Milagro Investigation: Serious burn injuries to a crew member

Simulation of what happened aboard Milagro
Simulation of what happened aboard Milagro

Transport Malta has published an investigation report in response to an incident that took place aboard Milagro on 26 September 2022. Whilst Milagro was drifting outside the Republic of Korea’s territorial waters, the fitter was assigned to replace a leaking hydraulic pipe on the main deck. An oxy-acetylene torch was used to cut the Ubolts, which secured the pipe to the pipe supports on the deck.

Whilst cutting the last U-bolt, which was close to the forward flange, the pipe slipped off its supports. Oil from the pipe splashed onto the fitter and immediately ignited. The crew members assisted the fitter in extinguishing the flames on his coveralls, following which he was administered first-aid. The injured fitter was eventually evacuated to a shore hospital for further medical treatment.

The safety investigation concluded that prior to the commencement of the task, the hydraulic oil pipe had not been completely drained. Two recommendations have been made to the Company to enhance onboard assessment of risks.


– The fitter’s coveralls caught fire, caused by the ignition of a spray of hydraulic oil from the pipe that the fitter was working on.
– The fitter was using an oxy-acetylene set to cut off the U-bolts on a leaking section of a hydraulic pipeline, which was part of the remote operating system for the water ballast tank valves.
– After the occurrence, the crew members found that a valve between one of the accumulators and the return pipeline, was open, as a result of
which, the return pipeline may have been under pressure.
– An observed reduction in the oil leak may have misled the crew members to believe that the pipeline had been depressurized and drained.
– Although a fire hose was connected to a hydrant and placed near the work site, the fire pump was not switched on.
– The fitter’s unawareness of the hazard was a pivotal factor on how the accident dynamics had evolved.
– It is highly likely that the fitter’s coveralls did not offer any fire protection.

Safety actions taken

During the safety investigation, the Company had carried out an internal investigation in accordance with the requirements of the ISM Code. Following their investigation, the Company took the following actions:

– The investigation report was discussed with all crew member on board Milagro;
– The investigation report was circulated across the Company’s fleet;
– The investigation report was used in its training centres as a case study for engineers at pre-embarkation training sessions;
– Instructions and precautions for the replacement of a unit, device or a pipe of the hydraulic oil system, were posted in the hydraulic power unit
room on board Milagro; and
– All crew members who were assigned to the task on board Milagro, were provided with additional training on the SMS procedures for hot work and work on pressurized systems.

Download the report here: Transport Malta Investigation Report: Serious Burn Injuries to Crew Member

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