Serious finger injury during valve installation

The incident occurred during valve operation function tests on a remotely operated pneumatic controlled valve for a vessel fuel system. There were some issues with the opening and closing of one particular valve. The decision was taken to change out the valve.

• The immediate cause of the incident was the engineer using his fingers directly on the valve-flap instead of using the correct tools.
• The job was considered routine by the engine crew.
• The valve was not secured whilst the engineer tested it.
• There was no rush when it came to replacing the valve; the crew could have used sufficient time to plan the operation in more detail and agree upon which equipment should be used.
• The engineer carried out simultaneous tasks – he was holding the air-gun with one hand, the valve with the left hand and simultaneously tried to move the valve-flap with his fingers, taking a shortcut.

• • inadequate or substandard planning
  • the use of short-cuts
  • Some of the causal factors were as follows
  • Poor or inadequate risk assessment: the engineer should have been aware that the valve-flap could suddenly close, and have prepared for it
• Routine – complacency and low awareness of risk: since the replacement of valves was considered a routine job and carried out regularly, it is possible that the engineer and motorman were not as alert as they ought to have been during this specific operation, nor did they have sufficient awareness of risk, and they did not properly assess the danger when it came to moving parts
• PPE: gloves were not used by the engineer during the replacement of the valve. Company procedures require that gloves in the engine room should be ‘readily available and worn as required in work permit/risk assessment’
• Failure to follow procedures: company procedures for Permit to Work state that work on the fuel system should been covered by a work permit. In order to replace the valve, the fuel system/pipe should have been isolated in order to avoid any risk of fuel entering the affected area, and the air system controlling pneumatic valves should have been isolated/disconnected. These would have been covered by the work permit and resulted in use of the Lock Out Tag Out procedure/checklist. The engine crew assessed the job to be a low risk routine job and took the view that a Permit to Work was not required.