- A fire incident aboard led to serious injuries and the death of a gas engineer due to a cargo ethylene leak and ignition.
- Human error in valve lineup and improper tools were significant contributors to the fire, along with issues with the water-spray system.
- A retributive workplace culture and inadequate stop work authority prevented the crew from stopping unsafe practices.
In the early morning of 27 October 2023, a ship had completed loading a cargo ethylene in Daesan, South Korea, when the vessel’s gas engineer identified that liquid cargo was leaking from the cargo manifold, reports Bahamas Maritime.
Fireball Engulfs Manifold Platform
A leak of liquid cargo occurred after the loading of ethylene, leading to an explosion when the crew attempted to fix the issue without a crucial gasket in place.
Having identified that the blank was probably missing a gasket, the gas engineer and duty able seafarer were unbolting the blank when the cargo vapour ignited, creating a fireball that engulfed the manifold platform and extended in excess of 10 meters in diameter.
The cargo vapour ignited, resulting in a large fireball. The automatic water-spray system did not function as expected, and the fire was manually extinguished after 17 minutes, causing serious injuries to one crew member and ultimately the death of the gas engineer.
Incorrect Valve Lineup Caused Ethylene Exposure
The ethylene was introduced to the manifold due to the incorrect line up of valves during cargo sampling. It was exposed to atmosphere from the leaking blank and when the manifold drain valve was opened.
The fire originated from an incorrect valve lineup during cargo sampling, which caused ethylene to leak into the atmosphere. This was further exacerbated by the opening of the manifold drain valve.
Possible Ignition Sources Identified
The ignition source could not be determined with certainty but the spanners being used at the manifold were not suitable for use with highly flammable cargoes due to the risk of sparking.
While the exact ignition source remains unknown, non-sparking tools were not used. The gas engineer’s cold-weather jacket may have also generated static electricity, which contributed to the fire.
Competency and Conduct Concerns
Despite concerns about the gas engineer’s conduct and competency, the gas engineer was working without support or supervision on a complex system.
The gas engineer had prior competency issues but was still allowed to work unsupervised on a complicated cargo system. This lack of oversight contributed to the tragedy.
Firefighting Complications
Firefighting efforts were complicated by a blocked head on the automatic water-spray system.
A blocked water-spray system head hampered firefighting efforts, with readiness reduced after cargo operations, as the risk of fire was underestimated.
Normalisation of Unsafe Practices
The use of non-suitable spanners on deck had become normalised as the necessary non-sparking tools to get the job done were not readily available.
Using improper tools for handling highly flammable cargoes had become a normalized practice due to the unavailability of the correct non-sparking equipment.
Weak Stop Work Authority
The Company’s stop work authority was not robust enough to counter individual culture – none of the crew that were aware of the cargo at the manifold felt empowered to stop the work of a superior.
The crew felt powerless to halt unsafe work being conducted by a superior officer, indicating that the company’s stop work authority failed to protect the crew from hazards.
Culture of Fear Undermines Safety
A retributive approach to mistakes and errors undermines a just culture: if people are worried about the consequences, it is more difficult for them to speak up.
The retributive workplace culture prevented crew members from raising concerns about safety, for fear of potential repercussions.
Inadequate Maintenance of Firefighting Systems
Manufacturer’s recommended planned maintenance methodology and frequency for water-spray systems may not ensure operability when the water-spray is actually needed.
The maintenance schedule for the automatic water-spray system was insufficient to guarantee that it would function properly during emergencies.
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Source: Bahamas Maritime
