While at berth, a water leak was suspected in the boiler/economiser so it was shut down for inspection. About five hours later, after the boiler had cooled, an engineer and a fitter entered the boiler space from the bottom manhole door. They were satisfied it was safe, as the pressure gauge indicated zero.
They identified a leaky boiler tube and plugged it from the bottom. Their plan was to plug the same tube from the top before restarting the boiler. As the engineer and fitter were exiting the bottom manhole door, the recently inserted boiler tube plug fell off along with a small broken section of the water tube. Hot water, steam and smoke poured out from the boiler water drum and covered the fitter. His injuries were so severe that he was declared deceased while still on board.
The investigation revealed that not only was the engineer probably in a fatigued state, there was no procedure to cover this task and no boiler work risk assessment had been completed.
- Vessel-specific procedures covering tasks with identified risks should be developed. Boilers, which involve heat and pressure, are inherently a risk and should be included in vessel procedures.
- Never make assumptions based on gauge pressure. Boilers should be depressurised and emptied before starting work.
- Additionally, the vent on top of the boiler should be opened to check that the boiler is truly depressurised.
- Working in a fatigued state increases the likelihood of negative consequences.