A member has reported an incident in which a part was expelled from a hydraulic system under pressure, causing a leak of hydraulic oil. The incident occurred when the hydraulics were activated to turn the winch drum to install a new wire rope. There was a loud bang from the hydraulic pack as a sensor was forced out of the unit. The sensor hit the bulkhead to the right. Approximately 2 litres of hydraulic oil was also expelled from the winch onto the deck and bulkhead.
Our member’s findings were:
- Company safe system of work had not been followed – there had been no permission or sanction to test this equipment;
- The hydraulic system had not been commissioned properly. The hydraulic hoses had been fitted the wrong way around;
- The handover between technicians following crew change had not identified these issues.
Our member’s recommendations were:
- Improve communication between crews at handover especially at crew change;
- Formal ‘sanction to test’ should be completed before it is handed over to the responsible person in charge;
- Suitable and sufficient risk assessment and pre-use check list to be created and used for this work and equipment;
- Status and condition of equipment should be clearly defined before planned maintenance is carried out.
Members may wish to refer to the following incidents (search words: ‘safe system’, hydraulic):
- Hydraulic company sentenced after employee loses sight in one eye
- Near-miss: Contained hydraulic oil spillages from cranes
Both incidents relate to inappropriate release of stored hydraulic pressure in which a causal factor was failure to follow a safe system of work.
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