Marine Accident Brief
Fire On Board U.S. Small Passenger Vessel Massachusetts
Boston Harbor, Massachusetts
June 12, 2006.

NTSB/MAB-07/01
PDF Document [966K]

Accident No.:	DCA-06-MF-016
Vessel:	M/V Massachusetts, 87.6 feet long, 99 gross tons, aluminum construction, built in 1988
Accident Type:	Engineroom fire
Location:	Boston Harbor, Massachusetts
Date:	June 12, 2006
Time:	1615 eastern daylight time 1
Owner/Operator:	Massachusetts Bay Lines
Damages:	$800,000
Complement:	4 crew, 65 passengers
Injuries:	2 minor (passengers)

Synopsis

On Monday afternoon, June 12, 2006, the commuter ferry Massachusetts (figure  1) was en route from Rowe’s Wharf in Boston Harbor to Hingham, Massachusetts, carrying 65 passengers and 4 crewmembers, when a fire broke out in the engineroom. The Massachusetts, owned and operated by Massachusetts Bay Lines, was inspected and certificated by the U.S. Coast Guard under the small passenger vessel regulations at 46 Code of Federal Regulations (CFR) Parts 114-122 (subchapter K). 2 The vessel’s certificate of inspection (COI), valid for 5 years, was issued on November 14, 2002. 3 The COI allowed a total of 350 persons on board, including 346 passengers (adults and children) and 4 crewmembers (a master and 3 deckhands). At the time of the fire, the Massachusetts was operating pursuant to a subcontract with Boston Harbor Cruises, which had a 5-year contract with the Massachusetts Bay Transit Authority to provide ferry service between Rowe’s Wharf and Hingham Shipyard. The contract specified that vessels had to comply with Coast Guard requirements.

The Massachusetts crew was alerted to the fire about 1615, when the ferry was near the Long Island Bridge (figure 2), by black smoke at the stern and an engine high-water-temperature alarm. The vessel did not have, and was not required to have, an engineroom fire detection system. The master maneuvered the vessel into shallow water southeast of the bridge, anchored, and waited for firefighters. Before a fireboat from the Boston Fire Department’s marine unit arrived, all the passengers safely transferred to the Laura, another commuter vessel in the vicinity. The fireboat extinguished the fire. The accident did not result in any serious injuries or fatalities. 4 Damage, estimated at $800,000, was confined mostly to the engineroom.

Figure 1. Commuter ferry Massachusetts at Rowe’s Wharf, Boston. (Photo courtesy Massachusetts Bay Lines)

Figure 2. Commuter route of Massachusetts between Rowe’s Wharf and Hingham Shipyard. Accident site is at anchor symbol southeast of Long Island Bridge.

Accident Narrative

Engine Repair. At 1230 on June 12, after completing three morning commuter runs and two sightseeing tours of Boston Harbor, the Massachusetts left Rowe’s Wharf and traveled 15 minutes away to a dock at Charlestown, Massachusetts. The master had arranged that morning to meet the company’s marine repair contractor at the Charlestown dock because the Massachusetts was experiencing a number of mechanical problems. The repair shop had three employees (diesel mechanic, welder, and mechanic-in-training), in addition to the owner. The diesel mechanic had been employed at the shop for almost 12 years and normally worked on the Massachusetts Bay Line vessels. He said that his knowledge of diesel repair and maintenance had been acquired solely through on-the-job experience and estimated that 80 percent of the diesel engines he worked on were manufactured by Detroit Diesel. The Massachusetts was powered by four 675-horsepower, 12-cylinder turbocharged model 12V-71 Detroit Diesel engines and had two generators (see “Vessel Information” section for details).

The diesel mechanic met the Massachusetts at the dock. The Massachusetts master and the mechanic discussed the work to be performed—(1) examining the starboard outboard engine for excessive blowby (venting) of combustion gases through the valve cover breathers; 5 (2) examining the port generator for sparking, which a crewmember had reported over the weekend; and (3) examining the port inboard engine, which had been idling at a higher speed than normal.

For the first item, the mechanic diagnosed a leaking head gasket on the starboard outboard engine, which he and the master decided to defer repairing until later in the week. 6 The owner of the repair shop arrived while the mechanic was working on the second item, examining the port generator. Although the mechanic found no sparking on the generator, the master decided to use only the vessel’s starboard generator until a marine electrician could examine the port generator.

For the third item, the port inboard engine, the shop’s owner advised the mechanic to look for a faulty injector, which the mechanic said he agreed might be the cause of the high idle speed. The owner left the vessel before the mechanic started work on the port inboard engine. The mechanic said that he removed the inboard valve cover to check the six fuel injectors on that side of the engine (figure 3). His inspection revealed that the injector on the No. 3 cylinder was faulty. The mechanic proceeded to replace the injector. First, he removed the fuel supply and return lines (“jumper lines”) connected to the injector.7 Then he unbolted the fasteners holding the injector to the engine, removed the faulty injector, and bolted another in its place.

The mechanic stated that in replacing an injector on a Detroit Diesel engine of that type, no calibrations or settings were necessary once the new injector was in place. He had access to the manufacturer’s service manuals but said, “Generally, I don’t need them,” noting that he had memorized the torque specifications. He told investigators that he used a torque wrench to torque the rocker stand bolts to 104 foot-pounds 8 and the injector hold-down clamp to 25 foot-pounds. He said that he did not use a torque wrench on the fuel lines because “If you overtighten them, you could split the side of the fuel line.” The engine manufacturer’s service manual warns, “When installing fuel jumper lines, Do Not Overtighten.” 9

The mechanic told investigators that after replacing the injector on the No. 3 cylinder, he ran the engine with the valve cover off to “inspect the fuel lines to make sure they’re not leaking.” The engine manufacturer’s service manual warns that leaking fuel oil can dilute the lubricating oil and damage the engine:

Maintenance and service personnel should be aware that severe engine damage could result from fuel oil leakage into the lubricating oil and should therefore follow proper procedures when removing, handling and installing fuel jumper lines . . . .

The manual also warns specifically of the fire danger posed by undetected leaks in the fuel jumper lines:

Severe fuel leakage, if not detected, can also result in an over-filled crankcase (oil pan) which can cause an abnormal amount of fuel and lubricating oil vapor to escape from the engine and crankcase breathers. An abnormal concentration of fuel and lube oil vapors is flammable and could ignite in a closed engine compartment.

The procedure in the manufacturer’s service manual for ensuring that fuel jumper lines are securely in place after replacing the lines is to run the engine with the valve cover off, which makes it possible to observe the jumper lines for any leaks. A Detroit Diesel marine service engineer stated that running the engine with a disconnected fuel jumper line would be like “‘running a garden hose inside the engineroom.” If the valve cover was off, the mechanic should have been able to see fuel leaking from the jumper line that investigators found disconnected after the fire (see “Wreckage” section).

Detroit Diesel Corporation, Diesel V-71 Service Manual

Figure 3. Typical fuel injector assembly in Detroit Diesel engine cylinder.

The master said that the idle on the port inboard engine was back to normal after the mechanic changed the injector. The mechanic completed his work between 1430 and 1500, according to the master, and left the vessel about 1530. The Massachusetts then departed Charlestown to begin itsafternoon commuter schedule. The master said that he ran only the two outboard engines on the return trip to Rowe’s Wharf, but that he always used all four engines on the commuter runs.

Departure. Back at Rowe’s Wharf, the Massachusetts boarded 65 passengers for the 1600 trip to Hingham Shipyard. Before departing, the master, who had been employed by Massachusetts Bay Lines for over 20 years, delivered a passenger safety briefing over the vessel’s public address system. The master informed passengers about the location and type of lifesaving equipment on board and told them to follow crewmembers’ instructions in case of emergency. 10 According to data from Logan International Airport, about 5 miles away, skies were clear, with unrestricted visibility at 10 miles and a broken cloud cover, the air temperature was 71° F, and winds were from the southeast at 12 knots.

The Massachusetts departed the dock on schedule (1600), running on all four engines, with the mate at the helm. Soon after leaving Rowe’s Wharf, the master went to the engineroom to bleed air from the air conditioning system. He said that he did not detect anything out of the ordinary. He then returned to the pilothouse.

Fire. About 1615, the upper deck deckhand entered the pilothouse to report black smoke at the vessel’s stern. At the same time, the high-water-temperature alarm for the port inboard engine sounded. The mate stopped the port inboard engine and slowed the remaining three engines from 2000 to 1300 rpm, as directed by the master. The master went to the engineroom to investigate.

The master said that when he opened the door to the starboard ladderway leading to the engineroom, he encountered heavy smoke and immediately closed the door. He went to the phone at the main deck bar and called the pilothouse, informing the mate of the situation and instructing him to shut down two of the remaining engines. The mate shut down the port outboard engine, which had already lost some power, and the starboard outboard engine, leaving only the starboard inboard engine running.

On his way back to the pilothouse, the master directed the main deck passengers and the main deck deckhand to go to the upper deck and told the deckhands to give the passengers lifejackets. One of the passengers happened to be a Coast Guard officer commuting home. The master told the Coast Guard officer about the fire and asked for his help in contacting the Coast Guard. The officer used his cell phone to alert the local Coast Guard office, Sector Boston, about the fire.

By that time, the vessel had passed south of the Long Island Bridge. The master relieved the mate at the helm and ordered him and one deckhand to the bow to prepare to drop anchor. The mate instructed the other deckhand to help.

Passenger Evacuation. Meanwhile, the master used very-high-frequency (VHF) channel 13 11 to contact the commuter ferry Laura, operated by Boston Harbor Cruises. The Laura was about 1/2 mile south, en route from Hingham to Rowe’s Wharf with three passengers on board. The Massachusetts master told the Laura master that his vessel had an engineroom fire and asked the Laura to come alongside and receive his passengers “expeditiously.” The Laura immediately altered course to assist the Massachusetts.

The Coast Guard officer entered the pilothouse and reminded the master to turn off the engineroom’s ventilation supply blowers. 12 After turning off the blowers, the master navigated the Massachusetts just outside the channel to the east, about 1/2 mile south of the Long Island Bridge (figure 2), and ordered the mate to drop the anchor. After the vessel was anchored, the master sent the mate to the main deck to close the emergency fuel shutoff valves, located in the bar area. The deckhands returned to the upper deck to attend to the passengers, and the master turned off the inboard starboard engine. The generator shut down from fuel starvation about 30 seconds after the mate closed the emergency fuel shutoff valves.

About 1630, the Laura came alongside the Massachusetts and tied up on the starboard side. The Massachusetts crew then led the vessel’s 65 passengers, wearing lifejackets, down the forward starboard ladder to the main deck and out through the starboard forward side door directly onto the Laura. Once on board the Laura, the Coast Guard officer again used his cell phone to call Sector Boston about the fire. The transfer of passengers was orderly, taking around 5 minutes, according to crew statements. The Massachusetts crew did not remember counting passengers as they left the vessel, but a count was taken and logged on board the Laura. At 1635, the Laura untied from the Massachusetts and moved to a safe distance. After the state police boarded and checked for casualties, the Laura departed for Hingham Shipyard. 13

Crew Decision on Firefighting. Once the passengers had transferred to the Laura, the master and crew discussed fighting the fire themselves. The Massachusetts carried approved firefighting equipment, including seven fire extinguishers 14 and two fire pumps, both located in the engineroom and run by the generators, 15 capable of providing a stream of water to any space on the ship by way of two fire stations (one behind the bar on the main deck and one at the top of the interior ladderway). The master stated, “I flatly decided we weren’t going to open either engineroom door. We weren’t going to do anything to give the fire any oxygen.” Throughout the accident, the master’s prudent decisions promoted the safety of his passengers and crew.

Police Boat. Meanwhile, the Protector, a police boat from Quincy, Massachusetts, 16 had been approaching the Long Island Bridge from the southwest when the crew observed the Massachusetts “dead in the water with smoke showing from its stern.” About 1635, the Protector came alongside the Massachusetts on the port side, and the Massachusetts mate told the Protector crew that the engineroom was on fire. Police on board the Protector immediately notified the Coast Guard, using VHF channel 16, 17 and requested a fireboat. The Protector crew also notified Quincy police headquarters about the fire. At approximately 1645, at the Coast Guard’s request, the crew transferred from the Massachusetts to the Protector, which remained on scene but at a distance from the burning vessel.

Emergency Response. According to emergency records provided by the Boston Fire Department, the dispatch operations center (known as “Fire Alarm”) received nearly simultaneous calls reporting the Massachusetts fire from the Coast Guard (at 1641) and Quincy police (at 1642). At 1644, the center dispatched the fire department’s marine unit to the Long Island Bridge from its station at Burroughs Wharf in Boston’s North End, about 6 nautical miles from the accident site.

After receiving the call from the dispatch center, marine unit personnel boarded the vessel Firefighter and were under way in 2 or 3 minutes, according to the pilot. 18 At 1656, the dispatch center dispatched Engine Company 2 and Ladder Company 19 to the Paul W. Conley terminal, located at the southeast end of the reserved channel 19 in South Boston, to be picked up by the marine unit. At 1703, the dispatch center dispatched the District 6 fire chief to the Conley terminal, also to be picked up by the marine unit. Firefighters told investigators that it took 10 minutes to load personnel and gear at the terminal.

The Firefighter (maximum speed 9 to 10 knots) arrived at the accident scene at 1730 and approached the burning Massachusetts on its port side. All passengers and crew had disembarked. The Firefighter crew noted heavy black smoke coming out the vents and doorways at the Massachusetts’s stern. Vessels were already on scene from the Quincy Police Department (the Protector and the Guardian), the Massachusetts Environmental Police Department, the Massachusetts State Police, and the Coast Guard (which had launched a 41-foot utility boat from Station Pt. Allerton, about 2 nautical miles east of the accident site 20). A MassPort fireboat 21 also stood by. The District 6 fire chief assumed on-scene command.

The Firefighter was secured to the Massachusetts and five firefighters went on board. According to the fire chief, the firefighters placed a 2 1/2-inch-diameter fire hose down each of the two engineroom ventilation shafts on the aft main deck, with two men operating each hose. Because of the intensity of the fire (the fire chief said the main deck had “steam coming out of the carpet”), firefighters could not enter the engineroom. They poured water into the engineroom and pumped firefighting foam down the port engineroom ventilation shaft, but their actions did not extinguish the fire.

Firefighters sought help from the Massachusetts crew, now on the Quincy police boat Protector, in finding better engineroom access. The mate and two deckhands of the Massachusetts transferred from the Protector to the Quincy police boat Guardian, and the Protector delivered the master to the Firefighter. The master told the firefighters about “soft patches” (metal hatches) in the main deck, directly above the engines, that could be opened. Firefighters removed enough screws so they could pry open the hatch over the port inboard engine and fight the fire from above. Their efforts filled the engine compartment with water nearly to the main deck level, above the tops of the engines. Out of concern for the vessel’s stability, the fighters began pumping water out of the engineroom. After they had lowered the water level by 5 to 6 feet, the firefighters entered the engineroom and checked for hot spots. At 1848, firefighters reported that the fire appeared to be out but set a reflash watch in case the fire should reignite. Firefighters left the scene at 2040.

Aftermath. The Massachusetts crew, which had transferred to the Coast Guard 41-foot utility boat, was transported to the Hingham Shipyard dock, arriving at 2130. The Massachusetts was taken under tow by a local harbor tug at 2240 and moved to a pier at Deer Island (figure 2).

Vessel Information

The Massachusetts, a double-deck vessel constructed entirely of aluminum (figure 4), was built for Massachusetts Bay Lines by Gulf Craft, Inc., of Patterson, Louisiana. The builder began construction in 1987 and delivered the Massachusetts in 1988. Massachusetts Bay Lines immediately put the vessel to use in the Boston Harbor commuter trade.

Figure 4. Profile view of the Massachusetts. Passengers were carried in the enclosed cabins on the main and upper decks.

The enclosed pilothouse at the bow of the vessel was accessed by a short ladder from the upper deck. The pilothouse was equipped with the following navigation and communication equipment: X-band and S-band Furuno^® radars, 22 two Raytheon^® VHF radios, an International^® depth sounder, a Magellan^® global positioning system unit, a horn, a searchlight, and a compass.

A control panel in the pilothouse registered alarms for high water temperatures in individual engines and for high water in the compartments equipped with bilge alarms. The pilothouse was also equipped with an engineroom air high-temperature alarm. 23 A public address system in the pilothouse was used to communicate with passengers and crew throughout the vessel and to deliver predeparture safety briefings and other announcements.

The upper deck contained both fixed and movable chairs for passenger seating. An enclosed passenger section in the middle contained a bar. The upper deck was connected to the main (lower) deck by an exterior ladderway (stairway) on the port side aft and by an interior ladderway on the starboard side forward.

The main deck was almost entirely enclosed to protect commuters from the weather. Seating consisted of chairs placed throughout and fixed seats in the forward area. A small bar/serving area was located amidships on the starboard side. Next to the bar were the emergency fuel shutoff levers for the propulsion engines and generators, as well as a fire station containing a fire hose. Restrooms were located at the aft end of the main deck. A small open deck aft of the restrooms allowed crewmembers to handle the lines during docking. Two sliding doors on each side of the main deck provided egress from the vessel. Passengers and crew could also exit through the door at the stern that led to the open deck. 24

The belowdecks area was divided into six compartments separated by transverse watertight aluminum bulkheads extending upward from the bilges to the main deck (figure 5). The forwardmost compartment (forepeak) contained anchor rope and spare lines. The next compartment (forward compartment) contained a sewage holding tank and macerator pump. 25 Aft of the forward compartment was a space that was used to store supplies such as coffee and also contained a small workshop; it was