201338 Stopper pin - when two is one too many

While the vessel was in dock, the bosun and an assistant carried out adjustment work on the windlass. After completing the job they intended to disengage the clutch by shifting the clutch lever. The bosun removed the stopper pin for the lever and instructed his assistant to shift the lever, which the assistant did (after first confirming all was clear and getting a confirmation back). However, the bosun’s finger was still positioned between the edge of the clutch lever and the stopper plate. As the assistant swung the clutch lever the bosun’s finger was crushed as the lever approached its end position. The victim sustained several superficial lacerations, a distal edge nail laceration and a fractured finger joint. He was treated with sutures and application of a prosthetic nail after surgical nail-bed repair.

The accident occurred at the end of a hard day’s work so fatigue may have played a part. Neither the bosun nor his assistant were aware the bosun’s fingers were in harm’s way.

Editor’s Note: This seemingly simple task still resulted in an unfortunate and rather serious accident – surgical nail bed repair is nothing to joke about. The two crew seemed to be communicating well enough but they both had less than adequate situational awareness. This company should be praised for identifying fatigue as a possible contributing factor – fatigue should always be considered until it can be shown not to have been a factor. It may be of interest however that from a formal investigative standpoint, fatigue is usually identified by documenting work and rest over a period of 72 hours or more, not just one day.

More importantly, had the bosun or his assistant accomplished this task alone, no injury could have occurred. If the same person first removes the pin and then throws the clutch lever their fingers cannot be in harm’s way. Of course, hindsight is 20/20 but this nonetheless highlights the advantages of carefully evaluating each task to be accomplished before acting.