Eye protection appears to come a poor second to the rest of the PPE wardrobe, with the result that eye injuries still occur quite frequently. Why not insist that crew always wear eye protection when working in the engine room or on deck regardless of the task?
A selection of Mars Reports has been published in SWZ|Maritime's January issue. You can now read the full report, including Mars Report No. 201777, about the importance of wearing eye protection, here.
Innocuous Task Leads to Serious Eye Injury: Mars 201777
An engine room crew member was assigned the task of dismantling the steering motor coupling chain. One of the steps in this job, was to pull out a locking split pin using pliers. The crew member gripped the split pin with the pliers and began pulling with some force to extract it. Suddenly, the plier jaw slipped off from the split pin and, due to the force applied and the trajectory, hit his right eye.
The injury was serious enough to require the crew member to be disembarked ashore for professional treatment and repatriation. Although the crew member had most of his personal protective equipment (PPE), he was not wearing eye protection. It was also discovered that instead of pulling on the pliers in line with the tool, he had pulled sideways, so that the serrated teeth of the pliers were less effective in keeping a grip on the pin.
Serrations on pliers give good grip when force is applied "in line" with the tool but less when force is perpendicular.
Lessons Learned
- No matter the task, simple or complicated, injuries can occur if you do not use tools correctly or wear appropriate PPE for the task.
- Eye protection appears to come a poor second to the rest of the PPE wardrobe, with the result that eye injuries still occur quite frequently. Why not insist that crew always wear eye protection when working in the engine room or on deck regardless of the task?
Mobile Phone Ringing During Tank Inspection: Mars 201778
The tanker, in ballast, was at anchor and preparing to have some cargo tanks surveyed by an independent surveyor. Once the surveyor had boarded the vessel, the enclosed space procedure was followed.
After the space had been tested for oxygen content and hazardous gases, he entered the first tank in the company of the chief officer.
As the inspection progressed, a ringing was heard; a mobile phone in the surveyor’s pocket was sounding. The chief officer instructed the surveyor to turn the phone off, as mobile phones are not explosion proof.
Lessons Learned
- Even experienced professionals can make mistakes. Mobile phones are ubiquitous, so assume every visitor is carrying one. Insist mobile phones are turned off if the tasks to be accomplished require it.
No Gloves Would Have Been Better: Mars 201779
While at sea, an engine room crew member began work using the ship’s drill press and a securing vice. He was drilling 18 mm holes into stainless steel plates of about 2-3 mm thickness, wearing his usual personal protective equipment (PPE), including cotton gloves. The hole was drilled without incident, but when the drill bit was retracted, it jammed in the plate hole.
Under the rotational force of the spinning drill bit, the plate came out of the vice and spun with the drill bit. The spinning plate caught the operator’s left hand, which was on the vice-handle.
The operator quickly stepped on the “stop control” foot pedal, but the momentum of the plate was high enough that the drill did not stop immediately. The victim was treated as far as possible on board and then evacuated to a shore hospital. Unfortunately, the severity of his injuries – complete removal of skin and muscle tissue down to the bone of the left index finger – required the amputation of the finger.
There was a high probability the drill bit would jam in the hole, because of the size of the drill bit compared with the thickness of the plates.
The investigation found that the cotton gloves worn by the victim probably aggravated his injuries. The company had issued a safety circular several years earlier prohibiting the use of gloves when working on the lathe and drill machines. However, this information was not displayed near these tools, nor had the victim received this information in any other way.
The investigation also determined that there was a high probability the drill bit would jam in the hole, because of the size of the drill bit compared with the thickness of the plates. Clamping the plate in the vice without other support is not good practice.
Lessons Learned
- A “dead man’s switch” is safer than an independent emergency stop switch. A dead man’s switch needs to be continually depressed to keep the machine operating.
- Under certain circumstances some kinds of PPE (such as cotton gloves in this instance) are actually counter-productive. Proper training and information placards can help inform crew what to wear and when.
A safety circular prohibiting the use of gloves when working on the lathe and drill machines was not displayed near these tools.
Girding Leaves Coxswain Trapped in Wheelhouse: Mars 201780
Edited from official MAIB report 10/2016
In the early evening, the crew of a chemical tanker in ballast were preparing for departure. The pilot advised the master that he intended to use a mooring launch/tug to assist in manoeuvring the vessel’s stern off the berth, given the 25 knot wind pushing the vessel on to the berth.
Additionally, there was an obstruction astern and another vessel was berthed 30 m ahead of the tanker.
The mooring launch made a line fast through the tanker’s starboard quarter fairlead. The pilot ordered the launch coxswain to make a “tight line” while the master made the engine and bow thruster movements necessary to clear the berth using the forward spring. The tanker began to move off the berth and the master brought the controllable-pitch propeller (CPP) to zero.
The forward spring was then let go, and the order “all easy” was passed by the pilot and acknowledged by the launch coxswain. The master moved the CPP control ahead and the tanker’s speed increased to 2-4 knots.
Meanwhile, the mooring launch coxswain attempted to turn the launch to port, but found he could not. The pilot ordered the launch to “run with me” and then to “come in and let go”. These orders were acknowledged by the coxswain even though he was experiencing difficulty in manoeuvring.
A crew member at the tanker’s stern overheard the pilot’s order for the launch to let go on the VHF radio, and waved the launch in. He immediately noticed that the launch appeared unable to respond and was listing to port. He instructed the bridge team by VHF radio to stop engines, but received no response. On board the launch, the coxswain attempted to operate the emergency release. This was unsuccessful.
The deckhand left the wheelhouse and attempted to release the towing hook by pulling directly on the emergency release wire. This was also unsuccessful. The tanker’s crew member aft repeated his instruction to the bridge team to stop engines. The master then asked for clarification and, on receiving it, brought the CPP control to zero.
In the following minutes the launch listed further to port and capsized, with the towline remaining attached to the tanker. The tanker’s master released a man-overboard lifebuoy and marker. At the same time, the pilot made a series of emergency calls on VHF radio, following which a search and rescue (SAR) operation was initiated.
The deckhand was able to swim clear of the launch as it capsized and was rescued, but the coxswain remained trapped in the wheelhouse.
The launch remained inverted for over an hour with the coxswain trapped inside, but still alive. He was finally rescued when the launch partially rolled on its side. The coxswain and deckhand were treated for shock and hypothermia.
Some of the analysis and findings of the official report were as follows:
- The crew of the launch did not know how to use a “gog” rope to best effect; instructions on the use of gog ropes were not included in the company’s safety management system, nor had the launch crews received specific training in their use.
- With additional controls in place, such as effective proactive communications between the pilot and the launch coxswain at defined stages of the operation, the risk of girding could have been reduced.
- The tanker’s pilot relied on the launch coxswain to act autonomously and to inform him when in doubt or difficulty. This practice appears to have diminished the value he placed on proactive and detailed communication.
Lessons Learned
- Always inform tugs of your vessel’s movements before that movement starts, to avoid trapping a tug in an unrecoverable position.
Shocking Accident Sheds Light on Best Practices: Mars 201781
A vessel was undergoing hold cleaning. A crew member needed better lighting, and decided to connect a cargo cluster light in the hold to improve visibility. As he connected the cluster to the electrical outlet, he received a severe electrical shock. He was shifted to the ship’s hospital in a semi-conscious state where further medical treatment was given. After some time, he regained consciousness and was feeling better.
On investigation, it was found that:
- The crew member’s hands and clothes were wet, because hold cleaning was in progress.
- The plug unit cover was in a short (grounded) state.
- The plug unit was made of brass.
- Proper insulated lugs were not used for the connecting wires inside the plug socket. One of the wires was not connected properly, causing it to touch the brass metal body of the plug unit.
Lessons Learned
- An earth cable should always be properly connected inside the socket at all times. R (circle) type insulated cable lugs should be used to connect the wires to the socket.
- If plug sockets are made of conducting material, the inside edge frames should be covered with insulated rubber packing and the wire connections should be covered with insulation tape.
- Ideally, all cargo cluster plugs should be of non-conducting material. Receptacles and switches should be fit for marine use.
- Electrical appliances should never be handled with wet hands.
If plug sockets are made of conducting material, the inside edge frames should be covered with insulated rubber packing and the wire connections should be covered with insulation tape.
Engine Room Fire Burns for Twelve Hours: Mars 201782
Edited from official report 314-MO-2014-008, Australian Transport Safety Bureau
A bulk carrier was being loaded when the ship’s fire detection system activated. Soon after, fire alarms began sounding throughout the ship and many (though not all) of the accommodation fire doors closed automatically. The chief engineer, who was in the engine control room (ECR), went to investigate and saw smoke and flames coming from the generator flat. He made an unsuccessful attempt to extinguish the fire using a portable fire extinguisher, then returned to the ECR and phoned the bridge, confirming there was a fire in the engine room. Shore-side assistance was called.
By this time, thick black smoke was building up quickly in the accommodation area. An announcement was made over the ship’s PA system; all crew members were directed to their muster stations.
Some duty engine room crew evacuated the engine room via the lift while others used the stairs. Once most of the engine room ventilation dampers were closed, the halon fixed fire suppression system was activated. However, a number of mushroom ventilators and dampers could not be fully closed because the closing mechanisms were difficult or impossible to operate. Consequently, the engine room was not effectively isolated. Smoke continued to billow from the openings and air entering the engine room sustained the fire.
It was later discovered that the halon gas was not fully released due to multiple failings linked to maintenance and testing of this equipment. Because the engine room was not effectively sealed, the fire continued for about twelve hours until it burnt itself out.
The fire was caused by fuel oil spraying from a generator onto a hot surface. A fuel oil pressure gauge compression fitting on the generator had failed due to a less than adequate repair.
Some of the other findings and safety issues of the official report were as follows:
- A number of the vessel’s engine room fire doors were held open by wire and/or rope. The open doors allowed the smoke to spread across the engine room and into the accommodation spaces.
- The maintenance of the opening and closing arrangements for the vessel’s engine room fire dampers, ventilators and other openings was inadequate. Several of them could not be closed, making it impossible to seal the engine room to contain and suppress the fire.
- The halon gas fixed fire suppression system for the engine room was not fully operational. The multiple failures of the system at the time of the fire were not consistent with proper maintenance and testing.
Lessons Learned
- The fixed fire suppression system is an essential safety element of your vessel – make sure it is properly tested and maintained.
Acknowledgement
Through the kind intermediary of The Nautical Institute we gratefully acknowledge sponsorship provided by:
American Bureau of Shipping, AR Brink & Associates, Britannia P&I Club, Cargill, Class NK, DNV, Gard, IHS Fairplay Safety at Sea International, International Institute of Marine Surveying, Lairdside Maritime Centre, London Offshore Consultants, MOL Tankship Management (Europe) Ltd, Noble Denton, North of England P&I Club, Sail Training International, Shipowners Club, The Marine Society and Sea Cadets, The Swedish Club, UK Hydrographic Office, West of England P&I Club
Submit a Mars Report
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