MSF provides lessons learned from an incident where the safety pins of the fixed CO2 system flexible hoses had not been removed and were still in place.
The incident
An MSF member vessel had recently undergone a Firefighting equipment survey, all equipment was fully inspected, and any faults or discrepancies were rectified. The Fixed CO2 system flexible hoses were renewed as the system had reached it`s 10 years of service life.
To allow the survey to be conducted in a safe manner the safety pins had been put in place, while the outside contractors carried out their inspection. When finished these should have been removed, to make the system ready for activation.
On re-joining the vessel at the scheduled crew change almost 4 weeks after the survey, the C/E/O after a routine inspection, found that the safety pins inserted during the survey had not been removed and were still in place making the system inoperable. This unnoticed action had a high potential to develop into a serious incident if the CO2 system had been required for extinguishing an engine room fire.
A similar safety alert had been issued by the vessel owner to their fleet in August 2021.
Probable cause
Details on causes and corrective actions specific to this incident were not provided by the submitting party / vessel owner but lessons learned, and actions below were re-enforced from the previously mentioned fleet safety alert that had been issues in August 2021. This guidance was relevant to the incident described
It should be noted that the below recommendations were specific to that vessel owner and each vessel should review against their own processes.
Lessons learned
- Before any work, including contractual work commences on essential Fire Fighting equipment, a permit to work should be issued, this must include an entry in the isolation log, to the effect that the system has been isolated. This should be backed up by an entry recorded in the deck log. This helps to ensure that the system cannot be left in an inoperable condition.
- Never assume and rely that all will be well and ok. Assumption is the pathway to undesired events. Always check and verify.
- Always inspect 3rd party actions to ensure any systems they work on, is reinstated to original design intent after completion of the task.
- Work is only complete when the isolations are removed, and the permit can be closed.
