Sudden Release of Stored Pressure Energy – Crewman Lost An Eye

Safety plays the most important role in all our activities.  Carelessness or poor risk awareness can be very dangerous.  The following incident teaches us the importance of awareness and safety compliance.

Incident:

The second engineer was installing the emitter protection tube while carrying out maintenance work on the UV disinfection unit for the freshwater system on an offshore vessel.  As he started to tighten the tension screw, it appears that he inadvertently touched the inlet valve handle – opening it by a third.  This led to water running into the UV disinfection unit, building up pressure below the emitter protection tube and forcing it out through the opening.  The glass element hit the crew member on the forehead and smashed.  He was hit in the face and eyes by pieces of glass, and was brought to hospital for surgery.  The doctors were unable to save the left eye.

Reasons Identified:

• Incomplete knowledge about vendor user manual which indicates which valves to close and how to change out the filter.
• The shut off valves before and after the UV disinfection unit were closed.  The bypass valve was open.  The valve upstream of the shut off valve ahead of the unit was open.  The fresh water inlet supply was also not shut off.
• The hydrophore pump was running and building pressure into the system.
• The 2nd Engineer wanted to verify the correct position of the seal ring so he used a torch and bent over and placed his head directly over the tube.
• Type of valves – It was possible to open the water inlet valve by accident due to the type of valve handle, which led to water running into the UV disinfection unit and building up a pressure below the emitter protection tube.  This resulted in the emitter protection tube being forced out through the opening in the tension screw with high speed, hitting the 2nd Engineer in the face.
• Location/layout of pipes and valves: Tight space and difficult ergonomics.
• There was no system description in place for this maintenance task.
• There was poor risk awareness related to this specific job.
• There are gaps in compliance with vessel company requirements.
• A permit to work including a Lock out Tag out (LOTO) or isolation of the pump should have been issued for the job in accordance with company work permit system – this was not done.
• Failure to use Proper Personal Protective Equipment (PPE) – The injured person was not wearing safety glasses, as required in company procedures when working on high pressure systems.

Recommendations:

• Crewman must have clear knowledge on the equipment.
• The Worker must comply with all safety precautions to be taken before the initiation of work.

Source: IMCA

Disclaimer: The featured image is for representation purpose only to match the actual contents of this case study. This case was reported to IMCA in the year 2016.

• 
• 
• 
• 
• 
• 
• 
•