A worker was found crushed by a piston assembly within the engine room of a ship docked at a shipyard. The accident occurred when the Deceased was carrying out engine overhaul works together with a group of workers. During the installation of the piston assembly, the Deceased entered the crank case to carry out alignment work. While doing so, the piston assembly suddenly fell, crushing the Deceased who was positioned directly beneath the assembly. The Deceased was immediately extricated by fellow workers and sent to the nearest hospital, where he succumbed to his injuries about two hours later.
Figure: The Deceased was crushed by the piston assembly when it suddenly fell on him.
Recommendations:
Industry stakeholders undertaking similar work activities are advised to consider the following to prevent a recurrence:
Risk Assessment:
- Conduct a thorough risk assessment (RA) before commencing engine overhaul works.
- Site-specific hazards are to be identified and control measures put in place to reduce all risks associated with the work to be carried out. In this case, the risk of working under a suspended load (i.e., the piston assembly) should have been identified and adequate control measures (e.g., by using a remotely-operated device for piston assembly alignment or by re-designing the entire internals to eliminate the need for manual alignment) implemented to protect the health and safety of workers.
Lifting Plan:
- Establish and implement a lifting plan for the lifting operation involving the piston assembly.
- The lifting plan should include the selection of appropriate lifting equipment (inclusive of lifting machine, lifting appliances and lifting gear), steps to be taken to fulfill the requirement for a permit-to-work, as well as safe lifting procedures.
- Additionally, the lifting plan should specifically indicate the safe positions for workers to adopt during the lifting operation. Under no circumstances should a worker be positioned under a suspended load at all times.
- To achieve a safe outcome, communicate the lifting plan to all workers and provide the necessary supervision to ensure that the operation is carried out according to plan.
Pre-Lifting Checks:
- Institute the requirement for operators of lifting equipment to conduct pre-use checks to identify any damage or fault in the equipment before each lifting operation. Pre-use checks should include the following:
- visual inspection of the lifting equipment (i.e., the overhead crane, chain slings, lifting hook and lifting clamp in this case.
- confirmation that the load being lifted is within the maximum safe working load of the lifting equipment.
- functional test of the lifting equipment;
- functional test of the safety system and devices; and
- functional test of the emergency stop device.
*Please note that the information provided is not exhaustive and is for the benefit of enhancing workplace safety and health so that a recurrence may be prevented. The information provided is not to be construed as implying any liability to any party nor should it be taken to encapsulate all the responsibilities and obligations of the reader.
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Source: WSH Council
Indeed, an unfortunate accident resulting in loss of a human life.
However, a bit confused by the series of events described above. Haven’t seen or heard of a case where a person needs to enter crankcase of an engine to align the piston assembly of a Crosshead type engine that has a diaphragm. Generally, when the piston is lowered into the liner the space below is cleared of everything.
Did the piston assembly fall on the person elsewhere in the Engine Room?
This vessel was in a shipyard undergoing engine maintenance. There is no excuse in any scenario for faulty or untested lifting gear to be used. It is the responsibility of the ship owners, ship management and onboard staff (also shipyard equipment) to ensure all items used or listed in the Ship Lifting Gear register is certificated and up to date. Quite often, shipstaff are required to use the equipment provided onboard for maintenance purposes, and almost always find themselves under time pressure to get the work completed. For this reason, they must be confident that the lifting appliances are in good order and fully tested. The minimum requirement is that a competent person must check and ensure all lifting gear is ready for use and not damaged in anyway. Engine builders should recognise the dangers of operating maintenance equipment, often in strenuous conditions with the ship rolling at sea and very hot conditions in the engine room, and design more efficient and safe loading devices. Accidents do happen but, although we often think the marine industry is over regulated, this incident proves that attention to detail is of upmost importance.