CHSE/29-2010

HSE Incident Lesson Learnt

Type of Incident: Eye injury while charging life boat air Lessons Learnt:
Learnt:
bottles.
• Keep well clear of “Snap- back” Zone for pressure
hoses
Location of Incident: Onboard ship
• Inspect thoroughly all couplings pressure hoses prior
Date of Incident: October 2010 use
• Discard immediately any couplings/connections
Brief Account of the Incident: found defective
• Wear proper PPE appropriate to the work undertaken
The Incident occurred while ship staff was charging air- at all times
bottles on lifeboat. Observing that the pressure had not • Properly maintain compressors and associated fittings
increased in the air bottle the compressor was stopped. regularly
The brass coupling connections were opened and fitted
back with thread seal and tightened by spanner. To test
for the leakage, with the compressor in stopped condition,
the filling valve was being slowly opened, when the (brass
coupling) hose connection disconnected by itself from the
compressor. (The actual cause of the pressure not rising in
the air bottle was Pressure Maintaining Valve (PMV) stuck
in closed position due to dirt). The hose snapped back and
struck the staff attending to the work causing an injury
(cut) on his left eye & eye-brow

Outcome:

• IP suffered injury to left eye’s cornea in addition to

cut on the eyebrows and heavy swelling on the left
cheek.

Keys
Keys Findings:
• Damaged coupling was not noticed and replaced
prior use. (Defective Equipment)
• The injured person was situated within the “Snap-
back” Zone. (Improper Procedure)
• The Compressor outflow side was not checked for
proper flow of air.(Incompatible Goals)
• Correct Procedure for leak test not followed
(Improper Procedure).
• The Maintenance of the Compressor was not proper,
choked PMV. (Maintenance Management)

PRECAUTIONS:

NO WORK IS SO URGENT THAT WE CANNOT TAKE THE TIME TO DO IT SAFELY

SAFELY


WHAT IS CONSIDERED A NORM IS NOT NECESSARILY THE SAFEST WAY OF DOING THINGS
THINGS