Lessons Learned: Training Gaps Can Turn Survivable Injuries Fatal


Training gaps can turn survivable injuries fatal, reports Safety4sea.

The Incident 

As UK MAIB reports in its most recent Safety Digest, it was late afternoon and a cargo vessel alongside in port had completed discharging its cargo of animal feed.

The port’s operational staff finished for the day shortly afterwards, switching off the terminal’s overhead shore crane floodlights as they left. It was dark and raining. With the cargo hold empty and the hatches open, the cargo vessel’s crew were instructed on the risk assessments for working in the hold and signed the working at height form. The crew then entered and installed a single spotlight at the aft end of the hold and began moving the hold’s internal dividing bulkheads. A couple of hours later, the ship’s cook/AB was working at the bulkhead at the forward end of the hold. Wearing a safety harness with a lanyard and safety hook, the AB used the recessed footholds in the side of the cargo hold to climb about 2.5m to access one of the bulkhead locking bolts and attached the safety hook.

The AB was unable to reach the locking bolt and, using one hand to hold on, disconnected the safety hook and attempted to move it to another position. The AB’s foot slipped from the foothold and their hand slipped from the single handhold before the safety hook could be attached to asecuring point. The AB fell to the hold bottom, resulting in an open fracture to their upper arm.

The ship’s master called the emergency services and, due to the difficulties of lifting a casualty out of the hold bottom, medical attention was administered at the scene for over an hour before the AB could be recovered to a waiting ambulance and transferred to hospital for further treatment.

Lessons learned

  • Equipment → The safety harness worn in this case was equipped with only one lanyard and hook, limiting the ability of the wearer to move around safely at height. Once the safety hook is disconnected to move to another locking point, the wearer remains at height without any fall arrest or fall prevention measures apart from hand and footholds; this might be unsuitable in the local conditions. A harness with twin lanyards and safety hooks enables movement at height while providing a means of fall prevention.
  • Risk → It was inappropriate for the AB to be working at height in the dark and rain with no shore floodlights and only a single spotlight at the aft end of the hold. The ship’s working at height risk assessments did not include such factors, demonstrating that all realistic scenarios in which crew might be expected to work had not been considered and resulting in documentation that was of little safety value.
  • Procedure → The ship did not have procedures or equipment to recover an injured person from the cargo hold. Without suitable crew training and recovery equipment, it is possible for a survivable injury to become a fatality. Think about what could go wrong and then plan and be prepared to respond in the event that it does; it could be you lying at the bottom of the hold in serious pain.

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Source: Safety4sea