MSF: LTI – Engineer scalded

What happened

The MSF published Safety Alert 23-14 in which an engineer received severe scalding injuries when working in the engine room. The incident occurred during operations on a platform supply vessel (PSV).  The engine alarm system was activated due to low level in the high temperature cooling water circuit on one diesel generator. The engineer examined the generator and identified a leak from one of the rubber compensators. He installed a new compensator and began filling the system with water. He went down to inspect the newly installed compensator to ensure it was not leaking. While standing in front of the compensator, another nearby compensator burst and the engineer was exposed to a blast of steam and scalding water. The engineer suffered partial thickness burns to the face and upper body. First aid treatment was administered on site and he was medevac’d to hospital. He made a full recovery after spending some time in hospital.

What went wrong

The following is the MSF’s summary of the several human factor and organization causes for the incident.

• The pressure in the cooling water system rose suddenly when the cold water was added to the hot system. This raised pressure exceeded the installed compensator’s structural integrity;
• The installed compensator did not have the correct temperature rating for the system it was installed on;
• There was no maintenance or replacement history on the compensator since the vessel was built (10yrs ago);
• The compensator material likely degraded and weakened overtime due to the incompatible temperature rating;
• The cooling water system had a pressure relief valve; however, it was perhaps not rated sufficiently and could not deal with a sudden pressure increase;
• The manufacturer’s procedure for filling the system while still hot was not followed. The system needed to be cooled before being filled with water.

Actions taken

• The primary corrective action was to ensure the compensators are rated for the media, pressure, and temperature of the system they are installed on;
• The compensators should also be checked to ensure they are not misaligned and are installed within manufacturer’s specifications;
• OEM procedures and instructions should be followed; this particularly so in this context of filling a high temperature cooling water system with water – time should be allowed for it to cool down to avoid a sudden increase in pressure;
• An appropriate inspection and maintenance plan to be implemented for this type of equipment. 

Members may wish to refer to:

• MAIB: A scalding injury
• Near Miss: steam and water released from filter
• Engineer suffered burn injuries in engine room incident