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What happened?
A fully-refrigerated Liquid Petroleum Gas carrier vessel was moored for loading.
After loading, it needed to blow loading arms with nitrogen.
Gas engineer was operating ship’s manifold valve to build up pressure. Shore personnel started blowing the cargo arm with nitrogen gas.
They accidentally opened the hydraulic operated quick (dis)connect coupler of the terminal arm.
Liquid propane (-43°C) released near the gas engineer.
Gas engineer suffered frostbite injury and needed 9 days treatment in hospital.
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Why did it happen?
Shore operator accidentally pushed the unprotected quick (dis)connect opening switch.
Switch opened as the arm was still loaded with liquid propane. The liquid propane was pressurised by nitrogen and escaped through the opening.
Procedure allowed opening of at any moment during draining and purging.
Procedure stated to disarm the emergency release and then inject nitrogen. However, once the emergency release was disarmed, the arm remote control was fully operational and quick (dis)connect switch could be opened.
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What did they learn?
Never disable a safety device without conducting a risk assessment.
Check safety critical procedures through systematic hazard and operability (HAZOP) studies.
Update HAZOP if equipment or interlock logic changes.
Check that personal protective equipment (PPE) is designed for cold resistance and liquid gas spray.
Cold resistant PPE, including full face protection visor, should be worn around manifold while loading/unloading.
Never underestimate cold burn. Immediately seek hospital treatment.
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Ask yourself or your crew
How can something like this happen here?
What other risk mitigation actions could have been taken?
Do you have the information you need to manage this risk?
What can we do to improve our procedures for this task?
Do we have the right PPE? What else do we need?
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What happened?
A fully-refrigerated Liquid Petroleum Gas carrier vessel was moored for loading.
After loading, it needed to blow loading arms with nitrogen.
Gas engineer was operating ship’s manifold valve to build up pressure. Shore personnel started blowing the cargo arm with nitrogen gas.
They accidentally opened the hydraulic operated quick (dis)connect coupler of the terminal arm.
Liquid propane (-43°C) released near the gas engineer.
Gas engineer suffered frostbite injury and needed 9 days treatment in hospital.
Why did it happen?
Shore operator accidentally pushed the unprotected quick (dis)connect opening switch.
Switch opened as the arm was still loaded with liquid propane. The liquid propane was pressurised by nitrogen and escaped through the opening.
Procedure allowed opening of at any moment during draining and purging.
Procedure stated to disarm the emergency release and then inject nitrogen. However, once the emergency release was disarmed, the arm remote control was fully operational and quick (dis)connect switch could be opened.
What did they learn?
Never disable a safety device without conducting a risk assessment.
Check safety critical procedures through systematic hazard and operability (HAZOP) studies.
Update HAZOP if equipment or interlock logic changes.
Check that personal protective equipment (PPE) is designed for cold resistance and liquid gas spray.
Cold resistant PPE, including full face protection visor, should be worn around manifold while loading/unloading.
Never underestimate cold burn. Immediately seek hospital treatment.
Ask yourself or your crew
How can something like this happen here?
What other risk mitigation actions could have been taken?
Do you have the information you need to manage this risk?
What can we do to improve our procedures for this task?
Do we have the right PPE? What else do we need?
Gas engineer was operating ship’s manifold valve to build up pressure. Shore personnel started blowing the cargo arm with nitrogen gas. Gas engineer suffered frostbite injury and needed 9 days treatment in hospital.
