Investigation Report
Accidental discharge of carbon dioxide during fixed CO2 fire extinguishing system test on tug SD Nimble with 1 person injured
Accidental discharge of carbon dioxide during fixed CO2 fire extinguishing system test on tug SD Nimble with 1 person injured
- MAIB
- Investigation Report
- Control of WorkHazardous Substances
- Hazardous substancesHuman factorsLoss of containmentPressure systems
- Inspection and maintenance
- Breathing apparatusGas cylinderHoseValve
- Competence and trainingFunctional testingEnergy and process isolationOperational supervision
- Marine industry
- Vessel
Summary
Investigation of an unintended carbon dioxide discharge during servicing of SD Nimble’s fixed firefighting system, injuring an engineer. Pilot lines remained connected to the cylinders during testing. The report examines isolation, training, supervision, system drawings and rescue, identifying an incorrect action plan as the likely explanation for the isolation mistake.
Classifications: Hazardous substances; hazardous chemicals; chemical exposure.
Classifications: Human factors; human performance; ergonomics.
Classifications: Loss of containment; containment loss.
Classifications: Pressure systems; stored pressure; pressurised systems; pressurized systems.
Classifications: Inspection and maintenance; asset inspection; equipment maintenance.
Classifications: Breathing apparatus; SCBA; self-contained breathing apparatus.
Classifications: Gas cylinder; compressed gas bottle; gas cylinders.
Classifications: Hose; flexible hose.
Classifications: Valve; valves.
Classifications: Competence and training; competency assurance; safety training.
Classifications: Functional testing; function test.
Classifications: Energy and process isolation; isolation; energy isolation.
Classifications: Operational supervision.
Classifications: Marine industry; shipping industry; maritime sector.
Classifications: Vessel; aboard ship; onboard vessel.
Themes: control of work, hazardous substances.