ACCIDENTAL RELEASE OF CO2 SYSTEM!

Vessel DocumentationCoast Guard Safety Alerts

IMPORTANCE OF DESIGN AND TESTING OF EMERGENCY SYSTEM CONTROLS

This safety alert serves to remind shoreside and vessel personnel of the importance of 1) designing and maintaining emergency systems to be logical and easily operated in high stress situations, 2) maintaining a high level of crew familiarity with emergency systems, and 3) exercising safeguards during testing to mitigate the risk of human error or system malfunction. Although regulations prescribe standards for safety systems aboard vessels, installations particularly those onboard uninspected vessels, can vary dramatically.

During a recent Uninspected Towing Vessel (UTV) exam, a vessel crewmember intending to test the fuel oil shut-off cables instead pulled the CO2 system release cables. As seen in photos directly below and at the end of this safety alert, the emergency control panel used during the incident contained pull cables for both the CO2 system and fuel oil shut-offs.

Accidental releases are not uncommon and vessel crewmember and Coast Guard inspector fatalities have occurred in the past. Fortunately, in this instance the audible alarm system and release time delay functioned as intended, allowing all personnel to safely evacuate the machinery spaces prior to discharge.

In a separate recent UTV examination, an inspector found two sets of remote emergency shutdowns with only one set operational. The original station (see image on the right) appears to be fully operational, but was not connected. The operational shutdowns were at a separate location.

Crew interactions with emergency systems often occur during periods of increased stress (e.g., a compliance exam, drill, or an actual emergency). System design, proper human engineering, labeling, and detailed training will substantially reduce the risk of human error. Inspections and Compliance Directorate Poor design characteristics: Similar activation pulls were collocated for fuel and CO2 systems. Fuel oil shut down signage was located on the left, but fuel oil pulls were located on the far right with three CO2 pulls in between. DISCONNECTED SYSTEM! Safety Alert 15-14 2

The Coast Guard recommends conducting a comprehensive pre-test meeting and simulated step-by-step “walk-through” between involved parties prior to actual testing of complex or potentially confusing systems. Operational controls should be implemented to maximize safety and reduce risk.

Furthermore, the Coast Guard strongly reminds all maritime operators of the importance in performing regular vessel specific emergency drills and to ensure that all crewmembers have the proper knowledge, skills, and abilities to respond to any potential emergency.

UTV regulations in 46 Code of Federal Regulations (CFR) 27.209 require all crewmembers to be familiar with the location and operation of engine room fuel-shutoffs and fire extinguishing equipment. All credentialed mariners are required by 46 CFR 15.405 to be familiar with firefighting and lifesaving equipment. Additionally, Coast Guard guidance on CO2 system safety and is available at: http://www.uscg.mil/hq/cg5/nvic/2000s.asp#2000 .

Remember:

• Emergency systems should be designed with human factors in mind – logically understood and easily operated during high stress situations.

• System training will provide the familiarity needed during an emergency.

• Pre-test coordination and review of procedures will minimize accidental and potentially fatal discharges.

This safety alert is provided for informational purpose only and does not relieve any domestic or international safety, operational or material requirements. It was developed by the Coast Guard Towing Vessel Center of Expertise and Office of Investigations and Casualty Analysis.