An incident involving an uncoordinated emergency shutdown during tanker cargo operations was reported and analyzed by IMCA (International Marine Contractors Association).
What Happened
During cargo discharging at a terminal, all cargo pumps tripped simultaneously when the Emergency Shutdown (ESD) system was activated. A duty crewmember, while on a routine pump room patrol, noticed a minor leak and immediately triggered the ESD without first coordinating with the Cargo Control Room (CCR). This caused an unexpected halt to operations. The leak was later assessed as non-critical, no injuries occurred, and operations resumed after safety confirmation
Why It Happened
The direct cause was a fractured copper tube on the suction side of one cargo pump, resulting from prolonged vibration fatigue. Several safety factors contributed.
- No documented procedure defining ESD activation thresholds in leakage cases.
- Insufficient training on communication protocols for extraordinary conditions.
- Lack of preparedness in the CCR for a sudden shutdown, leading to brief operational confusion.
- The root cause was identified as an absence of a structured decision-making process for emergency activation and inadequate monitoring of fatigue in piping systems.
Actions Taken
Shipboard ESD activation procedures were amended to include mandatory communication and verification steps. Additional training on emergency response coordination was provided for both deck crew and CCR operators. Periodic vibration risk assessments were introduced for suction-side pipelines and components. Consideration was given to installing vibration dampers or supports on vulnerable tubing sections.
Lessons Learned
- Quick action is essential in emergencies but must be accompanied by clear and coordinated communication.
- Emergency shutdown procedures should clearly define usage thresholds and include structured communication steps.
- Regular inspections and vibration monitoring help detect early signs of fatigue and prevent failures.
- Crew training should emphasize decision-making, communication, and coordination in emergency scenarios.
- Engineering controls, such as vibration dampers, can reduce the risk of fatigue-related component failure in critical systems.
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Source: IMCA
