Page 53 - CHIRP annual digest 2016.pdf

CHIRPAnnual Digest 2016

pre-arrival checklist that contains the requirement to Company issued a standard format for the “DO NOT
always conduct a pre-arrival and pre-departure briefing OPERATE” tags. Laminated reusable tags (in A5 size) have
to ensure that the whole team (deck and engine) has a been prepared and will be forwarded to all fleet vessels (8
shared mental model of the operation to come and thus pieces per vessel).
bring about effective and efficient teamwork.
Lesson Learned:
See also: It is important that the above procedures have been
(1) USCG Code of Federal Regulations 33. 164.25….. No communicated effectively to all crewmembers and are
vessel may enter, or be operated on the navigable implemented strictly at all times onboard.
waters of the United States unless the emergency
steering drill has been conducted within 48 hours CHIRP Comment:
prior to entry and logged in the vessel logbook….. The qualification of the electrician was questioned (ETO
(2) SOLAS V Reg. 26 requirements are subtly different – certification). The 2nd Engineer appreciated the high risk
drills/training are referenced in paragraph 4. associated with electrical equipment and did well to
https://mcanet.mcga.gov.uk/public/c4/solas/solas_ check but it is unclear if the work had started before he
v/Regulations/regulation26.htm. checked. It appears this was an ad hoc check and not
(3) SKULD P&I Club briefing “USA, MISSISSIPPI: HIGH driven by the SMS procedures. CHIRP is concerned the
RIVER SEASON – RISK OF GROUNDING” (March – preventative action of an A5 size notice was short term
and inadequate. A better approach would be to amend
May) when stronger currents may be experienced.
the design of the electrical panel casing and install a
The above article was published in MFB45
multi-lock system, or ‘Lock out for life’ system, that
creates a physical barrier, before operating the related
electrical system.
Article. 45
No Warning Notice on Electical Panel The above article was published in MFB 40

What did the reporter tell us?
During the overhauling of the Heavy Fuel Oil (HFO) Article. 46
transfer pump, the 2nd Engineer instructed the Electrician Incinerator Door Security System
to isolate the power of the pump and display the “warning What did the reporters tell us?
notice” on the electrical panel, “Do not touch under
During a Port State Control visit to the ship, it was noted
repair”. However, later when he inspected the panel, the the security system of the incinerator door was dis -
2nd Engineer realized that the electrician failed to imple -
connected.
ment his instructions. There was a risk of an accidental
start of the motor, resulting in an injury to the personnel Causal factors: Failure to follow planned repair/ main -
working on the pump. tenance instructions on defective equipment. Inadequate
guidelines listed in manuals.
The SMS states in the section “Execution of maintenance
work, based on the PMS” that all mechanical and electrical Preventative action: All waste oil incinerator alarms and
power connections must be isolated prior to work trip devices were tested as per the monthly checklist and
commencement and relevant “DO NOT OPERATE” tags all were in operational condition, without remarks. The
must be posted at the control positions. The relevant work main cause of the problem was two small securing bolts,
permits must be issued in this respect. There is also which keep an interlock plate connected to the door. They
allowance for the fact that prior to work commencement were not found during the investigation and probably fell
and depending on the nature/type of the inspection/ down into the incinerator furnace. This in turn was caused
repair/maintenance work, there might be the need, to by a wrong size or a bad thread condition that allowed
isolate/lock out and tag vessel’s equipment, valves, them to unscrew due to vibration or heat effect.
mechanical or electrical power connections, breakers,
The repair was put in place immediately and additionally
switches etc. In that case, a “DO NOT OPERATE” tag has
to be posted so as to prevent unauthorized use. LOCTITE glue used for better securing of these small bolts.
The officer in charge and the incinerator operator were
With a view to facilitating the uniform implementation of instructed to check all safety devices on the incinerator
the above requirement onboard the fleet vessels, the every time before operation.

52