Transcript Occurrence Report Review

2013 Marine Chemist Association
Sectional Technical Seminars
Lessons Learned from Occurrence Reports Reviewed by the Marine
Chemist Qualification Board during 2012
Presented by Lawrence B. Russell, NFPA Marine Field Service
Type of
Incident
Number
Type of Vessel
Number
Tank Vessel
5
Fire
14
Military
4
CO
Exposure
4
Tug/Towing
3
Explosion
1
Casino Boat
1
Arson
1
Coal Carrier
1
Flash of
1
Combustible
Vapor
Fall from
Height
1
Fatal Struck- 1
by Accident
Container Ship 1
Deck Barge
1
Dredger
1
Museum Ship
1
Work Boat
1
Vessel Area or Space
Number of Incidents
Engine Room – Machinery Space
3
Fuel Tank
3
Void Tank/Space
3
Accommodation Area
1
Ballast Tank
1
Cargo Tank
1
Fan Room
1
Hold
1
Pump Room
1
Vessel Section
1
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Combustible Material in
Hot Work Space (5)
Combustible Material in
Adjacent Space (4)
Ineffective/No Fire
Watch (4)
Ineffective/No Retest by
SCP (3)
Hot Work after a Change
Voided Certificate. (2)
No Certificate IAW 29
CFR 1915 (2)
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Unauthorized Hot Work
(2)
No Competent Person (2)
Electric Generator
Malfunction (1)
Fail to Follow CMC
Instructions (1)
Ineffective Barrier
Protection (1)
Ineffective Tank Cleaning
(1)
Failure to get a MCC (1)
Photo from www.baltimorefirefighters.net
The Certificate permitted hot work to the rub rail and vents/sounding tubes of aft fuel
tanks. However, workers did hot work in fwd engine room near day tank (partially filled).
A fuel line broke or was cut with the expected results - a fire.
Photo from http://www.recon2photo.com/BaltimoreCityFire/Fires-2011
Workers need to
understand and
follow the Marine
Chemist’s
instructions.
 Understand OSHA
29CFR 1915.14
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Understand the “25 foot Rule” in OSHA
29CFR1915.14(a)(1)(iv).
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Ship fitter left a torch line in
the engine room.
After lunch, the helper told the
fitter that he smelled gas.
The fitter checked his torch and
found the gas valve in a slightly
opened position.
He shut the valve off and
proceeded to commence
grinding on a piece of plate
without ventilating the area.
Gas that had accumulated
under the floor plate in the
area of the engine room where
he was working ignited
resulting in a small explosion.
Shipyard workers and contractors
need to understand and follow
requirements in OSHA
29CFR1915, Subpart P, Fire
Protection in Shipyard
Employment, Precautions for Hot
Work, Use of Fuel Gas and Oxygen
Supply Lines and Torches.
 No unattended fuel gas and
oxygen hose lines or torches are
permitted in confined spaces;
 No unattended charged fuel gas
and oxygen hose lines or torches
are allowed to remain in enclosed
spaces for more than 15 minutes;
and
 All fuel gas and oxygen hose lines
are disconnected at the supply
manifold at the end of each shift.
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All disconnected fuel gas and
oxygen hose lines are required to
be rolled back to the supply
manifold or to open air to
disconnect the torch; or extended
fuel gas and oxygen hose lines are
not reconnected at the supply
manifold unless the lines are given
a positive means of identification
when they were first connected
and the lines are tested using a
drop test or other positive means
to ensure the integrity of fuel gas
and oxygen burning system.
 The competent person should
have re-tested the engine room
following the lunch break.
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Two men were injured
while welding near two 80
gallon fuel tanks on a drydocked boat.
 The fuel tanks apparently
still contained 3 to 6 inches
of gasoline.
 Hot work ignited gasoline
vapor .
 One fuel tank sailed
through the air and landed
on nearby railroad tracks
and the other tank was
destroyed in the blast.
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A competent person
authorized hot work in a
fuel tank (of a tow boat).
 Fuel from an adjacent fuel
tank leaked into the fuel
tank where the hot work
was being performed.
 An effort was made to
prevent the spread of the
leaking fuel with absorbent
pads.
 But the hot work ignited
the fuel. There was no
injury or property damage.
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Photo of Work Boat involved in Explosion Courtesy P. Dovinh
Shipyard workers and
contractors need to know that
the Confined and Enclosed
Spaces and Other Dangerous
Atmospheres in Shipyard
Employment, OSHA 29 CFR
1915, Subpart B, is applicable
regardless of geographic
location.
Hot work within, on, on, or
immediately adjacent to fuel
tanks that contain or have last
contained fuel is prohibited until
the work area has been tested
and certified by a Marine
Chemist or a U.S. Coast Guard
authorized person as "Safe for
Hot Work“ 29CFR 1915.11(a).
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CMC inspected the pump room & ok’d hot work on ballast
pipeline.
During next 16 days other work on a cargo stripping pump resulted
in discharge of a flammable liquid into the pump room bilge.
Contractor’s competent person did not test and inspect pump
room.
Welding sparks from a repair to a ballast pipeline approximately
ten feet above the bilge fell into the bilge and ignited the
flammable liquid.
Effort to extinguish the fire with portable AFFF (foam) and hose
lines was unsuccessful apparently due to inadequate shipyard fire
main water pressure. The ship’s crew then activated the fixed CO2
extinguishing system to extinguish the fire. A local fire
department also responded.
The pump room sustained minor smoke damage.
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A Certificate was posted on a hopper dredge.
During the next 5 days hydraulic oil leaked from
a ¾ inch hydraulic line drain plug approximately
ten feet away from the hot work site.
2 pipe-fitters were removing the remnants of a
wasted ballast pipe line from a transverse
bulkhead between a void tank and a ballast tank
with an oxy-acetylene torch.
Sparks or slag from the hot work ignited the
hydraulic oil.
The workers extinguished the fire.
The release of product into the pump room bilge and leaking
hydraulic oil were each a change of conditions that voided each
Certificate as expressly noted in the boilerplate of the Marine
Chemist’s Certificate, “In the event of physical or atmospheric
changes affecting the Standard Safety Designations assigned to
any of the above spaces, this certificate is voided.”
 A competent person should have re-checked in accordance with
OSHA 29CFR1915.15(c) and (d) and NFPA 306 §4.6.2(2) and (3).
 The product should have been cleaned up and the Marine
Chemist recalled to inspect the spaces and issue another
Marine Chemist’s Certificate.
 Failure of the competent person to inspect whether or not the safe
conditions were properly maintained voided the Certificate in
accordance with NFPA 306 §4.6.2(4).
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Specifying the type of hot work and location of
hot work when using the designation: Safe for
Limited Hot Work - NFPA 306-2009 §4.3.6(2).
Including toxicity test results - NFPA 306-2009
§4.2.2, §4.3.1(3) and §4.4.1.
Listing all spaces tested and the test results –
NFPA 306-2009 §4.2.2 and §4.4.1.
Recording sufficient restrictions or exclusions
and instructions for fire barrier use, fire watches,
etc. for the competent person on the Certificate
- NFPA 306-2009 §4.4.2 and §4.4.3.
Unauthorized entry
Unauthorized hot work
Cargo residue in tanks
Hot work ignites vapor
Explosion in the DipTape gauging device
 Shrapnel strikes
worker
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Rising Stick Type Float-Gauge
Tank
Depth
Float-Gauge with Remote Read-out
Plastic Cylinder
Float (Vol. 96.5 ml)
Stainless Steel Sphere
Float (Vol. 62.2 ml)
Tank
Depth
Approx. 2 inch Diameter
Approx. 2 inch Diameter
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What is the proper method of tank testing?
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Marine Chemist Training Module Number
13, Field Instruments – Operation,
Application and Maintenance, page 21:
“Confined spaces must be sampled from the
outside. Generally, to sample confined spaces,
the air is actively drawn into the indicator
through a sampling hose by a pump.”
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The International Safety Guide for Oil
Tankers and Terminals, 5th Edition, Chapter
10, Section 10.3 Atmosphere Tests Prior to
Entry:
“No decision to enter an enclosed space should
be taken until the atmosphere within the space
has been comprehensively tested from outside
the space with test equipment that is of an
approved type…”
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Why does the Marine Chemist Training
Module and international tanker industry
best practices Guide (ISGOTT) make these
statements about testing?
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The correct way is the only way.
Short cuts & complacency result in disaster.
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4.5 Issuance of Certificates. ….Any additions
to or deletions from such a Certificate after
obtaining a signature for receipt shall void
the Certificate and require reissuance.
Can a Marine Chemist alter or amend a
Certificate?
Can a competent person alter or amend a
Certificate?
Can the CMC direct the CP to alter or amend
the Certificate?
Definitions:
 Personally Determine: to find out for
oneself
 Physically Enter: of or relating to the body;
and to go into
 Visual Inspection: The physical survey of the
space or compartment and surroundings in
order to identify potential atmospheric and
fire hazards. (NFPA 306-2009, §3.3.21)
NFPA 306-2009 (4.1) Determination of
Conditions
“The Marine Chemist shall personally
determine conditions….. whenever possible,
physically enter each compartment or space
and conduct a visual inspection to the extent
necessary to determine the atmospheric or fire
hazards that exist.”
 What does that statement mean?
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Rules §II.A Be of and maintain good character,
and physically able to perform the duties of
a Marine Chemist.
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Rules §II.F Perform all work in accordance
with the requirements of the Standard and
its official interpretations when acting as a
Marine Chemist.
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The CMC Program
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Program Sponsors (Industry)
USCG
USN
OSHA
Liability
 Criminal
 Civil
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Insurance Coverage
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Pay attention to details.
Avoid the common errors and omissions.
Consider using EMCC.
Make sure the CP knows what to do to
maintain safe conditions.
Make sure the CP knows what is a change of
conditions.
Make sure the CP knows when to call you
(and call you back).
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You all do great work
Shipbuilding and repair is a 76 billion dollar
industry
The industry relies on you
Train competent persons & shipyard workers
Volunteer to help, train and mentor trainees
Remain vigilant