Human factor in Indra II fatality

Failure to comply with safety measures while attempting to return engine power to a vessel in the midst of a mooring manoeuvre was the key contributor to the death of a 48-year-old Ukrainian onboard the bulk carrier Indra II in November 2015.

What happened

The 152.63-metre, 12,872-GT vessel Indra II had sailed from Odessa (Ukraine) to the Port of Burgas (Bulgaria) with a consignment of metal. Upon commencement of manoeuvring to the port on 9 November, the ship’s main engine stopped due to the activation of low pressure protection within the luboil system. With the ship temporarily drifting, the chief engineer informed the captain that the engine room staff would try to fix the problem in a short time.

The routine actions for such cases were undertaken – cleaning the luboil system filters – which saw the oil pump stopped before each filter opening. However, when attempting to dismantle the filter element from the left section of the main luboil filter, the cover of the section remained attached to the body of the filter box, although the retaining nuts were unscrewed.

At his own initiative, the third engineer climbed onto the filter housing and bent over the cover and attempted to release it using a hammer. The cover suddenly jumped out vertically, hitting the third engineer in the chest and pressing him against the pipelines passing under the deckhead of the compartment.

The injured person was released and given first aid by the crew and emergency help was requested from shore. However, despite the measures taken, the injured person subsequently died as a result of injuries.

Why it happened

According to the Republic of Bulgaria’s Maritime Accident Investigation Unit (MAIU), the main cause of the fatality was the failure to comply with safety measures when handling equipment working under pressure, “due to nervousness and the desire to solve the breakdown more quickly”.

No attention had been paid to the differential oil pressure gauge indications of the main oil filter (MAX filter). No account had been taken to the chief engineer's warning that workers should move away from the filter. The elementary safety precautions for the removal of the filter cover were not met – preliminarily partial unscrewing of the nuts holding the cover.

Key contributing causes were the poor maintenance of the main engine luboil system, resulting in:

• An inoperative oil centrifugal separator and, as a result, heavily contaminated oil in the main engine sump tank, with a heavy sludge, that could cause rapid contamination and clogging of the luboil filters.
• Deformed studs holding the MAX-filter left section cover.

The design and installation of the main oil filter resulted in:

• Restricted access beneath overhead pipework
• Difficulty removing the filter cover
• No practical method of rapid removal other than climbing onto the filter housing.

Finally, the oil separator had not worked for more than one year because of a lack of spare parts.

Analysis of human factor

The report found that although the crew’s step-by-step process of opening and cleaning the filters was considered “routine”, the emergency stop of the main engine during a manoeuvre brought added pressure. The attempts to restore the normal functioning of the oil system had continued for over two hours.

According to the crew, in any previous filter extractions and cleanings – given the longer period for these operations – no residual pressure had been observed in the oil system nor any spillage of oil. This, in all likelihood, had “blunted” the attention to the safe working of the engine room personnel and combined with the nervousness generated by the emergency situation and the desire to quickly restart the main engine, the third engineer was deprived of self-preservation in his pursuit to successfully complete the solving of the problem.

That the arrow of the differential pressure gauge was in the red sector – a sign that there was high residual pressure in the filter – had been completely overlooked. Whereas, “good maritime practice” implies that covers of vessels under pressure are released completely after a minimum unscrewing of the threaded connections to check for residual pressure. Instead of this, all eight nuts holding the cover of the left filter section were unscrewed and removed.

That the cover remained in place at this point further mislead the staff to believe there was a lack of pressure in the oil system.

Additionally, no account had been taken to the chief engineer's warning that workers should move away from the filter.

Safety recommendations

After the accident, in accordance with the safety management system adopted by the shipowner and manager of the Indra II, Bulcom, two specific measures were undertaken to prevent such accidents occurring again:

• The case was discussed at the Onboard Safety Committee Meeting.
• Issues substantial issues with the main engine oil system were rectified.

Corrective actions included cleaning the sump tank and oil cooler, repairing the oil separator, cleaning the MAX filter and restoring drainage functionality within the lubricating oil system.

The MAIU further recommended Bulcom:

• Organise a thorough inspection and diagnostics of the main ship’s machines and mechanisms, extra to the regular inspections made by the classification organisation, to introduce a schedule for oil samplings and send them for analysis as is the normal practice for ships' engines in service.
• Organise additional briefings on compliance with crews’ personal safety regulations in accordance with the instructions for a proper and safe operation of all ship’s machinery and mechanisms and systems, to focus attention to informal implementation of occupational safety briefings prior to commencing a work or a repair, especially when dealing in extreme situations.

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Main image: Aerial view of Port of Burgas, Bulgaria
Credit: Shutterstock