Vessel Name: Type of Vessel:
What’s inside…. Click on the events to read
Multiple finger injury while boxing incinerator sluice door Click to review
EVENT 1 (Source: SMPL Vessel)
event’s action
point(s)
Grounding at soft bottom in Rio Parana River Click to review
EVENT 2 (Source: SMPL Vessel) event’s action
point(s)
Click to review
EVENT 3 Pressure surge during loading operations
event’s action
(Applicable for Tankers) (Source: SMPL Vessel) point(s)
Applicable to Vessel: YES No
Eye injury during chemical handling Click to review
EVENT 4 (Source: Argo Navis Private Limited) event’s action
point(s)
For Office Use Only: Action Points Reviewed by MSI(Yes/No)
Safeguard (April-2022) 1 |Page
Multiple finger injury while boxing incinerator sluice door
EVENT 1 (Source: SMPL Vessel)
Summary
Post changing the incinerator refractory material, a team of two-members (Motorman (MTM)
and 4th Engineer (4/E)) was asked to fix
the incinerator’s inner sluice door.
While positioning, the 4/E held the
unsecured door in place and the MTM
was aligning the shaft yoke with the air
cylinder pin.
During that course, the 4/E lost control
resulting in the door swinging
uncontrollably under its weight.
Due to the sudden swing, the fingers of
the MTM holding the shaft lever (yoke) in
his right hand got crushed between the
rotating yoke and ash door below.
Pictorial recreation of the incident
Safeguard (April-2022) 2 |Page
➢ MTM was pushing and wedging the air cylinder piston when he inadvertently hit
the yoke. The action tilted the sluice door from its resting vertical position,
swinging under gravity.
➢ 4/E supporting the door could not control the swing as the weight was beyond
his lifting capacity.
➢ Manpower available for the task was insufficient. The weight of the sluice door,
and subsequent workforce needed to hold the swinging door if door inertia
(vertical resting position) gets disturbed was not assessed.
➢ The job was earlier planned to be conducted by the 2nd Engineer (2/E) with the
4/E and MTM in assistance. But later, the job was delegated to the 4/E and MTM
due to the mandatory participation of the 2/E in another major task planned for
that day. This decision resulted in a reduced workforce and expertise to complete
the job safely.
➢ The hazards involving the job were not fully assessed during work planning.
Multiple vital tasks in the engine room were planned simultaneously, resulting in
the distribution of the workforce. Eventually on the day of performance, there
was no supervision for the incinerator activity.
➢ The team did not consider the disconnection of pneumatic hoses of the air
cylinder that restricted its movement. The disconnection would have provided
more flexibility in aligning the sluice door’s shaft yoke with the air cylinder pin.
➢ MTM carried out the engineering task (aligning the air cylinder pin), whereas the
4/E was in a supportive role. This role distribution was contrary to their expertise.
➢ The staff did not use ‘Stop work authority’ as they were not assertive.
- MTM was not assertive in requesting additional workforce and did not
practice his stop-work authority.
- The 4/E did not respect the intervention made by the motorman for the
additional workforce and continued with the work.
Safeguard (April-2022) 3 |Page
Action Vessel shall use below editable box/sections for completing the action
required by points. Once completed, send Safeguard as an attachment along with
vessels April’s Safety Meeting Minutes form to respective MSI for office review.
Action Point 1
Discuss the incident and learnings with all ship staff.
Date incident and learnings discussed:
Action Point 2
List any two actual instances from the vessel’s Daily Work Planning meeting where the
performance of planned multiple tasks was proactively identified as hazardous (in terms of
workforce assignment, supervision, etc.) and they were re-scheduled to ensure a safer activity.
List the activities identified with reason for re-scheduling:
Safeguard (April-2022) 4 |Page
Grounding at soft bottom in Rio Parana River
EVENT 2 (Source: SMPL Vessel)
Summary
The vessel was drawing a maximum draft of 7.1 meters while going upriver in Rio Parana River
on her ballast passage to San Lorenzo, Argentina, under pilotage.
While approaching ‘km 330’, the pilot reduced the vessel speed since another vessel was
coming down the river and own vessel had to wait for the deep draft vessel to pass clear.
Pilot took the vessel outside the fairway channel for the other vessel to pass clear. Vessel was
still in safe waters, with ECDIS spot soundings more than 11.5 meters around the vessel.
However, soon after crossing the Southern Anchorage Area (near ‘km 330’), the vessel’s speed
over ground suddenly reduced
from 6.1 knots to 0.1 knot and
vessel was grounded.
Hand lead line soundings were
taken and followed by the decision
to deballast WBT 4P and 4S.
After deballasting, ME Astern
order was given, and the vessel
started moving astern.
The vessel was gradually safely
refloated, and she resumed her passage to San Lorenzo. No injury or pollution was reported
due to this incident.
Safeguard (April-2022) 5 |Page
➢ The pilot deviated from the planned route in fairway. The vessel also assessed the
situation and found that waiting outside the fairway for the deep draft downriver
vessel to pass clear was the only apt action at the time. So, the vessel followed the
orders of the pilot. But since the charted depth was not reflecting the correct
sounding, the vessel ran aground.
➢ Vessel’s deviation from the fairway channel was closer towards the banks where the
effect of siltation (prevalent in the area) is more pronounced, rather than staying
closer to the fairway channel.
➢ The effect of siltation was apparently not effectively ascertained/promulgated
outside of the fairway channel.
The latest information regarding depths within these rivers and the channels leading to
them is published regularly by the Argentine Authorities in “Boletin Fluvia DHVN”. The
level of the Rio Parana undergoes regular annual change caused by the periodic rain in
the tropical region of the river basins.
Action Vessel shall use below editable box/sections for completing the action
required by points. Once completed, send Safeguard as an attachment along with
vessels April’s Safety Meeting Minutes form to respective MSI for office review.
Action Point 1
Master to discuss the incident and learnings with all bridge team.
(When required to exit the fairway channel, vessels may consider, safety of navigation
permitting, keeping as close as possible to the fairway channel. The effect of siltation is more
pronounced closer to the banks.)
Date incident and learnings discussed:
Safeguard (April-2022) 6 |Page
Action Point 2
Use the existing user chart “Synergy UC” in ECDIS
Mark 0.1nm No go area centered around position 33-26.9S 060-02.0W
Make comment/active alert dialogue box “Depth may be less due to siltation (Refer Safeguard
April-2022)”
Note:
a. This User chart can be plotted even if the ECDIS is presently not having ENCs for the concerned area.
b. Ensure “Synergy UC” remain active in ECDIS, irrespective of vessel’s trading area.
(Previous broadcasts that included “Synergy UC” were SB (23-2021), MI (26-2021) and MI (33-
2021).
Confirm “Synergy UC” updated to reflect “Action Point 2”:
Confirm previous “Synergy UC” updates outlined in SB (23-2021), MI (26-2021) and MI (33-
2021) are present:
Safeguard (April-2022) 7 |Page
EVENT 3 Pressure surge during loading operations
(Applicable for Tankers) (Source: SMPL Vessel)
Summary
Vessel had completed loading two parcels of Motor Sprit & two grades of High-Speed Diesel
safely. As planned, the 3rd parcel of High-Speed Diesel was lined up using a 12” shore
connection to No. 4 ship’s manifold.
At 1802 hours, the terminal commenced
loading and the manifold confirmed receiving
cargo.
The manifold watch soon observed the
manifold backpressure rising to 1.0 kg/cm2
and the same was immediately reported to
CCR. Before C/O could completely
comprehend the situation, the manifold back
pressure was reported as 3.0kg/cm2.
At 1804 hours, with C/O picking up the radio
to communicate the development with the
terminal, the terminal informed the vessel that the shore loading pumps have trips as the
backpressure exceeded 5.0 kg/cm2.
The C/O immediately went on deck to investigate the cause of the sudden pressure surge. It
was observed that the No.4 drop valve was very hard to operate and was in a slightly open
condition.
The drop valve gear assembly was dismantled, the gearbox was greased and made free for
operation. The valve was boxed back, and the drop valve could now be fully opened from the
wheel handle.
Loading operations resumed and completed safely. No pollution, damage, or injury was
reported due to this incident.
Safeguard (April-2022) 8 |Page
➢ The vessel’s drop valve being only slightly opened at the commencement of
loading operation led to the development of a sudden pressure surge that resulted
in high backpressure causing tripping of shore pumps.
➢ The design of the No.4 drop valve, its indicator, and operating mechanism posed
an ergonomic challenge to ascertain the valve status upon operating it. This led
to the performance of a practice where the status of the drop valve is not
verified from its indicator before confirming it.
The same practice led to the slight open status of the drop valve being reported
as fully open and contributed to the incident.
(No.4 drop valve is operated from the top of the center walkway grating via an
extended rod with an operating wheel arrangement. The valve body and its
indicator are located underneath the grating)
➢ Unclear specific guidance in PMS towards manually operated cargo drop valves led
to these valves being neglected for proper maintenance and recordkeeping.
➢ Failure to comply with two personnel verification of cargo line-up apparently led
to missing out on the slightly open status of the No.4 drop valve.
Safeguard (April-2022) 9 |Page
Action Vessel shall use below editable box/sections for completing the action
required by points. Once completed, send Safeguard as an attachment along with
vessels April’s Safety Meeting Minutes form to respective MSI for office review.
Action Point 1
Discuss the incident and learnings with all ship staff.
Date incident and learnings discussed:
Action Point 2
Chief Officer to locate manually operated cargo/ballast valves on deck posing such ergonomic
challenges where operation status of the valve cannot be verified from the operating area.
List such valves and develop ‘Local Procedures’ overcoming the ergonomic challenge, ensuring
that two personnel verification of the valve indicator is always performed upon their operation.
(Crew and officers shall be trained with such procedures and the procedures be posted in a
common workplace area.)
List of manually operated cargo/ballast valves in deck that pose such ergonomic challenges:
Local Procedures developed for such valves, ensuring two personnel verification of the valve
indicator upon operation: Yes Not Applicable
Action Point 3
Ensure all manually operated cargo/ballast valves on deck are free to operate.
If spares are required, action plan should be in place and TSI appraised
All manually operated cargo/ballast valves on deck are free to operate: Yes No
If No, TSI/MSI appraised and action plan in place to correct the defect soonest: Yes No
Safeguard (April-2022) 10 |Page
EVENT 4 Eye injury during chemical handling
(Source: Argo Navis Private Limited)
Summary
One of ANPL’s managed vessels (bulk carrier) recently incurred crew eyes accident during
handling of chemicals for hold preparation on board whilst enroute to Canada. Full details of
incident can be read in the appended Statement of Facts.
“At 0815hrs: Two deck crew were transferring chemical (ALCACLEAN HD) using a wilden pump
to the empty drum, to be used for removing of cargo stains in cargo hold no. 6.
At 0820hrs: The deck crew notified that the discharge hose was leaking. They stop the transfer
and disconnected the discharge hose and air hose in order to repair.
At 0825hrs: After the repair was completed. The deck crew connected the hose to the discharge
inlet of the wilden pump, when they start the pump running, the discharge hose suddenly
bursted and chemicals leak which hit directly to the face of the crew.
Even though he was wearing a safety goggles, it penetrated to his eye due to strong pressure.
At 0830hrs: The crew was brought immediately to ships hospital to administered first aid as
MSDS recommendations. Rinse thoroughly with eye was continuously, and rinsing with running
water to the affected part.
At 0850hrs: The patient complains that his vision was blurry and foggy.
At 0900hrs to present: Presently the patient was resting on his cabin and continued
monitoring.”
Crew eye injury picture
Safeguard (April-2022) 11 |Page
➢ To ensure that all chemicals on board are properly stowed and declared hazardous to human
life.
➢ Each person on board must be fully aware how hazardous the chemical it is.
➢ Read and understand carefully the MSDS prior to handling.
➢ A toolbox meeting is to be conducted and full PPE (personal protective equipment) must be
worn during the entire operation
Action Vessel shall use below editable box/sections for completing the action
required by points. Once completed, send Safeguard as an attachment along with
vessels April’s Safety Meeting Minutes form to respective MSI for office review.
Action Point 1
Discuss the incident and learnings with all ship staff.
Date incident and learnings discussed:
Action Point 2
Safety Officers to verify and confirm following:
a. PS 15.01 (PPE during working with chemicals) is displayed, and the concerned PPE items are
available at the chemical locker
b. Train ship staff to identify PPE requirements and safety precautions to be exercised from the
chemical MSDS posted at the Chemical Locker.
Date the Action Point 2 completed:
END OF DOCUMENT
Safeguard (April-2022) 12 |Page
