| ▲ | 1970-01-01 9 hours ago | ||||||||||||||||||||||
So there were two big failures: Electrician not doing work to code; inspector just checking the box during the final inspection. | |||||||||||||||||||||||
| ▲ | nightpool 9 hours ago | parent | next [-] | ||||||||||||||||||||||
No, there was a larger failure: whoever designed the control system such that a single loose wire on a single terminal block (!) could take down the entire steering system for a 91,000 ton ship. | |||||||||||||||||||||||
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| ▲ | DannyBee 7 hours ago | parent | prev | next [-] | ||||||||||||||||||||||
No. Lots more : It's because they were abusing a non-redundant pump to supply fuel to the generators. Which then failed, which .... From the report: > The low-voltage bus powered the low-voltage switchboard, which supplied power to vessel lighting and other equipment, including steering gear pumps, the fuel oil flushing pump and the main engine cooling water pumps. We found that the loss of power to the low-voltage bus led to a loss of lighting and machinery (the initial underway blackout), including the main engine cooling water pump and the steering gear pumps, resulting in a loss of propulsion and steering. ... > The second safety concern was the operation of the flushing pump as a service pump for supplying fuel to online diesel generators. The online diesel generators running before the initial underway blackout (diesel generators 3 and 4) depended on the vessel’s flushing pump for pressurized fuel to keep running. The flushing pump, which relied on the low-voltage switchboard for power, was a pump designed for flushing fuel out of fuel piping for maintenance purposes; however, the pump was being utilized as the pump to supply pressurized fuel to diesel generators 3 and 4\. Unlike the supply and booster pumps, which were designed for the purpose of supplying fuel to diesel generators, the flushing pump lacked redundancy. Essentially, there was no secondary pump to take over if the flushing pump turned off or failed. Furthermore, unlike the supply and booster pumps, the flushing pump was not designed to restart automatically after a loss of power. As a result, the flushing pump did not restart after the initial underway blackout and stopped supplying pressurized fuel to the diesel generators 3 and 4, thus causing the second underway blackout (lowvoltage and high-voltage). | |||||||||||||||||||||||
| ▲ | IncreasePosts 8 hours ago | parent | prev [-] | ||||||||||||||||||||||
The terminal blocks could also have been designed to aid visual inspection. | |||||||||||||||||||||||