River Embley arrived at the anchorage off Gladstone at
0902 on the morning of 14 October. After 'finished with engines',
the diesel alternator was put on line and the steam plant was shut
down to allow for repairs on the number two turbo alternator
exhaust steam valve.
At about 1010, after checking that the exhaust steam system had
drained, the chief engineer and third engineer started working on
the valve. A short time later, while they were dismantling the
valve a thousand litres of pressurised hot water unexpectedly
started to spray from the valve and onto the chief engineer
standing on staging below.
In an effort to escape the hot water spray the chief engineer
tried to jump clear of the staging but became entangled in the
securing rope which had formed a barrier.
The ship's crew mounted an immediate first aid response and the
master organised a helicopter evacuation. The chief engineer was
transported to Gladstone Hospital and later transferred to the
Royal Brisbane Hospital intensive care unit.
The report concludes that the engineers did not fully assess the
exhaust steam piping system and its drainage arrangements, or allow
sufficient time for the exhaust steam system to completely drain
before starting to work on the valve.
The ship's work permit system and job safety analysis procedures
were not utilised by the engineering crew and deficiencies in
safety management were not identified in two audits prior to the
accident.
It is also considered that a sizable experience gradient between
the chief engineer and the other engineers along with a lack of
team training allowed a series of 'single person' errors to go
unchecked and unquestioned.
The ATSB has made several safety recommendations aimed at
preventing further accidents.
