Transport Malta has published an investigation report regarding an incident that took place in the morning of 26 September 2022, whilst Milagro was drifting outside the Republic of Korea’s territorial waters, the fitter was assigned to replace a leaking hydraulic pipe on the main deck.
The incident
An oxy-acetylene torch was used to cut the Ubolts, which secured the pipe to the pipe supports on the deck.
Whilst cutting the last U-bolt, which was close to the forward flange, the pipe slipped off its supports. Oil from the pipe splashed onto the fitter and
immediately ignited. The crew members assisted the fitter in extinguishing the flames on his coveralls, following which he was administered first-aid. The
injured fitter was eventually evacuated to a shore hospital for further medical treatment.
The safety investigation concluded that prior to the commencement of the task, the hydraulic oil pipe had not been completely drained. Two recommendations have been made to the Company to enhance onboard assessment of risks.
Vessel
Milagro was a 40,298 gt bulk carrier, owned by Ifestos Owning Co. Ltd. and managed by TMS Dry Ltd. (Cardiff Marine), Greece (the Company). The vessel was built by Hudong-Zhongua Ship Building (Group) Co. Ltd., China, in 2009. American Bureau of Shipping (ABS) acted as the classification society, while Det Norske Veritas (DNV) acted as the recognised organisation, in terms of the International Safety Management (ISM) Code, for the vessel. Milagro had a length overall of 225.00 m, a moulded breadth of 32.26 m and a moulded depth of 19.60 m. The vessel had a summer draft of 14.22 m, corresponding to a summer deadweight of 75,205 metric tonnes (mt). Propulsive power was provided by a 5-cylinder, two-stroke, slow speed, MAN B&W 5S60MC-C Mk7 marine diesel engine, producing 8,990 kW at 101 rpm. This drove a fixed-pitch propeller, enabling the vessel to reach a service speed of 14.0 knots. At the time of the occurrence, Milagro was in ballast condition, drawing forward and aft draughts of 4.82 m and 7.18 m, respectively.
Crew
Milagro’s Minimum Safe Manning Certificate stipulated a crew of 14. At the time of the accident, the vessel was manned by a Greek master and 22 Filipino crew
members. The seriously injured fitter was 45 years old. He had about 14 years of seafaring experience, all of which were served in the rank of a fitter. He had served for about three years in the Company, prior to the accident. The fitter held a certificate of proficiency for an able seafarer engine (STCW III/5), which was issued in July 2016, by the Maritime Industry Authority (MARINA) of the Philippines. He had joined the vessel on 21 September 2022, at the port of Donghae, Republic of Korea.
This was the fitter’s second employment term on board Milagro. The chief engineer was 55 years old. He had about 22 years of seafaring experience, 16 of
which were served in the rank of a chief engineer with STCW III/2 qualifications. His certificate of competency was last renewed in May 2021, by MARINA. He had served for five years in the Company, prior to the accident. He, too, had joined the vessel on 21 September 2022, at the port of Donghae.
Environment
The vessel’s records indicated that the sky was clear, and the visibility was about 12 nautical miles (nm) around the time of the accident. A gentle breeze was blowing from the East Northeast, while the sea state was moderate, with a low swell. The air and sea temperatures were recorded as 18 °C and 22 °C, respectively.
Reported injuries
The hospital reports indicated that the fitter had suffered deep, second and third degree burns over about 70% of his body and required several skin grafts. After completion of treatment at the hospital in the Republic of Korea, the fitter was deemed fit to be repatriated on 22 December 2022. At his home country, the fitter had to undergo several physiotherapy sessions, which were still in progress at the time of publishing this safety investigation report.
Analysis
Aim
The purpose of a marine safety investigation is to determine the circumstances and safety factors of the accident as a basis for making recommendations, and to prevent further marine casualties or incidents from occurring in the future.
Safety investigation actions
The MSIU was notified of this occurrence on 03 October 2022 i.e., one week later. By then, the vessel had received its voyage orders and was already en route to its destination port of Vancouver, USA.
A representative of the MSIU boarded the vessel at Vancouver to interview the crew members and collect relevant accident data for the safety investigation.
The Company advised the safety investigation that the injured fitter had communicated his unwillingness to participate in an interview until he recovered
completely. To this extent, the safety investigation was unable to interview him.
Cause of injuries
Hydraulic oil splashed onto the fitter from the hydraulic oil pipe and ignited when it came into contact with the flame of the oxyacetylene torch being used. As a result, the fitter’s coveralls caught fire, causing deep, second and third degree burns over 70% of his body.
Conclusions
- The fitter’s coveralls caught fire, caused by the ignition of a spray of hydraulic oil from the pipe that the fitter was working on.
- The fitter was using an oxy-acetylene set to cut off the U-bolts on a leaking section of a hydraulic pipeline, which was part of the remote operating
system for the water ballast tank valves. - After the occurrence, the crew members found that a valve between one of the accumulators and the return pipeline, was open, as a result of
which, the return pipeline may have been under pressure. - An observed reduction in the oil leak may have misled the crew members to believe that the pipeline had been depressurized and drained.
- Although a fire hose was connected to a hydrant and placed near the work site, the fire pump was not switched on.
- The fitter’s unawareness of the hazard was a pivotal factor on how the accident dynamics had evolved.
- It is highly likely that the fitter’s coveralls did not offer any fire protection.
Safety actions taken
During the safety investigation, the Company had carried out an internal investigation, in accordance with the requirements of the ISM Code. Following their investigation, the Company took the following actions:
- the investigation report was discussed with all crew member on board Milagro;
- the investigation report was circulated across the Company’s fleet;
- the investigation report was used in its training centres as a case study for engineers at pre-embarkation training sessions;
- instructions and precautions for the replacement of a unit, device or a pipe of the hydraulic oil system, were posted in the hydraulic power unit
room on board Milagro; and - all crew members who were assigned to the task on board Milagro, were provided with additional training on the SMS procedures for hot work and work
on pressurized systems.
Recommendations
Considering the safety actions already taken, TMS Dry Ltd. (Cardiff Marine), is recommended to:
17/2023_R1 bring this safety investigation report to the attention of serving crew members, to raise awareness on the expected potential differences in the way
seafarers may perceive (and hence) accept risk;
17/2023_R2 promote a training regime, which encourages crew members to engage in accident simulations to enhance risk assessment measures as part of the
implementation of the vessel’s safety management.
