200703 Fall in pump room

During a fire drill, the second engineer entered the emergency fire pump room to operate the emergency fire pump: this involved negotiating a vertical ladder section within a straight access trunking. While climbing down the ladder, he was holding the side rails for support.

In the course of its descent past an intervening deck and presumably in order to allow for flexing, the vertical ladder was split into an upper and lower section, with a gap in the side rails of about 95 mm. The engineer apparently overlooked this "missing" section in the side rails, and when he reached this spot, he suddenly lost his handholds and fell about three metres to the bottom of the pump room.

He was wearing all the regular PPE such as helmet, gloves, safety shoes. Fortunately, his injuries were limited to cuts and bruises. Had he fallen fully backwards, his injuries could have been crippling or even fatal.

 

 Gap between the upper and lower ladder: 95 mm; upper ladder: 2.7 m, lower ladder: 3.3 m

 

Corrective action
The upper and lower ladder sections were joined by welding flat bars across the gap in the side rails.

Root causes/contributory factors
Gap between upper and lower ladder sections;
Hasty descent, perhaps due to 'drill' environment.

Other lessons
It is an accepted design practice to include a gap in a vertical ladder over intervening decks or flats, as a single ladder section may be damaged by racking forces and flexing. However, just as expansion bends are incorporated in pipelines, such ladder sections could be joined by short, curved side rail sections, or even rope or chain links.
Warning signs located at appropriate levels within and outside the access trunking could remind personnel of the gap or discontinuity in the ladder.

FEEDBACK - October 2007

I totally disagree with the 'other lessons' stated in this report.
1. It is an absolutely unacceptable practice to include such large gaps (95 mm) in a vertical ladder, which could be reduced to, say, 10 mm. Any shipyard is surely capable of working to such tolerances.
2. Class, shipyards, owner's yard teams must prevent or
rectify such defects in the yard and not wait until crew injuries occur and then get them to repair yard's mistakes.

Editor's response: In 'Other lessons', it was also suggested that 'such ladder sections could be joined by short, curved side rail sections, or even rope or chain links.'