B SAFE Loss Prevention BSAFE INCIDENT CASE STUDY 01: DEATH OF THIRD ENGINEER DUE TO BURN INJURIES Published: 12 November 2020 The Third Engineer (3/E) on board an anchored capesize bulk carrier was splashed by hot sludge while opening the manhole cover of a settling tank and subsequently died from a septic shock having sustained 2nd degree burns to a large part of his body Figure 1: The level gauge of No.2 Waste Oil Settling tank. Source: HBMCI WHAT HAPPENED? The Third Engineer (3/E) on board an anchored capesize bulk carrier was splashed by hot sludge while opening the manhole cover of a settling tank and subsequently died from a septic shock having sustained 2nd degree burns to a large part of his body. A quantity of sludge had been transferred from the “Bilge Separator Oil Tank” (BSO Tank) to No.2 “Waste Oil Settling Tank” (No.2 WOS Tank) using the sludge pump. However, it was observed that the level gauge of No.2 WOS Tank (Figure 1) was not indicating the correct quantity and it was subsequently confirmed that the gauge had malfunctioned. A “Job Hazard Analysis” (JHA) was therefore prepared and the Second Engineer (2/E), was assigned to drain the sludge residues from No.2 WOS Tank, which was situated adjacent to No.1 WOS Tank (Figure 2) and repair the gauge assisted by the 3/E. The 2/E opened the valve to drain the sludge to the BSO Tank by gravity. In order to confirm that the tank was empty, the 3/E climbed on top and turned the scale reduction device wheel and reported it working. The 2/E noted a small movement of the level indicator while the valve was open. Finally, the 2/E opened the self-closing drain valve and a small quantity of water flowed through, then stopped. The 2/E was therefore convinced that the tank was empty and the 3/E proceeded to open the manhole (Figure 3), about two metres above the floorplates. He removed all of the nuts from the cover apart from four, which he loosened. AS HE DID NOT OBSERVE ANY LEAKAGE, HE THEN PULLED THE COVER WITHOU