M2311

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31st March 2025

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Near miss: poor configuration of CO2 firefighting system

Initial Report

Following a period of maintenance, a pre-sailing inspection revealed that the safety pins which prevented the CO2 firefighting system from operating were still in place. A contractor had inserted the safety pins to prevent accidental discharge while maintaining the system but had not removed them once the work was completed.

Had these remained in place, the system could not have been used in the event of an engine room fire.

CHIRP Comment

There is always a pressure to get vessels out of dock and back to operational service as quickly as possible. However, similar to report M2319 (Fire on large motor yacht), this pressure resulted in several important steps being missed. Whenever equipment is handed over to or from a contractor, it is best practice that a suitably qualified crewmember and the contractor jointly inspect the equipment so that both agree on its material condition and out-of-service status and operational readiness configuration at the start and end of a job.

The design of the pins is a contributing factor: they are a similar colour to other nearby items and CHIRP suggests that if they had been painted, or had a label like the ‘Remove before Flying’ tags used in the aviation industry, it would have been much easier to identify that the pins had not been removed.

Key Issues relating to this report

Pressure: Are your crew adequately qualified and resourced to withstand additional pressure that can come at the end of a drydock?

Teamwork: It is crucial to have a shared mental model when re-entering service after a drydock period, as this encourages facing challenges together.

Situational awareness- Actively seek input from other crew members and update your awareness. Never assume other people’s intentions- ALWAYS CHECK.

Local practices- Equipment hand-over checklists can be a valuable tool in these circumstances and should be used.

Communications– ‘Remove before sailing’ tags are useful to help crew and contractors identify the state of the system.