202352 - Missed steps in a procedure = misstep
A vessel was at sea, proceeding to the next scheduled port. An engineer was tasked with replacing the fuel filter on one of the diesel generators as part of planned maintenance schedule.
As he was removing nuts to replace the filter, the gasket suddenly burst. A jet of hot diesel fuel sprayed out and onto him and another attending crewmember who was in training.
The affected crewmembers were transferred to a safe place for first aid. One victim reported a skin burn to the right part of the neck and lips, while the other reported minor skin irritation on the hand near the fingers.
The manufacturer’s information manual contained the steps to be followed for this procedure. An analysis of the sequence of events showed the crewmember had missed four important steps in this task. Among other things, and most notably, he had not shut the inlet and outlet valves of the fuel filter nor checked the pressure gauge before unbolting.
Further investigation revealed that he was not sufficiently familiar with that specific maintenance job. The lack of strict supervision from senior staff also contributed to the chain of errors resulting in the incident.
Lessons learned