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Near-miss: Failure to reconnect fire suppression systems

A member has reported an incident in which it was discovered that key components of a fire suppression system had been left disconnected after a dry docking period. The omission was discovered when a crew member was undertaking a ‘routine’ tour of the vessel and noticed that a cylinder from the FM200 Fire Suppression System was disconnected. This was immediately reported, and upon further investigation, 6 out of 10 FM200 cylinders were found to be disconnected. All cylinders were immediately reinstated to operational status, both the integrity and readiness of the system was also confirmed.

During the incident investigation, it was discovered that the corresponding Isolation Confirmation Certificate (ICC), which would have highlighted the system’s inoperative state, could not be found. The extended period isolation register stated that the system had been reinstated, with ‘Original paper work missing’ written in the comments section. It is assumed the contractor returned the cylinders to their original locations, without reconnecting them, as the vessel was still in dry dock, and it was a yard requirement that the system remained isolated during dry docking.

Our member drew the following lessons:

  • There was insufficient management and control of the work task;
  • There was insufficient detail in planned maintenance work orders;
  • There was insufficient detail in area safety inspection checklists;
  • There was insufficient management and control of the Safe System of Work.

Our member took the following actions:

  • Developed and implemented a new vessel return to service procedure (for post dry dockings and maintenance periods);
  • Reviewed planned maintenance routines for FM200 Fire Suppression Systems and similar systems, to ensure controls and checks are suitable and sufficient;
  • Developed a Safety Officer Safety Inspections checklist.

Members may wish to review the following similar incidents (key words: fire, suppression):

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