This incident, reported within the UK MAIB Security Digest 1/2025 and reviewed by IMCA, highlights two separate issues of safety associated to power isolation procedures and short-term electrical modifications onboard vessels. Each circumstances underscore vital dangers as a result of deviations from commonplace practices.
What Occurred
Throughout a routine engine room audit, it was noticed that LOTO procedures weren’t absolutely carried out. Particularly, Electrical tools on the primary switchboard was turned off throughout hydraulic pipeline repairs, however no LOTO system was utilized. A valve concerned within the mechanical isolation of a hydraulic system was closed and tagged, however the required locking system was lacking.
Individually, undocumented disconnections and unauthorized bypassing of crucial electrical methods have been discovered onboard. These alterations have been presumed to have occurred throughout Dynamic Positioning (DP) trials. Nonetheless, no information existed, and no reinstatement procedures had been adopted after the modifications.
Why It Occurred
The incident revealed insufficient utility of normal isolation procedures by accountable personnel, together with failures in each mechanical and electrical isolation. Regardless of prior fleet-wide directions to keep up enough inventory, applicable Lock Out/Tag Out (LOTO) units weren’t out there for crucial electrical factors. There was a basic lack of control-of-work self-discipline, additional compounded by unauthorized system modifications doubtless made throughout Dynamic Positioning (DP) trials with none supporting documentation. These short-term adjustments weren’t reinstated as a result of miscommunication throughout shift adjustments, and there was no verification course of in place to make sure full system restoration after trials or troubleshooting.
Actions Taken
Whereas particular corrective actions weren’t detailed, the incidents prompted a evaluation of LOTO practices. They emphasised the necessity for improved stock of LOTO tools and tighter management of short-term system modifications.
Classes Discovered
Merely switching off tools or closing a valve doesn’t guarantee isolation. LOTO should be utilized to all power sources throughout upkeep or restore.
Vessels should carry appropriate LOTO units for all crucial isolation factors. Gaps in tools availability instantly compromise security.
Any short-term modification to crucial methods should be logged, accepted, and traced by correct channels.
After trials or testing, all altered methods should be formally returned to their unique state and verified by a accountable get together.
Group transitions ought to at all times embrace complete updates on any system adjustments or excellent restoration duties.
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Supply: IMCA Buying and selling Ltd
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