Lessons learned: Avoiding major steps to a task can lead to severe injuries

by 18, Dec, 2020Market News

The incident

A crewman was injured when there was an uncontrolled and unplanned closure of a fire flap.

Specifically, the crewman was filling an expansion tank through the engine room ventilation trunking, when the release mechanism for the fire damper was activated unintentionally, causing the fire damper to close on his left wrist, resulting in a wound.

Findings

The injured person filled the expansion tank in a way not detailed in procedures, via the filler cap from above, through the induction fan trunking.

There was a company standard operating procedure for this and he did not follow it.

The procedure for filling/topping up the high-temperature cooling system was via a portable pump with suction direct from a 20/25 litre drum.

This system was in place due to the problematic location of the expansion tank filling cap in the engine room.

Lessons learned

  • No physical action was taken on board to locate the pump.
  • There was no risk assessment into this nonstandard way of conducting the activity.
  • The available transfer system available in the engine room was not used.
  • Uncontrolled release of the fire damper.
  • The man’s arm was in the line of fire.

In light of the incident onboard, IMCA recommends to:

  • Ensure no improvisations are replacing designed, approved systems on board. Where not functional, work orders/defects should be documented and if in doubt, assistance sought for clarification or suitable management of change process;
  • Risk assessment should be conducted for non-routine tasks;
  • Don’t cut corners  crew should be reminded of the dangers of skipping or avoiding steps important to a task.

December 2020
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