Issue: 02/2010

Shell Ship Quality Assurance - Safety Flash

Incident Type : Fire & Explosion During Tank Cleaning
Additional : Fatality: 3

Fatality During Tank Cleaning Operations

What has happened?

A parcel size chemical tanker was in ballast voyage and was in the final stage of tank cleaning. The next
cargo parcels to be loaded, included a grade requiring a high standard of Tank Cleanliness. The Wall Wash
Test taken by the ship crew upon completion of tank cleaning revealed unsatisfactory results. The ship’s
crew decided to conduct a spray in the tank with methanol to achieve the required standard of WWT. This
was conducted utilizing a portable air driven pump placed on top of the methanol drum on the catwalk in
vicinity of the tank. The pump was connected to a PVC hose serving as the discharge hose.
Contributing to the above operation, there was hot work on the fire line involving cutting with a grinder
and welding of a pre-fabricated piece of about 1m section. No hot work permit had been issued nor any
approval taken from company as required by the SMS. The senior officers of the ship and the crew working
on deck were aware of both the operations involving the hot work and the tank cleaning operation.
The discharge hose connection to the pump was leaking resulting in a liquid/vapour trail reaching the source
of ignition (Hot work on the fire line 29 meters abaft). Upon ignition, the fire flashed back to the area where
the drum of methanol was positioned in vicinity of the cargo tank being sprayed with methanol resulting in a
subsequent explosion inside the cargo tank.
As a result of the explosion, three (3) crew members involved in the methanol spray operations were directly
affected. The first crew member inside the cargo tank and a second crew member positioned on the main
deck and in vicinity of the methanol drum, sustained severe burn injuries. The third crew member stationed
outside the cargo tank in vicinity of the tank entrance was reported as missing and assumed fallen overboard
due to the force of the explosion. The cargo tank, adjacent pair of cargo tank, the double bottom ballast tank
and main deck was damaged structurally.
The search and rescue operations for the missing crew member was carried out by the Ship with sea support
vessels of the regional rescue centre for the next two and half days without any success. The two (2) crew
members with severe burn injuries were medically evacuated by a helicopter to the nearest hospital and
subsequently to another hospital well equipped to treat burn patients. Unfortunately the crew members
succumbed to their injuries after a few days of the treatment due to the extensive nature of the burns
sustained.

What could be the cause?

 Unsafe conditions – Presence of fuel (from methanol spray) & a source of ignition for combustion
occurring concurrently. This completed the 3 sides of the fire triangle. The third side of the fire triangle –
oxygen was available in the cargo tank, as the space was gas free prior to the spray of methanol
 Unsafe act – The senior officers failed to realize the seriousness of the risk being taken with the
concurrent operations. The spray of methanol & source of ignition existed due to non-compliance of
procedures and operations conducted unbeknownst to the company. The company did not permit
Methanol Spraying or the hot work. Hence the existing controls were violated.

This document is made available for information only and on the condition that (i) it may not be relied upon by anyone, in the conduct of their own
operations or otherwise; (ii) neither the company issuing this document nor any other person or company concerned with furnishing information or
data used herein (A) is liable for its accuracy or completeness, or for any advice given in or any omission from this document, or for any consequences
whatsoever resulting directly or indirectly from any use made of this document by any person, even if there was a failure to exercise reasonable care on
the part of the issuing company or any other person or company as aforesaid; or (B) make any claim, representation or warranty, express or implied,
that acting in accordance with this document will produce any particular results with regard to the subject matter contained herein or satisfy the
requirements of any applicable federal, state or local laws and regulations; and (iii) nothing in this document constitutes technical advice, if such
advice is required it should be sought from a qualified professional adviser.
 Issue: 02/2010

Corrugated Longitudinal Bulkhead Damage to the Tank Bottom

Key learning’s

 The underlying/root causes derived as a result of this incident deal with human behaviour and each
company/organization should undertake their own methods which motivates their workforce to achieve
SAFETY, through compliance to their written procedures. Addressing the “Human Element,” is a long
term measure and efforts taken should be continual and conducted tirelessly.
 Review & reinforcement of the training system should be periodically conducted to monitor its
effectiveness.
 Consideration to Implement a separate session with senior officers to address leadership &
teamwork issues, reinforce Behaviour Based System (BBS) training, and special emphasis on
managing Non Compliance.

 Importance of intervention of an Unsafe Act - The crew working on deck at the time were aware of
both, the hot work and the methanol spray operations but no attempt made to stop either of the 2
operations being conducted concurrently resulting in a highly hazardous situation.

 Effective controls should be in place to increase compliance to the working procedure.

 In the trade practice onboard chemical tankers, it is not uncommon that the use of methanol or other
chemical/detergents is undertaken to achieve the required standard of cleanliness inside the cargo tank,
pipelines, cargo hoses, manifold adaptors/reducers, gauging equipment, etc. Industry publications
clearly highlight and caution regarding their use due to their flammability and toxicity hazards. The
spraying with Methanol is not supported due to the same.

 The easy availability of methanol on board the vessel attributed to this act being undertaken. As an
immediate measure, the company decided to remove all flammable solvents/detergents used for cleaning
of tanks, hoses and fittings. All existing stock of such solvents/detergents from the fleet has been off
landed to shore facilities.

 A safer alternative is being sought for use, which is both non-toxic and non-flammable and tests being
undertaken for the various commercially available detergents/chemicals for cleaning, achieving the
desired results. This may increase the time for tank cleaning but having a safer alternative clearly
outweighs the risk being taken to achieve tank preparedness utilizing flammable /toxic solvents.

This document is made available for information only and on the condition that (i) it may not be relied upon by anyone, in the conduct of their own
operations or otherwise; (ii) neither the company issuing this document nor any other person or company concerned with furnishing information or
data used herein (A) is liable for its accuracy or completeness, or for any advice given in or any omission from this document, or for any consequences
whatsoever resulting directly or indirectly from any use made of this document by any person, even if there was a failure to exercise reasonable care on
the part of the issuing company or any other person or company as aforesaid; or (B) make any claim, representation or warranty, express or implied,
that acting in accordance with this document will produce any particular results with regard to the subject matter contained herein or satisfy the
requirements of any applicable federal, state or local laws and regulations; and (iii) nothing in this document constitutes technical advice, if such
advice is required it should be sought from a qualified professional adviser.