Broken right hand index finger
A member has reported an incident in which a worker broke the index finger on his right hand. During a maintenance period it became necessary to deballast a methanol tank. As a result of the envisaged high work load there were three chief officers onboard and additional staff. The senior chief officer instructed the second chief officer to de-ballast the starboard tank through the port manifold Avery Hardoll connection to sea. It was known that the non-return valve (NRV) was not in place.
The second chief officer had noted on the previous day that the line was open and the Avery Hardoll cap was off, and therefore he started the pump. However, there was immediate back pressure showing on the gauge and no discharge was noted. The second chief officer concluded that the Avery Hardoll cap must in fact have still been on the line and so a deckhand was instructed to remove the cap. The deckhand stood to one side, and tried to move the cap by hand but was unsuccessful and therefore tapped it with a hammer. The cap was ejected from the manifold and struck the deckhand on his right hand, lacerating and breaking his index finger. The deckhand received first aid onboard and subsequently went to hospital for minor surgery to his finger.
Following investigation, the following points were noted:
- The cap had not been removed from the discharge manifold prior to energising the pump and pressurising the line;
- The second chief officer was experienced and the subject of good reports, who was not fatigued and acknowledged awareness of the procedure and the responsibility to ensure the lines were set up and the cap removed;
- The assumption that the line was open was incorrect – the second chief officer acted out of character, made an incorrect assumption and did not follow procedures;
- The risks associated with not having a NRV in place were not considered;
- Had procedures been followed the incident would have been prevented;
- The Avery Hardoll male connection was damaged and did not function as designed. Had it operated properly it would have sealed the pipework, preventing the pressure build up behind the cap;
- Whilst the decision to use the line cannot be faulted (i.e. the lack of a NRV made the configuration all but identical to a water ballast tank which does not have an Avery Hardoll) the presence of a NRV would still have been a barrier against incident;
- Having made the initial misjudgement and as a consequence pressurised the line, the task should have been stopped and a new toolbox talk convened to consider the risks and take appropriate action to mitigate them;
- The root cause of the incident was failure to follow procedure and to stop the job once a deviation from the norm was experienced.
A number of lessons were drawn from this incident:
- Had procedures been followed the accident would not have happened;
- The presence of a NRV in this context would act as an additional safety barrier;
- Having made the initial misjudgement and as a consequence pressurised the line, the task should have been stopped and a new tool box talk convened to consider the risks and take appropriate action to mitigate them.
Published: 27 January 2011
Download: IMCA SF 01/11
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