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Occurrence Report Review PowerPoint Presentation
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Occurrence Report Review

Occurrence Report Review

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Occurrence Report Review

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  1. 2013 Marine Chemist Association Sectional Technical Seminars Lessons Learned from Occurrence Reports Reviewed by the Marine Chemist Qualification Board during 2012 Occurrence Report Review Presented by Lawrence B. Russell, NFPA Marine Field Service

  2. 2012 Accident Review

  3. 2012 Accident Review

  4. Fires - Causal Factors • Combustible Material in Hot Work Space (5) • Combustible Material in Adjacent Space (4) • Ineffective/No Fire Watch (4) • Ineffective/No Retest by SCP (3) • Hot Work after a Change Voided Certificate. (2) • No Certificate IAW 29 CFR 1915 (2) • Unauthorized Hot Work (2) • No Competent Person (2) • Electric Generator Malfunction (1) • Fail to Follow CMC Instructions (1) • Ineffective Barrier Protection (1) • Ineffective Tank Cleaning (1) • Failure to get a MCC (1)

  5. Failed to follow instructions on the Certificate Photo from The Certificate permitted hot work to the rub rail and vents/sounding tubes of aft fuel tanks. However, workers did hot work in fwd engine room near day tank (partially filled). A fuel line broke or was cut with the expected results - a fire.

  6. Lessons Learned • Workers need to understand and follow the Marine Chemist’s instructions. • Understand OSHA 29CFR 1915.14 Photo from • Understand the “25 foot Rule” in OSHA 29CFR1915.14(a)(1)(iv).

  7. Unattended Fuel Gas –Oxy Lines & Torches • Ship fitter left a torch line in the engine room. • After lunch, the helper told the fitter that he smelled gas. • The fitter checked his torch and found the gas valve in a slightly opened position. • He shut the valve off and proceeded to commence grinding on a piece of plate without ventilating the area. • Gas that had accumulated under the floor plate in the area of the engine room where he was working ignited resulting in a small explosion.

  8. Lessons Learned • Shipyard workers and contractors need to understand and follow requirements in OSHA 29CFR1915, Subpart P, Fire Protection in Shipyard Employment, Precautions for Hot Work, Use of Fuel Gas and Oxygen Supply Lines and Torches. • No unattended fuel gas and oxygen hose lines or torches are permitted in confined spaces; • No unattended charged fuel gas and oxygen hose lines or torches are allowed to remain in enclosed spaces for more than 15 minutes; and • All fuel gas and oxygen hose lines are disconnected at the supply manifold at the end of each shift.  • All disconnected fuel gas and oxygen hose lines are required to be rolled back to the supply manifold or to open air to disconnect the torch; or extended fuel gas and oxygen hose lines are not reconnected at the supply manifold unless the lines are given a positive means of identification when they were first connected and the lines are tested using a drop test or other positive means to ensure the integrity of fuel gas and oxygen burning system. • The competent person should have re-tested the engine room following the lunch break.

  9. When to call a Marine Chemist • Two men were injured while welding near two 80 gallon fuel tanks on a dry-docked boat. • The fuel tanks apparently still contained 3 to 6 inches of gasoline. • Hot work ignited gasoline vapor . • One fuel tank sailed through the air and landed on nearby railroad tracks and the other tank was destroyed in the blast. • A competent person authorized hot work in a fuel tank (of a tow boat). • Fuel from an adjacent fuel tank leaked into the fuel tank where the hot work was being performed. • An effort was made to prevent the spread of the leaking fuel with absorbent pads. • But the hot work ignited the fuel. There was no injury or property damage.

  10. Lessons Learned • Shipyard workers and contractors need to know that the Confined and Enclosed Spaces and Other Dangerous Atmospheres in Shipyard Employment, OSHA 29 CFR 1915, Subpart B, is applicable regardless of geographic location. • Hot work within, on, on, or immediately adjacent to fuel tanks that contain or have last contained fuel is prohibited until the work area has been tested and certified by a Marine Chemist or a U.S. Coast Guard authorized person as "Safe for Hot Work“ 29CFR 1915.11(a). Photo of Work Boat involved in Explosion Courtesy P. Dovinh

  11. Understanding When a Certificate is Void • CMC inspected the pump room & ok’d hot work on ballast pipeline. • During next 16 days other work on a cargo stripping pump resulted in discharge of a flammable liquid into the pump room bilge. • Contractor’s competent person did not test and inspect pump room. • Welding sparks from a repair to a ballast pipeline approximately ten feet above the bilge fell into the bilge and ignited the flammable liquid. • Effort to extinguish the fire with portable AFFF (foam) and hose lines was unsuccessful apparently due to inadequate shipyard fire main water pressure. The ship’s crew then activated the fixed CO2 extinguishing system to extinguish the fire. A local fire department also responded. • The pump room sustained minor smoke damage.

  12. Understanding When a Certificate is Void • A Certificate was posted on a hopper dredge. • During the next 5 days hydraulic oil leaked from a ¾ inch hydraulic line drain plug approximately ten feet away from the hot work site. • 2 pipe-fitters were removing the remnants of a wasted ballast pipe line from a transverse bulkhead between a void tank and a ballast tank with an oxy-acetylene torch. • Sparks or slag from the hot work ignited the hydraulic oil. • The workers extinguished the fire.

  13. Lesson Learned • The release of product into the pump room bilge and leaking hydraulic oil were each a change of conditions that voided each Certificate as expressly noted in the boilerplate of the Marine Chemist’s Certificate, “In the event of physical or atmospheric changes affecting the Standard Safety Designations assigned to any of the above spaces, this certificate is voided.” • A competent person should have re-checked in accordance with OSHA 29CFR1915.15(c) and (d) and NFPA 306 §4.6.2(2) and (3). • The product should have been cleaned up and the Marine Chemist recalled to inspect the spaces and issue another Marine Chemist’s Certificate. • Failure of the competent person to inspect whether or not the safe conditions were properly maintained voided the Certificate in accordance with NFPA 306 §4.6.2(4).

  14. Areas for Attention for CMCs • Specifying the type of hot work and location of hot work when using the designation: Safe for Limited Hot Work - NFPA 306-2009 §4.3.6(2). • Including toxicity test results - NFPA 306-2009 §4.2.2, §4.3.1(3) and §4.4.1. • Listing all spaces tested and the test results – NFPA 306-2009 §4.2.2 and §4.4.1. • Recording sufficient restrictions or exclusions and instructions for fire barrier use, fire watches, etc. for the competent person on the Certificate - NFPA 306-2009 §4.4.2 and §4.4.3.

  15. Tank Gauging Tubes - Explosion with Injury – October 2010 • Unauthorized entry • Unauthorized hot work • Cargo residue in tanks • Hot work ignites vapor • Explosion in the Dip-Tape gauging device • Shrapnel strikes worker

  16. Tank Gauging Tubes - Fire with Minor Injury – January 2013

  17. Cargo Tank Level Gauging Tubes Rising Stick Type Float-Gauge Float-Gauge with Remote Read-out Plastic Cylinder Float (Vol. 96.5 ml) Tank Depth Tank Depth Stainless Steel Sphere Float (Vol. 62.2 ml) Approx. 2 inch Diameter Approx. 2 inch Diameter

  18. Confined Space Testing Best Practice • What is the proper method of tank testing?

  19. Confined Space Testing - MC Training Module • Marine Chemist Training Module Number 13, Field Instruments – Operation, Application and Maintenance, page 21: “Confined spaces must be sampled from the outside. Generally, to sample confined spaces, the air is actively drawn into the indicator through a sampling hose by a pump.”

  20. Confined Space Testing - ISGOTT • The International Safety Guide for Oil Tankers and Terminals, 5th Edition, Chapter 10, Section 10.3 Atmosphere Tests Prior to Entry: “No decision to enter an enclosed space should be taken until the atmosphere within the space has been comprehensively tested from outside the space with test equipment that is of an approved type…”

  21. Confined Space Testing • Why does the Marine Chemist Training Module and international tanker industry best practices Guide (ISGOTT) make these statements about testing?

  22. Confined Space Testing

  23. Confined Space Testing • The correct way is the only way. • Short cuts & complacency result in disaster.

  24. Question about Altering a Certificate • 4.5 Issuance of Certificates. ….Any additions to or deletions from such a Certificate after obtaining a signature for receipt shall void the Certificate and require reissuance. • Can a Marine Chemist alter or amend a Certificate? • Can a competent person alter or amend a Certificate? • Can the CMC direct the CP to alter or amend the Certificate?

  25. Questions about Determination of Conditions Definitions: • Personally Determine: to find out for oneself • Physically Enter: of or relating to the body; and to go into • Visual Inspection: The physical survey of the space or compartment and surroundings in order to identify potential atmospheric and fire hazards. (NFPA 306-2009, §3.3.21)

  26. Determination of Conditions • NFPA 306-2009 (4.1) Determination of Conditions “The Marine Chemist shall personally determine conditions….. whenever possible, physically enter each compartment or space and conduct a visual inspection to the extent necessary to determine the atmospheric or fire hazards that exist.” • What does that statement mean?

  27. Requirements for Certification • Rules §II.A Be of and maintain good character, and physically able to perform the duties of a Marine Chemist. • Rules §II.F Perform all work in accordance with the requirements of the Standard and its official interpretations when acting as a Marine Chemist.

  28. Consequences of Poor Practice • The CMC Program • Program Sponsors (Industry) • USCG • USN • OSHA • Liability • Criminal • Civil • Insurance Coverage

  29. Conclusion • Pay attention to details. • Avoid the common errors and omissions. • Consider using EMCC. • Make sure the CP knows what to do to maintain safe conditions. • Make sure the CP knows what is a change of conditions. • Make sure the CP knows when to call you (and call you back).

  30. Final Comment • You all do great work • Shipbuilding and repair is a 76 billion dollar industry • The industry relies on you • Train competent persons & shipyard workers • Volunteer to help, train and mentor trainees • Remain vigilant