M2297 - Unfinished maintenance creates hazard

Initial Report

During routine safety rounds in the engine room, the crew found that the vent pipe for the main engine lube oil settling tank had not been properly resecured back into position after it had been removed during maintenance. This oversight posed a significant risk, as the pipe could fall from the tank top while the ship was underway.

CHIRP Comment

Although the crew deserves praise for their diligent safety checks and quick response in reporting the issue to the chief engineer—especially given the difficult location of the settling tank vent pipe—leaving the job unfinished is unacceptable, given the tank’s importance.

If the pipe were to fall to a lower level in the engine room, it could result in fatal injuries or serious damage to nearby machinery. Additionally, the unsecured vent pipe leaves the settling tank exposed to potential contamination.

Work like this requires a detailed toolbox talk and a proper risk assessment. No task should be considered finished until it has been inspected and signed off by a supervisor, and this should be clearly stated in the toolbox talk.

This report raises several questions: were there enough people available to complete the task properly? Did the team get distracted by another task- if so, what procedures were in place to ensure that it wouldn’t be forgotten? Were supervision levels adequate?

Situational Awareness- The crew working on the job appeared unaware of the potential consequences of leaving the vent pipe unsecured. If the hazards had been properly identified during the risk assessment and toolbox talk, would the pipe have still been left unsecured?

 Teamwork- The crew should have questioned the security of the pipe and taken steps to re-secure it. If you were part of this job, would you discuss the necessary steps with your team? Does your company have a strong safety culture that fosters teamwork and a shared understanding of safety?

 Alerting- The crew member who reported the hazard to the chief engineer deserves recognition for their quick action in raising the issue.

 Procedures- No task should be considered complete until it has been inspected and signed off by a senior engineer.