Engine crew on the vessel MIKAWA suffered minor burns during operation of the incinerator due to a lack of risk assessment and supervision. Preventative measures include conducting safety education and requiring supervision for critical jobs. The accommodation area on the vessel MATSUMAE was found to be very dirty due to laziness, lack of responsibility in cleaning, and insufficient supervision. Preventative measures include implementing a regular cleaning schedule and higher cleaning standards with stricter supervision. A crew member on the vessel MUROTO injured their fingers while chipping a manhole cover due to a lack of safety checking and poor maintenance. Preventative measures include welding a nut to securely hold open the manhole cover and always being aware

1. GENERAL EDUCATION &
TRAINING ONBOARD
(Crew Issues)
Taiyo Sangyo Trading & Marine Service LTD.

2. Vessel MIKAWA
Date 12 OCTOBER 2019
Case
Engine crew suffered minor burns
during operation of Incinerator
RE-ENACTMENT OF THE INCIDENT
Collecting of Sludge
Pouring Sludge into
Incinerator chamber
Fire brake out after
pouring of sludge Stopped the Incinerator
Closed the Incinerator chamber and escapeMinor burns caused by Incinerator
Case No.1
Incinerator Operation

3. ROOT CAUSE:
 There is no Risk Assessment conducted before commencing
the operation.
 Master/Chief Engineer failed to discuss on crew concerning
previous TST Circular (H10015) pertaining to safe Operation
of Waste Oil Incinerator.
 Lack of Supervision by the Officer In Charge.
 Making shortcut and not following proper operation
procedure of Waste Oil Incinerator.
 Not Wearing adequate PPE in operating critical equipment.

4. PREVENTIVE MEASURES:
 Conduct education and precisely explain to all crew proper
procedures and safe operation of Waste Oil Incinerator.
 All Critical job must always have direct supervision by the Officer
in charge.
 Wear proper and adequate PPE before operating critical
equipment.
 Safety officer must survey the scene identifying/eliminating
possible hazards and ensuring safety practice is observed
accordingly.
 Briefly discussed/emphasized to all crew to adhere safety
procedures in operating such machineries and equipment.

5. 8 Common Problems of Ship’s Incinerator
1. Flame Failure Alarm
2. High Flue Gas Temperature Alarm
3. High Combustion Chamber Temperature Alarm
4. Sludge Oil Leaking
5. Cracks in Refractory of Combustion Chamber
6. Draft failure / Low Pressure Alarm
7. Leaking Mechanical Seal Sludge pump

6. Vessel MATSUMAE
Date 27 November 2019
Case
Very dirty accommodation area,
untidy, unorganized, etc.
Case No.2
Clean in the outside but full of trash inside
Very dirty laundry room and toilets
Yellowish Shower room
Too much dirt and dust accumulated on the walls and
ceilings around the accommodation
Very dirty basin and plate container
Accommodation General Cleanliness

7. ROOT CAUSE:
 Laziness and lack of sense of responsibility in cleaning.
 Improper way of cleaning (very low standard).
 Lack of supervision from Senior Officers.

8. PREVENTIVE MEASURES:
 Regular cleaning schedule all around accommodation area.
 Impose the proper way of cleaning with higher standard.
 Strict supervision of implementation from senior officers.

9. Vessel MUROTO
Date 16 November 2019
Case
Injured left hand fingers while
chipping on the manhole cover
Case No.3
Three fingers was injured, suffered minor
cuts. There was no fractured bones.
Before repair with
broken lock
Welded a nut, so that a
stopper pin can pass
through it and hold the
manhole cover
Finger Injury

10. ROOT CAUSE:
 Lack of safety checking before commencing of work.
 Poor maintenance on the manhole cover.
 Unaware of the surroundings for possible danger.

11. PREVENTIVE MEASURES:
 Welded a nut so that a stopper pin could pass through it
and hold the cover to remain open.
 Put additional lashing of manhole cover by fastening to the
bulwark using a cord strap.
 Always be attentive and aware on your surroundings while
working.

12. Case No.4
Signing w/o checking the correct
quantity of bunker to be supply
 Charterer sent message to the vessel that the supply quantity for
bunker is 250mt
 Barge arrived at the vessel presented BDR to C/E is 320mt
 C/E signed without reading
 Bunkering started
 During sounding while bunkering in progress, PIC reported that tank
capacity is already 90%
250mt = 80% Tank Capacity
320mt = 100% Tank full capacity
 As per SMS maximum acceptable tank loading capacity is 85%
Narration of the Incident:

13. ROOT CAUSE:
 Human error, not reading and verifying thoroughly the
documents before signing.
 Lack of focus while working.

14. PREVENTIVE MEASURES
READ THE DOCUMENT
CAREFULLY
CHECK AND CONFIRM IF
THERE IS NO DISCREPANCY
THEN SIGN ONLY IF ALL
ARE IN GOOD ORDER
 Always strictly follow this steps before signing a
document:

15. Vessel MIKAWA
Date 03 December 2019
Case
Cargo Damage caused by Heavy
Weather while drifting
Case No.5
Cargo Damage
Photos of Cargo damage in Forward part Cargo Hold No. 2
Photos of Cargo damage in Forward part Cargo Hold No. 2

16. ROOT CAUSE:
 Failure to monitor the weather forecast sent by the
Manager.
 Not taking immediate action and anticipation of Heavy
Weather.
 Improper stowage and securing of cargoes.
 Lack of crew supervision during loading

17. PHOTOS OF CARGOES DURING LOADING
 Improper stowage and securing of cargoes (There is no key
coiling or locking coil)

18. PREVENTIVE MEASURES
 Strictly monitor all weather forecast by Manager.
 Act immediately when weather suddenly
deteriorates.
 Always conduct thorough crew supervision
during loading and implement locking coil in
securing cargo.