Findings from TSB investigation M22A0258: July 2022 engine room fire of the passenger ferry Holiday Island

Investigations conducted by the Transportation Safety Board of Canada (TSB) are complex since an accident rarely results from a single cause. In the case of the July 2022 engine room fire of the passenger ferry Holiday Island, near Wood Islands, Prince Edward Island, several factors led to the accident. The seven findings below detail the causes and contributing factors that led to this occurrence. Additionally during the course of the investigation, the TSB also made 14 findings as to risk and four other findings.

Findings as to causes and contributing factors

1. For approximately a month after the initial leak in the fuel rail was observed, a series of temporary repairs using non-standard materials and methods was made while the vessel remained in service.
2. When the final temporary repair to the leaking fuel rail failed, fuel sprayed onto the hot engine components and ignited.
3. Water from a fire hose likely spread the burning engine fuel around the engine room and contributed to the spread of the fire.
4. An unlubricated component of the fuel valve assembly prevented the fuel valve from closing fully, allowing the contents of the day tank to drain through the damaged fuel rail and fuel the fire in the engine room.
5. The resistance felt when the carbon dioxide (CO₂) release mechanism cable was pulled provided a false indication that the CO₂ had been released and there was no unambiguous, direct feedback from the remote-release mechanism to indicate success. As well, the posted guidance was not explicit. Consequently, the CO₂ release was delayed, allowing the fire to grow.
6. The engine room space was not completely sealed and air continued to enter the space through open vents, likely displacing the released CO₂ and also adding oxygen to the fire. Consequently, the fire continued to burn.
7. The flexible connection between the cooling system and the forward main engine was not protected against heat and fire. When the flexible connection was damaged by the fire, seawater from the vessel’s cooling system entered and began flooding the closed engine room.

Findings as to risk

1. If the hazards posed by temporary repairs to a vessel are not objectively assessed in order to counter operational pressures, the practice of temporary repairs may be normalized. Consequently, risks may go unidentified or unmitigated, jeopardizing people on board and the vessel.
2. Once a vessel lists beyond its documented worst-case stability scenarios, the risk of sudden capsizing becomes high, posing a risk to the lives of the people on board.
3. If authorized representatives (ARs) do not ensure that procedures related to vessel operation and safety are periodically evaluated and updated with feedback from those who use them, there is a risk that these procedures will not support an effective emergency response.
4. If emergency procedures do not contain explicit, vessel-specific information that can be used immediately, there is a risk that crew members will not have critical information needed to effectively set priorities and make decisions during an emergency.
5. If a vessel’s safety management system does not include a decision process for the period of the emergency response that follows a partial abandonment, decisions may be delayed or tasks may be missed, increasing the risk to people on board and to the safety of the vessel.
6. If shipboard emergency drills do not represent realistic scenarios, there is a risk that crews will be unable to respond effectively to an emergency.
7. If a vessel’s muster list assigns crew members to duties in multiple emergency procedures, then leadership and communication issues, delays, or other problems are likely to occur when the emergencies happen at the same time, increasing the risk to people on board, the vessel, and the environment.
8. If there is no accurate count kept of passengers boarding a vessel, some passengers may not be accounted for in an emergency, increasing risks to passengers, crew, and first responders.
9. If a crew does not ensure that the number of lifejackets of the correct sizes is sufficient for the number of children and infants boarding the vessel, there is a risk that children and infants will not have lifejackets in an emergency.
10. If ARs do not have a clear understanding of the scope of their responsibilities with respect to safety, vessels may operate without the minimum defences provided by meeting regulatory requirements, increasing the risk of incidents and accidents.
11. Without effective oversight by an AR, practical drift can emerge in the execution of a vessel’s operational and emergency procedures, and the safety objective of the Canada Shipping Act, 2001, may not be achieved.
12. If Canada’s level of preparedness and coordination for marine emergencies, beyond the search and rescue regime, is not increased, there is a risk that these emergencies will not be managed in a timely and effective manner, endangering vessels, people on board, the environment, and the public.
13. When first responders do not have a communication plan for marine emergencies, information may be missed and decisions may be delayed, increasing the risks to those on board, to the vessel, and to the environment.
14. If emergency response procedures do not instruct crew to make an early and direct report to a radio ship reporting station, there is a risk that assistance will be delayed.

Other findings

1. The need for fire protection on the flexible connections between the seawater cooling system and the engine was not identified at the engine replacement planning stages or during post-installation and subsequent inspections.
2. The louvre dampers on the air intake vents were being replaced with the same type of damper, which is less effective at sealing vents than solid fire dampers.
3. The marine evacuation systems installed on the vessel contributed to the safe and rapid evacuation of passengers.
4. Beaching the Holiday Island on a sandbar stabilized the vessel during the passenger evacuation.