Cause & Consequence
- Fire or explosion
Any Location Type
Incident Info Source
Step change in safety
Specific Incident Equipment
A gas accumulator system linked to the crane GOP hydraulic system.
The deck crew did not identify that the gas cylinders selected contained Oxygen instead of Nitrogen.The crane op did not check the content of the gas cylinder being used to charge the accumulator.The crane op did not plan the recharge operation in advance had not obtain a work control certificate.
A Step Change Alert # 1025 contains information regarding the correct identification and selection of gases. http://stepchangeinsafety.net/stepchange/SingleItem_Incident.aspx?AlertNo=1025
Step Change ask the industry body/suppliers if there is anything they can do to minimise the likelihood of confusing the colour codes.