The Bahamas Maritime Authority (BMA) has issued an investigation report on an incident involving the Seapeak Napa, which experienced a cargo manifold leak that ignited on 27 October 2023.
What happened
In the early morning of 27 October 2023, Seapeak Napa had completed loading a cargo of ethylene in Daesan, South Korea, when the vessel’s gas engineer identified that liquid cargo was leaking from the cargo manifold. Having identified that the blank was probably missing a gasket, the gas engineer and duty able seafarer were unbolting the blank when the cargo vapor ignited, creating a fireball that engulfed the manifold platform and extended in excess of 10 meters in diameter. The automatic water-spray system did not operate as required, but the crew extinguished the fire after 17 minutes. The able seafarer was seriously injured. The gas engineer died due to complications from burns five days after the fire.
Why it happened
The ethylene was introduced to the manifold due to the incorrect lineup of valves during cargo sampling. It was exposed to the atmosphere from the leaking blank and when the manifold drain valve was opened. The ignition source could not be determined with certainty, but the spanners being used at the manifold were not suitable for use with highly flammable cargoes due to the risk of sparking. Additionally, the gas engineer was wearing a cold weather jacket that was of a type that could produce a static electricity charge. Despite concerns about the gas engineer’s conduct and competency, the gas engineer was working without support or supervision on a complex system. Firefighting efforts were complicated by a blocked head on the automatic water spray system. Readiness (both onboard and ashore) was reduced on completion of cargo operations when the risk of fire was thought to be reduced.
The ignition source could not be determined with certainty, but the spanners being used at the manifold were not suitable for use with liquid petroleum gas cargoes due to the risk of sparking. Additionally, the gas engineer was wearing a cold weather jacket that was of a type that could produce a static electricity charge. There was a crate of non-sparking tools onboard, but the tools available did not include spanners that the deck crew considered suitable for the task. The gas engineer’s cold weather jacket was one of a batch purchased directly by the ship’s agent during the last drydock and did not meet the Company’s personal protective equipment requirements. The gas engineer drained the cargo to the drip tray/atmosphere, contrary to guidance. His actions to rectify the situation without engaging help from the chief officer may have been informed by two written warnings. He was in his initial probation period with the Company.
Despite concerns about the gas engineer’s conduct and competency, the gas engineer was working without support or supervision on a complex system that could not be monitored remotely. The Company’s stop work authority was not effective—none of the crew that were aware of the cargo at the manifold felt empowered to stop the work of a superior. The use of non-suitable spanners on deck was normalized as the necessary non-sparking tools were not available to get the job done. Firefighting efforts were complicated by a blocked head on the automatic water spray system. Readiness both onboard and ashore was reduced on completion of cargo operations when the risk of fire was thought to be reduced.
Lessons learned
As a result of this casualty, OSM Thome has:
- Undertaken a full review of its safety management system.
- Introduced “life-saving rules” across the fleet.
- Updated requirements for personal protective equipment onboard its tankers.
- Overhauled the control of tools (including the supply and location of non-sparking tools) in hazardous areas.
- Adapted its generic risk assessment to include human factors.
- Adapted its cargo plans to include critical stages of operations from arrival until departure.
- Provided mimic plans in compressor rooms and cargo control rooms.
- Increased test frequency for the fixed water spray system and enhanced the schedule for replacement of pipework.
- Shared lessons learned from the casualty across its fleet.
- Conducted (onboard) workshops on stop work authority, leadership, risk assessment, and toolbox meetings.
Ongoing work includes the introduction of a cargo auditing process, changes to its recruitment and onboarding process, and the introduction of a quality safety program.
