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Remove cl-contigo example bowtie from repository.
Co-authored-by: Cursor <cursoragent@cursor.com>
This commit is contained in:
Andre482
parent
f71646c748
commit
f09015e70f
1 changed files with 0 additions and 474 deletions
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{
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"id": "cl-contigo-me-hydraulic-pipe-failure",
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"name": "CL Contigo - ME Hydraulic Pipe Failure",
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"hazard": "High-pressure Main Engine hydraulic oil system (HPS & HCU piping inside the cam case) of the MAN B&W 5S50ME-B9.3 TII",
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"topEvent": "Loss of containment of Main Engine hydraulic oil (failure/leakage of HPS & HCU pipes and securing arrangements in the cam case)",
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"threats": [
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{
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"id": "threat-1",
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"label": "Excessive 2nd-order vibration (RoT Compensator non-operational for a prolonged period)",
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"notes": "5-cylinder MAN B&W 5S50ME-B9.3 TII is highly sensitive to 2nd-order vibration. RoT Compensator in steering gear room was found not working; axial compensator and two top bracings were operational but insufficient alone.",
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"preventionBarriers": [
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{
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"id": "pb-1-1",
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"label": "RoT Compensator / vibration damper operational",
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"notes": "RoT Compensator was non-operational for a prolonged period. PMS recorded inspection on 23/02/2026 but did not note non-operational status. Equipment was not flagged as critical in PMS.",
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"escalationFactors": [
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{
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"id": "ef-1-1-1",
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"label": "RoT Compensator not flagged critical in PMS; no specific alarm / no HMI log",
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"notes": "Alarm system only indicates common alarm at ME Operating Panel. HMI has no log functionality to review when system stopped.",
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"escalationBarriers": [
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{
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"id": "eb-1-1-1",
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"label": "Restore RoT Compensator; update PMS criticality and alarm/HMI",
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"notes": "Preventive measure (Open, target 01-Jun-2026): restore RoT Compensator, verify during ME running, record in PMS. Restored to operational condition by 04/06/2026.",
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"escalationFactors": [],
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"stack": [
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{
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"id": "stack-eb-1-1-1-eff",
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"field": "effectiveness",
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"label": "Fair",
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"color": "#f1c40f"
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}
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],
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"stackCollapsed": true
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}
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]
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}
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],
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"stack": [
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{
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"id": "stack-pb-1-1-eff",
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"field": "effectiveness",
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"label": "Failed",
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"color": "#c0392b"
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}
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],
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"stackCollapsed": true
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},
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{
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"id": "pb-1-2",
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"label": "Axial compensator + two top bracings",
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"notes": "Axial compensator and two port-side top bracings confirmed operational during investigation, but alone could not compensate for non-operational RoT Compensator.",
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"escalationFactors": [],
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"stack": [
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{
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"id": "stack-pb-1-2-eff",
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"field": "effectiveness",
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"label": "Good",
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"color": "#27ae60"
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}
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],
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"stackCollapsed": true
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},
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{
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"id": "pb-1-3",
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"label": "PMS inspection of vibration-control equipment (4,000 hr)",
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"notes": "Inspection job existed at 4,000-hour interval but failed to identify non-operational RoT Compensator.",
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"escalationFactors": [
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{
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"id": "ef-1-3-1",
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"label": "Repeated PSC findings with weak shore follow-up",
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"notes": "Previous PSC findings and repeated technical deficiencies indicated pattern of weak follow-up and ineffective improvement of maintenance standards.",
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"escalationBarriers": [
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{
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"id": "eb-1-3-1",
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"label": "Shore management intervention and maker superintendent follow-up",
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"notes": "Preventive measure (Open, target 15-Jun-2026): maker superintendent inspection covering vibration control, cam-case piping and PMS compliance.",
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"escalationFactors": [],
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"stack": [
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{
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"id": "stack-eb-1-3-1-eff",
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"field": "effectiveness",
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"label": "Fair",
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"color": "#f1c40f"
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}
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],
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"stackCollapsed": true
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}
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]
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},
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{
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"id": "ef-1-3-2",
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"label": "VM inspections in port with ME not running",
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"notes": "Three VM inspections since last dry dock (Apr 2025) could not detect RoT Comp issue because ME was not running and vibration-control equipment was not operational.",
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"escalationBarriers": [
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{
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"id": "eb-1-3-2",
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"label": "VM inspection scope includes ME-running vibration-control verification",
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"notes": "Investigator note: quality of VM inspection for the period should be reviewed.",
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"escalationFactors": [],
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"stack": [
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{
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"id": "stack-eb-1-3-2-eff",
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"field": "effectiveness",
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"label": "Fair",
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"color": "#f1c40f"
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}
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],
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"stackCollapsed": true
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}
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]
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}
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],
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"stack": [
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{
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"id": "stack-pb-1-3-eff",
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"field": "effectiveness",
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"label": "Fair",
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"color": "#f1c40f"
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}
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],
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"stackCollapsed": true
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}
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]
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},
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{
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"id": "threat-2",
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"label": "Low HPS nitrogen accumulator pressure (~40 bar vs 136 bar maker spec)",
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"notes": "HPS nitrogen accumulator found with low pressure (~40 bar vs 136 bar maker requirement). Low accumulator pressure increases hydraulic pressure pulsations and contributed to pipe failure per Everllence.",
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"preventionBarriers": [
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{
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"id": "pb-2-1",
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"label": "Accumulator charge maintained per maker specification",
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"notes": "Accumulator pre-charge was not maintained at maker-required level. Confirmed by manufacturer as contributing factor.",
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"escalationFactors": [],
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"stack": [
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{
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"id": "stack-pb-2-1-eff",
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"field": "effectiveness",
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"label": "Failed",
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"color": "#c0392b"
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}
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],
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"stackCollapsed": true
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},
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{
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"id": "pb-2-2",
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"label": "Periodic accumulator pressure check and recharge",
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"notes": "No effective trending or monthly verification of HPS/HCU nitrogen accumulator pre-charge pressure in PMS prior to incident.",
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"escalationFactors": [
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{
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"id": "ef-2-2-1",
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"label": "No PMS trending of HPS/HCU N2 accumulator pre-charge pressure",
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"notes": "Maker requires pre-charge per specification with temperature correction where applicable.",
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"escalationBarriers": [
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{
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"id": "eb-2-2-1",
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"label": "Monthly accumulator pre-charge check, trending and VM verification",
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"notes": "Preventive measure (Open, target 01-Jun-2026): record results in PMS and send to VM for monthly verification.",
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"escalationFactors": [],
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"stack": [
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{
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"id": "stack-eb-2-2-1-eff",
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"field": "effectiveness",
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"label": "Fair",
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"color": "#f1c40f"
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}
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],
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"stackCollapsed": true
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}
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]
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}
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],
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"stack": [
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{
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"id": "stack-pb-2-2-eff",
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"field": "effectiveness",
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"label": "Fair",
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"color": "#f1c40f"
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}
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],
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"stackCollapsed": true
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}
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]
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},
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{
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"id": "threat-3",
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"label": "Progressive deterioration / loosening of pipe supports and brackets",
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"notes": "Increased vibration caused bolts of support brackets to loosen, further increasing vibration levels in hydraulic pipes until failure. Everllence identified vibration as main cause of pipe failures.",
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"preventionBarriers": [
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{
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"id": "pb-3-1",
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"label": "Cam-case inspection incl. pipe supports/brackets (PMS revised monthly)",
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"notes": "Pre-incident 2,000-hour scope did not include torque verification of supports/brackets. PMS revised post-incident to monthly inspection with maker torque values (Closed 15-Apr-2026).",
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"escalationFactors": [
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{
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"id": "ef-3-1-1",
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"label": "Continuity weakness of ship/shore teams (manning, crew turnover)",
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"notes": "No stable back-to-back crew arrangement; varying backgrounds reduced vessel-specific knowledge and ability to identify recurring defects.",
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"escalationBarriers": [
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{
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"id": "eb-3-1-1",
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"label": "Senior-officer screening and crew-continuity management",
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"notes": "Fleet-wide manning review for technically sensitive vessels recommended.",
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"escalationFactors": [],
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"stack": [
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{
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"id": "stack-eb-3-1-1-eff",
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"field": "effectiveness",
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"label": "Fair",
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"color": "#f1c40f"
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}
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],
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"stackCollapsed": true
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}
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]
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}
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],
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"stack": [
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{
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"id": "stack-pb-3-1-eff",
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"field": "effectiveness",
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"label": "Fair",
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"color": "#f1c40f"
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}
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],
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"stackCollapsed": true
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},
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{
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"id": "pb-3-2",
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"label": "Correct torque tightening of securing bolts (torque spanner)",
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"notes": "Chief Engineer failed to ensure proper technical control during repairs. Torque values not applied; hand spanners used instead of torque spanners, leading to inadequately secured connections.",
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"escalationFactors": [
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{
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"id": "ef-3-2-1",
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"label": "Chief Engineer supervision / technical-control deficiency",
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"notes": "CE had history of poor performance feedback. Concerns regarding supervision, quality of repairs, and control of pipe installation during incident.",
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"escalationBarriers": [
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{
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"id": "eb-3-2-1",
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"label": "Technical supervision capability and CE appraisal follow-up",
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"notes": "Lessons learned: crew competence and supervision directly impact technical reliability.",
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"escalationFactors": [],
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"stack": [
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{
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"id": "stack-eb-3-2-1-eff",
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"field": "effectiveness",
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"label": "Fair",
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"color": "#f1c40f"
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}
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],
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"stackCollapsed": true
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}
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]
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}
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],
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"stack": [
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{
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"id": "stack-pb-3-2-eff",
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"field": "effectiveness",
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"label": "Failed",
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"color": "#c0392b"
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}
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],
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"stackCollapsed": true
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},
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{
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"id": "pb-3-3",
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"label": "Robust securing arrangements and material standards",
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"notes": "Lock washers appeared installed on support bracket per manufacturer picture, but progressive deterioration of supports, brackets, retaining rings and securing arrangements continued.",
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"escalationFactors": [],
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"stack": [
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{
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"id": "stack-pb-3-3-eff",
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"field": "effectiveness",
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"label": "Poor",
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"color": "#e67e22"
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}
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],
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"stackCollapsed": true
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}
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]
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}
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],
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"consequences": [
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{
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"id": "consequence-1",
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"label": "Loss of propulsion and vessel drifting ~245 NM off the Brazilian coast (grounding/collision risk)",
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"notes": "At 04:00 on 18/03/2026, vessel lost propulsion while drifting ~245 NM off Brazil. Calm weather and distance from land reduced immediate grounding/collision risk.",
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"mitigationBarriers": [
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{
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"id": "mb-1-1",
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"label": "AMS low-hydraulic-pressure alarm detection and engine-room crew response",
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"notes": "Low hydraulic pressure alarms triggered repeated ME shutdowns. Crew responded to alarms and attempted repairs.",
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"escalationFactors": [],
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"stack": [
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{
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"id": "stack-mb-1-1-eff",
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"field": "effectiveness",
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"label": "Good",
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"color": "#27ae60"
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}
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],
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"stackCollapsed": true
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},
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{
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"id": "mb-1-2",
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"label": "Temporary onboard repairs to restore short-term propulsion",
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"notes": "Situational violation: crew used welding, fabricated collars and improvised gaskets due to loss of propulsion pressure and no genuine spares. Repairs failed under operating pressure and vibration.",
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"escalationFactors": [
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{
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"id": "ef-mb-1-2-1",
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"label": "No genuine spares on board (pipes, brackets, retaining rings, sealing parts not on critical spares list)",
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"notes": "Investigation: spare pipes not required on maker/SMS minimum list, but operational risk justified carrying critical spares.",
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"escalationBarriers": [
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{
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"id": "eb-mb-1-2-1",
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"label": "Review and update critical spare-parts list (MAN ME/ME-B)",
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"notes": "Fleet-wide review of hydraulic pipes, supports and sealing hardware for MAN ME/ME-B engines.",
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"escalationFactors": [],
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"stack": [
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{
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"id": "stack-eb-mb-1-2-1-eff",
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"field": "effectiveness",
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"label": "Fair",
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"color": "#f1c40f"
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}
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],
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"stackCollapsed": true
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}
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]
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}
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],
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"stack": [
|
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{
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"id": "stack-mb-1-2-eff",
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"field": "effectiveness",
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"label": "Poor",
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"color": "#e67e22"
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}
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],
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"stackCollapsed": true
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},
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{
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"id": "mb-1-3",
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"label": "ERT activation + shore/maker technical support (Everllence, Hitachi-MAN)",
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"notes": "ERT activated at 04:30. Everllence and Hitachi-MAN service engineers attended. Shore management and technical department provided remote support.",
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"escalationFactors": [],
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"stack": [
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{
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"id": "stack-mb-1-3-eff",
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"field": "effectiveness",
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"label": "Good",
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"color": "#27ae60"
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}
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],
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"stackCollapsed": true
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},
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{
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"id": "mb-1-4",
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"label": "Position/drift-rate monitoring, calm weather, distance from land",
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"notes": "Investigation confirmed weather conditions did not contribute to incident. Good visibility, moderate sea state, vessel rolling but no precipitation.",
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"escalationFactors": [],
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"stack": [
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||||
{
|
||||
"id": "stack-mb-1-4-eff",
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||||
"field": "effectiveness",
|
||||
"label": "Good",
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||||
"color": "#27ae60"
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}
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||||
],
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"stackCollapsed": true
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||||
}
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]
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},
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{
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"id": "consequence-2",
|
||||
"label": "Repeated Main Engine shutdowns / prolonged unreliable propulsion",
|
||||
"notes": "Hydraulic oil leakages caused low-pressure alarms, repeated ME shutdowns, and eventual total loss of propulsion on 18/03/2026.",
|
||||
"mitigationBarriers": [
|
||||
{
|
||||
"id": "mb-2-1",
|
||||
"label": "Operate on single HPS pump at reduced RPM and lowered pressure set point",
|
||||
"notes": "Crew attempted to manage system by operating on single HPS pump with reduced RPM and lowered pressure set point. Temporary measure only.",
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"escalationFactors": [],
|
||||
"stack": [
|
||||
{
|
||||
"id": "stack-mb-2-1-eff",
|
||||
"field": "effectiveness",
|
||||
"label": "Fair",
|
||||
"color": "#f1c40f"
|
||||
}
|
||||
],
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"stackCollapsed": true
|
||||
},
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||||
{
|
||||
"id": "mb-2-2",
|
||||
"label": "Sea trials and hydraulic system verification after repair",
|
||||
"notes": "Sea trials conducted after repairs at Sao Luis. NAV 024 risk assessment template applies to sea trials after main engine repair.",
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||||
"escalationFactors": [],
|
||||
"stack": [
|
||||
{
|
||||
"id": "stack-mb-2-2-eff",
|
||||
"field": "effectiveness",
|
||||
"label": "Good",
|
||||
"color": "#27ae60"
|
||||
}
|
||||
],
|
||||
"stackCollapsed": true
|
||||
}
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||||
]
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||||
},
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||||
{
|
||||
"id": "consequence-3",
|
||||
"label": "External towage, operational disruption, ~USD 318,398 cost and reputational impact",
|
||||
"notes": "Vessel towed to Sao Luis by tugs Svitzer Denise and Joaquim. Total estimated cost USD 318,398 (11 days delay, materials, miscellaneous). Reputational impact on company.",
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||||
"mitigationBarriers": [
|
||||
{
|
||||
"id": "mb-3-1",
|
||||
"label": "Emergency Towing Booklet and tug arrangement (Svitzer Denise / Joaquim)",
|
||||
"notes": "Towage commenced 19/03/2026. NAV 029 risk assessment template applies to towing operations.",
|
||||
"escalationFactors": [],
|
||||
"stack": [
|
||||
{
|
||||
"id": "stack-mb-3-1-eff",
|
||||
"field": "effectiveness",
|
||||
"label": "Good",
|
||||
"color": "#27ae60"
|
||||
}
|
||||
],
|
||||
"stackCollapsed": true
|
||||
},
|
||||
{
|
||||
"id": "mb-3-2",
|
||||
"label": "Flag/Class notification, dispensation and surveyor attendance",
|
||||
"notes": "Marshall Islands flag and Class notified. Dispensation granted for single voyage to Sao Luis with surveyor attendance.",
|
||||
"escalationFactors": [],
|
||||
"stack": [
|
||||
{
|
||||
"id": "stack-mb-3-2-eff",
|
||||
"field": "effectiveness",
|
||||
"label": "Good",
|
||||
"color": "#27ae60"
|
||||
}
|
||||
],
|
||||
"stackCollapsed": true
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||||
},
|
||||
{
|
||||
"id": "mb-3-3",
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||||
"label": "Permanent repairs with genuine spares at Sao Luis",
|
||||
"notes": "Permanent repairs completed at Sao Luis with genuine spare parts. RoT Compensator restored to operational condition by 04/06/2026.",
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||||
"escalationFactors": [],
|
||||
"stack": [
|
||||
{
|
||||
"id": "stack-mb-3-3-eff",
|
||||
"field": "effectiveness",
|
||||
"label": "Good",
|
||||
"color": "#27ae60"
|
||||
}
|
||||
],
|
||||
"stackCollapsed": true
|
||||
}
|
||||
]
|
||||
}
|
||||
],
|
||||
"view": {
|
||||
"zoom": 1,
|
||||
"panX": 0,
|
||||
"panY": 0
|
||||
},
|
||||
"createdAt": "2026-06-10T00:00:00.000Z",
|
||||
"updatedAt": "2026-06-11T07:12:25.997Z"
|
||||
}
|
||||
Loading…
Reference in a new issue