Transport Malta issued an investigation report on the fatal burn injury of a fitter onboard the bulk carrier ‘Iolcos Unity’ in June 2020. The incident occurred as the fitter was using an angle grinder which generated sparks on its covered-with-oil overall.
The incident
In the early hours of 28 June 2020, one of the fitters onboard bulk carrier ‘Iolcos Unity’ was instructed to investigate a hydraulic oil leak on one of the ballast valves on the main deck.
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Crawling to gain access to the leaking flange, the fitter’s overall was permeated with hydraulic oil. While using an angle grinder to cut the bolts, sparks generated by the grinder ignited his overall. The fire spread fast, covering his upper body, neck, and hands.
The fitter was evacuated to the ship’s hospital and later transferred by ambulance to a local hospital for burn injuries. The fitter eventually passed away on 08 July 2020 following medical complications.
Conclusions
- It is highly probable that metal sparks generated by the angle grinder ignited the fitter’s overall and the oil-contaminated synthetic fabric rapidly increased the burning rate.
- It was not excluded that the fitter would have known about the (incompatible) relationships between hydraulic oil and an ignition source, but that knowledge had not been activated when the ignition source was flying sparks from an angle grinder.
- Permit to repair the leaking flange indicated repair site free from hazard and for cold work only.
- Hydraulic oil Mobil DTE 10 had a flashpoint of ≥200 °C. The MSDS suggested precautionary measures to avoid contact with spilled material and listed several hazards resulting from the combustion of Mobil DTE 10.
- Prior authorization and dynamic risk assessment to use a portable angle grinder were not considered.
Actions taken
The company carried out an internal investigation in accordance with Section 9 of the ISM Code. The findings of the internal investigation were discussed during an extraordinary meeting. Moreover, relevant company procedures and risk assessments were reviewed to implement the necessary controls and procedures and avoid a reoccurrence of this accident. The following corrective/preventive actions were adopted by the company:
- communicated instructions with fleet vessels, to hold an extra safety committee meeting, discuss the events of the incident, carry out a thorough and detailed inspection of safety and fire-fighting equipment, rectify deficiencies and refresh familiarization/training on Company’s established safe working procedures and permit system in conjunction with the principles of the ‘Stop Work Authority’;
- forwarded full analysis and the lessons learned from this accident to all fleet vessels, with instructions to discuss with officers and ratings at the Safety Committee Meeting onboard;
- issued a Fleet Safety Circular, highlighting the importance of following procedures and policies, and requesting masters to ensure that all shipboard personnel is aware and familiarised with its contents;
- initiated a behavior-based safety programme to identify and mitigate unsafe behavior in a timely manner and launched a safety campaign on ‘Safety Culture and Stop Work Authority’.
Recommendations
Iolcos Unity’s managers are recommended to amend SMS procedures on the use of portable angle grinders and include portable angle grinding as a hot work activity.
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