Safety Protocol Breach Leads to Fatal Incident During Bulk Vessel Engine Repair: Report

A bulk vessel experienced an issue with the main engine’s exhaust gas temperature on one cylinder, prompting the engine crew to investigate. It was determined that the fuel oil injection valve (FOIV) of the number 4 cylinder needed replacement, a task estimated to take 1-2 hours. The chief engineer and the Master were promptly informed of the situation. The main engine control was shifted to the Engine Control Room (ECR), and the second engineer (2E) briefed the engine crew on the replacement plan.

As the engine crew prepared the necessary tools, the OOW on the bridge was notified that the main engine would need to be stopped. The 2E instructed the crew to close the main start air valve and remove the fuel oil high-pressure pipe of the cylinder. However, during the process, a crew member was injured when residual pressure within the main engine caused a forceful ejection of the FOIV, leading to a tragic accident resulting in the victim’s death.

The investigation revealed that several safety precautions, such as ensuring the engine RPM reached zero and engaging the engine turning gear, were overlooked. Additionally, there was no system in place to verify the completion of all safety measures as per the engine manual before the replacement task. The incident underscores the importance of strict compliance with lock-out/tag-out (LOTO) procedures for systems with stored energy, as well as the need for a ‘Safety First’ mindset over time pressures in maritime repair work.

Source .