On a hot and humid day at sea, the ship’s electrician and a junior engineer were fault tracing on a ship’s forward electric cargo crane that had given intermittent problems in the previous port. Simultaneously, the deck crew was chipping the forecastle deck under the crane, resulting in a very noisy environment. At some point, the electrician decided to have his assistant observe relays on the power distribution board within the narrow confines of the crane body, while he moved the crane control joystick. This involved the assistant descending into the narrow cylindrical space via a small hatchway located underneath the crane operator’s seat. The cover of the distribution board had been removed, with the result that the junior engineer was standing extremely close to the high voltage sections in the box. Despite the exhaust fan running, he was soaked in sweat, and ill advisedly rolled up his sleeves and undid the buttons of his overalls. He was also carrying uninsulated tools (spanners, screwdrivers etc) in the pockets of his overalls.
With the electrician moving the controls, shouted instructions and observations were being exchanged over the noise of the fan and din of the chipping machines. It is likely that their voices did not carry well through the hatchway, and when the electrician failed to get responses to further instructions, he looked down the hatchway and found the junior engineer collapsed at the bottom of the space. In panic, the electrician hit the emergency power cut-off switch, and realising that he would be unable to deal with the casualty unaided, attempted to hail the deck ratings below, first by shouting and then by throwing down some light tools on the deck. Unfortunately, the men operating the deafening descaling machines were well covered under balaclava-like cloth wraps, goggles and effective ear defenders and therefore were not aware of the events in the crane. Valuable seconds were lost while the electrician descended from the crane cabin, down the pedestal and finally got assistance from the deck crew.
The alarm was quickly raised in the accommodation by a crew member running some 150 metres aft, while the other seamen squeezed themselves inside the crane cabin, and managed to haul out the junior engineer from the contactor space. In a few minutes, the stretcher party arrived. However, the stretcher was unusable in the close confines of the crane cabin, and after some more minutes’ delay, a stout messenger line was fetched from the forward rope store and the now lifeless body was lowered on the deck. It is estimated that by this time, the junior engineer’s heart had stopped for more than 10 minutes and despite vigorous resuscitation efforts he never regained consciousness and was declared dead soon after. His body was placed in the ship’s cold rooms and flown onwards to his grieving family from the next port the following day.
Root causes/contributory factors
- Lack of proper risk assessment and work plan;
- Inappropriate use of protective clothing;
- Hazardous carriage of uninsulated tools on person;
- Inadequate coordination between electrician and deck chipping party;
- No rescue equipment prepared at site.
Other lessons
- Fault-finding operations must always be done methodically and strictly in accordance with maker’s service manual. Wherever possible, after isolating power supply, components may be safely removed and tested on a workshop bench or jig. In situ testing, especially where high voltages and currents are involved, can be very unsafe.
- Personal protective clothing and equipment must never be removed or adjusted for reasons of comfort.
- When two or more persons are involved in an operation, they must fully understand each other’s actions. If possible, they should be in full view of each other, and in any case, must have a reliable means of communication at all times.
- Critical operations must be only attempted under conducive conditions. Adverse external environmental factors, such as noise, vibration, and temperature must be eliminated or properly controlled.
- Contingency plans must be carefully explained and rehearsed before commencing work and emergency equipment must be available on site.
- Reliable means of communications with the bridge or other central control centre must be established and tested before beginning critical operations.
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