Safety Alert: Effective risk assessment, supervision and training are core to protecting lives
A newly promoted third engineer was working on an auxiliary engine fuel filter and had not effectively isolated the fuel system. Fuel under pressure sprayed onto a hot exhaust, penetrated its insulation and ignited.
Prompt actions by the crew limited the spread of fire. Despite multiple search attempts by crew, the third engineer was not found until a shore fire team recovered him an hour after the start of the fire. He died 9 days later from smoke inhalation.
The investigation found that, despite the vessel having a full range of safe systems of work in place, the third engineer, who had worked for the company for over 5 years, died while attempting an unnecessary job conducted in an unsafe way at an inappropriate time, without a risk assessment and in the absence of any direct supervision of the task.
Analysis of the third engineer‘s training programme activity log found that only two of the 65 rank-specific tasks he was required to undertake before his promotion to third engineer had been completed with the requisite evidence.
It also found that the training system permitted line management to confirm that training had been completed without evidence being provided. This facilitated promotion twice when he was not ready.
Other findings included a lack of any evidence of poor visibility enclosed space rescue drills or escape drills using Emergency Escape Breathing Devices.
The company’s investigation identified 32 actions relating to: communication, crew and competence management, safety management and technical management.
FOR THE FULL REPORT CLICK HERE: MAIBInvReport 4/2023 – Moritz Schulte – Very Serious Marine Casualty (publishing.service.gov.uk)
ICHCA International is committed to helping industry to learn lessons fast, learn them once and make sure that they stay learnt. This information is intended to provide all organisations in the cargo supply chain with the opportunity to consider the events and to review and adapt their own health and safety control measures to proactively prevent future incidents.
We are grateful to UK Marine Accident investigation Branchfor providing details and to the Safety4Seafor raising awareness. We acknowledge their commitment to sharing learning to benefit others. If you have similar operations, please share this information with managers, operatives and any potentially affected third parties as appropriate. Please also review any of your relevant operations for similar hazardous conditions, risks, and controls. Learning content like this is highly valuable as it is based on real-world experience. We encourage everyone with publishable information about incidents to send it to us, so that we can raise awareness across the whole industry. Please contact us at secretariat@ichca.com; sharing your insight could save a life or prevent injury.