 |
 |
 |
 |
| HOME |
| ABOUT US |
| PARTICIPATE |
| COLLECTIONS |
| DC EQUIPMENT MUSEUM |
| SHIP&SUBMARINE MUSEUM |
| WW II DAMAMGE REPORTS |
| SHIPBOARD CASUALTIES |
| DAMAGE CONTROL MUSEUM | ||
|
USS WHITE PLAINS (AFS 4), Main Space Fire, 9 May 1989 |
||
|
USS WHITE PLAINS
Description: Human error, a failure to follow proper tag-out procedures and accurately validate fuel transfer checklist resulted in the ejection of the valve stem on the main engine room fuel transfer system. This sent a high-pressure spray of fuel oil over the boiler, which ignited, creating a fireball which moved rapidly through the engineering space, in turn forcing space evacuation. Summary of Events and Causal Factors: Underway in the South China Sea enroute to Guam, while conducting fuel transfer to compensate for a list on the ship, a boilerman technician second class (BT2) (assistant oil king) discovered that a major valve in the 20-year-old piping system was cracked and no longer functioning properly. When informed of the problem, the ship's chief boilerman technician (BTC) directed the boilerman technician 2 (BT2) to remove the gear casing box from the valve (thus exposing the valve stem) and requisition the proper part from supply to conduct the repair. When the BTC checked the storeroom, he discovered the ship did not have a replacement valve of the same size but did have one of smaller dimensions. The BTC directed the BT2 to take the two valves to the machinery repairman (MR) to see if the smaller valve could be modified to fit. During these efforts, the butterfly valve was not noted "out of commission" (OOC) to the bridge nor was it properly tagged out to prevent inadvertent use. The MR stated he would work on the valves after lunch, (approximately two hours later). Just before lunch, the BTC directed another BT2 to open and close the valve using a crescent wrench to ensure it was working. Following this test, the BT2 asked the BTC if the valve was going to remain that way and was told, "Yes the MR shop is working on a new valve now." (referring to the smaller gear box). It was the BTC's stated belief that the valve was safe to leave in the disassembled condition, since he was confident the stem was physically attached to the disc and had not been damaged. The BTC then notified the main propulsion assistant (MPA), briefing him regarding the situation, the actions taken and the status of the valve. The MPA (an Ensign) concurred with the plan and understood the status of the valve. He did not question the maintenance procedure, repair philosophy, tag-out failure or ask about safety considerations. The BTC also briefed the chief engineer (CHENG) and accompanied him to inspect the valve. The CHENG viewed the disassembled valve, as well as the exposed stem and also concurred with the plan. He did not question the lack of a tag-out or the repair procedures being used. Both the CHENG and the MPA knew the ship was scheduled for refueling in about three hours and that the valve was in a strategic position in the fuel transfer system. As White Plains' engineers started planning and aligning the fuel system for the afternoon replenishment at sea (RAS), the condition of the valve and fuel routing was thoroughly discussed. Despite the fact that White Plains had an alternative route and an engineering operating procedure (EOP) requiring two-valve protection unless the CO authorized less, the engineering watch aligned the system to include the failed valve. The route was noted and inspected by the MPA and BTC and diagrammed on the fueling check-off list, which was delivered to the CO by the MPA just prior to the RAS. The CO reviewed the alignment document and approved the plan, even though the line-up was inconsistent with previous refuelings. It should be noted that the Underway Replenishment Instruction (AFS4INST 9550.1) being referenced to align the piping system for this event, had not been in effect on White Plains for four years and had been superceded by different information. Once the CO approved the plan, the causal factors of maintenance error, lack of attention to detail, poor decision-making and material failures crystallized. The critical failure of professionalism and lack of communication set the stage for the coming conflagration. Despite the fact that virtually all the senior leadership in the engineering department were aware of the situation, no one rose to object to what was being done. White Plains had, in the past, conducted extensive fire drills in their spaces and had developed a comprehensive main space fire doctrine. The proper number of EEBDs and OBAs were in the space; however, virtually no training on donning the personnel protection equipment had been conducted nor was egress training stressed. At 1305, the USS Sacramento (AOE-1) had maneuvered alongside and at 1329 White Plains commenced receiving fuel. Initial delivery pressure was noted at 40 PSI. A visual inspection of all system valves was conducted at 1334 and pressure was increased to 60 PSI. Again, no leaks were observed. However, just after increasing to 60 PSI, a high level alarm sounded on the main fuel storage tank indicating that it was filling rapidly. The boilerman technician of the watch (BTOW) shut the fill valve, causing the pressure in the transfer system to immediately surge to 70 psi, which caused the damaged butterfly valve to eject its valve stem and initiate a geyser of fuel, which sprayed onto numbers 2 and 3 boiler piping. The fuel ignited like a flamethrower on the back of the boiler. The time was approximately 1345. At 1348 the EOOW, sensing an increase in space pressure which caused his ears to pop, looked out from his position in the console operating space (COS) and saw an orange glow streaking above boilers 2 and 4. The EOOW used the 21MC to order the watchstanders to secure the plant. He did so without consulting the CO or officer of the deck (OOD) because he saw the fire moving rapidly through the space and knew immediate action was necessary. The reaction of the watchstanders in the space was rapid and efficient. All boiler stops, fuel oil service pumps, ship's service turbine generators (SSTGs) and throttles were immediately tripped and shut. The ship lost power and the space went dark. This initiated the emergency diesel engine which started within ten seconds. At the same time, the COS was engulfed in flames and filled with thick black smoke. The MPA ordered the space evacuated and informed the bridge of the situation. Of the eleven engineers in the MER, all either performed some immediate action prior to evacuating, or evacuated immediately. All personnel were able to evacuate the space through the escape trunk. Of eleven EEBDs which had been issued in the COS, only two were used by the evacuating personnel. Nine personnel either could not remove the EEBDs from the containers or did not attempt to do so due to panic. Five sailors made their way to the lower level and used the COS escape trunk to reach safety. All of these suffered burns but survived. One sailor in the oil shack could not open his EEBD and was asphyxiated in place. Five sailors attempted to evacuate via the upper level hatch but were overcome by severe heat and smoke on the upper level catwalk. When their bodies were discovered after the fire, all five had their EEBD either in their hands or lying next to them. The first warning the bridge had of a fire came from and was simultaneous with the sighting of black smoke from the stacks and holds. Sacramento was immediately ordered to stop pumping and emergency breakaway was initiated. However, at that moment, White Plains lost all power and steering control which caused the wire cutters at the replenishment stations to fail to operate. All hands were ordered to take cover. The outhaul and highwire parted at the forward station but Sacramento was able to detension the span wires at the midships and aft stations. Deck crews were then able to trip pelican hooks and release wires without additional damage or injuries. At 1349 the bow of White Plains passed under Sacramento's stern and GQ was sounded. The bridge rapidly filled with smoke. Communications failed and DC central was shifted to the main deck, while Repair 5 locker became inaccessible due to heat and heavy smoke. A muster taken there listed nine men unaccounted for. In engineering, all firemain pressure failed when power was lost to fire pumps 1 and 2, on line when the emergency started. Fire pump 3, normally powered up by the emergency diesel when power is lost, did not start because its controller had grounded out during the power shift. An electrician's mate second class (EM2) promptly ran through a smoke-filled passage to the controller, troubleshot the problem, reconnected the leads and started the pump. At that point, he discovered that the pump was only providing 50 psi to the firemain and, using a string, also discovered that the controller shaft was turning the wrong way. He reconnected the power leads and the pump discharge pressure jumped to 190 psi. It was now 1435, 50 minutes after the fire first ignited. While the EM2 was working on fire pump 3, repair parties tried to start five different P-250 pumps without success. The two pumps that did start could not develop sufficient suction to draw seawater from the waterline up to the main deck 30 feet above. After the firemain was restored, several attempts were made to enter the engineering spaces. Severe heat and heavy black smoke forced many of these efforts back and DC equipment such as thermal imagers failed to work properly. Fatigue and dehydration began to take their toll on the firefighting teams. Finally, hose and AFFF teams succeeded in reaching the lower level, where they were able to extinguish the fire and fill the bilge with foam to cool the space and prevent reflash. The performance of the crew in fighting the fire was professional and reflected their training. Leadership, maintenance, tag out and operating procedures in the engineering department, however, proved to be ineffective and costly in terms of both lives and material. Survivability Principles Applied: Lack of attention to detail, adherence to sound engineering practices and comprehensive training coupled with bad decision-making led to the events of May 9, 1989. Serious professional lapses caused White Plains to operate and refuel in an unsafe fashion. Although, clearly, the ship was trained and drilled in fighting engineering fires, all personnel interviewed after the mishap commented that training had not been realistic enough to prepare them for a major class B fire. White Plains had practiced only one fire scenario and prepared only one evacuation route. This training was never conducted in the dark and focused entirely on using the COS escape trunk. There was no diversification in their training; therefore, when the fire erupted, the main engineering space went dark and the COS was engulfed in flames. The actual conflagration scenario threw in a set of unexpected variables at a time when saving lives depended on split second reactions. Professional knowledge and training fell short, which in turn, caused a failure of the senior engineering leadership to recognize that their fuel oil transfer system was dangerously damaged and that, therefore, the refueling alignment was a critical violation of the applicable EOP. As events leading up to the fire unfolded, adherence to the EOP requirements would have forced a reexamination of the valve alignment or caused cancellation of the refueling. Lastly, failure to conduct extensive fire drills emphasizing personnel protection and the use of escape equipment left crewmembers unsure of either the capability or accessibility of their EEBDs. As a result, the men in the engine room were left in extremis and six fatalities occurred. The aggressive firefighting effort of the crew, the rapid efficient performance of the engineering team in securing the plant and the quick response of the underway replenishment (UNREP) teams teams are excellent examples of strong onscene leadership and professional knowledge. These actions combined to stop the spread of the fire and prevent further injury on both White Plains and Sacramento. The White Plains incident emphasized the need for new survivability initiatives:
|
||
