Part 1 - Merchant Vessels - Marine Accident Investigation Branch

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No, Not That One Narrative A job that was assessed to be simple and non-invasive turned out to be a catastrophe for the multinational engineering team of a container ship. With the second engineer supervising the work, the third engineer and fitter were tasked to fit protection shields on Nos. 1 & 7 cylinder units of the main engine. These shields, of a fairly new design, were meant to protect personnel in the vicinity from escaping hot gases under pressure should the cylinder become over-pressurised (Figure 1). Work started on unit No. 1 and was completed within an hour, with no problems encountered. The fitting of the protection shield on unit No. 7 became increasingly more complex, necessitating the removal of platform plates, a non-pressurised pipe and a protective Figure 1: No.7 cylinder arrangement MAIB Safety Digest 1/2012 No.7 cylinder CASE 10 bracket. No attempt was made to re-evaluate the risks. Shortly after the pipe was removed (Figure 2), the second engineer left the area to respond to an alarm on the boiler. The third engineer then thought that the main bracket (Figure 2), which had supported the pipe, also needed to be dismantled, and removed the bolts which also secured the jacket cooling water pipe connection. As the third engineer and fitter attempted to manoeuvre the shield around the cylinder unit, it dislodged the cooling water pipe and resulted in the fitter becoming drenched with hot water (85º C) at 3.4 bar. Although the second and third engineers were quick to respond, by isolating the circulating water, the fitter suffered 30-40% burns to his body, had to undergo skin grafts and remained in hospital for a prolonged period. Protective shield 31
CASE 10 Figure 2: Pipe securing arrangement Jacket cooling water pipe Supporting bracket Non-pressurised pipe 32 MAIB Safety Digest 1/2012
Page 1 and 2: Part 1 - Merchant Vessels ‘Keep i
Page 3 and 4: CASE 1 Heavy Weather - Serious Inju
Page 5 and 6: CASE 1 The Lessons 1. When the ship
Page 7 and 8: CASE 2 Figure 2: Hold ventilation c
Page 9 and 10: CASE 4 Lift Shaft Working Can Kill
Page 11 and 12: CASE 4 The Lessons 1. Lack of plann
Page 13 and 14: CASE 5 Figure 2: CPP command signal
Page 15 and 16: CASE 5 The Lessons Luckily, the out
Page 17 and 18: CASE 6 They immediately pushed the
Page 19 and 20: CASE 7 The Lessons 1. The cause and
Page 21 and 22: CASE 8 The Lessons 1. A good bridge
Page 23: CASE 9 The planned tracks of the ve
Page 27 and 28: CASE 11 Watch ‘Sleeping’ Leads
Page 29 and 30: CASE 13 Watch Your Step Narrative M
Page 31 and 32: CASE 13 The Lessons This was a simp
Page 33 and 34: CASE 14 Figure 1: AIS data Position
Page 35 and 36: CASE 15 Navigating the Cut Narrativ
Page 37 and 38: CASE 16 Is the Forward Store a Dang

Part 1 - Merchant Vessels - Marine Accident Investigation Branch

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