As IMCA informs an engineer was injured as he was walking in the engine room searching for a tool and he stepped on a loose floor plate. The floor plate was not bolted down and slipped sideways. The engineer suffered a large laceration to his abdomen, which made him go to the local hospital.

An engineer was injured during a dry dock. Namely, as he was walking in the engine room searching for a tool he stepped on a loose floor plate. The floor plate was not bolted down and slipped sideways.

As the plate moved, his leg started falling to the bilge well below, and the opposite end of the plate flipped upwards and struck his abdomen. He sustained a large laceration to his abdomen which was attended to in the local hospital and needed seven days off work to recover.

Probable cause

According to IMCA, the factors that contributed to the incident are the following:

• No stopping mechanisms were fitted on the supporting frames/bars of the plates in order to stop these plates from sliding to the side. One particular plate was bent upwards at one corner and was able to slide freely if not bolted down;
• An existing unsafe condition (the loose floor plate) had been spotted but had not been reported or addressed;
• The permit to work (PTW) closure protocol following the earlier generator maintenance was not followed. No check had been made that the worksite had been returned to safe condition;

Moreover, root cause analysis identified that standards, policies and administrative controls were not used effectively and enforcement was not adequate. Specifically:

• The shipyard safety bridging document had been signed, but was not properly completed and did not effectively bridge between vessel and shipyard safety systems;
• There had been daily morning meetings of supervisors of all parties in attendance, but these meetings had discontinued a week prior to the incident.

In addition, on a day-to-day level, there were gaps in enforcement of the following procedures:

• Job safety analysis (JSA) and task planning;
• Personal protective equipment (PPE) – the injured person was wearing a light t-shirt instead of a full coverall which contributed to the severity of the injury;
• Hazard observation – the hazard posed by the existing arrangements of the flooring plates in the engine room had not been properly identified;
• Managing contractors and third-parties – successful integration and supervision of sub-contractor workforce was not applied despite procedures being in place. This led to a loss of control and safety oversight of their activities to some extent as well as a diminishing of the safety culture.

Lessons learned

After the incident, the IMCA concluded to the following lessons were learned:

• Attention to detail; personal safety is an individual as well as collective responsibility. In this case, both the unsecured deck plates and IP’s insufficient PPE were noticed but neither concern was raised further or addressed;
• Failure to properly coordinate activities and to supervise the jobs performed by sub-contractors for safe work can lead to serious consequences;
• The shipyard safety bridging document sets the standard for the importance of safety within a shipyard period. The document dictates the involvement of the Technical Superintendent conducting supervision as well as vessel personnel and all contractors involved.

In order to prevent a similar incident from happening in the future:

• Stoppers were fitted for plates to prevent recurrence;
• Loose floor plates were secured by bolts;
• A hazard hunt inspection was carried out to identify all similar loose floor plates;
• The safety inspection schedule and risk assessment were modified to include checking of floor plates, gratings etc.;
• Re-assess high level response to shipyard safety was re-assessed.

Source:safety4sea