AN INCIDENT on an oil tanker where three engineering team members suffered burns highlights the importance of adhering to safety and management change procedures, the Australian Transport Safety Bureau (ATSB) says.
The incident occurred on May 6 this year as the engineering team conducted maintenance on the main deck steam valve for the heating system of the oil tanker Wisdom Venture (9773741), while it was drifting off Sydney.
After isolating the system, the team removed the valve bonnet, releasing residual hot condensate and resulting in burn injuries.
After receiving first aid on board, the crew members were transported to shore for medical treatment.
Drain line modification. Image: ATSB
An ATSB investigation found the crew had not allowed adequate time for the steam system to cool before starting work on the cargo heating system main deck steam valve.
The investigation also found a permanent modification to the steam drain line had been implemented on board Wisdom Venture without documentation.
“This undocumented change, which was not incorporated into a risk assessment or formally reviewed, likely introduced a system vulnerability that undermined the effectiveness of the steam system isolation,” chief commissioner Angus Mitchell said.
The ATSB also found the modification was not identified during routine technical inspections or multiple company superintendent visits to the ship.
“This resulted in the management of change framework, which required any system modification to be subject to a formal risk assessment and documentation, not being effectively applied,” Mr Mitchell said.
The ship’s manager has since advised that the drain line on Wisdom Venture had been returned to its original design configuration.
According to the ATSB, the manager has also initiated a fleetwide campaign to identify any unauthorised modifications to shipboard piping systems.
Ship staff are to be reminded that all modifications must be done in consultation with the company, in accordance with its management of change process.
Mr Mitchell said the accident highlighted the critical importance of adhering to established safety and management of change procedures.
“Where changes are to be made to a system, these need to be recorded and the processes to identify the risks need to be followed to ensure there are no unintended consequences,” he said.
“In addition, operators are reminded that maintenance involving steam systems must allow sufficient cooling time and include visual confirmation of isolation.”