On board the Wisdom Venture, a permanent modification to the steam drain line was implemented without documentation. During the modification process, the change was not incorporated into a risk assessment and no formal review was conducted. This undocumented change likely introduced a system vulnerability that undermined the effectiveness of the steam system isolation.
Response by master of Wisdom Venture and ship manager
Following the incident, the master and ship manager advised that the drain line on Wisdom Venture has been returned to its original design configuration. A fleetwide campaign has also been initiated to identify any unauthorised modifications to shipboard piping systems. Where such modifications are identified, internal investigations will be conducted, and action taken to restore the system to the original design.
To raise awareness of the risks associated with undocumented engineering changes, the incident will be included in pre‑joining briefings for senior engineering staff and discussed during crew seminars. Ship staff will also be reminded that all modifications must be undertaken in consultation with the office and in accordance with the company’s management of change process.
The ship manager has provided evidence that a fleetwide campaign was conducted to identify unauthorised modifications to equipment in the engine room. In addition, the senior officer briefing record was amended to include a section on the requirement to receive an office approval for pipeline and equipment modifications. The ATSB also received evidence that the modified pipeline had been reverted to its original design.
The ship manager advised that the drain line on Wisdom Venture has been returned to its original design configuration. A fleet-wide campaign has also been initiated to identify any unauthorised modifications to shipboard piping systems. Where such modifications are identified, internal investigations will be conducted. To raise awareness of the risks associated with undocumented engineering changes, the incident will be included in pre-joining briefings for senior engineering staff and discussed during crew seminars. Staff will also be reminded that all modifications must be undertaken in consultation with the office and in accordance with the company’s management of change process.
The ATSB acknowledges that the ship manager has advised the drain line on Wisdom Venture has been returned to its original design configuration and no further changes are required. To address the broader issue of undocumented modifications, the ship manager has initiated a fleet-wide campaign to identify similar changes across the fleet. Additionally, to raise awareness of the risks associated with undocumented engineering changes, the incident will be included in pre-joining briefings for senior engineering staff and discussed during crew seminars. Staff will also be reminded that all modifications must be undertaken in consultation with the office and in accordance with the company’s management of change process.
Please be advised that all safety actions related to the investigation have been completed. We have also verified that similar issues do not exist across other vessels in the fleet. As part of the corrective measures, the original pipeline was reinstated.
The incident and key learnings discussed during seminars and pre-joining briefing sessions for senior officers and engineers.
