An engineer suffered a crushed finger when there was an unplanned movement of a main engine exhaust valve during maintenance. The second engineer and a fitter were working together on the overhaul of a main engine exhaust valve. After completion, the valve was tested with compressed air. Once the air was shut off and the seat descended, the second engineer noticed some dirt on the face of the seat. He instructed the fitter to stand clear using hand signals, and attempted to clean the dirt with a rag. At that moment, the fitter opened the air and the seat face moved upwards, crushing the second engineer’s finger as he attempted to remove his hand.
The vessel had to deviate from its course to the nearest port to disembark the injured person for further treatment ashore, to substantial cost. The engineer suffered an LTI and loss of his fingertip.
A risk assessment had been reviewed and a toolbox talk had been carried out prior to the overhaul. It was not clear that communication with hand signals had been discussed at this stage. In the preceding weeks, the same team had undertaken overhaul of three similar exhaust valves.
What went wrong?
- Some of the immediate causes were found to be:
- Poor communication – although in plain sight of each other the noise of the engine room meant that verbal communication was not possible between the second engineer and the fitter. The fitter didn’t see or understand the hand signals from the second engineer, and the reopening of the valve was not communicated to the second engineer
- Hand placed in dangerous position ‘in the line of fire’
- Following the successful test of the overhauled valve, the compressed air was not disconnected prior to second engineer cleaning the face – crew were servicing equipment that was still in operation
- Inadequate planning – there was a failure to disconnect the compressed air prior to cleaning the face
- Hazardous environmental condition – noisy engine room;
- The root causes were found to be:
- There was no adequate system of communication and confirmation during operations in noisy environment was not identified during risk assessment neither discussed in the toolbox talk
- There was no isolation (lockout/tagout)
- Inadequate compliance – the risk in this routine, recurring task was seen as tolerable.
Lessons learnt/actions taken
- Develop method of communications in noisy work environment and ensure this is included in risk assessment;
- Review/familiarisation of crew on company lockout/tagout procedures.