The Incident
During vessel operations, a higher-than-normal exhaust gas temperature reading from the starboard engine was observed. The engineer, on duty at the time, proceeded to investigate and whilst doing so, lost his balance and placed his hand against a section of exhaust pipe from which the lagging had been removed. The temperature at that section was estimated to be approximately 400°C. The engineer, who was not wearing gloves at the time, suffered burns to his hand. The weather at that time was good.
The exhaust pipe had a history of defects and had undergone multiple repairs in the preceding months, before being replaced approximately three weeks prior to the incident. The lagging had not been reattached following the replacement (image 1).
The engineer was treated with first aid on board and was then taken to hospital where he was further treated and subsequently returned to work.
Image 1: Exhaust pipe without lagging
Observations
Inconsistent risk identification leads to improper practice
- The exhaust had undergone a series of repairs leading up to the incident, and the lagging was removed and refitted after each repair. However, the lagging was not replaced back after the replacement of the exhaust pipe.
- The crew appeared to not duly consider the risks associated with a lack of lagging.
Past safety bulletins not acknowledged
- A safety bulletin on the importance of lagging had been circulated by the company prior to this incident. As the engineer/master were not employed at the time, it is recommended that important safety notices are included as part of the on boarding process.
A lack of handover is a lack of information
- The exhaust had been replaced by the previous crew and the lagging had not been refitted to the new exhaust.
- There was no record of a handover on board, and while a verbal handover may have been carried out, a more comprehensive handover may have highlighted the missing lagging for the new crew to rectify.
Thorough checks may prevent incidents
- The master did not note the missing lagging as part of the weekly inspection of the vessel. The importance of Personal Protective Equipment (PPE)
- The engineer was not wearing safety gloves at the time of the incident which may have reduced the severity of the injury.
- However, the practice of wearing gloves around moving machinery varies within the industry. Therefore, the use of PPE in the vicinity of machinery should be duly assessed on a case-by-case basis.
Recommendations
- The assessment of on board risks should be a continuous process. The lack of situational awareness meant that the lagging of an exhaust pipe (the surface temperatures of which could reach 400°C) was missing. Crew should always be trained to ensure that any visible hazard, missing piece of equipment, bypass of a safety check, non-compliance with laid down procedures etc should be queried and rectified immediately and included as part of the repair process, where appropriate. The safety culture on board should be such that the crew feel empowered to speak up and raise any perceived issues or express their opinion.
- The missing lagging should have been noted as a deficiency during the daily rounds of the machinery space and also during the weekly inspections by the master. It should be ensured that such inspections are meaningful, rather than just a ‘tick-box’ exercise, should be vessel specific, and flexible should they require change. This allows features which may be unique to a vessel, or to certain situations, to be included where required.
- A proper and structured handover ensures key information is exchanged between crews and is especially important on vessels with lower crew numbers or when a vessel undergoes a major crew change. In preparing written handovers, the crewmember should allow themselves time to consider the items they wish to handover which may otherwise be forgotten on sign-off day.
- Emphasis should be place on learning from past incidents. Fleet and industry wide circulars, bulletins and case studies should be treated as an invaluable source of learning and applied uniformly, as appropriate, to all company vessels.
- Effective first aid can mitigate incidents and prevent them becoming more serious. In this incident, the fast response of the crew allowed the engineer to make a good recovery and return to work successfully. Crew should undergo regular first aid training and administering first aid can also be included in drills to ensure readiness and familiarity of crew