An engineer endured a freeze burn to his hand once there to be a leak of refrigerant gas when he to be refilling a vessel’s main air conditioning (AC) system. When the project was completed, the technician closed the suitable valves, disconnected the refrigerant gas bottle, and started the motor to check for any leaks in the system. The AC device was up and running at the time.

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But the engineer decided – through the AC compressor to run – to provide one critical torque come the valve come once an ext ensure it was correctly torqued. The crouched and also placed himself in prior of the allude of connection to the hose – “in the heat of fire”. Unfortunately, that inadvertently opened up the valve rather of tightening it further. That is considered likely the the pen of the ratchet wrench had actually moved come the the opposite position and also the technician did not inspect the direction the the torque.

There to be an instant refrigerant gas leak in the direction of him. He placed his left hand top top the leak and also tried unsuccessfully to close the valve v the ratchet wrench with his ideal hand. At that moment, a colleague pushed the engineer out of danger and was able come close the valve in a safe manner.

The engineer’s gloves were at first frozen on; as soon as they were off, his hands were put in running water. He experienced severe 2nd degree freeze burns come both hands. He to be treated on board through the telephone guidance of a doctor, and also subsequently moved ashore for hospital treatment.

It was listed that the customer was no made mindful of the occurrence by the contractor till the following morning, and therefore the customer (operators) emergency solution organization was not informed nor mobilized. The on-board courage crew did not immediately realize the severity of the injury and therefore did not connect it instantly to the client.


What to be the reasons of the incident?

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

Lack of hazard assessment and proper preparation:there to be no appropriate risk assessment nor project safety analysis (JSA) performed for the taskthere was no awareness that the threats involvedthere to be no expertise of the MSDS because that this refrigerant gas;Line the fire:the point from which the leak emerged pointed towards the operatorthe engineer inserted himself “in the heat of fire” in former of the allude of link to the hosethere was improper treatment on ‘live’ equipment without appropriate safety precautions;Procedures:the engineer did not examine the torque direction the ratchet wrench prior to use, because of this he torqued the valve in the wrong direction;Personal protective tools (PPE)the technician was wearing towel gloves rather of ideal thermal protection gloves together recommended in the MSDSthermal defense gloves were not obtainable on board nor had actually the need for them emerged to the company.


Eleven work in hospital consisting of intravenous medication and also surgery come the burnt hands;Following discharge indigenous hospital, a further month the physiotherapy before the injured human was fit for work.


Proper training in job risk analysis, hazard assessment and also “line that fire” because that crews;Permit to job-related (PTW) to become mandatory for work-related on high press equipment;Rotate the place of the discharge suggest of the compressor for this reason as not to suggest towards workers, and addition of safety/retention valve (Schrader form valves) ~ above compressor discharge lines;Provision of suitable and certain thermal security gloves;Reassessment the chemicals supplied on board and also their MSDS;

Ensure the client/operator is educated of any and also all injuries on board contractor ship on hire as quickly as possible.

Safety event

Published: 12 might 2017Download:

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