Page 11 - 2021 - Q3 - Minerva in Focus

“

As he did not observe any
leakage, the 3rd Engineer

pulled the cover without
removing the nuts. However,
hot oil started splashing Figure 3:
onto him from the manhole The manhole at the

bottom while he was still on aft side of the tank,
the folding ladder. almost one meter from
the bulkhead and two
” Source: HBMCI
meters from the floor.

Engineer away and took off his coverall, which was soaked with first aid to the 3rd Engineer. A helicopter arrived about two hours
the hot oil. The engine crew then moved the 3rd Engineer to the after the accident. The 3rd Engineer’s condition was considered
vessel’s hospital, where it was observed that he had sustained relatively good when he left the vessel as he managed to walk by
serious burns to various areas of his body. In the meantime, the himself to board the helicopter. The 3rd Engineer was transferred
Master was informed about the incident. to a Sao Luis hospital, where he was diagnosed with second-degree
The Master reported the incident to the company, then contacted burns on a large part of his body. He was admitted to the Intensive
the local agent and requested the immediate transfer of the 3rd En- Care Unit and remained hospitalised for the next 12 days until he
gineer ashore for treatment. Meanwhile, the Chief Officer provided died of septic shock.

Lessons Learned • Taking shortcuts from an established safe work

procedure to save time and effort may be appealing
but can lead to undesirable and even tragic conse-
The following lessons learned, which are not intended to quences. Other ways of confirming the tank had
apportion blame on the individuals or company involved, been drained could have been used - for example, by
have been identified based on the available information in measuring the quantity in the BSO Tank; this would
the investigation report: have helped identify that it was not safe to open the
manhole cover.
• The investigation found that the potential hazards • The vessel’s Planned Maintenance System (PMS) did
associated with the unknown amount of hot sludge in not address the foreseeable and preventable jam-
the tank due to the malfunctioning level gauge had not ming of the level gauges with sludge oil. It did not
been identified. A simple, complete, and meaningful risk provide guidelines for periodic routine maintenance/
assessment needs to be conducted before starting a task tank cleaning. Providing an appropriate and regular
to identify the hazards and required precautions; this will regime for cleaning the tank would have helped avoid
also help personnel maintain focus when most needed. the need for this unplanned and hazardous task.
• Making assumptions about the safety of the work • The WOS Tank was not fitted with a sounding pipe as
environment can lead to unexpected exposure to haz- an alternative means when the level gauge malfunc-
ards and injury. Experience and professional knowl- tioned. Although not a requirement, had a sounding
edge may not be enough to address the safety gaps pipe been fitted, this would have allowed the two
resulting from a risk assessment based on incomplete engineers to verify the tank’s contents.
hazard identification. • The 3E was wearing a common cotton coverall provid-
• Confirmation bias (favouring information that con- ed to him by the company. This only offered limited
firms one’s pre-existing beliefs) can create a window protection from heat and allowed the hot liquid to
of opportunity for an incident. This can be avoided by penetrate and transfer heat to the skin. The investi-
personally challenging oneself to take a minute and gation identified that an ISO 11612 compliant coverall
think about the job at hand – to consider what can could have possibly provided better protection to the
go wrong and how and what steps one can personally 3E despite being intended to protect against heat and
take to minimize the risk. flame rather than hot liquids.

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