Serious injuries due to electrical fire

Internal Incidents

November 2022 Safety

Published on 02 Nov 2022

What happened

The inert gas generator (IGG) system on a ship was running without any alarms during cargo operations. The ship was a new take-over and the IGG plant was used on four occasions before the incident without any problems.

The second engineer (2E) saw smoke coming from the IGG scrubber SW pump starter panel in the ECR and switched off the breaker. The chief engineer (CE) and electro technical assistant (ETA) started working on the IGG starter panel, which is directly connected to the 440 volts busbar.

The 2E and 4E managed to restore water supply to the IG scrubber using the fire and GS pump. However, they could not start the IGG either in manual or emergency mode. After several trials, the 2E came back to the ECR to report the situation to the CE.

The CE and ETA were attempting to replace the burnt breaker on the IGG scrubber pump starter with one removed from the main seawater pump. Suddenly there was an electric flash / short circuit resulting in burn injuries to the CE, 2E and ETA.

IGG scrubber SW pump starter panel
Main Switchboard of a ship.

Consequences

  • Burn injuries to chief engineer, second engineer and electro technical assistant
  • Cost of medical treatment and repatriation
  • Inert gas system rendered out of service
  • Cost of spares and repairs
  • Cost of class attendance for occasional survey
  • Cost of crew change for joining replacement crew
  • Delays/off-hire

Causes

  • Failure to follow procedures.

- No RA made for the breakdown maintenance task.

- No work permit made for work on electrical circuits.

- Lock-out / tag-out procedures not followed.

  • Lack of risk perception / risk awareness.

- The CE failed to recognise the hazards of working on the live busbar (440 V). Company SMS prohibits work on live circuits.

- The CE considered PPE (high voltage gloves) alone as safe enough to work on the live circuit.

  • Inadequate work planning - chief engineer and ETA continued working on MSB starter panel in the ECR. Instead, they should have attempted to re-start the IGG manually with the back-up arrangement for water supply using the fire pump.
  • Inadequate inspection - the crew did not test the IGG operation on auxiliary selection using the fire pump since the take-over of the ship. There is no specific requirement for such tests in the current post takeover checklist FMM 01a.
  • Improper attempt to save time / effort - the crew was under self-imposed commercial pressure to avoid any cargo stoppage / delays. They did not contact the office for guidance or support.
  • Substandard act by external party (not under own control) - one bolt connecting the R-phase of busbar to the IGG SW pump breaker was found loose. The loose connection on MSB dropper busbar connecting link to the breaker base board indicated poor workmanship by the shipyard during installation. This may have been the cause of the initial smoking on the starter panel.

Lessons learnt

  • Always adhere to company procedures and permits to work system for all routine and non-routine / breakdown tasks.
  • Include testing of back-up equipment in FMM 01a – post takeover checklist. Try out all back-up arrangements of essential machineries post takeover and regularly thereafter familiarise concerned crew members adequately. (In this case, auxiliary selection tab on the IGG panel had to be pressed for three seconds, which was not known to the ship staff before the incident).
  • Do not come under self-inflicted commercial pressure and take short cuts to safety. Seek advice and support from the office when faced with difficult situations.
  • Encourage and promote STOP WORK card culture on board and ensure that power/distance issues do not come in the way of its use (between junior ranks/ratings and senior ranks).
  • Remember PPE is only the last barrier and more effective controls must be put in place before starting work to prevent accidents.

caution_warning_bsm_icon.gif

Warning: Company SMS prohibits work on live circuits. In this case, the system should have been isolated by black out and emergency generator taken on load.

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