A modification to the cargo heating main steam system drain line which deviated from the approved system design, was not identified during multiple technical inspections and superintendent riding visits. This resulted in the Wah Kwong Ship Management (Hong Kong) management of change (MoC) framework, which required that any modification involving system layout changes be subject to formal risk assessment and documentation, not being effectively applied.
Response by Wah Kwong Ship Management (Hong Kong)
The company has decided to amend the superintendent's inspection report to include checking any modification in the piping system which has not been reflected in the vessels piping system drawing.
ATSB comment
The ATSB identified that a modification to the cargo heating system drain line had been made without formal approval or documentation and was not reflected in the ship’s design drawings. This contributed to the incident and highlighted a gap in the oversight of shipboard system changes. To address this, the ship manager advised that the superintendent’s inspection report will be amended to include verification of any system modifications not reflected in ship's drawings. This action is intended to improve oversight and strengthen procedural compliance, ensuring that future modifications to critical systems are properly assessed, documented, and communicated.
The Wah Kwong Ship Management (Hong Kong) has provided evidence that the superintendent inspection report has been amended to include a requirement that the inspector report any unauthorised modifications to equipment in the engine room.
To improve oversight and strengthen management of change procedural compliance, the superintendent’s inspection report will be amended to include verification of any shipboard system modifications not reflected in the ship’s design drawings. These actions are intended to ensure that future modifications to critical systems are properly assessed, documented, and communicated.
The ATSB acknowledges that, following the identification of a gap in oversight of shipboard design changes, the ship manager has advised that the superintendent’s inspection report will be amended to include verification of any modifications not reflected in the vessel’s design drawings. This action is intended to ensure future modifications are properly assessed, documented, and communicated.
The superintendent inspection report has been amended to include the requirement that the inspector report any unauthorised equipment modifications sighted during the engine room inspection.
The ATSB is satisfied that the superintendent inspection report has been amended.
