The second engineer distributed the day’s work to the engine room staff, verbally instructing the junior wiper to burn the garbage in the incinerator. He was familiar with the job, having done the task for the last seven months. A little while later, the fourth engineer went up to the incinerator room to check the safety parameters of the equipment. He found all systems in satisfactory condition and so he returned to the control room. The junior wiper was standing outside the incinerator room waiting for the combustion temperature to reduce prior to loading the second garbage pack.
About 30 minutes later the junior wiper rushed to the Master’s office; he had sustained very deep burns to his left palm. The vessel was diverted to an anchorage and the junior wiper disembarked for medical treatment. All five fingers of his left hand were badly burnt and after assessment by doctors, four fingers were amputated. The junior wiper had to return to his home country for further reconstructive treatment. To all intents and purposes, his seagoing career was over.
The company conducted an investigation and found the following:
It appears the junior wiper, because of his small stature, had always used a bench to better access the incinerator door. Also, in this case he may have tried to push an oversized garbage bag down the incinerator sluice with a long handled poker. To do this, the junior wiper had to hold down the incinerator door micro switch (to simulate a closed door) and press ‘start sluice action’, all while trying to push the bag down.
Proper training and supervision are critical with operations such as incineration.
Incineration on this ship is best undertaken by two persons.
Ship-specific Job Hazard Analysis should be done for incineration, as for all vessel activities.
Under normal conditions, safety devices such as micro switches should never be ‘tricked’.
Note: According to the company, ship’s personnel interviewed during the investigation indicated that the use of a bench to access the incinerator was not a safe practice. Yet this practice had been tolerated for many months and was never identified as a non-conformity or unsafe practice during the course of work or during safety meetings. This indicates some important latent unsafe conditions contributing to this accident: a less than adequate safety culture and poor safety leadership.