mins) 66 0.96 800.0 340.0 318.0 67 0.93 689.0 345.0 326.0 68 0.90 705.0 353.0 327.0 69 0.88 697.0 361.0 326.0 Max 70 0.88 807.0 360.0 332.0 71 0.89 759.0 364.0 325.0 72 0.94 757.0 367.0 321.0 73 0.94 760.0 363.0 327.0 74 0.94 740.0 361.0 338.0 62.0 75 0.94 737.0 374.0 337.0 76 0.92 723.0 377.0 345.0 77 0.93 781.0 391.0 355.0 78 0.94 730.0 390.0 353.0 79 0.94 728.0 393.0 350.0 80 0.93 727.0 397.0 351.0 81 0.94 763.0 398.0 368.0 82 0.95 735.0 395.0 371.0 83 0.94 748.0 403.0 375.0 USA Standard; 400ppm (4‐15mins) 84 0.94 725.0 408.0 370.0 64.0 85 0.94 783.0 409.0 377.0 86 0.96 728.0 430.0 366.0 87 0.92 724.0 420.0 371.0 88 0.93 737.0 414.0 371.0 89 0.93 757.0 416.0 377.0 Max 90 0.96 798.0 415.0 387.0 91 0.95 801.0 420.0 373.0 Max 92 0.91 793.0 431.0 376.0 93 0.88 767.0 417.0 359.0 94 0.88 731.0 406.0 370.0 95 0.86 793.0 412.0 370.0 96 0.90 787.0 413.0 361.0 66.0 97 0.91 802.0 406.0 351.0 98 0.92 798.0 404.0 350.0 99 0.91 773.0 404.0 353.0 100 0.90 766.0 407.0 352.0 101 0.91 755.0 393.0 351.0 102 0.93 789.0 405.0 358.0 103 0.92 792.0 402.0 354.0 65.0 104 0.92 757.0 415.0 366.0 Probe 123456CO Activation Range 105 0.94 723.0 414.0 363.0 106 0.94 737.0 404.0 350.0 107 0.94 756.0 412.0 360.0 108 0.93 776.0 403.0 348.0 109 0.94 735.0 395.0 348.0 110 0.93 727.0 405.0 372.0 111 0.90 790.0 411.0 353.0 112 0.86 793.0 409.0 336.0 113 0.89 736.0 395.0 297.0 114 0.90 771.0 362.0 257.0 115 0.90 777.0 310.0 250.0 116 0.91 797.0 305.0 253.0 117 0.92 246.0 292.0 251.0 66.0 118 0.92 795.0 307.0 262.0 119 0.92 769.0 311.0 282.0 120 0.94 743.0 328.0 288.0 69.0 Stop 121 768.00 122 776.00 123 751.00 124 689.00 125 684.00 126 687.00 127 679.00 128 728.00 129 906.00 130 1203.00 131 1090.00 132 1109.00 133 1130.00 134 1108.00 135 1084.00 136 1171.00 137 1223.00 138 1231.00 139 1224.00 Max 140 1239.00 962 401 USA Standard; 400ppm (4‐15mins) 141 1231.00 142 1228.00 143 1234.00 144 1226.00 145 1224.00 146 1210.00 147 1202.00 148 1185.00 149 1169.00 150 1143.00 151 1126.00 152 1109.00 153 1088.00 154 1058.00 155 1035.00 156 1008.00 157 976.00 158 952.00 159 916.00 Probe 123456CO Activation Range 160 894 555 111
Ave 0.88 704.15 259.17 224.36
Photograph 3
2. Head location of 1 of the fatalities Kelly
Photograph 4
3. At CO detector location within the Aft Cabin
Photograph 5
4. Dinette area
Photograph 6
Test Meter Location, remote testing point.
Photograph 7
Main Cabin Door
Photograph 8
Main Cabin Door Notice
Annex C
Report on the investigation into carbon monoxide emissions from a Hyundai HY 3000SEi generator set used on board the Arniston
Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
REPORT
on
INVESTIGATION INTO CARBON MONOXIDE EMISSIONS FROM A HYUNDAI HY 3000SEi GENERATOR SET USED ON BOARD THE ARNISTON
Dated
10 February 2014
by
Dr
Specialist Field Engines, Fuels, Lubricants and Lubrication, Exhaust Emissions
On instructions of The Marine Accident Investigation Branch of the Department for Transport and Cumbria Police
1 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
Contents
Section Item Page No.
1.00 Introduction 4 1.01 Formal Details 4 1.02 Synopsis 4 1.03 Instructions 4 1.04 Disclosure of Interests 5 1.05 Appendices 5
2.00 Background to the Case and the Issues 6 2.01 The Relevant Parties 6 2.01.1 The Marine Accident Investigation Branch 6 2.01.2 Cumbria Police 6 2.02 The Assumed Facts 6 2.03 The Issues to be Addressed 6
3.00 Technical Evaluation 8 3.01 Overview 8 3.02 Method 8
4.00 Results of Investigations 10 4.01 Background 10 4.01.01 Combustion 10 4.01.02 Lambda 11 4.01.03 Eltinge Chart 11 4.02 Type Approval 11 4.03 MAIB VOSA Emissions Tests 12 4.04 Cumbria Police VOSA Emissions Tests 12 4.05 Reconstruction 14 4.06 Modifications to Generator Set 15 4.07 As Received Condition 15 4.08 Exhaust Temperature Tests 17 4.08.01 Method 17 4.08.02 Loads 18 4.08.03 Results: MAIB Generator Set 18 4.08.04 Results: Arniston Generator Set 19 4.09 Engine Examination, Arniston Generator Set 21 4.09.01 Introduction 21 4.09.02 Air intake 21 4.09.03 Choke Mechanism 21 4.09.04 Carburettor 23 4.09.05 Spark Plug 24 4.10 Exhaust System 24 4.10.01 Introduction 24 4.10.02 Good Design 25 4.10.03 Initial Installation Considerations 26 4.10.04 Exhaust Fabricated for Generator Used on the Arniston 27
2 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
5.00 Summary of Conclusions 29 5.01 Tampering 29 5.02 Generator Set Carbon Monoxide Emissions 29 5.03 Modifications to Arniston Generator Set 30
Appendices
1 Curriculum vitae consisting of qualifications, experience, appointments and specialty of the writer. 31
2 Instructions 32
3 Documents which have been considered 33
4 Figures 34
3 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
1.00 Introduction
1.01 Formal Details
My name is of . I am self employed as an independent consultant specialising in fuels, lubricants and lubrication and exhaust emissions.
I have been jointly instructed by the Marine Accident Investigation Branch of the Department for Transport (MAIB) and Cumbria Police to investigate the emissions of carbon monoxide from a Hyundai HY 3000SEi generator set.
1.02 Synopsis
On 1 April 2013 three people were aboard a motor boat, named the Arniston, overnight on Lake Windermere. Two of the people on board died from carbon monoxide poisoning. A Hyundai HY3000SEi petrol engined generator set had been installed in the engine compartment of the Arniston.
The Hyundai HY3000SEi generator set comprises a petrol engine and generator mounted in a plastic housing. Such generator sets are free-standing and must be used outdoors. In this instance the generator set had been modified to accept fuel from an alternative supply, rather than its own built in tank, and the exhaust system had been modified to vent the exhaust outside the hull. In the event the modified exhaust system failed by falling apart. This would have resulted in exhaust gasses, including carbon monoxide, being emitted into the engine compartment of the vessel.
Cumbria Police had the carbon monoxide emissions of the generator set measured at the VOSA test station at Milnthorpe, Cumbria, where they were found to be high compared to those of another Hyundai HY3000SEi generator set purchased and tested at the VOSA test station at Botley, Hampshire, on behalf of the MAIB.
The MAIB and Cumbria Police are investigating the circumstances surrounding the deaths of the people on the motor boat and of interest are the reasons for the observed levels of carbon monoxide emissions.
1.03 Instructions
I have received instructions from the MAIB and from Cumbria Police. The essence of the instructions is similar in that I was asked to investigate the possible reasons for the high level of carbon monoxide emissions emitted by the Hyundai HY3000SEi generator set installed and used on the Arniston on which two people died as a result of carbon monoxide poisoning.
The MAIB instructed me to discover if the emissions were typical of generator sets of this type, or, if they were not, what reasons there might be which would account for the high levels observed during a reconstruction and in tests carried out by VOSA on behalf of Cumbria Police.
Cumbria Police instructed me to carry out an investigation into the reasons for the observed levels of carbon monoxide emissions measured from the generator set. In particular I was asked to
4 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
determine whether or not the concentrations observed were caused by wear and tear, by a malfunction, by a manufacturing factor or by interference, accidental or otherwise.
I was also asked to give an opinion whether the siting of the generator in the condition it was in with the fuel and exhaust system set-up employed in the motor boat, posed an obvious risk of death to the occupants of the vessel. I was also asked to comment on the suitability of the design, construction and materials used to fabricate the exhaust system
Further details of my instructions are presented in Appendix 2.
1.04 Disclosure of Interests
I have no personal interest in any party to this case other than being instructed by the MAIB and Cumbria Police.
1.05 Appendices
Appendix 1 contains details of my experience, qualifications, appointments and specialist field.
Appendix 2 contains my instructions from the MAIB and Cumbria Police,
Appendix 3 contains a list of the documents which I received from my instructing solicitors or other sources and which I have considered in forming my opinions and reaching my conclusions.
Appendix 4 contains the figures referred to in the text of my report.
5 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
2.00 Background to Case and the Issues
2.01 The Relevant Parties
2.01.1 The Marine Accident Investigation Branch
The Marine Accident Investigation Branch (MAIB) is part of the Department for Transport. It examines and investigates all types of marine accidents to, or onboard, UK ships worldwide, and other ships in UK territorial waters.
2.01.2 Cumbria Police
Cumbria Police are investigation the deaths of the people on the motor boat because the incident occurred on Lake Windermere which is part of Cumbria Police's area.
2.02 The Assumed Facts
In reaching my conclusions contained in this report I have assumed the following to be facts.
The generator was running with an electrical load of approximately 1 kW when the incident occurred.
During tests at the VOSA stations when the generators were described as being under load the applied load was 1 kW. The analysers use by the VOSA test stations were calibrated using reference gas mixtures so the results from the analysers can be relied upon.
2.03 The Issues to be Addressed
In this case there are four principal technical issues to be addressed.
The first issue is whether or not the carbon monoxide emissions measured from the Hyundai HY3000SEi installed in the Arniston were unusually high.
The second issue is to determine the reasons for the observed carbon monoxide emissions. In particular whether or not the observed emissions levels were caused by a manufacturing factor, normal wear and tear, lack of maintenance, or by any modifications made to the generator set. The generator set had in any case been modified to accept fuel from an alternative fuel tank and the exhaust system extended to discharge the exhaust gases outside the hull of the vessel. However I was asked to identify any other changes which might have been made which might have an impact on the carbon monoxide emissions.
The third issue to be addressed is the impact of the modifications to the fuel and exhaust systems on carbon monoxide emissions.
The fourth issue is the suitability of the modified exhaust system, particularly the design and materials used for fabricating it. I was asked to provide information on good practice in the design
6 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
and fabrication of an exhaust system and to compare those practices with the practices used to modify the exhaust system on the Hyundai HY3000SEi generator set on the Arniston.
7 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
3.00 Technical Evaluation
3.01 Overview
I shall first give some brief background of terminology and pertinent matters relating to exhaust emissions from spark ignition (petrol) engines. This is intended to facilitate an understanding of the technical discussions later in my report.
Firstly I shall examine existing evidence in my possession relating to this case in order to a) understand the present state of knowledge and b) to discover any evidence which might point to possible reasons for the high carbon monoxide emissions reported on the generator set from the Arniston.
Following my evaluation of the evidence to date I shall run the engine and measure exhaust temperatures at a range of loads in order to generate information which might further assist in understanding the disintegration of the modified exhaust system.
The third phase of my investigation will be to progressively dismantle the generator set to seek reasons for the reported carbon monoxide exhaust emissions. As exhaust emissions are controlled principally by the air inlet system and the fuel system I shall concentrate my investigations on those areas. However I shall investigate any other areas of the generator set if it appears that they might be having an impact on the exhaust emissions.
3.02 Method
I had access to two Hyundai HY 3000SEi generator sets. One was the unit from the Arniston which was involved in the incident on 1 April 2013, and the other was a new unit which had been purchased for comparative purposes by the MAIB. This will enable me to determine if my observations concerning the generator set from the Arniston are replicated by a similar generator set, or are essentially unique to the generator set from the Arniston. Where I have concerns regarding dismantling any part of the Arniston generator set I shall first carry out operations on the MAIB generator set to minimise the risk of destroying evidence.
The carbon monoxide emissions from the generator set from the Arniston had been measured previously during the reconstruction which took place on 23 to 25 September 2013 and by the VOSA station at Milnthorpe, Cumbria, on the instructions of Cumbria Police. I did not repeat the tests but I did assess them to form an opinion as to their reliability.
Similarly the MAIB had had the exhaust emissions from the generator set which it purchased measured at the VOSA test station at Botley, Hampshire. Again I did not repeat the tests but examined them to form an opinion as to their reliability.
The Arniston generator set exhaust system failed with an applied electrical load of 1 kW. However these generator sets are rated at 2.6 kW at 230 volts ac, so I shall carry out exhaust temperature tests at no load and in approximately 0.5 kW intervals up to 2.5 kW. I shall do this for both the MAIB and Arniston generator sets with the econ switch in the `on' and in the `off' positions. I understand that the switch was in the `on' position at the time of the incident and during the reconstruction.
8 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
In order to understand the operation of the controls of the generator set and in particular those of the engine I shall run the engine and observe the actuation of valves etc. so that I am aware of their running positions when I dismantle the engine. I shall take measurements where appropriate and where reference data is available for comparative purposes. To assist me with the latter I have obtained a copy of the Hyundai HY 3000SI/HY 3000SEi workshop manual dated November 2011 from the importer Genpower Ltd of Milford Haven.
I shall take photographs of relevant parts to record my investigation and to show my findings. These images are shown at Appendix 4.
I am not medically qualified so I am unable to make any comments on the physiological effects of carbon monoxide on the body.
9 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
4.00 Results of Investigations
4.01 Background
4.01.01 Combustion
In a petrol engine air and fuel are mixed in the carburettor and the mixture passes into the engine where it is ignited by the spark plug. It is the task of the carburettor to mix the air and fuel in the correct proportions. The chemically correct mixture of air and fuel is known as the stoichiometric air fuel ratio. For petrol it is taken as 14.7:1 (by mass) though it might vary very slightly from this depending on the exact composition of the fuel.
Ideally at the stoichiometric air fuel ratio all of the fuel is completely burnt and all the oxygen in the air is consumed. The result is, theoretically at least, only carbon dioxide and water as the exhaust products. In practice there will also be some nitrogen oxides and nitrogen from the air. (Nitrogen does not `burn' in these conditions but can combine with oxygen at the combustion temperatures (2000+ C) to form nitrogen oxides, principally nitric oxide, NO.)
In practice when fuel burns the gaseous products of combustion are a mixture of carbon dioxide; carbon monoxide and hydrocarbons from incomplete combustion together with nitrogen oxides from the reaction between nitrogen in the air and oxygen. There will also be nitrogen and possibly some oxygen.
As carbon monoxide is the emission of interest in this case further discussion will be limited to this gas.
The concentration of carbon monoxide in the exhaust gas will depend on the air fuel ratio. If the ratio is greater than 14.7:1 the mixture is said to be lean and oxygen will be found in the exhaust because it has not all been used by the petrol. The concentration of carbon monoxide will be low, of the order of parts per million, rather than percent, for good combustion.
If the air fuel ratio is less than 14.7:1 the mixture is said to be rich. There will be only a small amount of oxygen but potentially high concentrations of carbon monoxide. The actual concentration of carbon monoxide will depend on how rich the mixture is, the richer the mixture the more carbon monoxide is produced.
Petrol engines manufactured since 1993 for cars have been equipped with exhaust catalysts to reduce the exhaust emissions emitted to the atmosphere. These engines are fuel injected and, apart from recent stratified charge engines, operate at stoichiometric air fuel ratio. However industrial engines, such as these generator sets, are fitted with carburettors and no catalyst for reasons of cost and legislation not requiring low exhaust emissions. They are therefore inherently potentially high emitters of carbon monoxide.
Running an engine at lean air fuel ratios improves fuel economy. However running at rich air fuel ratios, say about 12.5:1 to 13:1 gives maximum power output. The latter is desirable from a performance point of view when an engine has to respond to sudden loads. However rich mixtures invariably result in high carbon monoxide emissions (and high hydrocarbon emissions).
In order to start a petrol engine from cold some form of mixture enrichment is required. This is often referred to as the choke, as the air intake to the carburettor is literally choked by a valve. In
10 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
some industrial engines the choke is manually operated, whilst in others it is automatic. In the case of these Hyundai HY 3000SEi generator sets the choke is automatically controlled by a vacuum system.
4.01.02 Lambda
A value known as lambda is often used when describing air fuel ratios. It is defined as the actual air fuel ratio divided by the stoichiometric air fuel ratio. For a stoichiometric air fuel ratio lambda equals 1. For a lean mixture lambda is greater than one and for a rich mixture it is less than one.
4.01.03 Eltinge Chart
The Eltinge Chart (Document 7 and Figure 1) is a graph which was developed to enable the air fuel ratio to be determined from the concentrations of carbon monoxide, carbon dioxide and oxygen in an exhaust sample. The Eltinge chart is valid only for raw exhaust from a petrol engine measured as it is emitted from the engine.
The chart is used by engine test laboratories to verify the result obtained during a raw exhaust emissions test. If the results for carbon monoxide, carbon dioxide and oxygen are plotted on the Eltinge Chart the results should coincide at a single point. In practice, because of experimental error, the results produce a small triangle. A laboratory will set a limit to the size of triangle formed as the cut off for acceptable results and those results which prompt an investigation into the performance of the exhaust gas analysers and sampling system.
The Eltinge Chart is very useful for not only verifying the reliability of exhaust emissions results from petrol engines, but if the air fuel ratio is known from another source it can be used to give an indication of the likely concentration of carbon monoxide in an engine's exhaust.
4.02 Type Approval
It is a legal requirement in the EU that engines have to be type approved before they can be sold. This means that they have to meet the appropriate parts of various ECE Regulations (European regulations based on EU Directives). If they do a certificate is issued by the appropriate national body, in the case of the UK the Vehicle Certification Agency, VCA. The certificate bears a reference number which must be shown in some specified way on the engine. The certificate for the 157F engine fitted to these Hyundai generator sets is shown at Document 1. The certificate contains critical design details which must be retained for the certificate to be valid and the engines legally sold.
The measurement of exhaust emissions are part of the certification process. The emissions are measured at specified speed and load conditions and then `averaged' in a defined way to give a value in g/kW.hr for the test. It is not possible to convert the certification value to a concentration from a particular engine under any specified operating condition.
Fuel flow and, for spark ignition engines, air fuel ratio have to be specified. In the case of the 157F engine the value for the air fuel ration is given as 13.3:1 at full load, rated speed. From the Eltinge chart this air fuel ratio would indicate a carbon monoxide concentration in the exhaust at
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this condition of a little over 3%. This information indicates that the engine is set up with a rich mixture. This is technically sensible in that maximum power is developed with rich mixtures and a generator needs to be set up to respond to sudden loads imposed by connected electrical equipment being switched on. However, as can be seen from the Eltinge chart, rich mixtures can result in very high emissions of carbon monoxide (and hydrocarbons).
In view of the information contained in the type approval certificate I should expect to see relatively high concentrations, 3% or more, of carbon monoxide from this engine.
4.03 MAIB VOSA Emissions Tests
The MAIB had the exhaust emissions from its generator set measured at the VOSA test station at Botley, Hampshire. The emissions measured were carbon monoxide, carbon dioxide and hydrocarbons. From this data lambda was calculated. This calculation would have been carried out automatically by the measurement equipment and displayed on the printout. A copy of the printouts is shown at Document 5.
I understand from the MAIB that the generator was operated at no load and with a load of nominally 1 kW.
I noted that the values of lambda shown on the printouts ranged from 2.334 to 3.293 when the generator was loaded and from 6.367 to 6.757 when under no load. From the lambda values I calculated the air fuel ratios to be from 34:1 to 48:1 and from 93:1 to 99:1 respectively. These results are not credible. The leanest air fuel ratio at which a petrol engine can operate is about 20:1 (lambda = 1.3). Even then lean misfire is likely to occur and possibly stalling if a sudden load is applied.
When I examined the generator set supplied to me by MAIB I noted that there was a spark arrestor fitted to the outer end of the exhaust pipe stub. This comprised a wire mesh. The presence of this mesh would prevent the exhaust analyser set probe from entering the exhaust pipe. The analyser set is equipped with a pump to draw the gas sample into the analysers. If the probe is not inserted a sufficient distance into the exhaust pipe the sample probe will suck in ambient air. This has the effect of diluting the sample of exhaust gas to showing excessively high levels of oxygen which results in the high values of lambda. I have therefore disregarded the exhaust emissions data obtained by the MAIB at the Botley VOSA test station.
The only conclusion which can be drawn from these results is that engine was most likely emitting a greater concentration of carbon monoxide than that recorded during these tests. It is not possible to quantify the actual concentration of carbon monoxide in the exhaust at either test condition.
4.04 Cumbria Police VOSA Emissions Tests
Document 6 shows the results of exhaust emissions tests carried out at the VOSA test station at Milnthorpe on the Arniston generator set. I understand that the tests were carried out without any load applied and with a load of nominally 1 kW.
The sequence of no load, with load and a repeat of the no load condition shows good practice to identify any drift in the engine's emissions during the period of the test.
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The lambda for the no load condition varies between 1.523 and 1.639 for the initial tests and was 1.68 for the repeat test. As noted in section 4.03 of this report a petrol engine will not run at a lambda of greater than 1.3 (air fuel ration not greater than 20:1). These results very strongly show me that the sampling procedure was flawed in that the sample probe was not inserted far enough into the exhaust pipe to obtain a proper sample of exhaust gas. Instead the analysers were measuring a mixture of exhaust and diluting ambient air.
In the case of the MAIB generator there was a spark arrestor preventing proper insertion of the sample probe. As part of the modification of the exhaust system on the Arniston generator the spark arrestor had been removed. The stub pipe on these Hyundai engines is approximately 60 mm long. With the extension pipe, left on the Arniston generator set following the reconstruction, the total end pipe length was 85 mm. Because of the pulses of exhaust gas coming out of the exhaust system the very end of the pipe will contain a mixture of exhaust gas and air, which is why it is critical to insert the probe sufficiently to avoid the volume where the exhaust gas is diluted. Added to this is the fact that VOSA test stations are normally long large buildings so that heavy duty vehicles can drive through during the testing process. The doors are often left open at both ends to minimise the build up of exhaust gases from the vehicles being tested. The buildings are therefore often draughty. In my opinion it is almost certain that the probe was not taking a representative sample of exhaust gases and was therefore showing carbon monoxide levels well below the actual emissions from the engine.
Since the final no load test results were similar to the first two results it is more rather than less likely that the tester was consistent in the probe position.
With regards to the three tests carried out with the generator set under load the lambda values recorded were 0.965, 0.895 and 0.836. It appears that either the mixture was getting richer over the six minutes as the tests proceeded or the conditions around the probe were changing. The hydrocarbon emissions show the same trend as would be expected. I calculated the air fuel ratios to be 14.2, 13.2 and 12.3 respectively which area about what I should expect to see.
The tests show concentrations of carbon monoxide of between 7.12 and 8.19%. These results are extremely high indicating an air fuel ratio richer than 12:1. These results are not consistent with the calculated lambda values. I attempted to plot the carbon monoxide, carbon dioxide and oxygen emissions on an Eltinge chart. The results were outside plottable ranges which must raise doubts over the reliability of the results. Because the algorithm for calculating lambda is `hidden' in the analysis system I cannot comment on whether or not the concentration of one of the other measured gases was having the effect of distorting the calculated value of lambda.
When the generator is run under load the engine speed is increased by the generator's control system. This results in more gasses passing through the exhaust system. It is therefore likely that the effects of ambient air dilution might be less at the higher load making the emissions results more reliable.
On balance it would be my opinion that the carbon monoxide emissions levels recorded were semiquantitatively representative of the actual emissions. In my opinion it is not possible to reliably quantify the actual concentration of carbon monoxide in the exhaust at either test condition from these test results.
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4.05 Reconstruction
A reconstruction was performed at , on 23 to 25 September 2013. As part of the reconstruction carbon monoxide concentrations were measured by at various locations. Most of the reconstruction involved measuring the concentration of carbon monoxide around the internal parts of the Arniston.
The carbon monoxide emissions from the generator set were measured under no load on 24 September 2013 and under load on 25 September 2013 (Document 12). The four results with no load can be summarised as the generator set emitting between 2.87 % and 4.54 % carbon monoxide, with an average of all four readings of 3.93 % carbon monoxide. I note that results of readings 2 to 4 were in the range 3.89 % to 4.54 %, the average of which would be 4.28 % carbon monoxide.
I watched the video of the reconstruction, taken from Exhibit BS/344176, to study the sampling method. I noted that in one instance the sample probe was held at right angles to the exhaust pipe outlet and in another at an oblique angle and barely inserted into the end of the exhaust pipe. This method risks the drawing in of ambient air thus giving spuriously low results for the carbon monoxide concentration. The difference in the observed readings might be accounted for by the different sampling positions.
On 25 September 2013 a test was carried out to measure the carbon monoxide emissions from the generator set operated under load. The three results taken over the four to five minutes of testing were unusually and remarkably consistent, all being 4.56 %. Again I examined the video of the reconstruction taken from Exhibit BS/344177. In this instance the sample probe was inserted into the end of the exhaust pipe to collect a sample away from the end where the pressure pulses of the exhaust gasses would tend to draw fresh air around the sample probe, thereby diluting the exhaust gas concentrations and giving spuriously low results.
It appears therefore that at the load the engine was tested, and under the ambient conditions, the carbon monoxide concentration in the exhaust was 4.56 %. To put this figure into context the MOT test has a requirement for the carbon monoxide emissions at idle to be below a certain limit. For current catalyst cars this limit is defined by the vehicle manufacturer. Before the advent of catalysts there was the option for the manufacturer to provide the limit to be met. However for older vehicles whose type approval did not require the in service carbon monoxide level to be specified, the default limit for the concentration of carbon monoxide at idle is 4.5 %. At this time engines were fitted with carburettors and so were of a similar technology to this Hyundai engine except that carburettors were generally a little more complex in order to obtain the good drivability demanded for an engine in a vehicle.
When comparing the VOSA results with those obtained during the reconstruction there is a significant discrepancy, 7-8 % versus 4.5% respectively. Without investigating the details of the analysis equipment used by VOSA and its calibration, and the effects of possible interferences of petrol derived exhaust gas components on the carbon monoxide analysers used during the construction I cannot offer a substantiated reason for the difference. However it is my opinion from this data that the engine was running rich and was probably emitting between 4 and 8 % carbon monoxide. These levels are extremely high.
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4.06 Modifications to Generator Set
The generator set as supplied by the importer is fitted with an integral fuel tank. In the case of the generator installed in the Arniston the integral fuel tank had been removed and an alternative fuel supply pipe, with a priming bulb and bayonet end coupling on the inlet end, fitted in its place. This new pipe bypassed the standard fuel cut off switch and was connected directly to the inlet side of the generator set's fuel pump. A metal clip secured it to the inlet stub of the pump as shown in Figure 2. The fuel pipe bore the markings 3/16" Fuel hose, SAE J30 R6 indicating that it is suitable for use with unleaded petrol.
It would have been necessary to remove the casing completely to enable the fuel tank to be removed. The two parts of the casing are secured by six screw/nut assemblies. The screw and nut at the bottom front position was missing Figure 3.
I was supplied with a metal fuel tank which I understand was placed in a compartment on the Arniston just to the rear of the engine compartment. The tank bore the name Volvo Penta, the marine division of Volvo. The tank is a typical marine tank which can be removed for refilling on land. It has a bayonet type outlet, to prevent fuel spillage when disconnecting the fuel pipe, and a fuel gauge. This particular tank also had a 0.5 l oil tank for filling with two stroke oil when the tank is to be used on a two stroke engine. The Hyundai engine is a four stroke engine, not a two stroke unit, so the tank was empty.
The gauge on the fuel tank showed the tank to be between ¾ and full, Figure 4. For my tests on the Arniston generator I used the fuel contained in the Volvo Penta fuel tank.
In my opinion it is unwise, for safety reasons, to bypass the fuel cut off switch. In the installation on the Arniston it would be possible to stop fuel flow to the engine by disconnecting the bayonet coupling at the fuel tank. However the engine and fuel tank were in different compartments so it would not have been possible to cut off the fuel within the engine compartment.
The generator set as originally supplied is fitted with a blue plastic full casing to reduce noise emissions. The casing is fitted with access panels held in place by screws. Access panels exist for the battery compartment, one for routine maintenance such as checking the oil, cleaning the air filter etc and one allowing access to the spark plug. In addition there is a vented safety cover which allows cooling air to the engine and protects the user from contact with the hot exhaust silencer. A spark arrestor, comprising a wire mesh is fitted over the end of the exhaust stub pipe.
When I received the Arniston generator set the battery compartment and exhaust safety covers were missing, Figures 5 and 6 respectively.
4.07 As Received Condition
When I received the generator set from the Arniston two panels were missing as noted in section 4.06. I took photographs of the generator set as a whole. The unit number was recorded on a label as HYK 311120002199
The remote switch was in the `on' position as was the econ switch. There was no key supplied to enable a key start. A wireless remote was provided in an exhibit bag exhibit no JAM/9. I did not test or use the remote wireless start during my investigations.
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Before running the engine I checked to make sure that it was in a condition that no damage should be caused to it by its being run.
I removed the maintenance cover and noted the engine number which was XG11121287, the engine type number which was 157F and the type approval number which was e11*97/68SA*2004/26*0910*00, Figures 7 and 8 respectively. This is the same number as cited on the type approval certificate supplied to me (Document 1).
I visually examined all clips for security. I noted that the clip on the inlet side of the fuel filter had been moved from its original position as shown by residual marks on the rubber fuel hose, Figure 9. The clip which was supposed to retain the fuel hose on the outlet side of the fuel filter was sitting loose around the pipe downstream of the stub on the fuel filter, Figure 10. In this position the clip would not hold the pipe in place and its retention would depend solely on the friction of the pipe on the fuel filter stub. I flexed the connection and decided that the joint was sufficient for the purposes of my tests only. During testing I checked it at frequent intervals for movement.
There was no evidence of engine oil in the bottom of the casing below the filler/level checking neck. I checked the oil level and found it to not be at the maximum level (the top of the filler neck) but part way down the filler neck. I decided that the engine clearly had sufficient oil for its safe running for the duration of the test programme, Figure 11. I did not want to add or use another oil as this might influence any subsequent results.
I checked the battery and found that the wire terminal on the negative lead had become disconnected and was attached to the battery. There was also evidence of loose strands of wire at the positive wire terminal and the joint appeared to have been re-crimped at some stage, but not using both pairs of tags on the terminal as should be the case, Figure 12.
Neither the positive nor the negative terminals were securely tightened to the battery terminals. There was corrosion present on the negative terminal. I cleaned this to ensure good electrical connections.
There were no insulating covers protecting the battery terminals. This lack of insulators is a potential hazard as there is no protection to avoid shorting the battery terminals which can cause sparking. I compared the Arniston generator with the MAIB generator. The latter had protective covers fitted, Figure 13.
I re-crimped the wire terminal onto the negative supply lead, Figure 14, and refitted the supply leads to the battery and wound the exposed electrical parts with insulation tape, Figure 15.
I subsequently found the red, positive, terminal cover loose in the generator set casing. I placed it in an exhibit bag labelled Exhibit HCS/ 2.
I checked the battery voltage which was 12.7 V on open circuit. I connected the battery to a CTek MXS 5.0 battery charger/tester. This showed that there was sufficient energy in the battery to start the engine. I allowed the battery to be charged to its full capacity to avoid later electrical problems or variable loads caused by the battery being charged.
When attempting to refit the battery I noted that part of the retaining strap was missing so the battery could not be properly secured in its L shaped base.
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I noted that there was an electrical box secured using a cable tie to the base on which the fuel tank would normally have sat, Figure 16. I believe that this is the wireless receiver/control unit for the remote wireless start. It is normally located between the back of the control panel and the fuel tank on the right hand side as viewed from the front.
I took the key supplied with the MAIB generator to use to key start and stop the Arniston generator. It was apparent that the internal plastic retainer in the run/stat key switch was displaced preventing key operation. There were marks on the plastic possibly indicating the use of some other device to operate the generator, Figure 17. I realigned the sleeve so that I could use the key so as to be able to control the generator from the key rather than by remote. It appears from the video of the reconstruction that stop and start were carried out using a wireless remote control.
I visually examined the carburettor and choke arrangement for leaks. There were none. I did notice a witness mark on the rod of the diaphragm assembly, Figure 18. This rod is connected to a stranded wire and operates the choke plate. The witness mark indicates that the rod had been rubbing on the casing or the diaphragm. I did not investigate this further at this stage to avoid changing any settings.
On checking the underside of the generator I recovered some silver adhesive tape. I retained this as exhibit HCS/1.
4.08 Exhaust Temperature Tests
4.08.01 Method
The object of this test is to measure the temperature of the exhaust gas from the Arniston generator set at a range of electrical loads including no load and nominally 1 kW. I carried out two series of tests, one with the econ switch in the `on' position and the second with the econ switch in the `off' position. The econ(omy) switch is intended to enable the generator set to run at a lower speed. This not only reduces noise but also fuel consumption.
In each case I commenced with no load and increased the load in steps of nominally 0.5 kW to a maximum of 2.5 kW. (The rated output of the generator set is 2.6 kW.) This sequence ensures that the temperature of the exhaust system increases in steps and avoids residual heat from previous higher load operation. I carried out the tests first with the econ switch on and then off for the same reason. Once these tests were finished I allowed the engine to cool until the inside face of the silencer at the inner end of the exhaust stub pipe was below 120 C, i.e. below the exhaust temperature at no load.
Exhaust temperature is very sensitive to location. For comparable results it is necessary to use a fixed, defined position. To achieve this I used a rigid K type thermocouple attached to a Robin RT 550 digital thermometer. I measured the length of the stub pipe which was 60 mm. I marked the thermocouple body at 35 mm, at 60 mm and at 85 mm, Figure 19. The 35 mm mark gave a repeatable position part way (35 mm) into the exhaust pipe whilst the 60 mm mark gave a position at the inner end of the stub pipe for the standard MAIB generator set. The 85 mm mark gave the inner end of the stub pipe having taken account of the copper extension fitted to the Arniston generator set during the reconstruction.
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I carried out the testing first using the MAIB generator set and then using the generator set from the Arniston.
In addition, for the Arniston generator, set I fitted a reflective tape to the rear face of the fan located just in front of the exhaust muffler. This enabled me to use a Kent Moore infra red digital tachometer to measure the rotational speed of the engine. I was unable to obtain sensible speed values from the MAIB generator as there appeared to be some reflection from the fan disc itself thereby sometimes indicating twice rotational speed.
4.08.02 Loads
In order to apply loads to the generator sets I obtained heaters of nominal power consumptions of 250 W, 400 W, 500 W and 1.5 kW. I connected each to a 230 volt ac supply and measured the current consumption using a Kewtech KT71 PAT Tester. From this I calculated the actual power consumed. The values obtained were 209 W, 370 W, 444 W and 1.444 kW respectively. I selectively connected the heaters to give loads of 0.444 kW, 1.023 kW (444+370+209), 1.444 kW 2.023 kW (1444+370+209) and 2.467 kW (all loads together). I verified the output voltages of the generators as: the Arniston generator, 225.6 V and the MAIB generator 233 volts. The slight variations from 230 volts introduce an error of less than 2 %. Since accuracy of the applied load was not a critical parameter I accepted this error.
4.08.03 Results: MAIB Generator Set
The results I obtained for the MAIB generator set are shown in table 1.
Econ Switch Position Load Temperature 35 mm Temperature 60 mm kW into exhaust system C into exhaust system C on 0 150 not measured on 0.444 196 not measured on 1.023 272 not measured on 1.444 349 not measured on 2.023 435 - 442 not measured on 2.467 (*) (*)
off 0 157 204 off 0.444 143 226 - 236 off 1.023 148 270 off 1.444 305 - 318 354 - 358 off 2.023 393 - 405 458 - 468 off 2.467 412 - 418 459 - 470
Table 1 Results of exhaust temperature tests on MAIB generator. Ambient temperature 4 C. Note: * see text
I found initial starting of this generator set to be difficult. I removed the maintenance cover to examine the choke operation. I noted that the choke was pulling off almost as soon as the engine first fired. This would have left too weak a fuel mixture for continued running. I therefore 18 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
manually held the choke closed to start the engine and subsequently let the engine warm up for 15 minutes under no load prior to testing.
When applying the 2 kW load when the econ switch was in the `on' position the overload warning light initially illuminated, but then extinguished and the engine continued to run. However when the 2.5 kW load was applied the overload warning light illuminated and remained illuminated. The generator continued to run but did not supply any electrical output. It was therefore not possible to obtain a meaningful exhaust temperature reading. With the econ switch in the on position the exhaust temperatures increased with increasing load as would be expected.
During this testing I noted that the engine speed was not constant with load but the control system increased the engine speed to provide more load. I examined this further when running the generator set from the Arniston.
When testing with the econ switch in the `off' position I noted unexpectedly low exhaust temperatures at the 0.44 and 1 kW loads. Investigations involving screening the exhaust showed that external air currents were causing cooling of the exhaust gas at the measurement point. To overcome this I carried out a set of measurements with the temperature probe inserted 60 mm, i.e. to the inner end of the exhaust stub. Temperature readings became more stable and consistent with what would be expected. I recorded both sets of results. At higher loads it can be seen that at 35 mm deep the temperatures are still fluctuating, but, because of the higher exhaust temperatures and gas flow rates, they become less affected by the external air currents.
Using a surface thermocouple I measured the temperature of the exhaust muffler outer surface adjacent to the stub pipe and the outer surface of the stub pipe adjacent to the muffler surface at 2.5 kW load. The temperatures I recorded were 257 C and 235 C respectively.
At the end of testing I observed a strong smell of newly hot engine. I suspect that this was the first time that the engine had been run under anything but a relatively light load. That being so the engine was not fully run in and I should expect further testing on this engine to yield different exhaust temperatures until the unit was fully run in. This might also account for the engine's reluctance to not operate at higher loads with the econ switch on.
I note that the exhaust gas temperatures I recorded were, as I should expect, well above the melting range of the solder used when modifying the exhaust system on the generator used on the Arniston.
4.08.04 Results: Arniston Generator Set
I warmed the engine for 15 minutes under no load prior to testing. The engine started easily with the choke pulling off slowly to enable the engine to continue to run following initial firing.
As I had noted variable engine speed when testing the MAIB generator set I took engine speed measurements during this set of tests.
The results I obtained for the Arniston generator set are shown in table 2.
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Econ Switch load kW Engine Speed Temperature 60 Temperature 85 Position rpm mm into exhaust mm into exhaust system C system C on 0 3128 113 - 115 133 on 0.444 3280 - 3317 157 - 159 184 - 187 on 1.023 3942 - 3967 249 - 252 278 - 281 on 1.444 4332 - 4346 280 - 281 334 - 336 on 2.023 4860 - 4905 395 - 400 422 - 425 on 2.467 4930 - 4947 488 - 496 518 - 524 0 3143 - 3160
off 0 4290 - 4308 183 - 185 219 - 221 off 0.444 4260 - 4277 231 - 232 259 - 260 off 1.023 4481 - 4491 313 - 315 343 - 346 off 1.444 4750 - 4771 336 - 338 370 - 371 off 2.023 4890 - 4913 415 - 417 443 - 447 off 2.467 4930 - 4948 477 - 486 518 - 521 0 4299 - 4314
Table 2 Results of exhaust temperature tests on Arniston generator. Ambient temperature 5 C.
After testing with the economy switch in the `on' position I noted carbon deposits on the end of the thermocouple indicating rich running. I wiped the end on a Kimwipe Precision Wipe and bagged the wipe as Exhibit HCS/2. Figure 20 shows the deposit on the wipe. I had wiped the thermocouple prior to starting the test.
Using a surface thermocouple I measured the temperature of the exhaust muffler outer surface adjacent to the stub pipe and the outer surface of the copper tube extension piece on the stub pipe adjacent to the muffler surface at 2.5 kW load. The temperatures I recorded were 163 C and 231 - 236 C respectively with the econ switch in the on position.
I repeated the test with the econ switch in the off position and at 2.5 kW load and at 1 kW load. The temperatures I recorded at 2.5 kW load on the outer surface of the muffler adjacent to the stub pipe was 113 C and on the outer surface of the copper tube extension piece on the stub pipe adjacent to the muffler surface was 155 – 158 C. The temperatures I recorded at 1 kW load on the outer surface of the muffler adjacent to the stub pipe was 116 - 118 C and on the outer surface of the copper tube extension piece on the stub pipe adjacent to the muffler surface was 138 – 141 C.
It is clear from these tests that the econ switch has the effect to reducing the engine's running speed but only at loads up to about 1.5 kW. The greatest effect of the switch on speed is at no load.
The results also show that the exhaust temperature decreases relatively quickly once it comes into contact with cooled surfaces. It should be noted that during these tests the ambient temperature was 5 C. On the Arniston, where the generator was being run in a confined space, ambient temperatures would be elevated and exhaust component surface temperatures would also be elevated compared to the results obtained during these tests.
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When listening to the engine running the sound did not appear constant. During running I removed the maintenance cover to examine the throttle movement. On the Hyundai HY 3000SEi generator set the throttle position is controlled by a stepper motor linked into the generator part of the unit. The throttle was continually changing its position. This leads to variations in load and engine speed. The latter is shown in table 2. Changing the throttle position affects the mixture strength. Generally repeated changes result in richer average mixtures as the mixture has to be enriched to enable the engine to accelerate.
4.09 Engine Examination, Arniston Generator Set
4.09.01 Introduction
Following the exhaust temperature tests I examined the engine in some detail. As this involved removing some parts I chose to carry out this work after all engine running tests. The main components which affect mixture strength are the carburettor and air inlet systems. The condition of the spark plug can give information regarding combustion.
4.09.02 Air intake
A blocked air filter will restrict the flow of air into an engine which results in the mixture become richer.
I removed the air filter element by removing the access cover and pulling out the element itself. The filter element appeared clean with no evidence of blocking. I tapped the filter on a clean sheet of white paper. No particles were deposited on the paper which would be expected for a partially blocked filter. I also shone a light through to ensure that there were no areas which were blocked whilst others were clear. There was no evidence of blocking. Figure 21 shows light clearly passing through the filter.
4.09.03 Choke Mechanism.
In order to enable a petrol engine to start from cold the mixture strength has to be increased, i.e. made richer. The reasons for this are associated with the volatility of the fuel and the design of the intake system.
On some industrial engines the choke is manually operated, but on the Hyundai HY 3000SEi generator set the choke is automatic. In essence the choke plate, which reduces the amount of air entering the carburettor, is connected via a stranded wire to a diaphragm actuator. The actuator consists of a rod, to which the stranded wire is attached at one end, and a diaphragm at the other end. The diaphragm is held in a steel housing. The side of the diaphragm opposite to the rod is connected, via flexible tubes and a check valve, to the engine manifold. As the engine's piston goes up and down it creates a reduced pressure in the manifold which causes the diaphragm to move thereby moving the choke plate and un-choking the engine. In this particular arrangement the choke is held in the closed (i.e. start) position by a spring and the depression causes the choke to open.
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For the purposes of adjustment of the choke system the stranded wire is clamped by two screw clamps, one at each end.
I noted when I was running the engine that there were witness marks on the rod indicating that it was rubbing against the diaphragm housing, Figure 18. I therefore checked the system for free movement. There appeared to be no restriction to fee movement.
When the choke was pulled off during starting I observed that the end of the stranded wire stopped against the body of the diaphragm housing, Figure 22 which had left a mark on the housing. It is usual to allow free movement of the connection system and control the choke plate movement by means of a stop on the choke lever arm. I therefore investigated this further by removing the outer casing completely to gain better access to the mechanism.
I removed the air filter cover to gain good visual access to the choke plate. I found no evidence of the air filter housing itself having been removed previously. There were also no marks on the air cleaner to carburettor screws which would indicate that the carburettor had not been removed, Figure 23.
There is a single post on the carburettor body which acts as a stop for the choke lever arm, on one side setting fully closed and on the other side the fully open (running) position. I observed that the wire's abutting the diaphragm casing was preventing the choke plate from opening fully. I measured the gap between the lever arm and the stop using feeler gauges. The gap was 1.5 mm. Figures 24 to 28 show the effect of this on the position of the choke plate and the presence of the gap between the stop post and the lever arm.
The fact that the choke does not open fully would have the effect of making the mixture richer than it was designed to be.
My instructions from Cumbria Police were that I should retain forensic opportunities. I therefore did not release the two adjusting screws on the stranded wire to see if there was one indentation caused by the screw, or two at one or other end. If there were one indentation at each end I would draw the conclusion that the adjustment was as it left the manufacturer. If more than one indentation were present at either end I would conclude that the choke mechanism had been adjusted post manufacture, either by the importer when checking the unit before delivery, or by someone subsequently.
I examined the same parts of the generator set supplied by the MAIB. It showed exactly the same characteristic, apart from the witness marks, with the choke not opening fully. In this case I measured the gap between the stop and the lever arm to be 2.6 mm. In my opinion this evidence suggests that the choke operating mechanism may be maladjusted before it reaches the first user.
I checked the integrity of the diaphragm itself by connecting a `Mityvac' vacuum pump. The choke opened at a depression of 20 kpa and showed no signs of leakage, Figure 29. This opening pressure is, in my opinion, appropriate.
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4.09.04 Carburettor
The carburettor mixes fuel and air in the required proportions. Factors affecting this mixing are the main jet, emulsion tube and the level of the fuel in the float chamber. I investigated these parameters.
I could find no evidence of the carburettor having been removed. The edges of gaskets were intact and there were no tool marks on the screws holding the air cleaner housing to the carburettor. This housing would have to have been removed to remove the carburettor.
I removed the float chamber bowl by draining the fuel and releasing the centre bolt. Inside the bowl were traces of a gritty material, Figure 30. This is not unusual. Grit getting into the carburettor usually causes blockage of the small fuel passageways in the carburettor resulting in fuel starvation. There was no evidence from the spark plug of fuel starvation and the engine did give 2.467 kW output indicating adequate fuelling.
I removed the main jet to check that it was the correct one. During removal the edges of the screw slot became damaged due to the difficult angle to access the slot without removing the carburettor. This area of the jet is immaterial in terms of the performance of the jet.
The jet should have a diameter of 0.7 mm according to the Hyundai Maintenance Manual, (Document 3). There were no markings on the jet so I measured the jet size. I selected a thin metal wire, in this case a needle which would just slide through the jet hole. I them measured the diameter of the wire using a 0-25 mm micrometer. I measured the diameter as 0.75 mm, Figure 31. I retained the needle as exhibit HCS/4.
0.75 mm is oversize and would result in the carburettor being able to deliver about 15 % more fuel than a 0.7 mm jet. This would have an influence on the maximum power output of the engine and mixture strength at high loads but relatively little on the mixture strength at part loads. Any effect on mixture strength would be to make the mixture richer.
I checked the condition of the emulsion tube. All the holes were clear and clean.
I refitted the emulsion tube and main jet using a special tool which I made specifically for the purpose.
The position of the float in the float chamber is important as it controls the level of fuel and thereby the amount of fuel mixed with the air. A higher fuel level results in a richer mixture.
The specification for the float position is given in the maintenance manual (Document 3) as 12 mm. The manual however fails to state where the measurement should be taken. It is normal for the float to be horizontal when the fuel level is correct. I therefore connected the fuel line used on the Arniston to the carburettor, pumped fuel through the system and manually adjusted the float position until no fuel flowed from the inlet valve. The position of the float at which this occurred was horizontal. I measured the distance from the shoulder on the float to the flange of the carburettor float chamber using a 150 mm steel rule. The distance was 12 mm. In my opinion the level of fuel in the carburettor was very likely correct.
I reassembled the carburettor float chamber bowl and confirmed that there were no fuel leaks.
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The carburettor is equipped with a mixture adjusting screw. For some markets it is sealed by the manufacturer but for the European market this is not the case. I examined the adjuster but could find no evidence of any changes having been made to its position, Figure 32. The Hyundai workshop manual (Document 3) contains no instructions for the adjustment of the mixture strength.
4.09.05 Spark Plug
I attempted to remove the spark plug using the manufacturer's tool supplied with the generator set from MAIB. I was unable to remove the plug as it was too tight for the tool. I used a spark plug socket and swivel handle to remove the plug. Normally once the first tightness is released the plug can be removed with the fingers. On this occasion the plug would not unscrew by hand. This indicates that either the plug was over-tightened at some point and the threads damaged or the threads were crossed and therefore damaged. Having removed the plug it was visually apparent that the threads in the cylinder head were damaged. In my opinion the sealing washer on the plug was particularly flattened and the corresponding marks on the mating face on the cylinder head indicate that over-tightening was the most likely scenario.
The plug installed was an NKG brand CR7HSA. According to the maintenance manual it should have been a Torch brand A7RTC as original equipment. I telephoned Adrian Griffiths of Genpower Ltd., the importer, on 22 January 2014, to enquire what plug was originally fitted. He advised me that Genpower removes the original Torch plug and fits the NKG alternative before the generator is shipped out for first use.
I measured the gap between the electrodes. It was between 0.63 mm and 0.71 mm, the specification being 0.6 mm to 0.7 mm. I visually examined the plug tip, Figure 33. It was in good condition and showed no signs of excessive wear and no damage. There was some build up of carbon deposits which would indicate running on a rich mixture. There were no oily deposits which might indicate that the engine was burning oil. There were no signs of overheating which would have indicated a weak mixture. I formed the opinion that there was no abnormal combustion occurring but that the mixture was rich.
When attempting to refit the spark plug it was apparent that the threads in the cylinder head were seriously damaged. Rather than force the plug back into place I retained the spark plug as exhibit HCS/3.
4.10 Exhaust System.
4.10.01 Introduction
I was asked to comment on the construction of the exhaust system on the Hyundai generator used on the Arniston. In my opinion it was unsuitable for a number of reasons which I shall describe in the following sections. However I shall first describe the characteristics which I should expect to see in a well designed exhaust system.
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4.10.02 Good Design
The first stage is to ensure that the engine is positively and firmly secured and will not move in use. If it does it could cause breakage of the exhaust system even if well designed.
Sizing of pipework should be undertaken to avoid unnecessary back pressures which would compromise the performance of the engine. Such information is usually available from the manufacturer. In the case of the Hyundai 157 F engine used in this generator set information is provided in the type approval certificate.
In view of the temperatures encountered in an exhaust system the materials used for pipework and mufflers should be steel. Either mild steel or stainless steel may be used, the latter having better corrosion resistance and hence a longer useful working life. Where it is not necessary to separate two parts tubes should be welded together. Welds should be continuous and result in a gas tight join.
For parts which need to be separated a secure mechanical joint should be made. This could be by expanding one tube so that the other slides inside to effect a gas tight seal. It is normal practice to cut two slits on opposite sides of the larger sleeve to allow it to be clamped firmly onto the smaller diameter tube. Clamps should be strong and capable of squeezing the tubes together. An example is a `U' clamp which is often used on passenger car exhaust systems. If there is any risk of gas leakage then a suitable exhaust system sealant should be used. Pipe joiners comprising sleeves split at both ends for joining two tubes of the same diameter are readily available off the shelf.
Another way of joining two tubes is to weld a flange onto each and bolt the flanges together with a steel gasket or high temperature composite gasket as a seal. The use of flanged joints is more suited to larger installations.
As an engine vibrates there must be a flexible coupling between the engine and the main part of the exhaust system. This flexible coupling should be the first part of the exhaust system after the immediate parts of the engine, such as the exhaust manifold, catalysts, turbochargers etc. The reason for fitting the flexible coupling first is to minimise the movement on the coupling. If the coupling is further down the exhaust system the magnitude of vibrations of the engine is amplified by the distance between the engine and the flexible coupling. This increased amplitude of vibration would result in failure of the exhaust system as the flexible coupling may well be working outside its designed range and other parts of the system would be un-necessarily stressed.
The choice of flexible coupling would depend on the application. Flexible stainless steel bellows type couplings fitted with flanges are often used on fixed installations such as larger generator sets, pumping sets and ships engines. Other designs include the use of two sockets with a woven metal mesh doughnut type gasket which allows relative movement as well as gas sealing.
A readily available type of flexible coupling comprises two stubs with a flexible stainless steel bellows protected with a braided stainless steel outer casing. These can be clamped or welded into the exhaust system. It can be a good idea to make a pair of matching flanges and weld one onto the inlet to the flexible coupling and the other onto the outlet from the engine. This allows the exhaust system and engine to be separated without having to move either significantly.
The weight of the whole exhaust system must be securely supported at several points. The method of support should include flexible connections such as rubber hangers or pads. This is to minimise
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the transmission of vibrations, and hence noise, from the exhaust system to the surrounding structure. Various types of rubber mounting are readily available. The supports should be positioned to support the flexible coupling and close to bends to avoid the system twisting.
Mufflers are used to reduce the noise emitted at the open end of the exhaust pipe. These are readily available in a range of sizes for clamping or welding to other pipes.
A complete system would therefore comprise, in essence and starting from the engine, a flexible connector, steel tubes, with or without mufflers as needed, and a tail pipe to eject the exhaust gases to atmosphere. Flexible supports would be provided close to the flexible connector, close to the end of the system and close to any muffler, possibly one at either side. If the system is long additional flexible supports should be present to support the weight of the system and to prevent its twisting as a result of the use of bends.
If the system is in an enclosed space, following testing to confirm the absence of leaks, a heat resistant wrapping can be applied to minimise heat transfer to the immediate area of the engine.
The system should be tested under all anticipated operating systems from idle, no load up to maximum speed and load to confirm integrity.
As a matter of good practice the system should be visually inspected at regular intervals for signs of exhaust gas leakage. This is usually shown as black marking at, or adjacent to, the site of the leak. Appropriate steps should be taken to rectify any leak, especially if it is within the confines of a building, vehicle or vessel. Carbon monoxide or hydrocarbon gas detectors used manually can be useful when testing for leaks.
4.10.03 Initial Installation Considerations
In considering installing a generator set in any situation consideration should be given to the most appropriate location.
In the case of the Arniston in my opinion consideration should have been given to mounting the generator on deck in the open air and connecting the generator electrical output to the electrical input provided on the vessel for connection when alongside.
When installing an engine attention should be paid to routine maintenance. All parts needing to be accessed for routine checks and servicing should be readily accessible. Access to a clean air supply should be arranged.
The removal of heat from the engine must also be considered, especially in the case of an air cooled engine. It is a rough rule of thumb that of the chemical energy going into an engine as fuel one third is used to produce useful work at the flywheel, one third goes into the cooling system and one third passes down the exhaust system. Therefore for this generator set, where the engine is rated at 3.95 kW (Document 1), there will be potentially 3.95 kW emitted into the immediate vicinity of the generator from the cooling system alone when it is running at full power. In addition there will be heat lost from the exhaust system which will add to the heating effect of the vicinity. (The generator set is rated at 2.6 kW continuous but because of losses within the system engines used in generator sets always have to have a significantly higher power output.)
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Overheating of the fuel system should be avoided as this can cause the formation of vapour bubbles in the fuel system which interfere, and can stop or prevent and engine from starting. Overheating of the intake air will also reduce its density and therefore the power output of the engine. It may also affect the air fuel ratio. Fuel leakages in an enclosed space also present a risk of fire or explosion.
4.10.04 Exhaust Fabricated for Generator Used on the Arniston
As far as I can determine from the reconstruction and other information the generator set was not securely fixed to the structure of the vessel. Instead it appears that the location where it stood could be variable from time to time. It appears that it stayed in position, if it did, only by friction between the rubber mounting feet of the generator and the mat beneath it, and the friction between the mat and the structure of the vessel. This is unsatisfactory on a land installation and, in my opinion, worse in a marine application where the vessel can pitch and roll thereby not providing a stable base.
Copper tube was used as the main tube-work material. Copper is unsuitable as a material for constructing an exhaust system. Apart from the risk of chemical attack from exhaust gases, especially if the engine burns some oil, the material does not have suitable physical properties.
Joining copper tubes is difficult. Copper is soft, so tight clamping results in deformation of the copper and any subsequent relaxation releases the clamping pressure. Unlike steel, copper cannot be `welded' by fusing copper into joints. Therefore the joints will have to have a lower melting point material fused into them. This is, as was used in the construction of the exhaust system for the generator on the Arniston, solder, a mixture of lead and tin. The melting point, or at least softening point, is likely to be at or below the temperature of the exhaust gases, depending on how far away the joint is from the engine exhaust manifold. In my opinion solder is completely unsuitable because of its relatively low melting point compared to the temperature of exhaust gases.
Copper has the property of work hardening. In other words as it is repeatedly flexed it becomes hard and brittle and breaks. I have seen this property frequently used by `plumbers' and electricians to break tube and wire. Since the exhaust system will flex the copper will work harden and eventually fracture. Therefore, had the system not fallen apart by the melting of the solder in a soldered joint, in my opinion it is likely that in time the copper would have fatigued and fractured.
There was no flexible coupling installed as the first part of the exhaust system. In this case the full engine vibration and movement was transferred to the whole of the exhaust system. The movement was also magnified by the lengths of the tube used.
A muffler was fitted in the system. The muffler is relatively heavy and there was no means of supporting its weight. This is incorrect. The muffler was cantilevered out from the exhaust stub on the generator. This means that a large weight was being shaken up and down with a large amplitude. This motion will strain the system as a whole and fatigue the copper tube. In the event it can be seen from the video taken during the reconstruction that a) the amplitude of vibration of the muffler was great, to the extend that the thermocouple broke off and b) the weight of the muffler caused a torsional force on a preceding joint which caused it to twist and come apart.
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A flexible connector was fitted between the downstream end of the muffler and the outlet through the hull. Whilst there is a case for putting a flexible coupling to minimise stress on the seal between the exhaust pipe and the hull it is inappropriate to have this as the main flexible coupling in the exhaust system as the main part of the exhaust system is not isolated from the vibrations from the engine.
I note that the flexible coupling was of the spiral wound steel type. Sealing these at the ends on to a tube is very difficult because of the spiral gas escape path naturally created by the forming of the tubing used. This problem can be overcome by welding or hydraulically crimping stub pipes onto the ends. However in this case it appears that the fabricator of the exhaust system used a worm drive clip (sometimes called a Jubilee clip). Worm drive clips are suitable for clamping elastomeric tubing materials onto metal stubs, e.g. rubber coolant hoses onto metal radiator stubs. They are not suited, and are not effective, even when tightened as much as possible, for clamping metal tubes together. I note from the Test House report (Document 9), that the worm drive clips were not tightened. In my opinion the joints at each end of this flexible tube were bound to leak exhaust gases into the engine compartment even without any catastrophic failure occurring.
The first copper fitting with was fitted to the stub on the generator's exhaust stub pipe was held by three self tapping screws. These would effectively secure the pipe from falling off but there appears to be no evidence of any exhaust sealant being used. Copper has a significantly higher coefficient of expansion so even if the connection were tight when cold it could tend to become loose as the temperature rose. It would have been wise to use a sealant as was done for the copper fitting at muffler inlet.
It would appear that it is unlikely that the fabricator of the exhaust system subjected the exhaust system to any effective testing. Testing should comprise running at no load to ensure basic integrity and to check for exhaust gas leaks. There are a number of simple tests to effect the latter. One is listening for hissing sounds. One is looking for signs of leakage. Splashing dilute washing up liquid on a suspect joint will reveal a leak if bubbles are formed. To test the system under pressure the outlet of the exhaust can be partially blocked whilst the engine is running. This provides a back pressure which reveals leaks which might not be observable at normal operating pressures.
Once satisfactory operation with no load has been confirmed, and any problems rectified, the system should be run at full speed, full load for at least an hour. Following this the system should be allowed to cool and the high load-high speed test should be repeated. This technique should reveal any problems caused by thermal expansion and contraction during use. In my opinion had the system been tested at full load, at least 2.5 kW electrical load, then the observed lack of integrity of the system would have become apparent. Since during the reconstruction the system disintegrated in less than five minutes with an electrical load of only 1 kW, it is likely that at an electrical load of 2.5 kW it would have fallen apart in rather less time.
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5.00 Summary of Conclusions
I have examined the evidence presented to me and formed the following conclusions.
5.01 Tampering
I formed the opinion that the engine had not been tampered with in a way which would affect its emissions of carbon monoxide. However since I did not fully investigate the maladjustment of the choke mechanism I cannot, without further investigation, state whether or not it had been tampered with.
5.02 Generator Set Carbon Monoxide Emissions
The choke mechanism was maladjusted on the generator set used on the Arniston. A similar maladjustment was present on the MAIB generator set indicating a possible manufacturing problem. The maladjustment would tend to make both engines run richer, i.e. produce more carbon monoxide.
In my opinion the carbon monoxide emissions from the generator set on the Arniston were higher than they should have been by virtue of the maladjustments found. However there was no other evidence to suggest that the carbon monoxide emissions were exceptionally high or atypical of what I should expect to observe from similar types of generator set.
The engine used in the Hyundai HY 3000SEi generator set would be expected to have carbon monoxide emissions of at least 3 to 4 % given the manufacturers specified air fuel ratio of 13.3 at rated speed, wide open throttle.
The carbon monoxide emissions results obtained by the VOSA test station on behalf of Cumbria Police should be treated with caution. I formed the conclusion from those results that at an electrical load of 1 kW the carbon monoxide emissions were probably in the range 4 % to 8%, which is very high.
The carbon monoxide emissions results obtained by the VOSA test station on behalf of the MAIB are not quantitatively credible as the samples were almost certainly not taken correctly. All which can be concluded is that the engine was emitting much more than the 0.23 to 1.46 % carbon monoxide reported during those tests.
The carburettor main jet on the Arniston generator set was oversize. This would allow a greater power output from the engine but would not necessarily increase its carbon monoxide emissions at lower loads. This is most likely the condition of the engine from the manufacturer as there was no evidence of the jet's having been removed.
The air intake system was clean and free from blockages which might have increased carbon monoxide emissions
The condition of the spark plug confirmed that the engine ran with a rich air fuel ratio.
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5.03 Modifications to Arniston Generator Set
In my opinion installing an air cooled petrol engine in an enclosed space should only be undertaken as a last resort because of the technical problems relating to the safe discharge of exhaust fumes, effective cooling of the engine and fire hazards associated with fuel vaporisation in a hot confined space.
In my opinion the design and fabrication of the modified exhaust system on the Arniston were fundamentally flawed. The generator set was not fixed to the vessel allowing it to move. The vibrations from the generator set were not isolated from the main part of the exhaust system which would promote fatigue failure. The weight of the exhaust system was not properly supported and the materials used to make the exhaust system were unsuitable.
It is my further opinion that the exhaust system was highly likely to have leaked into the engine compartment even without falling apart as it appears to have done. I would expect the system to have suffered fatigue failure had the soldered joint not become detached first.
In my opinion testing the installation at full electrical load on completion would have revealed that the system did not have adequate structural integrity.
It is my opinion the bypassing of the fuel cut off switch on the generator itself was unwise and not a safe practice as it means that in the event of a leak an operator has to move to a separate area of the vessel to isolate the fuel supply. This is especially important in a confined space where fuel vapour build up can reach flammable limits quite quickly.
There was evidence of lack of attention to detail regarding work carried out on the generator. For example the clip which should have secured the outlet side of the fuel filter was displaced and loose. Also one of the screw and bolt assemblies which retained the two halves of the generator set casing was missing and the connections to the battery were faulty.
Signed 10 February 2014
Dr
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Appendix 1
Qualifications, Experience, Appointments and Specialist Field of Writer of Report
I graduated from Imperial College in 1972 with a Bachelor of Science degree in Chemistry and as an Associate of the Royal College of Science. I gained the degree of Doctor of Philosophy from Imperial College in 1978 after carrying out research in mechanical engineering on lubrication. I also obtained a Diploma of Imperial College. Since 1986 I have been a member of the Institute of Petroleum now called the Energy Institute. I was elected a member of the Academy of Experts in 2000 and qualified as a mediator in 2003. I have written scientific papers on lubrication and exhaust emissions.
From 1977 until 1986 I worked for Ricardo Consulting Engineers, a research and development company specialising in engine design and development, being the company's Chief Chemist and managing variously the Chemistry and Exhaust Emissions Laboratories and the Lubricants Laboratory, latterly specialising in both lubricants and fuels testing. I became an independent consultant in 1986 and work for a range of clients from the motor, petroleum and chemical industries, for engine and vehicle users as well as for local authorities, enforcement agencies and other organisations.
I have accepted instructions from the legal profession in a range of matters. I have acted in both civil and criminal cases for both claimant/pursuer/prosecution and respondent/defendant as well as a single joint expert. I have acted in a public enquiry and a class action in the USA. I have attended and given evidence in Court.
I have been active in the British Technical Council of the Motor and Petroleum Industries and in the Co-ordinating European Council for the Development of Performance Tests for Lubricants and Engine Fuels. I have sat on, been secretary of, and chairman of various national and European groups involved with exhaust emissions and with the specification and testing of fuels and lubricants. I am currently involved with the British Standards Institute technical panel relating to standards for petrol and diesel fuel. Between 2005 and 2007 I was an associate investigator with the Office of the Parliamentary and Health Service Ombudsman.
I specialise in the areas of tribology, fuels, lubricants and exhaust emissions particularly relating to reciprocating engines of all sorts, and vehicles. I also have an expertise in metrology, engine building, engine operation and other functional fluids such as coolants, transmission lubricants and hydraulic oils. My work covers all aspects ranging from specification through to the investigation of failures.
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Appendix 2
Instructions from the Marine Accident Investigation Branch and Cumbria Police.
In my instructions I was asked to investigate the possible reasons for the high level of carbon monoxide emissions emitted by a particular Hyundai HY 3000SEi generator set. This generator had been installed and used on a motor boat, the Arniston, on which two people died as a result of carbon monoxide poisoning.
The MAIB instructed me to discover if the emissions were typical of generator sets of this type or if they were not what reasons there might be which would account for the high levels observed during a reconstruction and in tests carried out on 23 to 25 September 2013.
Cumbria Police instructed me to make an assessment of emissions from the subject generator and to compare them with data published by the manufacturer. They asked me to examine the internal mechanisms in the generator set to establish whether the internal mechanism had been modified in any way. If any modifications were to be found I was asked to give an opinion on what effect those changes might have had on the functionality of the generator and its carbon monoxide emissions. I was also asked to give and opinion as to whether or not those mechanisms had been altered or modified deliberately.
In carrying out my investigations I was asked to preserve, as far as possible, any forensic evidence of any interference with the mechanisms and to prevent contamination of any forensic opportunities. I was also asked to keep a photographic record of any changes, or not as the case may be.
Having carried out my investigations I was instructed to give opinions as to: whether any mechanism was faulty and what has caused it to be, including the effects of general wear and tear and age, the level of difference of carbon monoxide emissions, if any, between the subject generator and those stated as expected by the manufacturer, and whether the siting of the generator in the condition it was in with the fuel and exhaust system set- up employed in the boat, posed an obvious risk of death to the occupants, if I could comment on this.
I was asked to prepare a full report of my investigations.
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Appendix 3
Documents Which Have Been Considered
Following is a list of the documents which I received from the MAIB, Cumbria Police, or other sources and have considered in forming my opinions and reaching my conclusions.
Document no
1 VCA type approval certificate for approval no e11*97/68SA*2004/26*0910*00, dated 16 October 2007, comprising 15 pages. 2 MAIB Safety Bulletin 2/2013, Carbon monoxide poisoning on board the Bayliner 285 motor cruiser Arniston on Windermere, Cumbria resulting in two fatalities, undated, comprising 5 pages. 3 Hyundai Power Products Hyundai Generators HY 3000SI/HY 3000SEI Shop Manual, dated November 2011, comprising 71 pages. 4 Hyundai Spare Parts Catalogue 2012-2013 HY 2000Si-HY 3000 Si, comprising 12 pages. 5 Printouts from VOSA emissions tests on MAIB generator set, dated 23 October 2013 comprising 1 page. 6 Printouts from VOSA emissions tests on Arniston generator set, dated 31 October 2013 comprising 3 pages. 7 Eltinge Chart, undated, comprising 1 page. 8 Arniston, Pre-purchase Report, dated 26 June 2008 comprising 14 pages. 9 Laboratory Report, Examination of a Hyundai Generator and Associated Exhaust System from the Recreational Craft Arniston, by The Test House, dated 10 July 2013, comprising 60 pages. 10 Images of Hyundai Generator and fuel system provided by Cumbria Police, undated, comprising 4 pages. 11 Witness Statement of , dated 7 November 2013, comprising 12 pages plus Appendices: 12 Appendix 1 comprising 7 pages. 13 Appendix 5 comprising 4 pages. 14 Material Safety Data Sheet for Boss Leader Solder Wire 86032000, dated 5 March 2013 comprising 5 pages. 15 Reporting and investigation of gas-related incidents, IGEM, IGE/GL/8 Edition 2, comprising 57 pages.
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Appendix 4
Figures
Following is s list of the figures in this Appendix.
Figure 1 Eltinge Chart showing the relationship between the composition of the exhaust emissions from a petrol engine and air fuel ratio.
Figure 2 Photograph showing the clip securing the alternative fuel supply pipe to the inlet side of the generator set's fuel pump.
Figure 3 Photograph showing the screw and nut at the bottom front position holding the two halves of the casing to be missing.
Figure 4 The gauge on the fuel tank showing the tank to be between ¾ and full as received.
Figure 5 Arniston generator as received showing the battery compartment cover missing.
Figure 6 Arniston generator as received showing the exhaust safety cover missing.
Figure 7 Photograph showing the engine number.
Figure 8 Photograph showing the engine type number and the type approval number.
Figure 9 Image showing the clip on the inlet side of the fuel filter had been moved from its original position as shown by residual marks on the rubber fuel hose.
Figure 10 The clip which was supposed to retain the fuel hose on the outlet side of the fuel filter sitting loose around the pipe downstream of the stub on the fuel filter.
Figure 11 Oil level part way down the filler neck.
Figure 12 Arniston generator showing a) the wire terminal on the negative lead had become disconnected but was attached to the battery, b) loose strands of wire at the positive wire terminal, c) corrosion present on the negative terminal and d) no insulating covers protecting the battery terminals.
Figure 13 MAIB generator showing protective covers fitted to battery terminals.
Figure 14 Re-crimped wire terminal on the negative supply lead.
Figure 15 Refitted supply leads to the battery with exposed electrical parts wound with insulation tape.
Figure 16 Electrical box secured using a cable tie to the base on which the fuel tank would normally have sat.
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Figure 17 Marks on the plastic sleeve of start – run - stop switch possibly indicating the use of some other device to operate the generator.
Figure 18 Witness mark on the rod of the diaphragm assembly operating the choke plate.
Figure 19 Thermocouple body marked at 35 mm, at 60 mm and at 85 mm.
Figure 20 Material wiped from end of thermocouple following exhaust temperature tests on Arniston generator with econ switch on.
Figure 21 Image showing light clearly passing through the filter with no areas of blockage.
Figure 22 Choke actuation system showing that the end of the stranded wire stopped against the body of the diaphragm housing, upper image, which had left a mark on the housing, lower image.
Figure 23 Screw holding air filter housing to carburettor. Lack of tool marks would indicate that the carburettor had not been removed.
Figure 24 Image showing choke plate lever in fully closed position abutting stop.
Figure 25 Image showing choke plate in fully closed position.
Figure 26 Image showing choke plate lever not contacting stop to achieve fully open position.
Figure 27 Image showing choke plate in not fully open position caused by stranded wire fouling diaphragm body.
Figure 28 Image showing choke plate in fully open position.
Figure 29 Image showing checking the integrity of the diaphragm, opening depression and leakage using a `Mityvac' vacuum pump.
Figure 30 Gritty material found at the bottom of the carburettor float chamber bowl.
Figure 31 Upper image shows needle passing through carburettor main jet. Lower image shows diameter of needle being measured using a 0-25 mm micrometer.
Figure 32 Mixture adjusting screw on carburettor.
Figure 33 Image of plug tip showing no evidence of oily deposits or overheating. The carbon deposits on the body indicate a rich mixture.
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Figure 1 Eltinge Chart showing the relationship between the composition of the exhaust emissions from a petrol engine and air fuel ratio.
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Figure 2 Photograph showing the clip securing the alternative fuel supply pipe to the inlet side of the generator set's fuel pump.
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Figure 3 Photograph showing the screw and nut at the bottom front position holding the two halves of the casing to be missing.
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Figure 4 The gauge on the fuel tank showing the tank to be between ¾ and full as received.
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Figure 5 Arniston generator as received showing the battery compartment cover missing.
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Figure 6 Arniston generator as received showing the exhaust safety cover missing.
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Figure 7 Photograph showing the engine number.
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Figure 8 Photograph showing the engine type number and the type approval number.
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Figure 9 Image showing the clip on the inlet side of the fuel filter had been moved from its original position as shown by residual marks on the rubber fuel hose.
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Figure 10 The clip which was supposed to retain the fuel hose on the outlet side of the fuel filter sitting loose around the pipe downstream of the stub on the fuel filter.
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Figure 11 Oil level part way down the filler neck.
46 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
Figure 12 Arniston generator showing a) the wire terminal on the negative lead had become disconnected but was attached to the battery, b) loose strands of wire at the positive wire terminal, c) corrosion present on the negative terminal and d) no insulating covers protecting the battery terminals.
47 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
Figure 13 MAIB generator showing protective covers fitted to battery terminals.
48 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
Figure 14 Re-crimped wire terminal on the negative supply lead.
49 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
Figure 15 Refitted supply leads to the battery with exposed electrical parts wound with insulation tape.
50 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
Figure 16 Electrical box secured using a cable tie to the base on which the fuel tank would normally have sat.
51 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
Figure 17 Marks on the plastic sleeve of start – run - stop switch possibly indicating the use of some other device to operate the generator.
52 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
Figure 18 Witness mark on the rod of the diaphragm assembly operating the choke plate.
53 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
Figure 19 Thermocouple body marked at 35 mm, at 60 mm and at 85 mm.
54 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
Figure 20 Material wiped from end of thermocouple following exhaust temperature tests on Arniston generator with econ switch on.
55 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
Figure 21 Image showing light clearly passing through the filter with no areas of blockage.
56 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
Figure 22 Choke actuation system showing that the end of the stranded wire stopped against the body of the diaphragm housing, upper image, which had left a mark on the housing, lower image. 57 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
Figure 23 Screw holding air filter housing to carburettor. Lack of tool marks would indicate that the carburettor had not been removed.
58 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
Figure 24 Image showing choke plate lever in fully closed position abutting stop.
59 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
Figure 25 Image showing choke plate in fully closed position.
60 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
Figure 26 Image showing choke plate lever not contacting stop to achieve fully open position.
61 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
Figure 27 Image showing choke plate in not fully open position caused by stranded wire fouling diaphragm body.
62 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
Figure 28 Image showing choke plate in fully open position.
63 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
Figure 29 Image showing checking the integrity of the diaphragm, opening depression and leakage using a `Mityvac' vacuum pump.
64 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
Figure 30 Gritty material found at the bottom of the carburettor float chamber bowl.
65 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
Figure 31 Upper image shows needle passing through carburettor main jet. Lower image shows diameter of needle being measured using a 0-25 mm micrometer.
66 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
Figure 32 Mixture adjusting screw on carburettor.
67 Report of: Specialist Field: Engines, Fuels, Lubricants, Exhaust Emissions
Figure 33 Image of plug tip showing no evidence of oily deposits or overheating. The carbon deposits on the body indicate a rich mixture.
68 Annex D
Carbon Monoxide Safety on Boats - Boat Safety Scheme and CoGDEM
CARBON MONOXIDE SAFETY ON BOATS
How to protect you, your crew, your visitors and pets on your boat from the 'Silent Killer' - Carbon Monoxide Carbon monoxide... what's the risk ?
When carbon-based, appliance CO build-up in the cabin can and engine fuels, such as gas, occur with one or a mix of LPG, coal, wood, paraffin, oil, these factors: petrol and diesel don’t burn completely, CO is produced. • Faulty, badly maintained or misused appliances • Exhaust fumes from a boat’s engine or generator • Escaped flue gases from solid Each year boaters die or are fuel stoves made seriously ill from • Blocked ventilation or short carbon monoxide (CO) supply of air - fuel needs poisoning. oxygen to burn safely In recent years, solid fuel stoves Boats are built to keep water and engine or generator out, but this also makes exhaust gases have been them good containers for responsible for most deaths of gases and fumes. boaters from CO poisoning.
2 How the silent killer works!
But even breathing-in lower CO can kill in minutes - be levels of CO over a longer prepared to act quickly if you period, you can still suffer think you are being serious effects such as memory poisoned! problems and difficulty concentrating.
CO is a highly poisonous gas that Some people will be affected weighs about the same as air. much more quickly:
At high concentrations, CO can kill • Pregnant women and unborn without warning, sometimes in babies; only minutes. • Babies and young children • Older people It cannot be seen, smelt, tasted, • People with respiratory or felt, that’s why it’s known as problems or heart conditions the silent killer! For other reasons, some When you breathe in CO, it people may be at higher risk: replaces the oxygen in your bloodstream, preventing essential • Those who have been doing supplies to your body tissues, something active and are heart, brain and other vital breathing more rapidly and organs. deeply and have a greater need for oxygen Where victims survive severe CO • Those who have been poisoning, they can be left with drinking heavily - because the long-term brain damage such as symptoms may be masked poorer concentration, or mood swings, etc. If CO is in your cabin space, everyone is at risk, no one is immune!
3 CO poisoning can creep up on you – recognise the signs
If you are asleep, you may not The greater the amount of CO notice any symptoms as they there is in air, or the longer you develop. are breathing in CO, the worse your symptoms may get: Even if you are awake • Drowsiness, lethargy, extreme We have listed some of the tiredness, difficulty common symptoms, but not concentrating everyone suffering CO poisoning • A feeling of general weakness, will have all of them. difficulty in walking or moving • Loss of balance and sight and Common symptoms include: memory problems • Headache and bad temper ...and with very high CO levels • Feeling sick and dizzy • Feeling tired and confused • Chest pains • Stomach pains and being sick • Increased heart rate • Difficulty breathing or breathlessness For more information visit • Seizures the NHS website • Collapse, unconsciousness http://www.nhs.uk/conditio and death ns/carbon-monoxide- poisoning
4 If you think you are suffering – ACT QUICKLY
Seek medical help and don’t Fast action could save your delay! Tell the doctor or nurse life. Ask yourself 'Are people that you may have suffered ill on my boat, but feel OK carbon monoxide poisoning. ashore?' If other crew members, or pets, are feeling ill or have the If you suspect you have carbon symptoms, they need medical monoxide poisoning or the CO help too. alarm activates, you need to act fast. Anyone with severe symptoms needs to get to hospital as Get all people and pets out to quickly as possible! Contact the fresh air as quickly as you can and emergency services stay out in the fresh air. straightaway.
If you can, on your way out, turn Severe CO poisoning needs off appliances and engines… immediate medical treatment
…also leave doors, windows and CO poisoning can only be tested awnings open to allow fresh air to shortly after exposure as its flow through the boat. traces begin to disappear as soon as you start breathing clear air.
5 Know any danger signs on your boat
• An unfamiliar or burning smell Routine checking that your when an LPG or oil appliance boat’s fuel-burning is on appliances and engines are • Smelling or seeing smoke free from signs of problems escaping regularly into the and in good condition will cabin when running your help keep you safe. wood-burner or coal stove
Any of the following could be Flue gases from solid fuel signs that CO is filling your boat: stoves can have up to 100 times the concentrations of • Staining, sooty smears, or CO found in gas hob-burners discolouration on surfaces with problems. around an appliance or its flue • Appliances that are difficult to • Smelling engine exhaust light, keep lit or burn weakly fumes regularly inside the • Burners with yellow or orange cockpit or cabin or ‘floppy’ flames that threaten to go out
If there's a CO problem on your boat - get a properly qualified person to find and fix the appliance or engine before it is used again.
6 How to prevent CO on your boat
The required ventilation can be CO can be prevented. Take a calculated by using the formula few sensible steps to reduce in Ch.8 of the BSS Essential the risk dramatically. Guide Check the cabin vents for Only buy appliances that meet blockages and build-ups of the latest standards and are spiders’ webs and debris. suitable for use in boats. Open windows for extra Have appliances properly installed ventilation when cooking, and serviced routinely by especially when using large competent fitters. pans on LPG hobs.
Annual servicing of appliances is Check solid fuel stoves for recommended where the boat is cracks, missing cover plates, used frequently or for longer warped doors and poor periods. condition rope seals.
Ensure all repairs use proprietary Follow appliance instructions - components. Make no mistake, burn the right fuel for your gash fixes or bodge jobs bring stove, in the right way. Burning risks. damp fuel or plastic rubbish can cause clogging of the flue. Good air supply in the cabin is vital to running appliances. When removing hot ashes and embers, use a metal ash bucket with lid and keep it outside in the open.
7 Keep flue pipes and terminals in tip top condition!
Check all appliance flue pipes Crushing your boat's routinely for rusting, pitting, chimney terminal on a bridge blockages, loose or missing arch can damage more than connections. your pocket. Look for signs of leaks. A sooty smear at a flue joint is a bad Ensure all flues or exhausts vent sign. on the outside of awnings, covered decks or cratches. Check that vents and flue terminals, especially on cabin A clean flue pipe kept in good tops, are not damaged, blocked condition will help keep a good or restricted by stowed draw and help the boat keep free equipment, ropes, tarpaulins or from toxic flue gasses. decorative objects.
Ensure solid fuel stove chimneys Fix all problems without delay are swept at least annually, or and before the equipment is even several times a year - the used again! more a stove is used, the more often the chimney needs cleaning.
8 Beware of engine exhaust gases in the cabin space!
Inefficient petrol engine Petrol generators and performance, running the outboard motors can engine cooler than its design produce dangerously high temperature or using levels of carbon monoxide, contaminated or stale fuel, can but don’t forget, diesel increase the concentration of engine exhaust fumes have CO in exhaust fumes. also been linked to illness Whether the boat is moving or and deaths. moored, under certain running and or wind conditions CO at Check the boat’s exhaust system dangerous levels can be routinely. Inspect every part for deflected or drawn in from leaks or problems including; engine exhausts. manifolds, pipes, joints, hoses, clamps, silencers, and Be a good neighbour; see if you through-hull fittings. can avoid running your engine when moored in a crowded Do not install or fix a portable marina, particularly when the generator inside any air is still. accommodation space.
Proprietary conversion kits must be used if adapting a portable generator to fixed use.
9 Steer clear of danger, never do these things
Never block cabin ventilators. Never use an appliance you think is faulty or unsafe. Never leave LPG appliances on overnight, unless they are Never use an appliance that has designed to be left on and/or are a crushed flue terminal. the room sealed type. Never run portable generators Never use mobile (cabinet) gas in a cabin or covered cockpit heaters - they are not suitable for area, or close to any door, use in boats and create extra fire opening or ventilator that opens safety hazards. into the boat.
Never bring lit or cooling bar- Never run a boat’s petrol becues into a cabin or covered engine with the exhaust outlet cockpit area – hot charcoal gives restricted in any way including off dangerous amounts of CO. when the craft moored against Charcoal is only safe when it’s a high-sided object such as a stone-cold. wall, another boat or inside a lock. Never block an appliance’s air inlet or heat outlet. Never swim near to boats with their engines running – many Never run a solid fuel stove with boats’ exhausts are at low level its doors open, apart from when and can create a toxic atmos- refuelling. phere at water level .
10 CO alarms save lives
Fit alarms that meet the Take the belt and braces international standard BS EN approach but note this, CO 50291-2; these are best suited alarms are not a substitute for boats. Alarms with life-long for the good installation, batteries are available. regular servicing and proper Look out for the BSi Kitemark or maintenance of fuel burning LPCB horseshoe 'approval' appliances and engines. symbols when buying alarms for additional assurance. If you have any fuel burning appliances aboard, an engine or If in doubt about the choice of generator, fit a suitable audible alarm, call the manufacturer’s carbon monoxide alarm for an or supplier’s support line for added re-assurance. more advice.
‘Black-spot’ colour-changing If there is potential for CO indicator cards are not good poisoning on your boat, it is enough. You won’t have an better to have an alarm, than instant warning of dangerous CO not. levels and there’s no alarm to wake you up. Alarms and warning devices for people with hearing loss are available.
11 Where should you place your CO alarm?
All cabins with a fuel burning But if the placement directions appliance should have a CO alarm are difficult to meet on your fitted. boat, these are the ‘best practice’ points. If fuel burning appliances, generators or engines are used Try to place the alarm: whilst people sleep, all sleeping quarters will need their own • In living quarters between 1m alarms. If the boat has a single and 3m (on plan view) from multi-use cabin, one alarm is OK. the appliance • In living quarters fix alarms high up on a wall, but at least Never fit an alarm directly 150mm from the ceiling and above a source of heat or where the indicator lights can steam. be seen • In sleeping quarters have the alarm in the “breathing zone”, For the best protection, follow the i.e. near the bed head alarm manufacturer’s installation • Before fixing, test that you instructions as far as the space can hear an alarm from any and nature of the boat allow. position in the boat (or buy an additional alarm)
12 Living with your CO alarm
Test the alarms when you first board the boat. Test the alarm Always re-install any alarm weekly when the boat is in use. after winterisation. Then test the alarm before any CO alarms do not last forever and appliance or engine is used. have a replacement date marked on them. Do not use the alarm beyond that date and if in any Note these points: doubt, replace it earlier. CO alarms only detect, they When working on the boat with cannot prevent the dangerous paints, solvents, degreasers or build-up of carbon monoxide strong chemicals, cover or remove the alarm temporarily to protect CO alarms may not fully the sensor. Remember to remove safeguard individuals with the cover or replace the alarm as specific medical conditions soon as the air clears and before you use any appliance or engine. CO alarms will not detect fires, smoke or leakages of petrol or Consider removing the alarm LPG fuel vapours from a winterised boat because long periods of sub-zero A CO alarm can activate if it temperatures may affect its senses the explosive gas hydro- sensor and battery. gen; e.g. from the boat’s batteries gassing off when under charge, perhaps indicating a charging problem
13 If you are a tenant afloat
The law provides several additional protections for tenants including this:
If your landlord has provided LPG appliances, he/she must arrange for an annual gas safety check to be carried out by a Gas Safe registered engineer.
If you are a tenant in a rented boat with concerns about CO, raise the issues with your landlord or letting agent without delay If your concerns are not dealt with, go to the local council for help If you feel unwell get medical help straightaway.
Go to www.hse.gov.uk/gas/domestic/faqtenant.htm for more information for tenants and the health and safety in privately rented accommodation pages on www.gov.uk
Further information on CO and boating
For more information on CO and fire safety on boats and routine safety check items - Boat Safety Scheme: www.boatsafetyscheme.org/stay-safe
For alarm information - Council of Gas Detection and Environmental Monitoring (CoGDEM) cogdem.org.uk/CoGDEMCOsite/index.html
For general CO advice Health & Safety Executive (HSE) Gas Safety Advice Line 0800 300 363 www.hse.gov.uk/gas/domestic/co.htm
Gas Safe Register – to find registered gas fitters www.gassaferegister.co.uk
British Marine Federation – to find local boatyards www.britishmarine.co.uk
14 Charities concerned about CO
The Carbon Monoxide and Gas This information is supported by Safety Society the CoGDEM member www.co-gassafety.co.uk companies that produce CO alarms www.cogdem.org.uk CO-Awareness www.covictim.org Published with the generous Gas Safety Trust support of the Gas Safe Charity www.gas-safety-trust.org.uk – helping directly to make gas safe where it’s most needed Gas Safe Charity www.gassafecharity.org.uk The authors gratefully acknowledge the assistance of the Public Health England staff CO-Angels www.co-angels.co.uk especially linked to the medical information. Acknowledgements The authors acknowledge the HSE leaflet ‘Gas Appliances - Get them checked, Keep CoGDEM is the UK trade body for them Safe’ ref: INDG238 (rev2) and the companies and experts in the Department of Health leaflet 289814 field of gas detection. CoGDEM ’Carbon monoxide: Are you at risk?’ as provides its expertise to UK, source documents. European and global Design based on the Fire Safety On Boats standards-writing bodies, and leaflet with permission from Fire Kills provides technical guidance and www.gov.uk/firekills support to all CO awareness-raising projects and The authors are grateful to Safelincs for its organisations, including the HSE. help with the artwork www.safelincs.co.uk , suppliers of smoke alarms, CO alarms and other safety equipment.
PDF on demand & web realisation by Plan 9 www.plan9.co.uk
15 CO threatens lives – stay safe, stay aware:
Install fuel burning appliances properly
Maintain appliances and engines routinely
Use the equipment correctly
Don’t allow engine fumes into the cabin space
Deal with problems immediately
Never bring a lit or cooling BBQ into any covered area
Don’t allow bodged repairs and maintenance
Install a CO alarm
Test the alarm routinely
Never remove the batteries
Know the signs of CO poisoning and how to react
Copyright belongs to the owners of the Boat Safety Scheme and CoGDEM jointly.
This publication may be freely reproduced, except for advertising, endorsement or commercial purposes. Please acknowledge the source as Boat Safety Scheme & CoGDEM.
Printed with vegetable based inks on recycled paper by Greenshires
Carbon Monoxide Safety On Boats v3 April 2014 Annex E
MAIB Safety Bulletin 2/2013
MAIB SAFETY BULLETIN 2/2013
Carbon monoxide poisoning on board the Bayliner 285 motor cruiser Arniston
on Windermere, Cumbria resulting in two fatalities
Marine Accident Investigation Branch Mountbatten House Grosvenor Square Southampton SO15 2JU MAIB SAFETY BULLETIN 2/2013 This document, containing safety lessons, has been produced for marine safety purposes only, on the basis of information available to date. The Merchant Shipping (Accident Reporting and Investigation) Regulations 2012 provide for the Chief Inspector of Marine Accidents to make recommendations at any time during the course of an investigation if, in his opinion, it is necessary or desirable to do so. The Marine Accident Investigation Branch is carrying out an investigation into the deaths of two persons on board the motor cruiser Arniston on 1 April 2013. The MAIB will publish a full report on completion of the investigation.
Steve Clinch Chief Inspector of Marine Accidents
NOTE
This bulletin is not written with litigation in mind and, pursuant to Regulation 14(14) of the Merchant Shipping (Accident Reporting and Investigation) Regulations 2012, shall not be admissible in any judicial proceedings whose purpose, or one of whose purposes, is to apportion liability or blame.
This bulletin is also available on our website: www.maib.gov.uk Press Enquiries: 020 7944 3387/6433; Out of hours: 020 7944 4292 Public Enquiries: 0300 330 3000 BACKGROUND A bank holiday weekend on board an 11 year old Bayliner 285 motor cruiser ended tragically when a mother and her 10 year old daughter died. Initial findings indicate the deceased were poisoned by carbon monoxide.
INITIAL FINDINGS A “suitcase” type portable petrol-driven generator (Figure 1) had been installed in the motor cruiser’s engine bay to supply the boat with 240v power. The generator had been fitted with an improvised exhaust and silencer system which had become detached from both the generator and the outlet on the vessel’s side (Figures 2 and 3). As a result, the generator’s exhaust fumes filled the engine bay and spread through gaps in an internal bulkhead into the aft cabin where the mother and daughter were asleep. When the owner of the boat awoke in the boat’s forward cabin, he was suffering from carbon monoxide poisoning but was able to raise the alarm. The mother and daughter could not be revived. The boat’s carbon monoxide sensor system did not alarm because it was not connected to a power supply.
Petrol generator
Figure 1 Silencer
Figure 2 Exhaust outlet
Silencer
Figure 3 SAFETY ISSUES 1. Portable air-cooled petrol generators are readily available and inexpensive, but they are usually intended for use in the open air. The use or permanent installation of these engines on boats, particularly in enclosed spaces or below decks, increases the risk of carbon monoxide poisoning. 2. It is essential that engine exhaust systems are fitted and maintained to direct poisonous fumes outside the vessel clear of ventilation intakes and accommodation spaces. Work on these systems should therefore only be undertaken by suitably qualified marine service engineers using approved parts and following the equipment manufacturer’s instructions for marine installations. 3. Carbon monoxide is a lethal gas, which has no smell, no taste, is colourless and is extremely difficult for human senses to detect. All boaters need to be vigilant and recognise the signs of carbon monoxide poisoning, which can include: headaches, dizziness, nausea, vomiting, tiredness, confusion, stomach pain and shortage of breath. 4. Carbon monoxide is a silent killer that is just as lethal afloat as it is ashore. The correct positioning and the regular testing of any carbon monoxide sensors, whether powered by a boat’s electrical supply or self-contained, is essential. Carbon monoxide sensor alarms that do not work correctly should be replaced. When selecting a carbon monoxide alarm preference should be given to those marked as meeting safety standard EN 50291-2:2010 which are intended for use in a marine environment. Further advice on how to avoid carbon monoxide poisoning on boats and more detail about carbon monoxide alarms, produced by the Boat Safety Scheme (BSS) and the Council of Gas Detection and Environmental Monitoring (CoGDEM), can be found at: http://www.boatsafetyscheme.org/stay-safe/carbon-monoxide-(co)
Issued May 2013 Annex F
MAIB Safety Bulletin 1/2014
SAFETY BULLETIN MA RINE ACCI DENT INVES TIGAT ION BRA NCH
SB1/2014 February 2014
Extracts from The United Kingdom Merchant Shipping (Accident Reporting and Investigation) Regulations 2012 Regulation 5: “The sole objective of a safety investigation into an accident under these Regulations shall be the prevention of future accidents through the ascertainment of its causes Carbon monoxide poisoning on board the scallop-dredger and circumstances. It shall not be the purpose of such an investigation to determine ESHCOL liability nor, except so far as is necessary to achieve in Whitby, North Yorkshire its objective, to apportion blame.” on 15 January 2014 Regulation 16(1): “The Chief Inspector resulting in two fatalities may at any time make recommendations as to how future accidents may be prevented.” Press Enquiries: 020 7944 3231/3387
Out of hours: 020 7944 4292
Public Enquiries: 0300 330 3000
NOTE This bulletin is not written with litigation in mind and, pursuant to Regulation 14(14) of the Merchant Shipping (Accident Reporting and Investigation) Regulations 2012, shall be inadmissible in any judicial proceedings whose purpose, or one of whose purposes is to attribute or apportion liability or blame. © Crown copyright, 2014 See http://www. nationalarchives.gov.uk/doc/ open-government-licence for details. All bulletins can be found on our website: www.maib.gov.uk For all enquiries: Email: [email protected] Tel: 023 8039 5500 Fax: 023 8023 2459
1 MAIB SAFETY BULLETIN 1/2014
This document, containing safety lessons, has been produced for marine safety purposes only, on the basis of information available to date.
The Merchant Shipping (Accident Reporting and Investigation) Regulations 2012 provide for the Chief Inspector of Marine Accidents to make recommendations at any time during the course of an investigation if, in his opinion, it is necessary or desirable to do so.
The Marine Accident Investigation Branch is carrying out an investigation into the deaths of two persons on board the scallop-dredger Eshcol on 15 January 2014.
The MAIB will publish a full report on completion of the investigation.
Steve Clinch Chief Inspector of Marine Accidents
NOTE
This bulletin is not written with litigation in mind and, pursuant to Regulation 14(14) of the Merchant Shipping (Accident Reporting and Investigation) Regulations 2012, shall be inadmissible in any judicial proceedings whose purpose, or one of whose purposes, is to attribute or apportion liability or blame.
This bulletin is also available on our website: www.maib.gov.uk
Press Enquiries: 020 7944 4833/3387; Out of hours: 020 7944 4292
Public Enquiries: 0300 330 3000
2 Background
An overnight break from fishing ended tragically when the skipper and a crewman sleeping on board the 9.95m scallop-dredger Eshcol died in their bunks. Initial findings indicate the men were poisoned by carbon monoxide.
Initial Findings
Before going to bed, the skipper (aged 26) and the crewman (aged 21) had lit the grill of a butane gas cooker fitted in the wheelhouse (Figure 1) in order to warm both the wheelhouse and the adjacent sleeping area. When they were not seen as expected the following morning, crewmen from fishing vessels tied up close by forced open the wheelhouse door. The gas grill was still lit (Figure 2) and the wheelhouse was full of fumes; the two men were dead in their bunks.
Eshcol was not fitted with a carbon monoxide alarm.
Figure 1
Figure 2
3 Safety Issues
1. Gas cookers are designed for cooking, not domestic heating. Accommodation areas need to be heated, especially during the winter months and, for this, appropriate, purpose built heaters are required.
2. Fossil fuel burning appliances, such as cookers, need to be checked and maintained to ensure they are in good condition. A yellow flame indicates poor combustion, resulting in an excess of carbon monoxide that, in a poorly ventilated space, can quickly build up to lethal levels.
3. Carbon monoxide is a lethal gas, which has no smell, no taste, is colourless and is extremely difficult for human senses to detect. Crew need to be vigilant and recognise the signs of carbon monoxide poisoning, which can include: headaches, dizziness, nausea, vomiting, tiredness, confusion, stomach pain and shortage of breath.
4. Carbon monoxide alarms are not expensive and should be fitted. When selecting a carbon monoxide alarm, preference should be given to those marked as meeting safety standard EN 50291-2:2010, which are intended for use in a marine environment.
Further guidance for fishermen on the use of liquid petroleum gas (LPG) heaters and cookers can be found in Marine Guidance Notes 312 (F) and 413(F). More detailed advice on how to avoid carbon monoxide poisoning and on carbon monoxide alarms, can be found at: http://www.boatsafetyscheme.org/stay-safe/carbon-monoxide-(co)
Issued February 2014
4