201928 Missing out on the LOTO ticket

25 Apr 2019 MARS

Missing out on the LOTO ticket

While at sea in good weather conditions, two crew members were detailed to grease the mooring winches, a job they had done in the past. Before starting the work, a tool box meeting was carried out and a job plan agreed. The greasing was to be carried out with the winch in slow running mode. After greasing, the winch control lever was put to neutral and they began to wipe away the excess grease.


Although crew member A had started the job with gloves on, the gloves became soiled while cleaning the excess grease and were difficult to work with so he removed them. He continued cleaning the excess grease without gloves.


The winch lever safety locking mechanism had not been engaged and at one point, crew member A accidentally touched the winch control lever with his back, which caused the winch to move in the heave-up direction. His hand got stuck in the winch gear engaging assembly and he shouted for help. Crew member B immediately stopped the winch and, after checking with crew member A, slowly moved the winch in the opposite direction to clear his hand from winch.



Lessons learned

  • Tool box meetings are serious affairs and should account for all known risks and reiterate PPE use. In this accident it is hard to imagine that the tool box meeting accomplished this end.
  • If machinery is running, as in the greasing phase, at no time should parts of your body be close to the moving parts of the machinery.
  • If body parts are to be close to machinery that can potentially move, as in the excess grease cleaning phase of this report, lock out – tag out (LOTO) procedures should be employed. In this case, the power supply to the winch should have been locked out before the grease clearing began.