200934 Eye injury caused by splashing chemical

Eye injury caused by splashing chemical
MARS Report 200934

Our third engineer suffered chemical burns to his face and right eye while transferring boiler treatment chemical from a storage drum to a measuring jug. Fortunately the vessel was coasting at the time of the accident and as a result of efficient response and communications with the shore, a doctor was able to come aboard and assess the injuries and oversee the medical evacuation (medevac). The crew member was repatriated from the hospital some days later.

Result of investigation

 

The engineer had been instructed to prepare chemicals for routine boiler water treatment. To do this, bulk chemical from a 20-litre container needed to be transferred into a smaller measuring jug before being applied to the dosing pot. To accomplish this task, the engineer donned the PPE provided (including goggles) and proceeded to transfer the chemical. On completion, he removed the goggles to view the quantity and seeing it was slightly less than the required amount, proceeded to pour a further 0.5 litre into the measuring jug. With his eyes unprotected, and the container's mouth open, he inadvertently let the tilted chemical container swing back upright. The impact on the bottom of the container caused some chemical to squirt from the open mouth on to the engineer's exposed face and eyes. He immediately flushed his face with the saline solution nearby and proceeded to the engine control room, from where the alarm was raised.

The incident occurred while the vessel was navigating one of the world's most congested sea lanes and following medical advice from ashore, it was decided to execute an offshore rendezvous with a shore-based boat. The unscheduled deviation from the passage plan and engine movements imposed additional demands on both the bridge and engine room teams, culminating in the transfer of personnel to/from the ship and medevac of the casualty. This placed the safety of the ship and personnel at additional and avoidable risk. Furthermore, by delegating the critical task of boiler water treatment to a relatively inexperienced engineer, the safety management system (SMS) had been contravened which could have also potentially compromised boiler safety.

Root cause / contributory factors

Lack of proper work planning;
After estimating the quantity drawn and deciding to pour out more chemical, the engineer failed to put the goggles back on;
The engineer replaced the chemical container on the storage rack with a jerk without replacing the lid;
The fact that the third engineer was performing without adequate supervision, in the belief that it was not a hazardous operation, demonstrated insufficient risk assessment and training.
Lessons learned

Always use a clean protective face shield when handling chemicals.
Always replace the container lids on completion of transfer.
Comply with SMS procedures.