An engineer experienced a freezing burn come his hand when there to be a leak that refrigerant gas if he to be refilling a vessel’s central air conditioning (AC) system. Once the project was completed, the technician closed the proper valves, disconnected the refrigerant gas bottle, and started the engine to check for any kind of leaks in the system. The AC device was up and also running at the time.

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But the engineer made decision – through the AC compressor to run – to give one critical torque come the valve come once more ensure that was effectively torqued. The crouched and also placed self in front of the suggest of link to the hose – “in the line of fire”. Unfortunately, the inadvertently opened the valve rather of tightening that further. The is thought about likely the the pin of the ratchet wrench had actually moved come the the contrary position and the technician did not examine the direction of the torque.

There was an prompt refrigerant gas leak in the direction of him. He put his left hand ~ above the leak and tried unsuccessfully to close the valve v the ratchet wrench v his best hand. At the moment, a colleague driven the engineer out of danger and was able to close the valve in a safe manner.

The engineer’s gloves were initially frozen on; when they to be off, his hands were placed in to run water. He endured severe 2nd degree freeze burns come both hands. He to be treated top top board v the telephone indict of a doctor, and also subsequently moved ashore because that hospital treatment.

It was noted that the customer was no made mindful of the event by the contractor till the adhering to morning, and also therefore the customer (operators) emergency solution organization to be not educated nor mobilized. The on-board courage crew walk not immediately realize the severity of the injury and therefore walk not connect it immediately to the client.


What to be the reasons of the incident?

Refrigerant gas Freon™ 404A reaches temperatures of roughly -46°C once it is released (i.e. Decompressed).

Lack of danger assessment and proper preparation:there to be no ideal risk assessment nor job safety analysis (JSA) conducted for the taskthere was no awareness of the dangers involvedthere was no expertise of the MSDS because that this refrigerant gas;Line that fire:the suggest from which the leak emerged pointed in the direction of the operatorthe engineer put himself “in the line of fire” in front of the suggest of connection to the hosethere was improper intervention on ‘live’ devices without appropriate safety precautions;Procedures:the engineer did not inspect the speak direction the ratchet wrench prior to use, therefore he torqued the valve in the wrong direction;Personal protective devices (PPE)the engineer was wearing towel gloves rather of appropriate thermal security gloves as recommended in the MSDSthermal security gloves were not obtainable on board nor had the need for them developed to the company.


Eleven work in hospital including intravenous medication and surgery come the charred hands;Following discharge native hospital, a more month the physiotherapy before the injured human was fit for work.


Proper cultivate in job risk analysis, danger assessment and “line that fire” for crews;Permit to occupational (PTW) to come to be mandatory for occupational on high push equipment;Rotate the position of the discharge point of the compressor therefore as no to allude towards workers, and addition of safety/retention valve (Schrader type valves) top top compressor discharge lines;Provision of proper and specific thermal defense gloves;Reassessment the chemicals used on board and their MSDS;

Ensure that client/operator is notified of any and all injuries on plank contractor vessels on rental as shortly as possible.

Safety event

Published: 12 may 2017Download:

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