WATCHOUT Poor leadership; explosive results

01 Jun 2017 The Navigator

In this series, we take a look at maritime accident reports and the lessons that can be learned.

What happened?
A tanker was transporting around 22,000 tonnes of methyl tert-butyl ether (MTBE), as well as several million litres of ethanol. At her first port of call, the MTBE was unloaded, but the empty tanks were not filled with inert gas to reduce the risk of explosions as they should have been. Once back at sea, a senior officer ordered junior crew members to open all the empty tanks for cleaning. The tanks still contained MTBE vapours, which mixed with oxygen to cause a highly flammable mixture. The MTBE flowed out onto the decks, and collected in pockets at various places.

As cleaning progressed, crew members began to blow compressed air down the cargo lines to clean them, unaware of the danger that a resultant static electrical charge could cause a spark that would ignite the vapour. The spark occurred, and there were two major explosions. In the panic, there was little or no attempt at an organised evacuation. Crew members jumped off the vessel as she sank – most with lifejackets; none with survival suits. Despite rescue efforts by the coast guard, the only survivors were six crew members who had managed to climb onto a life raft.

Why did it happen?
From the start, the three senior officers on board had created an atmosphere of fear and intimidation. Junior crew members felt unable to question unsafe decisions made by their superiors and were actively prevented from reading safety, quality and environmental protection management documents. The senior officers also failed to train their subordinates in the technical skills they needed to work proficiently. When the CO ordered an unsafe cleaning process that ultimately led to an explosion and the loss of the vessel, junior officers did not have the knowledge or the confidence to question it. Fire and lifeboat drills were infrequent, making the aftermath of the accident even more catastrophic.

The issues

  • The senior officers discouraged questions from junior crew members and actively prevented them from learning how to do their jobs safely
  • The tanks were not rendered safe with inert gas after the MTBE was delivered
  • Inexperienced crew members carried out highly dangerous processes when cleaning the tanks and received no supervision or correction
  • Safety measures such as immersion suits and regular fire and lifeboat drills were absent

You can download the full report at http://bit.ly/2r9TFoG

WHEN THE CHIEF OFFICER ORDERED AN UNSAFE CLEANING PROCESS, JUNIOR OFFICERS DID NOT HAVE THE KNOWLEDGE OR THE CONFIDENCE TO QUESTION IT

If you find our accident reports useful, check out The Nautical Institute’s Mariners’ Alerting and Reporting Scheme (MARS). A fully searchable database of incident reports and lessons, updated every month. Seen a problem yourself? Email the editor at mars@nautinst.org and help Mariners’ Alerting and Reporting Scheme others learn from your experience. All reports are confidential – we will never identify you or your ship.

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