From f09015e70fa511c798bf014c01389a5fa08bcc2d Mon Sep 17 00:00:00 2001 From: Andre482 Date: Fri, 12 Jun 2026 15:05:00 +0300 Subject: [PATCH] Remove cl-contigo example bowtie from repository. Co-authored-by: Cursor --- examples/cl-contigo.bowtie | 474 ------------------------------------- 1 file changed, 474 deletions(-) delete mode 100644 examples/cl-contigo.bowtie diff --git a/examples/cl-contigo.bowtie b/examples/cl-contigo.bowtie deleted file mode 100644 index c705d43..0000000 --- a/examples/cl-contigo.bowtie +++ /dev/null @@ -1,474 +0,0 @@ -{ - "id": "cl-contigo-me-hydraulic-pipe-failure", - "name": "CL Contigo - ME Hydraulic Pipe Failure", - "hazard": "High-pressure Main Engine hydraulic oil system (HPS & HCU piping inside the cam case) of the MAN B&W 5S50ME-B9.3 TII", - "topEvent": "Loss of containment of Main Engine hydraulic oil (failure/leakage of HPS & HCU pipes and securing arrangements in the cam case)", - "threats": [ - { - "id": "threat-1", - "label": "Excessive 2nd-order vibration (RoT Compensator non-operational for a prolonged period)", - "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.", - "preventionBarriers": [ - { - "id": "pb-1-1", - "label": "RoT Compensator / vibration damper operational", - "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.", - "escalationFactors": [ - { - "id": "ef-1-1-1", - "label": "RoT Compensator not flagged critical in PMS; no specific alarm / no HMI log", - "notes": "Alarm system only indicates common alarm at ME Operating Panel. HMI has no log functionality to review when system stopped.", - "escalationBarriers": [ - { - "id": "eb-1-1-1", - "label": "Restore RoT Compensator; update PMS criticality and alarm/HMI", - "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.", - "escalationFactors": [], - "stack": [ - { - "id": "stack-eb-1-1-1-eff", - "field": "effectiveness", - "label": "Fair", - "color": "#f1c40f" - } - ], - "stackCollapsed": true - } - ] - } - ], - "stack": [ - { - "id": "stack-pb-1-1-eff", - "field": "effectiveness", - "label": "Failed", - "color": "#c0392b" - } - ], - "stackCollapsed": true - }, - { - "id": "pb-1-2", - "label": "Axial compensator + two top bracings", - "notes": "Axial compensator and two port-side top bracings confirmed operational during investigation, but alone could not compensate for non-operational RoT Compensator.", - "escalationFactors": [], - "stack": [ - { - "id": "stack-pb-1-2-eff", - "field": "effectiveness", - "label": "Good", - "color": "#27ae60" - } - ], - "stackCollapsed": true - }, - { - "id": "pb-1-3", - "label": "PMS inspection of vibration-control equipment (4,000 hr)", - "notes": "Inspection job existed at 4,000-hour interval but failed to identify non-operational RoT Compensator.", - "escalationFactors": [ - { - "id": "ef-1-3-1", - "label": "Repeated PSC findings with weak shore follow-up", - "notes": "Previous PSC findings and repeated technical deficiencies indicated pattern of weak follow-up and ineffective improvement of maintenance standards.", - "escalationBarriers": [ - { - "id": "eb-1-3-1", - "label": "Shore management intervention and maker superintendent follow-up", - "notes": "Preventive measure (Open, target 15-Jun-2026): maker superintendent inspection covering vibration control, cam-case piping and PMS compliance.", - "escalationFactors": [], - "stack": [ - { - "id": "stack-eb-1-3-1-eff", - "field": "effectiveness", - "label": "Fair", - "color": "#f1c40f" - } - ], - "stackCollapsed": true - } - ] - }, - { - "id": "ef-1-3-2", - "label": "VM inspections in port with ME not running", - "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.", - "escalationBarriers": [ - { - "id": "eb-1-3-2", - "label": "VM inspection scope includes ME-running vibration-control verification", - "notes": "Investigator note: quality of VM inspection for the period should be reviewed.", - "escalationFactors": [], - "stack": [ - { - "id": "stack-eb-1-3-2-eff", - "field": "effectiveness", - "label": "Fair", - "color": "#f1c40f" - } - ], - "stackCollapsed": true - } - ] - } - ], - "stack": [ - { - "id": "stack-pb-1-3-eff", - "field": "effectiveness", - "label": "Fair", - "color": "#f1c40f" - } - ], - "stackCollapsed": true - } - ] - }, - { - "id": "threat-2", - "label": "Low HPS nitrogen accumulator pressure (~40 bar vs 136 bar maker spec)", - "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.", - "preventionBarriers": [ - { - "id": "pb-2-1", - "label": "Accumulator charge maintained per maker specification", - "notes": "Accumulator pre-charge was not maintained at maker-required level. Confirmed by manufacturer as contributing factor.", - "escalationFactors": [], - "stack": [ - { - "id": "stack-pb-2-1-eff", - "field": "effectiveness", - "label": "Failed", - "color": "#c0392b" - } - ], - "stackCollapsed": true - }, - { - "id": "pb-2-2", - "label": "Periodic accumulator pressure check and recharge", - "notes": "No effective trending or monthly verification of HPS/HCU nitrogen accumulator pre-charge pressure in PMS prior to incident.", - "escalationFactors": [ - { - "id": "ef-2-2-1", - "label": "No PMS trending of HPS/HCU N2 accumulator pre-charge pressure", - "notes": "Maker requires pre-charge per specification with temperature correction where applicable.", - "escalationBarriers": [ - { - "id": "eb-2-2-1", - "label": "Monthly accumulator pre-charge check, trending and VM verification", - "notes": "Preventive measure (Open, target 01-Jun-2026): record results in PMS and send to VM for monthly verification.", - "escalationFactors": [], - "stack": [ - { - "id": "stack-eb-2-2-1-eff", - "field": "effectiveness", - "label": "Fair", - "color": "#f1c40f" - } - ], - "stackCollapsed": true - } - ] - } - ], - "stack": [ - { - "id": "stack-pb-2-2-eff", - "field": "effectiveness", - "label": "Fair", - "color": "#f1c40f" - } - ], - "stackCollapsed": true - } - ] - }, - { - "id": "threat-3", - "label": "Progressive deterioration / loosening of pipe supports and brackets", - "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.", - "preventionBarriers": [ - { - "id": "pb-3-1", - "label": "Cam-case inspection incl. pipe supports/brackets (PMS revised monthly)", - "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).", - "escalationFactors": [ - { - "id": "ef-3-1-1", - "label": "Continuity weakness of ship/shore teams (manning, crew turnover)", - "notes": "No stable back-to-back crew arrangement; varying backgrounds reduced vessel-specific knowledge and ability to identify recurring defects.", - "escalationBarriers": [ - { - "id": "eb-3-1-1", - "label": "Senior-officer screening and crew-continuity management", - "notes": "Fleet-wide manning review for technically sensitive vessels recommended.", - "escalationFactors": [], - "stack": [ - { - "id": "stack-eb-3-1-1-eff", - "field": "effectiveness", - "label": "Fair", - "color": "#f1c40f" - } - ], - "stackCollapsed": true - } - ] - } - ], - "stack": [ - { - "id": "stack-pb-3-1-eff", - "field": "effectiveness", - "label": "Fair", - "color": "#f1c40f" - } - ], - "stackCollapsed": true - }, - { - "id": "pb-3-2", - "label": "Correct torque tightening of securing bolts (torque spanner)", - "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.", - "escalationFactors": [ - { - "id": "ef-3-2-1", - "label": "Chief Engineer supervision / technical-control deficiency", - "notes": "CE had history of poor performance feedback. Concerns regarding supervision, quality of repairs, and control of pipe installation during incident.", - "escalationBarriers": [ - { - "id": "eb-3-2-1", - "label": "Technical supervision capability and CE appraisal follow-up", - "notes": "Lessons learned: crew competence and supervision directly impact technical reliability.", - "escalationFactors": [], - "stack": [ - { - "id": "stack-eb-3-2-1-eff", - "field": "effectiveness", - "label": "Fair", - "color": "#f1c40f" - } - ], - "stackCollapsed": true - } - ] - } - ], - "stack": [ - { - "id": "stack-pb-3-2-eff", - "field": "effectiveness", - "label": "Failed", - "color": "#c0392b" - } - ], - "stackCollapsed": true - }, - { - "id": "pb-3-3", - "label": "Robust securing arrangements and material standards", - "notes": "Lock washers appeared installed on support bracket per manufacturer picture, but progressive deterioration of supports, brackets, retaining rings and securing arrangements continued.", - "escalationFactors": [], - "stack": [ - { - "id": "stack-pb-3-3-eff", - "field": "effectiveness", - "label": "Poor", - "color": "#e67e22" - } - ], - "stackCollapsed": true - } - ] - } - ], - "consequences": [ - { - "id": "consequence-1", - "label": "Loss of propulsion and vessel drifting ~245 NM off the Brazilian coast (grounding/collision risk)", - "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.", - "mitigationBarriers": [ - { - "id": "mb-1-1", - "label": "AMS low-hydraulic-pressure alarm detection and engine-room crew response", - "notes": "Low hydraulic pressure alarms triggered repeated ME shutdowns. Crew responded to alarms and attempted repairs.", - "escalationFactors": [], - "stack": [ - { - "id": "stack-mb-1-1-eff", - "field": "effectiveness", - "label": "Good", - "color": "#27ae60" - } - ], - "stackCollapsed": true - }, - { - "id": "mb-1-2", - "label": "Temporary onboard repairs to restore short-term propulsion", - "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.", - "escalationFactors": [ - { - "id": "ef-mb-1-2-1", - "label": "No genuine spares on board (pipes, brackets, retaining rings, sealing parts not on critical spares list)", - "notes": "Investigation: spare pipes not required on maker/SMS minimum list, but operational risk justified carrying critical spares.", - "escalationBarriers": [ - { - "id": "eb-mb-1-2-1", - "label": "Review and update critical spare-parts list (MAN ME/ME-B)", - "notes": "Fleet-wide review of hydraulic pipes, supports and sealing hardware for MAN ME/ME-B engines.", - "escalationFactors": [], - "stack": [ - { - "id": "stack-eb-mb-1-2-1-eff", - "field": "effectiveness", - "label": "Fair", - "color": "#f1c40f" - } - ], - "stackCollapsed": true - } - ] - } - ], - "stack": [ - { - "id": "stack-mb-1-2-eff", - "field": "effectiveness", - "label": "Poor", - "color": "#e67e22" - } - ], - "stackCollapsed": true - }, - { - "id": "mb-1-3", - "label": "ERT activation + shore/maker technical support (Everllence, Hitachi-MAN)", - "notes": "ERT activated at 04:30. Everllence and Hitachi-MAN service engineers attended. Shore management and technical department provided remote support.", - "escalationFactors": [], - "stack": [ - { - "id": "stack-mb-1-3-eff", - "field": "effectiveness", - "label": "Good", - "color": "#27ae60" - } - ], - "stackCollapsed": true - }, - { - "id": "mb-1-4", - "label": "Position/drift-rate monitoring, calm weather, distance from land", - "notes": "Investigation confirmed weather conditions did not contribute to incident. Good visibility, moderate sea state, vessel rolling but no precipitation.", - "escalationFactors": [], - "stack": [ - { - "id": "stack-mb-1-4-eff", - "field": "effectiveness", - "label": "Good", - "color": "#27ae60" - } - ], - "stackCollapsed": true - } - ] - }, - { - "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.", - "escalationFactors": [], - "stack": [ - { - "id": "stack-mb-2-1-eff", - "field": "effectiveness", - "label": "Fair", - "color": "#f1c40f" - } - ], - "stackCollapsed": true - }, - { - "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.", - "escalationFactors": [], - "stack": [ - { - "id": "stack-mb-2-2-eff", - "field": "effectiveness", - "label": "Good", - "color": "#27ae60" - } - ], - "stackCollapsed": true - } - ] - }, - { - "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.", - "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 - }, - { - "id": "mb-3-3", - "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.", - "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" -} \ No newline at end of file