On May 5th 2020 around 20:18 hours, the engineer on duty received a “Separator N°1 fail” and a “Fuel oil bowl leak” alarm on the computer. Experience learned that this was a consequence of the contamination of the separator bow2 l as the discharge line of the separator got clogged.
The engineer informed the bridge that he was going to the engine room alone. He did not put on his coveralls and entered the engine room where he switched off separator N°1 and switched on separator N°2. Thereafter, he opened the plug of the inspection hole of the sludge discharge line in order to verify the condition.
Upon opening the plug, hot sludge oil gushed out of the inspection hole and covered the arms and legs of the engineer.
On 7 May 2020, the patient was evacuated from the vessel and transferred to a hospital in Cape Town, where the patient was diagnosed with 12% total body surface area mixed partial thickness burns, which were covered in sludge, involving both arms and legs.
Due to the cold flow characteristics of a certain blend of RMG 380 VLSFO, the separation of this fuel at +-40°C caused a blockade of the sludge discharge line, FEBIMA found.
The heating and pressurizing of the sludge in the discharge line in case of a complete blockade was not detected as a risk and so the inspection plug was opened very soon after the separator was switched off. Safety rules were not strictly followed outside the daily working hours in the engine room,
…the report reads.
The victim was not accompanied when inspecting the sludge discharge line and he was not protecting his skin with the necessary PPE. The hot and sticky sludge came into direct contact with the skin of the victim, aggravating the consequences of this accident.
- The cold flow properties of this blend of VLFSO most probably led to the regular clogging of the fuel oil separator on board. Action was taken to keep the fuel cleaning process running as good as practically possible, but the source of the burden had not been dealt with.
- Although the temperature at which wax crystals appear in blended fuel is very difficult to determine with sufficient accuracy, Veritas Petroleum Services, the same company that analyzed the fuel sample of MV MINERAL TEMSE, developed a test method to determine the wax appearance temperature of a certain blend of VLSFO.
A more detailed analysis of the fuel regarding cold flow properties could have solved the separation problems with this blend of VLFSO.
- Safety procedures to prevent working alone in the engine room and to wear the necessary PPE were ignored, what indicates a lack of safety responsibility on board.
- Regular clogging of the sludge discharge line of the separator occurred during the consumption of this batch of fuel oil on board. It was decided to clean the separator two times a day.
This was not a standard job on board, but no further risk assessment or safety measures had been implemented to mitigate the risks associated to this job.
- On May 7 th 2020, extra crew training was given on board regarding personal protective equipment and safety precautions during routine work on deck and/or in the engine room. All crewmembers confirmed their participation.
- Disciplinary measures are implemented on board in case of a breach of safety procedures: first a verbal warning will be given and in case of re-occurance, a written warning or caution letter will be issued. In case of coarse violation of safety procedures, a caution letter will be issued immediately.
- The company will compile and issue a more comprehensive and specific Personal Safety Manual as part of MLC manual. The Personal Safety Manual will particularly focus on PPE and streamline existing procedures. The company will focus on the implementation of PPE procedures during internal audits.
- The implementation of additional procedures as part of the SMS will be discussed by the company. Due to the fuel characteristics of different blends of VLSFO, additional job instructions might be necessary.
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Mineral Temse report