What did the reporters tell us?
In CASE 1, during a new build sea trial, the low level alarm of a main engine lubrication oil sump tank sounded; yard staff noticed that 5-8m3 of oil had been lost. It was found that incomplete actuation of a 3-way valve at the oil purifier inlet was to blame for a slow but continuous leak. This leak went unnoticed because, though the yard stuff regularly checked the oil residue tanks, the measurements were not recorded.
In CASE 2, during safety rounds in an engine room, a deck seal seawater pump was leaking. The pump was stopped and the valves were closed. In the absence of warning signs to this effect, another engineer later restarted the pump before repair.
In CASE 3, a bourdon tube on a pressure gauge for high pressure cleaning oil on an auto backwash filter was found to be damaged. The damage was caused when the line pressure exceeded the maximum allowable pressure of the gauge. It had been replaced with a gauge of much lower specification. After it was put into service, the bourdon tube punctured, the pressure being well above the new gauge’s limit; oil sprayed the surrounding area, with consequent high risk of fire.
The lessons to be learnt
In CASE 1, daily sounding of tanks need to be recorded; otherwise losses may be missed. Pre-planned responses and actions in the event of activation should be available for all alarms. Routine tests of alarms are crucial and should include checks of settings and thresholds where appropriate.
In CASE 2, the occurrence could have caused both injury and equipment damage. It highlights the importance of the permit to work system, isolation procedures, “do not operate” notices and effective information exchange within spaces, especially engineering spaces at handover or following maintenance periods.
In CASE 3, the potentially disastrous consequences of fitting of subspecification gauges or components is clearly demonstrated.
