Transport Malta has published an investigation report about an incident which resulted in serious injury to three crew members during maintenance work on the fire jockey hydrophore tank on 23 February 2022. The ‘violent’ dislodging of the inspection cover was the result of a pressurized hydrophore.
Shortly after 1430 on 23 February 2022, three crew members on board the Maltese registered LNG carrier Pearl LNG, were involved in an accident about 185 nautical miles West Southwest of Saint Nazaire, France. At the time, the crew members were attempting to remove an inspection cover on one of the vessel’s hydrophores, when the cover dislodged violently from the hydrophore. This caused a serious injury.
The safety investigation established that the hydrophore was still pressurised when the cover was dislodged, with all its securing bolts removed. Taking into consideration the safety actions implemented by the Company, no recommendations have been issued by the Marine Safety Investigation Unit (MSIU).
Analysis
It was immediately clear to the crew members that the ‘violent’ dislodging of the inspection cover could only be the result of a hydrophore whose internal pressure (behind the inspection cover) was higher than atmospheric pressure.
Taking into consideration the effective area of the inspection cover opening and the (residual) pressure inside the hydrophore, the force acting on the inspection cover at the time of the accident was approximately 2.74 tonnes-force (26.88 kN). This force (acting against the second engineer’s chest as soon as the inspection cover was dislodged), was significant, considering also that the inspection cover weighed 54 kg. The safety investigation concluded that prior to the removal of the inspection cover, the crew members used air to push the water out of the hydrophore but that was not enough to depressurise the vessel.
Conclusions
- The ‘violent’ dislodging of the inspection cover was the result of a pressurised hydrophore.
- Prior to the removal of the inspection cover, the crew members used air to push the water out of the hydrophore but that was not enough to depressurise
the vessel. - The hydrophore’s safety valve postaccident popping test confirmed that the valve was stuck in the closed position and did not open at the set pressure of 9.9 bar.
- Manual release of the pressure through the safety valve (by operating the attached lever) was not possible.
- Observing no relief of pressure (accompanied with a previous drop in the water level observed in the sight glass), the engineer thought that the hydrophore was at atmospheric pressure and therefore safe for the engineers to open the inspection cover.
Actions taken
During the safety investigation, the Company carried out an internal investigation in accordance with the relevant requirements of the ISM Code. Following the investigation, the Company:
- Sent a Fleet Notification on the occurrence and issued instructions, requiring office approval prior to maintenance works on pressure vessels.
- Has shared the investigation analysis and lessons learnt with the fleet and discussed them during the first monthly HSE meeting (on board and ashore) after the investigation was complete.
- Has included a detailed procedure for pressure vessels inspection and maintenance instructions in its Safety, Quality and Environmental Management System.
- Has carried out an internal audit on board the vessel.
- Has placed safety notices on all pressure vessels hatches to prevent improper dismantling and to ensure that safety bolts remain in place until de-pressurisation is completed.
- Has facilitated training and refresher courses to all crew members serving on board Company vessels
- Has developed tailor made training programmes, driven by specific incidents to emphasize effective communication. The training programme is mandatory for all senior officers and must be completed within 12 months.
- Has implemented physical and virtual training to all crew members on effective communication, effective toolbox, and permit-to-work system.
- Has rescheduled the frequency of the safety valve operational test on the vessel’s preventive maintenance system.
- Has re-evaluated the frequency of the planned engineering audits on all vessels in the fleet.
- Has requested a daily work planning meeting across the fleet to ensure planning of scheduled maintenance works.
- Has requested the use of eye protection during all maintenance tasks on deck and inside the engine room.
- Required that the company briefing form includes a discussion on the accident for a period of six months.
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Source: Transport Malta
