According to news sources, Coast Guard investigators have explained that the cause of the engine room fire on the Carnival Triumph was a leaking fuel return line. There is a lesson to be learned for all vessel operators, especially towing vessel operators considering adopting a towing safety management system (TSMS) under Subchapter M.
Back in the late 1980s I served aboard the Coast Guard Cutter Wedge. She was a 75 foot push boat with a 68 foot crane barge known as a construction tender. Even though it was a small crew with a relaxed atmosphere, I had been trained on my previous cutters to make a round every hour when on duty. During one round of the engine room I noticed the fluid in the bilge ripple from a drip. I found that the source was diesel dripping from the bottom of the generator. I traced the stream of diesel around the generator to the top of the engine but could not tell where it was originating. As I stared at the components for a while it finally came into focus. It was a thread of diesel, barely visible to the naked eye, shooting out of a pin hole in one of the fuel lines. The engineers replaced the fuel line quickly and the Wedge, I am happy to say, is still in operation today.
When we set up companies with a safety management system we proved a number of vessel inspection job aids. Conducting proactive inspections of equipment in order to uncover problems before they become major is a basic concept of safety management. In some cases we have had the inspection job aids hard-laminated, to be used in the engine room with a grease pencil. After all, the idea is not to generate paper to cover our behinds. The idea is to ensure that nothing is missed during the inspection. During one of our quarterly visits to a client's boat, the engineer informed me that he didn't use the job aid, he went from memory. I said Okay, and asked him to imagine going through the engine room as he does, and to explain all the things he checks. When he was done remembering everything he could, I did some quick math and wrote in the inspection report that his failure to use the job aids provided by the company resulted in him checking only 14 percent of the items on the job aid. He got the point, and now makes sure to use the job aids. We get complacent because the likely hood that a similar situation will happen to us is extremely small, but the severity of the consequence in this type of scenario dictates that the threat must be mitigated.
Back in the late 1980s I served aboard the Coast Guard Cutter Wedge. She was a 75 foot push boat with a 68 foot crane barge known as a construction tender. Even though it was a small crew with a relaxed atmosphere, I had been trained on my previous cutters to make a round every hour when on duty. During one round of the engine room I noticed the fluid in the bilge ripple from a drip. I found that the source was diesel dripping from the bottom of the generator. I traced the stream of diesel around the generator to the top of the engine but could not tell where it was originating. As I stared at the components for a while it finally came into focus. It was a thread of diesel, barely visible to the naked eye, shooting out of a pin hole in one of the fuel lines. The engineers replaced the fuel line quickly and the Wedge, I am happy to say, is still in operation today.
When we set up companies with a safety management system we proved a number of vessel inspection job aids. Conducting proactive inspections of equipment in order to uncover problems before they become major is a basic concept of safety management. In some cases we have had the inspection job aids hard-laminated, to be used in the engine room with a grease pencil. After all, the idea is not to generate paper to cover our behinds. The idea is to ensure that nothing is missed during the inspection. During one of our quarterly visits to a client's boat, the engineer informed me that he didn't use the job aid, he went from memory. I said Okay, and asked him to imagine going through the engine room as he does, and to explain all the things he checks. When he was done remembering everything he could, I did some quick math and wrote in the inspection report that his failure to use the job aids provided by the company resulted in him checking only 14 percent of the items on the job aid. He got the point, and now makes sure to use the job aids. We get complacent because the likely hood that a similar situation will happen to us is extremely small, but the severity of the consequence in this type of scenario dictates that the threat must be mitigated.
There is a lot of chatter these days about what is the best and easiest path forward for Subchapter M compliance. There should be more focus on the quality of the TSMS itself, and the training on what safety management is really all about, rather than focusing on convenient and easy solutions. The easiest way is not always the best way to go. It takes hard work to be excellent. As a wise man once said, "If you do what is easy in life, your life will be hard; but if you do what is hard in life, your life will be easy."