A member has reported an incident in which a rigging foreman sustained a serious hand injury during operations to recover two redundant 4″ diameter rigid steel pipelines of around 16km in length, together with a power and communications umbilical. The two 4″ pipes and umbilical were being recovered over the stern of the vessel and pulled up the deck with a tugger winch in order to cut them into 10m sections for transfer ashore and disposal. The process involved securing the pipes/umbilical bundle in a clamp at the stern of the vessel and cutting the bundle with a hydraulic cutter further up the deck. A chain stopper was then secured around the bundle just aft of the cutter in order to pull the bundle a further 10m up the deck for the next cut. This was a repetitive, continuous operation scheduled to take three to four weeks with two rigging crews working 12-hour shifts.
The injuries were sustained less than two days before the completion of this recovery operation. The injured person was preparing to fit the chain stopper immediately after a cut and was rearranging the two 4″ pipes and umbilical into a triangular configuration to ensure the chain stopper would not slip. During this process, residual tension in the pipes caused one to spring against the other. The injured person’s hand was crushed between the two pipes resulting in partial amputation of two fingers.
Investigation revealed a number of failures, particularly with reference to ‘routine’ or repetitive tasks, and identified a number of questions that project and vessel management teams could ask themselves.
- There was a lack of defined process:A procedure and risk assessment for the recovery operation was prepared onshore. However, during the course of the work (five weeks) various changes were allowed to creep in without recognition or challenge – something that is not uncommon with ‘routine’ and repetitive work. The actual work processes were no longer being defined by the procedure, nor, as a consequence, by the risk assessment.
- How does your team ensure that work is always conducted to an up-to-date and risk assessed procedure?
- Are all supervisory staff conscious of the tendency for ‘routine’ and repetitive tasks to creep away from original procedures and risk assessments? How do you check?
- Do toolbox talks ‘routine’ly involve using the procedure and the risk assessment to ensure personnel are familiar with the planned process, its hazards and consequent safety controls?
- There was a failure to apply the management of change process:The management of change process was not applied to changes in equipment, process or operational conditions. As a result, procedures were not updated and the changes were not subjected to risk assessment.
- Is your team applying the management of change process correctly?
- Are all key personnel familiar with the circumstances in which management of change must be applied?
- Have any changes crept into ‘routine’ processes that haven’t been subjected to management of change, and therefore risk assessment?
- There was a lack of adequate supervisory controlThe management team on the vessel did not ensure that the work was completed to an approved and risk assessed process. Differing approaches developed within each shift.
Much of the work conducted by IMCA member’s is ‘routine’ and repetitive work and potentially hazardous. A key lesson to be learnt is the need for constant vigilance for actual practice creeping away from intended practice. When procedures are no longer followed accurately, control of work can be lost, resulting in a loss of assurance that work is being conducted safely.
IMCA Safety Flashes summarise key safety matters and incidents, allowing lessons to be more easily learnt for the benefit of all. The effectiveness of the IMCA Safety Flash system depends on Members sharing information and so avoiding repeat incidents. Please consider adding [email protected] to your internal distribution list for safety alerts or manually submitting information on incidents you consider may be relevant. All information is anonymised or sanitised, as appropriate.
IMCA’s store terms and conditions (https://www.imca-int.com/legal-notices/terms/) apply to all downloads from IMCA’s website, including this document.
IMCA makes every effort to ensure the accuracy and reliability of the data contained in the documents it publishes, but IMCA shall not be liable for any guidance and/or recommendation and/or statement herein contained. The information contained in this document does not fulfil or replace any individual’s or Member's legal, regulatory or other duties or obligations in respect of their operations. Individuals and Members remain solely responsible for the safe, lawful and proper conduct of their operations.