Bad, confusing design is a hazard we don’t hear about very much but in an emergency the difference between good design and bad design may be the narrow gap between success and tragedy. Take a look at the picture at the top of this page: Can you immediately tell which tags to pull to cut off fuel and which to pull to activate the CO2 fire suppression system? In the dark? In rough weather? In a hurry?
MAIB’s report on the Figaro incident in December 2007 in which an accidental activation of the ship’s CO2 smothering system led to the vessel losing propulsion and electrical power in rough weather, sending it drifting toward Wolf Rock off the southern English coast, reads almost like an adventure story full of derring-do and not a little personal courage and is well worth the read.
All the same, it shouldn’t have happened. Says MAIB: “The investigation identified that the maintenance instructions for the CO2 system were contradictory and vulnerable to misinterpretation. The crew of Figaro were unfamiliar with the equipment and were unable to recognise the problem that occurred during the routine test, or realise the risk posed by leaving the system in an unstable condition. The incident also highlighted some areas where ETV procedures could be improved to help maintain the successful reputation that this service has gained.”