The incident

On 31 July 2018, at about 1100, the second engineer observed a condensate / steam leak from the sight glass, fitted right above the atmospheric condenser return line.

He approached one of the engineers and asked him to rectify the leak together with another crew member.

Soon after his safety round, the second engineer noticed the engineer was using a hammer to tighten the sight glass.

At this stage, the sight glass failed, spilling hot condensate and steam into the engine-room.

The two injured crew members were helped to remove their wet clothes. Cold water was also applied to the burns.

Eventually, they were assisted out of the control room and transferred ashore. Nine days after the accident, one of the crew members succumbed to his injuries.

Conclusions

  1. Two valves on the condensate line after the sight glass were found closed.
  2. A hammer had actually been used to tighten the sight glass.
  3. The closing of both valves meant that a part of the system, which included the leaking sight glass, was under pressure.
  4. The status of the valves may have exacerbated the effects of leaking water and steam into the engine-room as soon as the sight glass failed.
  5. Although the better option would have been the shutdown of the boiler before the commencement of the maintenance work on the sight glass, this option may have been perceived as an excessive action which could not be justified.
  6. The potential failure of the sight glass had not been anticipated by the crew members (even if cautioned against the use of the hammer) and possibly, the crew members did not analyse what other options could have been available.
  7. The task must have not been considered complex and technically challenging to necessitate the conventional processes and dynamics which one would expect to find in a typical team performance.
  8. The crew members involved may have considered the use of a hammer as a necessary risk which had to be accepted, especially if the sight glass still leaked following the hand tightening of the sight glass.
  9. The protective clothes worn by the crew members did not offer any protection against scalding by hot water.

Actions taken

The Company carried out an internal investigation in accordance with the requirements of the ISM Code. The aim of the internal investigation was to identify long term safety corrective actions.

As a result of the internal investigation, the Company has:

  • Included a specific cautionary note in the engine-room training programme on the hazards related to potential residual pressure release from pipes and joints;
  • Posted additional warning signs in the engine-room to caution about pressurised systems and pressure relief before repairs and maintenance are carried out.

 

Explore more herebelow: