High potential near miss: dropped object – spark arrestor

What happened?

An 18kg spark arrestor fell 16 metres from the funnel stack and landed on the FRC deck. No-one was injured but this was considered a serious near miss. The spark arrestor was installed at the direction of the charterer only days before the incident. It was installed by a third-party sub-contractor; it was a requirement for working in the field and was new to the vessel.

What went wrong?

• The spark arrestor became dislodged due to exhaust pressure and vibration;
• The clamp was not secured tightly enough;
• The mechanism of securing was pop rivets;
• Vessel management did not manage the quality control of the third-party work when the spark arrestor was installed.

What were the causes?

• A causal factor was:
  • installation (fixing) of the spark arrestor was not adequate or to industry standards and not quality checked by the vessel crew or management;
• Root causes were:
  • failure of vessel operator to conduct a management of change (MoC) process for spark arrestor being installed
  • the vessel operator did not follow contractor management procedures as the third-party installer was not contracted by the vessel.

What lessons were learnt?

• There should be a management of change (MoC) process applied to all significant modifications or additions to vessel plant and equipment. This should include quality control to verify installation meets industry standards;
• Contractor management principles still apply even if there is no actual contractual relationship between the vessel operator and the third party doing the work.

What actions were taken?

• Review and update of safety management system (SMS) documentation (management of change (MoC) and Contractor Management processes) to ensure this scenario involving third parties is properly dealt with;
• Additional MoC training provided to vessel management teams.

Members may wish to refer to:

• Guidelines for management of change

Members may also wish to refer to the following incidents:

• Control of sub-contractor personnel: Unplanned and uncertified lifting operations
• Two near misses: loads fell from height to deck