Wrong Directions: A Recipe for Failure

Wednesday, December 22, 2010

This U.S. Coast Guard safety alert addresses critical concerns uncovered during an ongoing marine casualty investigation and should be of vital interest to Ship Builders, Classification Societies, Owner / Operators and others involved with vessel operations.

A machinery space fire onboard a relatively new vessel was effectively responded to and extinguished by the vessel’s quick response team firefighters using portable extinguishing equipment. However, before it was declared completely extinguished and approximately five hours after the fire started, the master of the vessel made the decision to release CO2 from the vessel’s fixed firefighting system. It failed to operate as designed. Subsequently, crewmembers were unable to activate it manually and CO2 was never directed into the machinery space.

While the casualty investigation remains ongoing, the following issues were discovered that could have negatively affected the crew’s emergency response and may have contributed to the CO2 system failure.

Shipyard commissioning test procedures appear to differ from procedures documented in the vessel’s Firefighting Instruction Manual (FIM). Commissioning procedures indicate that the discharge line selection to a specific protected zone should be made prior to releasing the gas contrary to the directions in the FIM.

•    The FIM refers extensively to a Control Panel (left following image) that differs vastly from the one onboard the vessel (right following image).
•    The FIM states that the CO2 Release station is on the Starboard side of the vessel when In fact it is located on the Port side.
•    The FIM incorrectly uses the word “Pull” when it should read “Turn” in reference to the operations of valves.
•    The FIM contains the following confusing language “Once the fire has been extinguished make sure that the temperature has decreased before investigate the area same time is needed to wait hours.”
•    The FIM references elements of an Emergency Shut Down (E.S.D.) graphic on numerous occasions. However, the graphic display was not found on the vessel.
•    The FIM contains photographs of the internals of the CO2 release stations that appear to differ from actual CO2 release stations onboard the vessel.
•    The CO2 release stations installed on the vessel have instructional placards that refer to elements of a completely different control panel then the one used onboard the vessel.
•    Shipyard piping schematics and drawings do not appear to match the actual installation. The schematic at the right shows the “A valve” for the Aft Machinery Space in the center position vice the bottom position as it is installed on the vessel.

Because of these and other issues, the United States Coast Guard strongly recommends that vessel builders / shipyards, classification societies, insurers, owners / operators, system service personnel, and others involved with these systems:
•    Ensure that all supporting documentation, piping schematics, plans, manuals, component labeling and instructions are consistent with each other and relevant to the systems, equipment, and components installed onboard the vessel.

Developed by the U.S. Coast Guard Headquarter’s Office of Investigations and Analysis, Washington, DC. Questions may be addressed to: HQS-PF-fldr-G-PCA@uscg.mil

 

Maritime Reporter February 2015 Digital Edition
FREE Maritime Reporter Subscription
Latest Maritime News    rss feeds

Coast Guard

Sri Lanka Says No to Docking of Chinese Submarines

Sri Lanka declared that it will not allow Chinese submarines to dock in its waters as part of a new policy barring hosting of foreign submarines.   Sri Lanka's

Container Ship Runs Aground at Fremantle Port

A ship that ran aground at Fremantle Port early Saturday has been refloated. The 62,000-tonne Denmark-registered container ship Maersk Garonne became stuck in soft sand about 500m off South Mole.

Coast Guard Foundation Announces 2015 Scholarships

The Coast Guard Foundation, a non-profit organization committed to the education and welfare of Coast Guard members and their families, announced yesterday that

Maritime Safety

Sri Lanka Says No to Docking of Chinese Submarines

Sri Lanka declared that it will not allow Chinese submarines to dock in its waters as part of a new policy barring hosting of foreign submarines.   Sri Lanka's

Container Ship Runs Aground at Fremantle Port

A ship that ran aground at Fremantle Port early Saturday has been refloated. The 62,000-tonne Denmark-registered container ship Maersk Garonne became stuck in soft sand about 500m off South Mole.

Drowning at Castaway Cay

Police are investigating the apparent drowning of an American cruise ship passenger off at Disney’s private island in the Bahamas - Castaway Cay in the Abacos.

 
 
Maritime Careers / Shipboard Positions Maritime Standards Naval Architecture Offshore Oil Salvage Ship Electronics Ship Repair Ship Simulators Shipbuilding / Vessel Construction Winch
rss | archive | history | articles | privacy | terms and conditions | contributors | top maritime news | about us | copyright | maritime magazines
maritime security news | shipbuilding news | maritime industry | shipping news | maritime reporting | workboats news | ship design | maritime business

Time taken: 0.2063 sec (5 req/sec)