HUMAN ERROR AND NEGLIGENCE WHILE CARRYING OUT MAINTENANCE WORK :
The incident relates to a container Vessel at Colombo in the year 1993. Ship was berthed at 0900 hrs. It was a British built container vessel, with multinational crew. Main engine B&W 6K74EF model. C/E instructed us to carryout the E/R survey job. Surveyor was supposed to visit at 1300 Hrs, Vessel had to sail out at 1800 hrs from the port. Pedestal bearing survey job was allotted to 3/E, 2/E was instructed to carry out preparation for M/E unit 6 Crosshead survey . 2/E fitted hydraulic jack on top of the cross head bolt with hose. He started turning crosshead by Turning Gear. Accidentally 3/E noticed the scene and he informed 2/E not to turn the T/G along with hydraulic jack. Then 2/E removed the hydraulic hose, and still jack was in place. Later 3/E left that place to concentrate on his job.
After some time 2/E, again turned the cross head by T/G without removing the hydraulic jack. Consequently Hydraulic jack hit the frame inside the c/c and subsequently crosshead bolt threaded area got bent. He was unable to remove hydraulic jack from the place. Situation became panic. Matter informed to C/E and Captain. Ultimately survey was cancelled. It was suggested, to inform about this matter to company, so that technical assistance can be availed and prevent further damage to machinery and delay in vessel’s programme. It was not agreed by C/E. Finally it was decided to cut the hydraulic jack by gas cutting. C/E left the ship to shore for making phone call to his family.
2/E took over the situation. M/E all units c/c doors opened and well ventilated. E/R fitters started the job. To prevent hot spot gunny bag roll passed starboard side to port side on the particular unit. Hydraulic jack was cut into small pieces and simultaneously E/R staff start spraying freshwater on molten pieces. Job continued till next day early morning. End of the operation C/E visited the spot. -- Crank case was cleaned and inspection carried out. All clearances checked and found within limit. Sea trial was taken, and performance found satisfactory. Voyage was continued V/L was due for dry-dock. In dry-dock, particular unit crosshead blots and nuts replaced by spare one and survey carried out.
Lesson Learnt :
This incident purely due to human error, which could have definitely been avoided. Do not hesitate to consult the manufacturer in such cases after informing the company. It is always important to keep the Technical Superintendent in the picture, who can always help in arranging the technical assistance and also required spares.