During cargo operations, a crewman got his finger stuck between the cargo and the lifting chain. The incident occurred when a vessel was discharging modules with a weight of 220 tonnes direct from the vessel to a trailer on the quay. One hook of a chain tackle which was connected to the cargo, fell off. The other hook was still connected to the trailer. When reconnecting the hook that fell off, a sudden movement of the module meant that one finger got stuck between the module and the chain. When the module swung back the crewmember was able to remove his hand. His finger was seriously damaged, and he had to be sent to hospital for X-ray and stitches. He came back onboard some hours later.
Our member noted:
- The lifting was taking place at a relatively unsheltered location; there was some vessel movement from swell, but this was considered to be within acceptable limits;
- The crew were experienced in this discharge operation; it was second time the ship was discharging in this port.
What went wrong? What were the causes?
- There had been a change of plan, for which there had been insufficient management of change (MoC). The company has a technique for use in exposed harbours where swell is an issue. It was felt that there was insufficient equipment available for that technique to be used safely, so the decision was made to land the cargo straight on the trailer, using chain tackles to reduce the horizontal motion;
- No job hazard analysis or toolbox talk took place for the alternative lifting technique; this is considered to be the cause of the incident.
What actions were taken?
- New technique was to be developed for landing cargo in a swell port, based on tools/equipment the company used in another product group (cross learning).
Members may wish to review the following incidents, both of which have inadequate management of change (MoC) as a casual factor:
See also Guidelines for management of change (IMCA SEL 001)
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