Lessons Learned: Crew Person Cracked Shin Bone

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IMCA reports of an incident where a crew person cracked shin bone.

What happened

An engineer suffered a broken shin when he slipped taking a shortcut into the engine room. He went into the engine room down some stairs, in order to access a control panel, and found that access to the control panel was blocked by a plastic bag installed to collect paint chippings from maintenance work on the stairs. He took an alternative route behind the staircase, hit the stairs with his right shoulder, and lost his balance. He fell in such a way as to hit his ankle on a valve on the floor of the engine room, causing a cracked tibia (shin bone).

What went wrong

No-one stopped to think:

  • Maintenance work created new, additional hazards – the crew conducting the maintenance work had blocked the walkway.
  • There were no barriers or controls in place to stop anyone from using the stairs being maintained, nor was the available alternative route highlighted.
  • The crew doing the maintenance work had not communicated what they were doing to the engineers.

The engineer took an unnecessary shortcut when there was an easily accessible walkway to the control panel.

  • None of this was identified in any risk assessment or pre-job toolbox talk.

IMCA member noted the following learnings

  • Understand the need for thorough risk assessment that identifies all potential hazards including those which might arise from maintenance work.
  • Ensure effective communication is in place between departments, shifts, crews etc especially with regard to blocked access, maintenance, and any simultaneous operations going on.
  • Ensure proper signage and physical barriers are in place where required during maintenance work.
  • Take FIVE…STOP!! Think and look again. Remember you have a right and a duty to STOP THE JOB if it is unsafe.

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Source: IMCA