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

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.