Page 10 - 2021 - Q3 - Minerva in Focus

SAFETY & SECURITY Case study:

Death of third engineer due to burn injuries

The 3rd engineer (3E) on board an anchored Capesize bulk carrier was
splashed by hot sludge while opening the manhole cover of a settling
tank and subsequently died of septic shock, having sustained sec-
ond-degree burns to a large part of his body

What happened

The Chief Engineer (CE) was informed about the gauge malfunction and
decided that the No.2 WOS Tank should be cleaned and the level indicator
repaired the following day. Therefore, he prepared a “Job Hazard Analysis”
(JHA) for the tank cleaning operation in accordance with the vessel’s Safety
Management System Manual.
The next morning, while still at anchor, the 2nd Engineer, assisted by the
3rd Engineer, was assigned to drain the No.2 WOS Tank in order to clean the
sludge residues from the tank and repair the level gauge mechanism. The
2nd Engineer opened the No.2 WOS Tank drain valve to allow the sludge to
drain back into the BSO Tank by gravity. He left the valve open for about 10
minutes until the level gauge indicated 300 litres.
Figure 1: In order to confirm the No.2 WOS Tank was empty, the 3rd Engineer got on
top of the tank, turned the wire wheel of the scale reduction device, and reported to
The level gauge of No 2 the 2nd Engineer that it was working. The 2nd Engineer noticed a slight movement of
Waste Oil Settling tank the level indicator while the drain valve was open. Finally, the 2nd Engineer opened
the self-closing drain valve used to drain water accumulated in the tank. A small
Source: HBMCI
quantity of water flowed through the drain valve and then stopped.
Based on the above, the 2nd Engineer was convinced that the tank was empty and
told the 3rd Engineer to proceed
with opening the manhole. The
3rd Engineer used a small folding
ladder to reach the manhole cover
located about two metres above the
floorplates and started removing
the cover nuts using an air impact
wrench. The 3rd Engineer removed
most of the nuts from the manhole
apart from four, which he then
loosened by a half turn. As he did
not observe any oil leakage from
the cover seat, he loosened the re-
maining nuts further. Then, without
removing the nuts, he pulled the
cover, which detached from the
seat.
However, hot oil at a temperature Figure 2:
of approximately 86°C started
Depiction of the two Waste Oil Settling Tanks:
splashing onto him from the man-
Thermometer: blue/Drain to BSO tank: green/
hole bottom while he was still on
Self-closing valves: red/Scupper: light blue/
the folding ladder.
by Slav Ostrowicki The 2nd Engineer who was about Level Gauges: black
Britannia P&I Club one metre away, pulled the 3rd Source: HBMCI

8 MINERVA IN FOCUS – ISSUE 17 / Q3 2021