The Australian Transport Security Bureau (ATSB) investigated an incident involving crew accidents throughout upkeep on an oil tanker about 60 km east of Sydney, New South Wales, on 6 Might 2025. The report examines the sequence of occasions, underlying causes, and security actions taken.
What Occurred
Whereas the vessel was drifting offshore, engineering crew started upkeep on a leaking principal deck steam valve related to the cargo heating system. After isolating the system, the workforce eliminated the valve bonnet. Throughout this course of, residual scorching condensate was unexpectedly launched, leading to burn accidents to a few crew members. Quick first support was supplied on board, and the injured personnel had been later evacuated ashore for hospital therapy.
Why It Occurred
The incident occurred as a result of the crew didn’t enable enough time for the steam system to chill earlier than starting work. Verification procedures to make sure the road was absolutely depressurised weren’t correctly adopted, with reliance positioned solely on stress gauge readings. Complicating the state of affairs, an undocumented modification had been made to a drain line, altering its unique design. This modification was neither subjected to a threat evaluation nor reviewed or accredited, compromising the effectiveness of system isolation. The modification went undetected throughout routine inspections and was not famous within the chief engineer’s handover course of, leaving subsequent crews unaware of the altered configuration. Extra time stress to revive steam heating for the primary engine gasoline system contributed additional to the unfinished isolation and verification course of.
Actions Taken
The modified drain line was restored to its unique design configuration. A fleetwide marketing campaign was launched to determine and rectify any unauthorised modifications to shipboard piping programs, and inner investigations will likely be carried out wherever such modifications are discovered. Consciousness of dangers linked to undocumented engineering adjustments will likely be strengthened by way of senior engineering employees briefings and crew seminars. Crew members will likely be reminded to observe the formal administration of change course of for all modifications, and superintendent inspection procedures will likely be up to date to incorporate verification of system modifications towards design drawings.
Classes Discovered
At all times enable enough cooling time earlier than performing upkeep on steam programs.
Verification of depressurisation ought to embrace visible affirmation and never rely solely on stress gauges.
Any modification to shipboard programs should be documented, reviewed, and accredited by way of a proper administration of change course of.
Engineering handovers ought to clearly talk all system adjustments, short-term or everlasting.
Common technical inspections should be thorough sufficient to detect undocumented modifications.
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Supply: ATSB
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