Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation M-02-022
Details
Synopsis: The recommendation addresses the adequacy of the instructions for the installation of engine accessories. The recommendation is derived from the Safety Board's investigation of the fire on board the high-speed domestic vessel Seastreak New York near Sandy Hook Point, New Jersey, on September 28, 2001, and is consistent with the evidence we found and the analysis we performed. As a result of this investigation, the Safety Board has issued safety recommendations to Cummins Engine Company, Inc., and Circle Navigation Company of New York. The Safety Board would appreciate a response from you within 90 days addressing actions you have taken or intend to take to implement our recommendation.
Recommendation: The National Transportation Safety Board, therefore, makes the following safety recommendation to Cummins Engine Company, Inc.: Revise your manufacturing and installation literature for the Centinel System to specify how to safely route and secure the lube oil hose between the oil filter assembly and the control valves on the engines.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Marine
Location: Harbor, NJ, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA01MM056
Accident Reports:
Fire On Board the Small Commuter Vessel Seastreak New York
Report #: MAR-02-04
Accident Date: 9/28/2001
Issue Date: 9/26/2002
Date Closed: 4/15/2004
Addressee(s) and Addressee Status: Cummins, Inc. (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: Cummins, Inc.
Date: 4/15/2004
Response: The Safety Board notes that Cummins has taken the following action in response to this recommendation: · Issued a Marine Application Bulletin detailing requirements for lube oil and fuel hoses used for marine applications. · Identified and inspected all known North American KV engines installed with the Centinel System in marine applications to confirm the proper installation of the Centinel System in each marine application. · Modified new and existing Centinel kits to include a single page of installation warnings. · Published and sent a Service Parts Topic to all of Cummins' distributors and dealers communicating the revised installation procedures planned for inclusion in the Centinel Master Repair Manual. · Completed an electronic early warning containing the single page of installation warnings on January 14, 2004. The Board also notes that appropriate sections of the installation guidelines portion of the Centinel Master Repair Manual will be revised to include the same caution and warning statements contained in the single page of installation warnings that accompanies the Centinel kits. Because the action taken by Cummins, Inc., satisfies the recommended action, Safety Recommendation M-02-22 is classified "Closed--Acceptable Action." The Safety Board would appreciate receiving a copy of the revised sections of the installation guidelines portion of the Centinel Master Repair Manual that include the same caution and warning statements contained in the single page of installation warnings that accompanies the Centinel kits.

From: Cummins, Inc.
To: NTSB
Date: 1/29/2004
Response: Letter Mail Controlled 2/13/2004 9:34:41 AM MC# 2040058 Marine Application Bulletin: As noted, on February 19, 2003 Cummins Marine issued a Marine Application Bulletin detailing requirements for lube oil and fuel hoses used for marine applications. KV engine inspections: All known North American KV engines installed with the Centinel System in marine applications were identified and inspected on or about October 11, 2002 so as to confirm the proper installation of the Centinel System in each marine application. Warnings in Centinel Kits: All HHP Centinel plumbing kits were modified to include a single page of installation warnings by December 2002. Centinel Master Repair Manual: It is anticipated that by April 16, 2004 appropriate sections of the installation Guidelines portion of the Centinel Master Repair Manual will be revised to include the same caution and warning statements contained in the single page of installation warnings that accompanies the Centinel kits. Service Parts Topic: It is anticipated that by January 30, 2004 a Service Parts Topic will be published and sent to all of Cummins' distributors and dealers communicating the revised installation procedures planned for inclusion in the Centinel Master Repair Manual. Early Warning: On January 14, 2004 an electronic early warning containing the single page of installation warnings was completed. Cummins trusts that the steps it has taken meet with your approval and are responsive to the M-02-22 safety recommendations. Should you have any questions concerning this letter or any of the actions taken by Cummins in response to the safety recommendations please feel free to call Miguel R. Rivera, Senior Counsel, (812) 377-7512.

From: NTSB
To: Cummins, Inc.
Date: 12/17/2003
Response: On November 8, 2002, you wrote on behalf of Cummins, Inc., regarding Safety Recommendation M-02-22, that Cummins, after conducting an independent review of the fire on the Seastreak New York and reviewing the Safety Board’s report, either has taken action or plans to do so as follows: Cummins Marine, a wholly owned subsidiary of Cummins, Inc., issued a Marine Application Bulletin on February 19, 2002, detailing requirements for lube oil and fuel hoses used for marine applications. All KV engines installed with the Centinel system in marine applications were identified and inspected to confirm the proper installation of the Centinel System in each marine application. New and existing Centinel kits will be modified to include a single page of installation warnings. Completion of this modification is planned on or before February 1, 2003. The appropriate sections of the Installation Guidelines portion of the Centinel Master Repair Manual will be revised. Installation procedures will include the same caution and warning statements listed in the aforementioned warning page enclosed within each kit. Publication of the revised manual is tentatively scheduled for September 2003. A Service/Parts Topic will be published and sent to all of Cummins’ distributors and dealers. The Service/Parts Topic will communicate the revised installation procedures planned for inclusion in the aforementioned Centinel Master Repair Manual. Publication of this Service/Parts Topic is planned for May 2003. An electronic Early Warning that includes the aforementioned warning page will be published on-line by the end of this year. On January 27, 2003, because Cummins, Inc., was taking action as requested, Safety Recommendation M-02-22 was classified "Open--Acceptable Response." The Safety Board requested receiving notification when these actions were completed along with the revised installation warnings and repair manual pages. The Safety Board has not received further response from Cummins, Inc. regarding actions being taken in response to this safety recommendation. The Board is interested in knowing whether and how its recommendations are implemented, both to ensure the public the highest level of safety and to identify creative solutions that might be shared with others. That is why we monitor the progress of our recommendations. We would appreciate being informed of the specific actions taken in response to this recommendation. Please address your response to Ms. Ellen Engelman Conners, Chairman, National Transportation Safety Board, and refer to the recommendation by number. A copy of the recommendation letter and the Board’s letter of September 26, 2001, are enclosed for your reference.

From: NTSB
To: Cummins, Inc.
Date: 1/27/2003
Response: Because Cummins, Inc., is taking action as requested, Safety Recommendation M-02-22 is classified "Open--Acceptable Response." The Safety Board would appreciate receiving notification when these actions are completed along with the revised installation warnings and repair manual pages.

From: Cummins, Inc.
To: NTSB
Date: 11/8/2002
Response: Letter Mail Controlled 11/13/2002 11:47:48 AM MC# 2020942 As you know, a fire on board the Sea Streak precipitated the NTSB's Safety Recommendation. The NTSB's investigation determined that the probable cause of the fire on board the Sea Streak was the improper installation of the Centinel's System's lube oil hose, which allowed the hose to come in contact with the hot exhaust manifold. As you are aware, Cummins Inc. did not install the Centinel System that was the subject of the Sea Streak fire and was unaware of the installation of this system in the Sea Streak. After conducting our own independent review of the fire on the Sea Streak and having reviewed your recommendations, Cummins plans to do the following: · Cummins Marine, a wholly owned subsidiary of Cummins Inc., issued a Marine Application Bulletin on February 19, 2002, detailing requirements for lube oil and fuel hoses used for marine applications. · A copy of this Bulletin is enclosed for your review. All KV engines installed with Centinel in marine applications were identified and inspected to confirm the proper installation of the Centinel System in each marine application. · New and existing Centinel kits will be modified to include a single page of installation warnings. A draft of this warning page is attached for your review. Completion of this modification is planned on or before February 1, 2003. · The appropriate sections of the Installation Guidelines portion of the Centinel Master Repair Manual will be revised. Installation procedures will include the same caution and warning statements listed in the aforementioned warning page enclosed within each kit. · Publication of the revised Manual is tentatively scheduled for September 2003. · A Service/Parts Topic will be published and sent to all of Cummins Distributors and Dealers. The Service/Parts Topic will communicate the revised installation procedures planned for inclusion in the aforementioned Centinel Master Repair Manual. Publication of this Service/Parts Topic is planned for-May of 2003. · An electronic Early Warning that includes the aforementioned warning page will be published on-line by the end of this year. Cummins appreciates the NTSB's involvement in investigating the fire on the Sea Streak.