HOT WORK RESULTS IN A MELTDOWN
A ro-ro ferry was operating to a normal schedule with contractors on board to conduct repairs to an auxiliary boiler. The work was planned to start during an evening passage. The repairs involved hot work inside the boiler. Hot work and enclosed space entry permits to work (PTW) were completed by the chief engineer and accepted by both the safety officer and the ship’s master. The safety officer stressed the importance of maintaining a fire watch as a number of fire detector heads in the engine room were going to be isolated for the duration of the hot work. The ferry sailed on schedule and work on the boiler was started as planned. On arrival at its destination port, discharge of passengers and vehicles commenced. The chief engineer then informed the safety officer that a small fire had occurred in the boiler about an hour earlier while the contractors were using flame- cutting equipment. Investigations revealed that a portable light unit, used earlier in the day, had been left at the bottom of the boiler and that sparks from the cutting process had caused the unit to ignite. The contractors had reacted quickly and had extinguished the fire using fire-fighting equipment that had been located close to the work-site as part of the PTW requirements.
CCTV recording of the period leading up to the incident showed the fire watch moving potentially flammable material away from the area outside the boiler. However, the portable light unit, which was located inside the boiler, was not readily visible and so was left in place during the hot work.
The Lessons 1. It is vital that emergency procedures are followed. Although in this case the fire was successfully extinguished at an early stage, the master needs to be made immediately aware of all incidents that could affect the safety of the passengers, crew and vessel. Sharing of information also allows a review of actions taken and of potential consequences, such as re-ignition.
2. The raising of a PTW should always involve conducting a thorough risk assessment. In this case, the likelihood that the flame-cutting process would generate sparks should have prompted a thorough inspection of the surrounding area, both outside and inside the boiler, to identify and remove flammable items.
3. Paragraph 14.1.1 of the Code of Safe Working Practices for Merchant Seafarers states: ‘Based on the findings of the risk assessment, appropriate control measures should be put in place to protect those who may be affected…’ The safety officer had cited the fire watch as an important control measure in this case. However, the particular danger posed by flammable items potentially left inside the boiler had not been identified by the fire watch.
Reprinted from the MAIB Safety Digest 1/2018
CARBON MONOXIDE POISONING STRIKES AGAIN
The owner of a small motor cruiser boarded his vessel at its marina mooring, unzipping one side of the cockpit canopy to gain access. His plan was to start and run the inboard petrol engine. Before starting the engine, however, he noticed a significant amount of water in the engine compartment bilge, which stretched into the cabin area. He started the boat’s electric bilge pump to clear the water. Once the water was below the level of the starter motor he started the engine. To assist with pumping out the water, the owner engaged slow ahead while still moored, to force the boat’s bow up and cause the water to flow aft into the engine compartment. Approximately an hour later a friend called the owner, but there was no answer. He called another friend who was a berth holder in the marina and asked him to check if the owner was okay. The owner was found face-down in the cabin by two berth holders, with the engine still running. One raised the alarm while the other commenced CPR on the owner. Another person arrived and assisted with the CPR. The first rescuer felt dizzy 10- 15 minutes later, and developed a headache. Shortly afterwards, he was helped out of the boat into fresh air.
Paramedics arrived and were directed to the first rescuer initially. After quickly examining him, the paramedics rapidly removed the cockpit canopy and took over first-aid of the boat owner. He was transferred ashore and taken to hospital, but never recovered consciousness. The two rescuers were also taken to hospital suffering from carbon monoxide (CO) poisoning; both made full recoveries. On examination, it was determined that at least two of the flexible rubber bellows of the boat’s wet exhaust system were leaking, allowing water and exhaust gas into the boat.
Reprinted from the MAIB Safety Digest 1/2018
The Report • June 2018 • Issue 84 | 17
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