Lessons Learnt: Catastrophic machinery failure resulting in multiple fatalities
A shipyard pipe fitter was tasked with disassembling a section of steam piping in the engine room. He was not expected to read the repair specification for the job but instead he was to receive general repair guidance from his foreman, who did have a copy of the repair specification.
After the fitter resurfaced the portions of the gate and valve body that controlled steam flow, the vessel's Chief Engineer and another ship's staff engineer inspected the initial work. The shipyard foreman was required to inspect the work but did not do so as he was confident in the pipe fitter's ability even though neither spoke the other's language. This was against standing instructions aboard the vessel for contract workers, which required at least one English speaking employee to be on board when work was being done.
Not aware of the stringent material control on the work he was performing, the pipe fitter approached a crew member for new parts. The ship's crew, despite the language barrier, showed the contractor the spare parts bin from which he selected four bolts, eight studs and 20 3/4 -inch nuts. The fitter did not notice that some of the nuts he chose were brass, due to the fact they had a manufacturer-applied black coating. At a glance, they could be mistaken for the correct grade 4 steel nuts. Brass nuts are not appropriate for use on any system exceeding 400° F and the vessel's propulsion plant operated in excess of 800° F.
Without further guidance from his foreman the fitter reassembled the valve, mixing eight studs with four bolts. The valve should have been reassembled using only B-16 steel studs; doing otherwise was a violation of good engineering practice.
As a consequence of mixing the brass and steel components the repair failed two days later resulting in the death of 10 personnel.Lessons learned:
- Vessels in shipyards can be expected to undergo works which are non-routine or involve a higher level of hazard requiring increased vigilance on the part of the crew.
- Ship and shore personnel should be fully briefed on the practical and safety requirements of the work, which should be performed in accordance with manufacturer’s instructions and fully supervised by a responsible person.
- When work is being performed by shore contractors, there activities must be carefully planned, agreed upon and overseen by the vessel’s Master and/or Chief Engineer.
- Language barriers and cause accidents. Arrangements should have been made to ensure ship and shore personnel were capable of communicating effectively.
- All relevant vessel and shipyard safety procedures should be strictly observed. The work must be subject to a proper risk assessment and a Permit to Work checklist completed to identify and eliminate potential hazards.
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