Challenges faced and Lessons to be learned
Confidential Hazardous Incident Reporting Programme (CHIRP) has received a report regardingwork planning and risk assessment processes.
Report text:
“Report Text: It was after finishing a coffee break, where I was told by my 2/E to take out the connecting pipe of a condenser S.W. side in order to clean up inside the tube. The we together closed the inlet & outlet of S.W. line of the condenser and he (2/E) bypass the condensate stem that goes to the condenser, but he forget to closed the supply steam from the boiler; so as I was told to take out the pipe that has no more bolts and nuts and ready to taken out and the water has been drain already, the 2/E order me to lift up the pipe, as I lift up it, hot water poured into my neck and I covered it with my left arm and, because I was using a ladder, I tumbled down the floor. Luckily I did not hurt my head, only burn arms & neck down and then at a few minutes it was still ok.
“I did not yet feel pain but my arm and body is hot, so I rushed to the ship’s hospital together with my 3/E and 2/E. In there they call the Capt. And the 2/O who is acting as a doctor in the ship, but the 2/O only looking at me and did not do anything. Maybe he did not know what he would do! Only the3/E give me cold ice water for first aid and at that time already the burn is now painful and the Capt. said if I can manage to dress up in order to get into a hospital and I said “Yes”, but the burn getting really painful. After dressing up the C/O told me to go with the agent to take me to a doctor and I did.
“The engineer officer must have a checklist of the job or a major job for the future, in order to be sure that all necessary v/v’s, pumps, etc..is been done before the taken up or ordering the crew to take out something and must be checked by the C/E.
“And with regards to the 2/O on board he ok they must know what to do in time of emergency to apply first aid not just looking at the patient or person’s hurt! The IMO must evaluate this kind of officers and take up some necessary steps to improve them.
CHIRP Comment
Unfortunately this is an all too common accident. On the facts reported there are serious failings in the work planning and risk assessment processes, as the reporter has correctly observed. A good deal of useful guidance in this area is contained in the UKs Code of Safe Working Practices for Merchant Seaman, which is recommended reading.
In section 1.3 Principles of risk assessment, the Code states:
1.3.1 A risk assessment is intended to be a careful examination of what, in the nature of operations, could cause harm, so that decisions can be made as to whether enough precautions have been taken or whether more should be done to prevent harm. The aim is to minimise accidents and ill health onboard ship.
1.3.2 The assessment should first establish the hazards that are present at the place of work and then identify the significant risks arising out of the work activity. The assessment should include consideration of the existing precautions to control the risk, such as permits to work, restricted access, use of warning signs or personal protective equipment.
There is little evidence in this report to suggest any such assessment took place and a permit to work system with appropriate double checking does not appear to have been used. In such circumstances the risks of an accident are much higher.
Even without risk assessment, applying the general guidance contained in 22.4 Maintenance of machinery, may have prevented this accident from happening:
22.4.2 Where valves or filter covers have to be removed or similar operations have to be performed on pressurised systems, that part of the system should be isolated by closing the appropriate valves. Drain cocks should be opened to ensure pressure is off the system.
22.4.3 When joints of pipes, fittings, etc, are being broken, the fastenings should not be completely removed until the joint has been broken and it has been established that no pressure remains within.
Much of the Code (Reproduced under the terms of Crown Copyright Guidance issued by HMSO) is based upon the learning points from accidents, so others do not always have to learn the hard way.
The report was also forwarded to the Chief medical Adviser to the UK Maritime and Coastguard Agency, who provided the following comments with respect to the first aid aspects of this report:
Reading the report indicates that the vessel was in port and as such first aid onboard rather than definitive treatment would be expected. Also I am writing as if it was a UK flag ship but for others the International Medical Guide for Ships or another national equivalent would give the relevant information. All responsible officers on any but the smallest coastal vessel should have received medical first aid training as this is an international requirement.
It would appear that the appropriate first aid measures were not taken, however without further clinical information it is not possible to form a view on the severity of any scalds and hence the need for action. The responsible officer should have received training in medical first aid and this would have included the use of both the ship’s medical stores and the Ship Captain’s Medical Guide (22 Edn.) The first aid treatment is, where possible, to immediately cool the area with cold water and then to cover with a dry, non-fluffy dressing (SCMG p 17). It seems that medical care was close at hand, but had this not been so then longer term treatment recommendations should have been followed (SCMG p 82-83)
What is the work planning like on your ship? Are you confident this could not happen to you and, if it did, that you would receive the appropriate treatment?
Source:CHIRP
