An incident reported by IMCA involved a worker sustaining a back injury during confined space operations on board a vessel. The incident highlights access and egress challenges related to structural design during maintenance tasks.
What Happened
During planned maintenance, a worker was exiting a confined space through a lightening hole. The individual attempted to exit feet-first while facing upward, using a grab handle and a stiffener plate located above the opening. During this maneuver, the worker’s hands slipped, resulting in a fall that caused them to strike their lower back on a beam at deck level. Despite the impact, the worker was able to exit the compartment without assistance. However, they later required onshore medical assessment and treatment.
Why It Happened
The exit technique required the worker to face upward and rely solely on hand grip, which limited control during movement and prevented fall prevention once grip was lost. The confined space design prioritized structural requirements over ergonomic access and egress. The access/egress arrangement included only one external grab handle, limiting safe support options. The task risk assessment focused primarily on the maintenance activity itself and did not adequately address access and movement within the confined space.
Actions Taken
- Additional grab handles were installed inside the compartment.
- An evaluation was initiated to explore installing platforms on either side of the lightning hole to assist movement in and out of the space.
- A full review of confined space entry procedures was conducted, focusing on safe entry and exit techniques, body positioning, and navigation through structurally challenging areas.
Lessons Learned
- Risk assessments for confined space tasks should equally emphasize safe access, egress, and internal movement, not just the work being performed.
- Access design must consider worker ergonomics and not rely solely on structural constraints.
- Repetitive exposure to high-risk tasks, such as routine maintenance, can lead to normalization of risk and overlooked hazards.
- Comprehensive reviews of confined space procedures can help identify overlooked risks and improve overall safety measures.
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Source: IMCA
