A worker inside a ballast tank fell from height. The incident happened when a welder and two welder helpers were installing additional stiffeners on the inside of a water ballast tank. Whilst going to the work site inside the tank, one of the welder helpers fell through an opening on the tween deck. The opening is part of the design of the vessel to allow water to pass through.
The crewman was rescued in a medical evacuation. He was taken by helicopter to an intensive care unit and is currently recovering at home.
What were the causes? What went wrong?
- The work was considered a “small” job. The risks of the route taken to the workplace were not properly assessed. A permit to work was put in place for the confined space entry and the hot work. However, the specifics for the job were not considered;
- Stop Work Authority was not used. On at least one occasion scaffolding or other means to improve access to the worksite was brought up. The last inspection led to a call to the scaffolding foreman, with the request to install scaffolding. However, the welding team was not advised to wait;
- Due to a last-minute change, the person who fell, joined the team only after the last minute risk assessment for the job was performed;
- The injured person crossed a barrier (handrail) inside the tank on the way to the work site. It is not known why he took that route and what caused the fall. The surfaces of a tank are slippery when it is empty;
- The team were not accustomed to working in confined space; they considered it a routine job and did not stay together in the confined space.
What actions were taken?
Immediate actions taken included making the access to the tank safer and holding a Time out for Safety with the whole crew. A presentation with a summary of the investigation was shared with all sites.
- Updated risk assessment for confined space entry to highlight measures for safe access and the hazard of working at height if applicable;
- Retraining for crew in last minute risk assessments, focusing on importance of managing change – stop and re-evaluate when anything changes;
- Further emphasis on Stop Work Authority.