STEP CHANGE FOR SAFETY GLOBAL SHARING JUL 2013 - THE FIRST 100 STEPS | Page 10

INJURY – BODY
S. No. 5 Date 09-Jan-2013 Occurrence 05 - CREW POISONED BY ELECTRICAL CLEANER 1. CHEMICAL HAD BEEN PLACED IN A PLASTIC WATER BOTTLE ? Deck Trainee gulped down what he thought was water At 2330 hours on the 8th of August, A deck trainee on a managed tanker accidently swallowed approx 100 ml of N-Propyl Bromide (Brand name: Fast dry electro clean). The chemical was in a plastic water bottle and was one of three bottles with chemicals kept together in plastic water bottles for use in electrical repairs ongoing after the vessel had sustained heavy weather damage in the forecastle during a typhoon due to flooding caused by water ingress. At the time the deck crew were involved in water removal and cleaning while engine staff worked on the mooring winch motors that had been submerged. Initial reports indicate the bottles were stored in a dark area and there was a prevailing smell of electro cleaner throughout the focsle store as the Engine staff were flushing the electrical motors. The deck trainee saw the bottles and believing it was water gulped down 100 ml of the chemical in a hurry to quench his thirst. Although the crew onboard rendered first aid according to doctor’s advices and was able to obtain medical evacuation to hospital with 48 hours, the victim was in critical condition with serious liver damage. It should be noted that this incident occurred late at night, during darkness hours, and after extensive repair efforts had required extensive crew involvement. The victim was young and still in training. The victim slowly improved and managed a full recovery. Immediate Causes: • Darkness in the area of the forecastle • Transport and storage of clear hazardous chemical, N-Propyl Bromide (a.k.a. Fast Dry Electro Clean), in a drinking water bottle • Storage of drinking water in the same type bottles in the same work area • The victim, in a hurry to quench his thirst, gulped down 100 ml of the liquid before realizing it was a chemical Basic Causes: • Continuous long and hard work in hot, humid, and poorly ventilated spaces • Electro Clean was being used within the space dulling sense of smell • Inadequate supervision of junior personnel • Inadequate dissemination of information about activities being carried out jointly by deck and engine personnel working in the same area; No risk assessment or tool box was conducted prior to conducting repair operations • Inadequate warnings / instructions posted at chemical store Type Impact Primary Incident Personnel Severity Impact Secondary Significant

Lessons Learned ? Supervisors to be counseled on need to monitor and direct junior staff when working in difficult environments ? Chemical Mixing / Warning Instructions to posted at all Chemical Stores ? Risk Assessment and Job Safety Analysis of Routine & Non-Routine tasks need to ? Risk Assessment and Job Safety Analysis of Routine & Non-Routine tasks need to 1. A quick review and clean-eye approach of the existing arrangement is needed. Please check that the vessel has the suggested T piece / alternative. 2. Ensure proper ship specific procedure for blowing of lines and RA are available for these