A crewman on a vessel lost his balance going down some stairs and fell, resulting in a fractured ankle. His foot got caught in a gap as he landed at the bottom of the stairs. He suffered 3 broken bones and his foot was dislocated. He was evacuated by helicopter to hospital, where surgery was performed a number of days after the event.
What went wrong?
- The injured person lost footing when descending staircase:
- he was not rushing, and it was stated he was not showing any signs of pressure or stress prior to the event
- there was no significant vessel movement (wave height 2mHs, wind NE 25knots)
- person stated he was holding the handrail;
- His safety shoes were in a poor condition and did not meet company standard (ankle height).
What were the causes?
- Immediate causes:
- person lost footing and fell forward
- complacency/lack of situational awareness
- potentially poor standard of footwear, however soles of shoes were not excessively worn;
- Underlying causes:
- potential for tiredness/fatigue – the incident occurred on a nightshift
- failure to identify that the gap at the bottom of the staircase may present a hazard. Although it should be noted that the stairs were classified in accordance with local regulatory standards.
What lessons were learned?
- Worn out personal protective equipment (PPE) should be checked regularly and replaced when required;
- Never rush on stairways and always keep one hand firmly on the handrail, utilising the trailing hand technique where possible.
What actions were taken?
- Additional warning signage was placed at top of the staircase;
- Review of instructions/expectations regarding company standard of safety footwear;
- Improvement modification was added to staircase in order to prevent a person’s foot from becoming caught between the single protruding step and the staircase.