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BSafe Case Study 8 — Eight Days of Failed Tank Cleaning, Then Caustic Soda

🕑 5 min read words Safety • Incident

Vessel: Chemical tanker, operational four months, interim ISM certification
Date & location: Cargo tank, during caustic soda residue removal
Outcome: Severe chemical burn injuries to the Third Officer
Human factors: Missing Tank-Specific Risk Assessment · Inadequate PPE for a Corrosive Chemical · Absent Stop Work Authority
Source: Britannia P&I Club, BSafe Incident Case Study No. 8, drawn from Federal Bureau of Maritime Casualty Investigation (BSU) Report 301/09

1 real case studyBSU Report 301/09~4 min read

Eight Days That Should Have Been a Warning Sign

Cleaning cargo tanks on a chemical tanker is routine — but this crew couldn't get it done. Over eight days, despite guidance from an attending tank inspector, they weren't able to clean the tanks to a standard that would allow loading of caustic soda. A mobile pump was brought in to remove residues, including an unusually high level of leftover palm oil from the previous cargo. A Port State Control inspection carried out the day after the eventual injury put it plainly: the crew wasn't very familiar with handling the cargo, or didn't have enough chemical tanker experience — an internal audit was required.

No ship-specific tank cleaning plan existed. No documented risk assessment for the job was found. The vessel had only interim ISM certification, having been operational for four months.

The Injury

The Third Officer was wearing the PPE typically worn on board for this kind of work: cotton overalls, a rubberised jacket, safety boots, gloves, goggles, a helmet. The investigation found the overalls weren't suitable for the task, and the goggles were open at the sides, exposing his eyes — neither met European safety regulations or the IBC Code's requirement for tight-fitting eye protection and full-body chemical-resistant coverage. During the residue removal, a hose clamp on the pump's suction line parted — the investigation couldn't establish why, as the clamp itself wasn't recovered afterward — and caustic soda reached the Third Officer, causing severe chemical burns.

What the Investigation Found

No tank-specific cleaning plan or documented risk assessment existed, despite fleetwide guidelines being available — the gap was in translating general guidance into a plan for this ship, this cargo, this job.
PPE worn did not meet the IBC Code's requirements for handling a corrosive chemical — tight-fitting eye protection and full-body coverage, specifically, were both missing.
No decontamination shower or eyewash station was used on deck — the Third Officer was taken to his cabin for first aid instead, losing time the investigation notes matters directly for caustic soda exposure.
Neither the master nor bosun intervened to stop work despite inadequate PPE being worn for a known-hazardous task — a working Stop Work Authority culture would have given either of them, or anyone else present, standing to halt it.
Eight days of failed attempts, PSC's own post-incident assessment of inexperience, and repeated exposure to the same equipment and PPE likely bred complacency — familiarity read as adequacy.

Recommended Actions

Drawn from BSU's investigation and Britannia's own commentary, not invented:

A tank-specific cleaning plan, built from a real risk assessment, is required before the job starts — fleetwide guidelines alone don't capture this ship's or this cargo's specific hazards.
PPE for corrosive chemical handling must meet the IBC Code's actual specification — tight-fitting goggles or a face shield, full-body coverage with no exposed skin — checked against the requirement, not against ‘what’s normally worn.’
Decontamination showers and eyewash stations required by the IBC Code need to be positioned for genuine immediate use, and used immediately — not treated as a fallback to first aid in a cabin.
A real Stop Work Authority culture means any crew member, and certainly the master or bosun, can and should halt work the moment PPE or preparation doesn't match the hazard — without it costing them anything.
Repeated failed attempts at a task are themselves a signal worth escalating, not absorbing into ‘this is just how long it takes’ — eight days of failure is eight days where the underlying training or planning gap could have been raised.

Human Element Analysis

Missing tank-specific risk assessment

General fleetwide guidance existed. What didn't exist was the step that turns general guidance into a real plan for this specific tank, this specific cargo, this specific crew's actual capability — the gap BSU's investigation identified as central.

PPE that looked right and wasn't

Every PPE item expected for the job was present. None of it actually met the standard the chemical required. Familiarity with ‘what we normally wear’ stood in for checking against the real requirement.

Absent stop work authority

Britannia's own commentary is direct: had the master or bosun intervened over the inadequate PPE, the incident could have been prevented. The authority to stop existed in principle; nothing in this case shows it being exercised in practice.

Test Your Knowledge

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