The C/E, fitter and oiler were engaged in the routine maintenance of the common cooling water system of the ship’s refrigeration plant and air conditioning plants. While they were opening up the condenser cooling water line, due to a leaking line valve, a large quantity of water spurted out and fell on the main power transformer located directly below. A fire started around the transformer and there was an immediate blackout. The crew put out the fire by using a portable CO2 extinguisher.
Root cause/contributory factors1 System failure: company procedures did not contain specific instructions on carrying out work on refrigeration and heating, ventilation and air-conditioning (HVAC) systems;
2 Defective equipment: section valve in the cooling water line was leaking in shut position;
3 Inadequate risk assessment: cooling water line should have been blanked and drained before disconnecting;
4 Inadequate work planning; electrical equipment directly below work site was not protected against likely discharge of water.
Corrective/preventative actions (post-incident)1 Defective valve in cooling water line was replaced;
2 QHSE safety bulletin on the incident issued to the fleet;
3 New SMS procedure and risk assessment checklist created with guidelines on cleaning and maintenance of cooling water systems.
Root cause/contributory factors1 System failure: company procedures did not contain specific instructions on carrying out work on refrigeration and heating, ventilation and air-conditioning (HVAC) systems;
2 Defective equipment: section valve in the cooling water line was leaking in shut position;
3 Inadequate risk assessment: cooling water line should have been blanked and drained before disconnecting;
4 Inadequate work planning; electrical equipment directly below work site was not protected against likely discharge of water.
Corrective/preventative actions (post-incident)1 Defective valve in cooling water line was replaced;
2 QHSE safety bulletin on the incident issued to the fleet;
3 New SMS procedure and risk assessment checklist created with guidelines on cleaning and maintenance of cooling water systems.
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