Continuing our series with Alert 10(b) -10 Simple failures render CO2 system inoperative. However before doing so we should like to draw your attention to the Supplement Note from TSB Canada in the previous post of this series. It refers to another incident all too similar to the incident we are covering here.
On further investigation of the MS Carnival Splendor CO2 system the following points saw the light of day. Clearly for the first time by either the ships Safety Officers or the USCG Marine Safety Officers. We quote from Alert 10(b)-10:
"Numerous piping and hose connections leaked extensively. When the system was activated, on scene video taken by the firefighters showed numerous leakages into the CO2 room. Post casualty while the pressure was still on the system, some of the leaks continued even after the connections were tightened."
"The zone valve for the aft machinery space which admits CO2 from the bottle bank manifold to the space failed. Specifically the ball valve's opening actuating arm fell off the valve when the gas powered piston actuator attempted to move it. The ball valve actuating arm was held in place by a very small machine screw and washer. When firefighters attempted to open the valve manually using the provided hardware it could not be moved. the valve was only able to be moved after the gas pressure was relieved from the inlet side of the valve."
"Actuating arms to five of the six other zones valves were found loose. They were also attached by small machine screws."
"Hemp type pipe sealant was used extensively on pipe threads throughout the system and in some instances seems to have entered the system."
"Certain elements of the distribution manifold contained low points which allowed the accumulation of water within the piping that could not be drained. Such a circumstance could cause corrosion that could possibly negatively effect operation of other components."
"The CO2 system's pilot and co-pilot bottles did not appear to operate correctly according to the firefighters involved and thus had to be manually activated using valve handles located on top of the cylinders. Additionally, during the event, the bank bottles were similarly activated due to the uncertainty of their release. At least one pilot bottle activation hose was reported to have leaked."
"The system had been recently serviced and inspected by an authorized service provider."
Well now where does one begin. All the above should never have happened of course but it did. This would seem to NAUTICAL LOG to be the classic case of leaving things to other people, improper supervision of the work being done and/or inspecting the system prior to signing off on servicing. This is the clear duty of the ships Safety Officer - no excuses. The company has a serious problem which it must solve immediately or should have its US Passenger Certificate withdrawn as they could have lost 4000 lives.
The system had serious design flaws, the shipboard maintenance was slack and that 'service provider' one hopes has been fired. Clearly the service was not done at all or so carelessly done as to be useless - the result of this was a CO2 system that suffered catastrophic failure when needed. Repairs cannot usually be effected when a system is active under high pressure, one of the firefighters could very easily have been injured. NAUTICAL LOG was taught to line a system up first, check connections, then active it, so maybe manual activation is desirable. Reduce our increasing dependence on automation and increase our knowledge of how a system works.
The Investigation continues NAUTICAL LOG and indeed many others in the maritime industry, hopes the Carnival Group will have the courage to 'come clean' and reveal just what happened. In the meantime one would suggest the USCG proscribe all the Carnival vessels and initiate monthly inspections of all vessels. By going through the ships section by section and if things are not 'up-to-scratch' withdrawing the vessels US Passenger Ship Certificate until such time as they are corrected. Money talks and staying in port with the loss of a cruise has a marked effect on all concerned.
As to the USCG Marine Safety Officers involved over the two years of Quarterly Inspections all should receive a 'Letter of Reprimand'. They should further be detached for a full retraining course in Marine Inspection with particular emphasises on Passenger Carrying Vessels, at USCG HQ. They should then return to Marine Safety Offices as they will be the best Safety Inspectors one could find.
Good Watch.
On further investigation of the MS Carnival Splendor CO2 system the following points saw the light of day. Clearly for the first time by either the ships Safety Officers or the USCG Marine Safety Officers. We quote from Alert 10(b)-10:
"Numerous piping and hose connections leaked extensively. When the system was activated, on scene video taken by the firefighters showed numerous leakages into the CO2 room. Post casualty while the pressure was still on the system, some of the leaks continued even after the connections were tightened."
"The zone valve for the aft machinery space which admits CO2 from the bottle bank manifold to the space failed. Specifically the ball valve's opening actuating arm fell off the valve when the gas powered piston actuator attempted to move it. The ball valve actuating arm was held in place by a very small machine screw and washer. When firefighters attempted to open the valve manually using the provided hardware it could not be moved. the valve was only able to be moved after the gas pressure was relieved from the inlet side of the valve."
"Actuating arms to five of the six other zones valves were found loose. They were also attached by small machine screws."
"Hemp type pipe sealant was used extensively on pipe threads throughout the system and in some instances seems to have entered the system."
"Certain elements of the distribution manifold contained low points which allowed the accumulation of water within the piping that could not be drained. Such a circumstance could cause corrosion that could possibly negatively effect operation of other components."
"The CO2 system's pilot and co-pilot bottles did not appear to operate correctly according to the firefighters involved and thus had to be manually activated using valve handles located on top of the cylinders. Additionally, during the event, the bank bottles were similarly activated due to the uncertainty of their release. At least one pilot bottle activation hose was reported to have leaked."
"The system had been recently serviced and inspected by an authorized service provider."
Well now where does one begin. All the above should never have happened of course but it did. This would seem to NAUTICAL LOG to be the classic case of leaving things to other people, improper supervision of the work being done and/or inspecting the system prior to signing off on servicing. This is the clear duty of the ships Safety Officer - no excuses. The company has a serious problem which it must solve immediately or should have its US Passenger Certificate withdrawn as they could have lost 4000 lives.
The system had serious design flaws, the shipboard maintenance was slack and that 'service provider' one hopes has been fired. Clearly the service was not done at all or so carelessly done as to be useless - the result of this was a CO2 system that suffered catastrophic failure when needed. Repairs cannot usually be effected when a system is active under high pressure, one of the firefighters could very easily have been injured. NAUTICAL LOG was taught to line a system up first, check connections, then active it, so maybe manual activation is desirable. Reduce our increasing dependence on automation and increase our knowledge of how a system works.
The Investigation continues NAUTICAL LOG and indeed many others in the maritime industry, hopes the Carnival Group will have the courage to 'come clean' and reveal just what happened. In the meantime one would suggest the USCG proscribe all the Carnival vessels and initiate monthly inspections of all vessels. By going through the ships section by section and if things are not 'up-to-scratch' withdrawing the vessels US Passenger Ship Certificate until such time as they are corrected. Money talks and staying in port with the loss of a cruise has a marked effect on all concerned.
As to the USCG Marine Safety Officers involved over the two years of Quarterly Inspections all should receive a 'Letter of Reprimand'. They should further be detached for a full retraining course in Marine Inspection with particular emphasises on Passenger Carrying Vessels, at USCG HQ. They should then return to Marine Safety Offices as they will be the best Safety Inspectors one could find.
Good Watch.
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