Safety Flash
Vessel engine block blown open in and around cylinder
Vessel engine block blown open in and around cylinder
- IMCA
- Safety Flash
- IMCA SF 14/18
- Human FactorsInspection and MaintenanceMachinery and EquipmentManagement of Change
- Human factorsLine of fireMechanical failure
- Inspection and maintenance
- Rotating machinery
- Management of changeOperating and work proceduresSafety communication
- Marine industry
- Vessel
Summary
A vessel engine connecting rod separated and breached the block following failure to replace and correctly torque four temporary bolts. Preliminary findings identified schedule pressure, poor handovers, missing checklists and incorrect cylinder marking. Lessons emphasise change management, handovers, checklists and limiting personnel exposure during engine start-up. No injuries, fluid spill or fire occurred.
Classifications: Human factors; human performance; ergonomics.
Classifications: Line of fire; struck-by hazards.
Classifications: Mechanical failure; equipment failure.
Classifications: Inspection and maintenance; asset inspection; equipment maintenance.
Classifications: Rotating machinery; rotating equipment.
Classifications: Management of change; MOC; change management.
Classifications: Operating and work procedures.
Classifications: Safety communication; toolbox talk; toolbox talks.
Classifications: Marine industry; shipping industry; maritime sector.
Classifications: Vessel; aboard ship; onboard vessel.
Summary
An engine connection failure damaged the block, with temporary bolts, poor handovers and work-schedule pressure identified as contributing factors.
IMCA SF 14/18. Themes: human factors, inspection and maintenance, machinery and equipment, management of change.