After a severe chemical burn to an engineer onboard, CHIRP analyzes the incident, explaining the circumstances that led to it and provides lessons learned for the future.
During maintenance work on the purifier, an engineer was instructed to bring a specific chemical (carbon remover) from the chemical locker to clean the purifier. The engineer went into the chemical locker to transfer a quantity of the above-mentioned chemical from the drum to a small can.
However, during this activity a quantity of the chemical liquid was spilt on their thigh, resulting in a severe chemical burn. First aid and medical treatment were provided on board before the engineer was landed ashore two days later when the ship reached port. The engineer was subsequently repatriated for further treatment. The engineer had recently joined the vessel and during the familiarisation tour received training on the safe handling of chemicals.
The company’s safety instructions which were posted at the entrance to the chemical locker were not reviewed, nor was the chemical personal protective equipment (which was also positioned at the locker entrance) used.
Cleaning the purifier was a planned work activity that took place almost every day. The company’s documented procedures directed that the appropriate Job Hazard Analysis be reviewed prior to work starting. However, the Job Hazard Analysis for this task did not require a toolbox meeting, nor was one carried out.
Human factors related to this report
- Culture: Does your company have a safety culture that operates throughout the whole organisation and operates with a top-down bottom-up approach? Are you encouraged to challenge apparent safety infringements?
- Local practices: Do you see local practices becoming the norm on your ship? If you are used to good working practices on other ships, how do you resist accepting lower standards and attempt to raise standards?
- Teamwork: If this was a daily task why did nobody say “stop”? Would you alert a crew member when you see potential problems concerning their safety
- Capability: Was the management company capable of understanding the hazards associated with this chemical? The report states that other less toxic and corrosive chemicals should have been used for removing carbon deposits, so why did management continue to procure this
chemical if they were aware of the risks?
In order to prevent and avoid such incidents, the following points should be taken into consideration:
- Taking shortcuts by not wearing PPE for a job that is done regularly and which takes a very short time is common. It is a typical example of “it won’t happen to me” syndrome. This new crew member should have been shown the way that chemicals are handled using the PPE matrix and donning the PPE.
- A new joiner to a ship or company should be supervised for their own safety during their induction period.
- It is best practice that all staff or crew are empowered to challenge any apparent infringement of safety standards and to raise concerns if they discover even minor equipment defects.
- The post-incident investigation identified that a less hazardous chemical could have been used as a carbon cleaner. In the hierarchy of controls, substitution is only second to elimination. Personal protective equipment is the least effective method of protecting against a hazard.
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