船種：タンカー　事故の経緯：一等機関士がボイラーバルブ・ガスケットの不具合を点検をする際、２等・３等機関士にバルブ内の蒸気を排出するよう指示しましたが、一等機関士がバルブを開けた途端、高熱の蒸気が噴出し大火傷を負いました。

: Tanker

While the 1st engineer was performing his normal daily duties as day work team leader, he instructed the 2nd & 3rd engineers to check a boiler valve gasket that had been reported as leaking.

The 1st engineer told them to stop the boiler operation and drain out all steam and water in preparation for the job. They were specifically instructed to ensure that the system was empty before commencing work.

During the inspection, as the 1st engineer tried to open the valve bonnet, steam and boiling water was suddenly released at high pressure. Before avoiding action could be taken, the steam had burnt the 1st engineer's left leg, both arms and backside along with the left side of his face.

The 1st engineer suffered shock but remained conscious. However, he was not able to comprehend what had gone wrong with the valve and how the high pressure steam and water had escaped as this was supposed to have been checked by the 2nd & 3rd engineers prior to opening.

The medical team urgently provided first aid to the injured 1st engineer who suffered severe injuries as a consequence of this incident.

• The operation should have been subject to a risk assessment and pre-work meeting to identify potential hazards and necessary safety precautions.
• The responsible officer did not adequately supervise the operation by positively directing the actions of the crew members involved.
• Inadequate crew familiarisation with safe operational procedures and maintenance requirements for the boiler.
• Failure to properly observe the boiler manufacturer's instructions in relation to the work being performed.