Fire during hot work in confined space causes fatality, serious injury

The incident

At about 0900 on 28 October 2018, both crew members were inside the forepeak tank and hot work was being carried out on the lower platform.

The fitters organized their work, started ventilation by means of shore supplied compressed air, and switched on the illumination by portable lights from vessel store.

Fitter 2 was slightly delayed looking for a large wrench to free the jammed valve shaft.

When he reached the lowest platform (no. 5) inside the forepeak, fitter 1 had already started heating with the acetylene torch, while fitter 3 remained at the upper platform.

While fitter 1 started heating the valve shaft with the acetylene torch, fitter 2 was behind him, about 1.5 m away and was not able to see directly the work being carried out.

Soon after the commencement of the hot work, it was reported that a significant volume of fumes started to be generated, prompting fitter 1 to shout to fitter 2 to run.

Soon after, both fitters’ clothes were on fire; while fitter 2 managed to reach the ladder and climb up to the upper platform, fitter 1 did not manage and remained trapped inside the bilges of the forepeak tank.

The safety investigation considered two scenarios of fire ignition; either oxygen coming in direct contact with oil and grease, or oxygen enrichment inside the forepeak tank on the face plates of the forepeak bottom girders (platform no. 5).

Conclusions

1. Whilst it cannot be ascertained as to what had started the fire, the safety investigation identified two potential scenarios – oxygen coming in direct contact with oil and grease, or oxygen enrichment inside the forepeak tank, in way of platform no. 5;
2. The flame from the torch was considered as a potential ignition source;
3. The damages observed in the space were not conducive of an explosion;
4. Considering the injuries sustained by the two crew members, a flash fire may have resulted at some point;
5. Whatever the flammable medium (gas), the accumulated volume, albeit within the flammable range, was not excessive and large enough to cause an explosion;
6. No portable fans (and large diameter plastic hoses) were used to ventilate the forepeak tank;
7. Any oxygen-enrichment of the space may have happened well after the atmosphere tests had been carried out;
8. The clothing worn by the crew members was not flame-resistant; conventional protective clothing alone is not considered to be sufficient to mitigate the dangers of an oxygen fire.

The checklist “Permission for Entry in Confined Space”, dated 27 October, specified that all relevant requirements had been fulfilled, along with triple measurement of atmosphere, allowing entry and hot works for three fitters between 0800 and 1700.

Actions taken

During the course of the safety investigation, the company took the following safety actions:

• Soon after the accident, ventilation inside the forepeak tank was provided by means of a portable ventilator, fitted with a flexible hose;
• Distributed a Safety Circular (149/Dec 2018) within the fleet, highlighting fire prevention, hot work permits, use of flammable aerosols and availability of fire detection and fire fighting equipment;
• Significant amendments to the ‘hot work permit’ procedure have been carried out;
• A fresh risk assessment is specified in the new version of the checklist, prior to the commencement of hot work;
• Levels of O2, H2S, CO, LEL, and CH4 shall be measured and recorded;
• The accident was discussed during the shore-held ISM seminars;
• Pre-boarding briefs with crew members include discussion of the accident;
• Crew members received further training in advanced fire-fighting;
• All crew members proficiency in fire safety is upgraded in the company’s training centre. The training is tailored for the crew members’ needs.

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