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What happened

On 1 February 2014, a crew member carrying out routine maintenance on the passenger ship Seven Seas Voyager’s waste incinerator was injured when a pneumatically (air) operated valve closed against his body. The ship was berthed in Sydney and the crew member, a fitter, was taken to a local hospital.

The fitter was treated for serious bruising and shock before returning to the ship. While it was expected that the fitter could resume duties after 2 days, his condition did not sufficiently improve and he was later discharged from the ship to recuperate at home.

What the ATSB found

The ATSB found that the incinerator ash dump valve’s control systems had not been properly isolated and residual air pressure remained in the valve’s operating system. The fitter assumed that it was safe to start his assigned task of replacing the incinerator ash grates, and accessed the incinerator through the ash dump valve. He then inadvertently activated the electric sensor that automatically closed the valve – driven by the pressure of the residual air remaining in the valve operating system.

The investigation identified that Seven Seas Voyager’s engineering staff did not have an adequate understanding of the incinerator’s control systems and its maintenance. Furthermore, the task of replacing the ash grates was not adequately planned and shipboard safety management system requirements, including taking necessary risk mitigation measures and completion of a permit to work before the task, were not complied with.

The investigation also found that neither the ship’s planned maintenance system (PMS) nor the incinerator manufacturer’s instruction manual contained any information with respect to the maintenance or replacement of the ash grates. Such information would have been useful to shipboard staff planning the grate replacement task, particularly with identifying all the risks associated with the task.

What's been done as a result

The ATSB has issued a recommendation to Seven Seas Voyager’s manager to take action to address the safety issue with respect to the ship’s PMS. The ATSB has also recommended that the incinerator manufacturer address the safety issue concerning the equipment’s instruction manual.

Safety message

Shipboard equipment and machinery commonly incorporates automated, power-operated systems which must be isolated, stored energy released and locked out before undertaking maintenance or repair tasks. Safely completing a task relies on personnel having a proper understanding of the system involved, coupled with adequate planning, risk assessment and the effective implementation of all safety management system requirements - including permits to work.

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The occurrence

Context

Safety analysis

Findings

Safety issues and actions

Sources and submissions

 
 

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Safety issue

MO-2014-001-SI-02 -  

Manufacturer’s instructions

The manufacturer’s instruction manual for Seven Seas Voyager’s waste incinerator contained no specific instructions for ash grate maintenance or replacement. Such instructions would have provided useful information for the ship’s crew to plan and safely complete periodic ash grate maintenance.

Safety issue details
Issue number:MO-2014-001-SI-02
Who it affects:All persons charged with maintaining equipment
Status:Not addressed

 
General details
Date: 01 February 2014 Investigation status: Completed 
Time: 0910 UTC +11 Investigation type: Occurrence Investigation 
Location   (show map):Sydney  
State: New South Wales  
Release date: 23 January 2015 Occurrence category: Serious Incident 
Report status: Final Highest injury level: Serious 
 
Vessel details
Operator: Prestige Cruise Services LLC 
Vessel: Seven Seas Voyager 
Flag: Bahamas 
IMO: 9247144 
Sector: Passenger 
Type of Operation: Marine shipboard 
Damage to Vessel: Nil 
Departure point:Melbourne, Vic.
Destination:Sydney, NSW
 
 
 
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Last update 24 August 2015