Real Life Incident: Checklist Mentality Is A Burning Problem

A tanker was at anchor waiting for a berth. During the anchor period routine maintenance was to be done on the auxiliary boiler fuel oil pump. According to the vessel’s records, a job hazard analysis had been carried out and a cold work permit and a pressure pipeline work permit had been issued before the work began. The senior person of the group undertook the work while the three junior members of the team watched.

The senior engine room crewmember switched the pump to manual control and put it in the stop position. He isolated the pump from the system by closing the inlet and outlet valves. He then proceeded to loosen the bolts of the filter cover. Suddenly hot fuel and gases spewed out of the loosened filter cover. All four crew were struck by hot fuel on their faces, necks and hands. The victims were given first aid and quickly disembarked to a shore hospital.

Checklist mentality is a burning problem

While two of the victims were only slightly injured and returned to light duty on the vessel soon after the accident, the two other victims suffered more severe burns. They required 11 days of hospitalisation before being repatriated.

The accident investigation revealed that the crewmember had loosened the filter cover without first releasing the system pressure from the vent cock. The vessel’s ‘Permit to Work on Pressurized Systems’ included a check box for pressure release, and the box had been ticked, but the check had not in actual fact been done.

Lessons learned

Avoid the ‘checklist mentality’. The Safety Management System (SMS) tools are there for your benefit; use them.
A supervisor cannot supervise if they are doing the work themselves.

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