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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
                                                 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
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