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Safety Lessons from Marine Incident Investigation (AMSA Report) No.19 - May 2023

Lack of regular planned maintenance results in engine fire.


A Class 1 passenger vessel’s port engine caught fire whilst northeast of Fraser Island with 82 passengers and crew onboard. The investigation found that regular planned engine maintenance, in accordance with manufacturer’s specifications, was not in place at the time of the incident. 

The crew’s response to the incident was immediate and effective. The transfer of the 77 passengers to a nearby vessel, which attended the distress call within 10 minutes, was undertaken quickly and effectively by the master and crew. 

What happened

On 10 October, at approximately 10:30, a fire broke out in the port engine room of a Class 1 passenger vessel while located 2 nautical miles northeast of Fraser Island. There were 77 passengers and 5 crew onboard. 

The crew responded to the emergency quickly, extinguishing the fire in under 5 minutes. Boundary cooling was established, engine room ventilation and fuel shut-off managed, and fire suppression released while 2 crew mustered passengers. A nearby passenger vessel responded to the distress call and was alongside the distress vessel within 10 minutes. 

Following consultation between the 2 masters, the attending vessel approached the stern of the distressed vessel and was attached via the port and starboard aft lines. The mustered passengers, which included 20 disabled persons and 10 carers, were transferred with the aid of 2 crew on each deck onto the attending passenger vessel. The transfer of passengers was achieved in under 15 minutes and the attending vessel returned to port. 

The owner of the distressed vessel returned it to port. No passengers or crew were injured.

Investigation findings

The investigation identified the following contributory factors:

  • The source of the fire was a ruptured high-pressure fuel hose that sprayed fuel onto the exhaust manifold and turbo of the port engine.
  • The vessel’s record of maintenance did not refer to any scheduled replacement of fuel hoses or the manufacturer’s requirements for such servicing. Any documented evidence of a suitable schedule of maintenance from the vessel safety management system (SMS) was not made available to the inspectors.
  • A regular planned engine maintenance schedule, in accordance with manufacturer’s specifications, was not in place at the time of the incident.
  • The presumed structural fire protection which melted, was identified as not fire rated. The suppression and fire detection worked; the structural fire protection did not work.

Safety message

Vessel owners/operators must ensure a well-documented regular program of inspections and maintenance is implemented. It is critical that proper planning and procedures for the planning and scheduling of maintenance be in place in the vessel’s SMS. 

Safety information on this topic

To learn how to safeguard your vessel and operation with an active maintenance plan, find out more about planned maintenance

Office of Transport Safety Investigations (OTSI) has published a Safety Advisory SA04/23 on managing fire risks on domestic commercial vessels in response to a vessel fire on Sydney Harbour in February 2023.

This advisory contains useful guidance for operators and highlights the importance of conducting risk assessments and emergency plans including training/induction, emergency preparedness and the use of emergency equipment in responding to fires.

Last updated: 29 August 2023