On board the Wisdom Venture, a permanent modification to the steam drain line was implemented without documentation. During the modification process, 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.
ATSB comment
The ATSB welcomes advice of the above safety action and notes that the ship manager has committed to providing evidence of the planned actions once completed. While this action, once implemented, will likely address the safety issue, it will remain open to ensure appropriate follow-up and verification of corrective actions.
To be advised
