An 18kg spark arrestor fell 16 metres from the funnel stack and landed on the FRC deck. No-one was injured but this was considered a serious near miss. The spark arrestor was installed at the direction of the charterer only days before the incident. It was installed by a third-party sub-contractor; it was a requirement for working in the field and was new to the vessel.
What went wrong?
- The spark arrestor became dislodged due to exhaust pressure and vibration;
- The clamp was not secured tightly enough;
- The mechanism of securing was pop rivets;
- Vessel management did not manage the quality control of the third-party work when the spark arrestor was installed.
What were the causes?
- A causal factor was:
- installation (fixing) of the spark arrestor was not adequate or to industry standards and not quality checked by the vessel crew or management;
- Root causes were:
- failure of vessel operator to conduct a management of change (MoC) process for spark arrestor being installed
- the vessel operator did not follow contractor management procedures as the third-party installer was not contracted by the vessel.
What lessons were learnt?
- There should be a management of change (MoC) process applied to all significant modifications or additions to vessel plant and equipment. This should include quality control to verify installation meets industry standards;
- Contractor management principles still apply even if there is no actual contractual relationship between the vessel operator and the third party doing the work.
What actions were taken?
- Review and update of safety management system (SMS) documentation (management of change (MoC) and Contractor Management processes) to ensure this scenario involving third parties is properly dealt with;
- Additional MoC training provided to vessel management teams.
Members may wish to refer to:
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