A vessel main engine was started while the divers were in the water, and the engine was immediately shut down again by the bridge. The diver was able to exit the water and was unhurt in the incident. The incident occurred during diving operations in a dockyard to remove debris from a bow thruster.
What went wrong?
- Engine room to bridge communications procedures were not followed. The engineers started the engine without consulting the bridge;
- There was a failure to follow the diving permit to work (PTW) procedures;
- There was a failure to implement lockout/tagout (LOTO) procedure;
- There was no risk assessment conducted.
What actions were taken? What lessons were learnt?
- Only the vessel Master should have the authority to start the vessel’s engines;
- Sometimes, isolation tags (LOTO) are not enough, and physical isolations and barriers should be put in in place;
- Our member recommended the following specific actions:
- before divers enter the water, all subsea equipment should be physically isolated including the auxiliary engines and HVAC system
- lifting operations on the main deck are to be stopped while divers are in the water
- control of work documentation to be completed in full before any tasks are started, including any associated documentation from the diving teams
- do not sign off on the control of work unless you have physically checked to ensure that the control measures listed in the risk assessment and associated PTW have been put in place
- any mistakes in any official logbook should be corrected by placing the mistake in brackets or a single line through it so that it is still eligible – scraping out and use of correction fluid not to be permitted.
Members may wish to refer to:
- Near-miss (HIPO): Engine started and running whilst crew member working on shaft generator
- Dropped object fell from crane – Poor communication/lack of awareness/control of work
- Lost time injury (LTI): Finger injury during main engine exhaust valve overhaul [root causes: no adequate system of communication and confirmation; no isolation (lockout/tagout); inadequate compliance – the risk in this routine, recurring task was seen as tolerable].
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