A crew person was checking the water tightness of the engine room’s emergency hatch cover. Safety lock pins, used to prevent the hatch cover from closing, were missing. To hold the hatch cover from closing, the crew person improvised using a nearby chain which he hooked to a hose support. However, the improvised arrangement failed and the hatch cover closed unexpectedly. The injured person had his left hand in the mouth of the hatch, and the hatch cover landed on his fingers. The tips of his two longest fingers were very badly injured, and had to be amputated.
This incident contains a link to a graphic photograph of the injuries sustained.
- Poor spatial awareness: the injured person was not aware of the pinch point; therefore he didn’t stop the job when he saw that there were no safety lock pins on the hatch;
- The injured person improvised an inadequate and inappropriate method of securing the hatch cover;
- The toolbox talk did not highlight potential hazards such as line of fire, pinch point, etc. and its mitigation.
What was the cause
Our member notes the cause as being an inadequate planned maintenance system which did not highlight the lack of safety-critical locking pins.
Lessons and actions
- Review and modify existing planned maintenance system onboard to ensure it is properly implemented and is not just a “checklist tick”;
- Reiterate importance of thorough toolbox talks before the job – take the time to think things through;
- Don’t just improvise safety equipment – stop the job, think it through, get it right;
- Are there areas in your work where you might be tempted to “just do it anyway?” without the right safety equipment?
Members may wish to refer to:
- LTI: crew member crushed finger when opening fire flap [an inappropriate tool was used]
- Hand injury during closing of hatch [hatch would not lock properly because locking mechanism was mis aligned]
- Injury caused by closing fire flap [crew failed to follow existing procedures, improvised and “cut corners”]
- Graphic photograph of the injured fingers in this safety incident
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