What happened

Two engine crew members were shifting vertically stacked metal sheets (1200x 2500 x 3 to 5 mm) in the engine room. Towards the end of the task, two of the sheets suddenly started moving backwards resulting in both crew members getting caught between the sheet and a wooden box situated behind them.

Consequences

  • One crew member was in a state of shock and had to visit shore doctor for further medical examination.
  • Potential for severe injuries/fatalities

Causes

  • Failure to follow procedures/instructions - work planning and toolbox meeting did not adequately assess all hazards and counter measures. COSWP guidelines not properly adhered to.
  • Improper position for task - incorrect positioning of the crew while handling the plates lead to getting caught between the plates and the wooden box.
  • Improper lifting - suitable tools for handling the steel plates were not available or used (plate clamps, chain blocks etc.).
  • Poor housekeeping - permanent stowage and safe securing arrangement (horizontal or vertical storage rack) was not available for the metal sheets.
  • Lack of situational awareness / risk perception - both crew members were caught unaware by the metal sheet due to lack of situational awareness. Only two persons was considered enough for shifting the plates. Adequate human resources not utilised.
  • Inadequate supervision and coaching - lack of proper initial instructions and lack of regular supervision.

Lessons learnt

  • Assess appropriate number of persons required for a task, do not hesitate to ask for help.
  • Appoint a senior officer to supervise the entire operation. Ensure situational awareness.
  • Do not move loads over people working below.
  • Assess weather conditions and use appropriate PPE for the task.
  • Identify and discuss number, size and weight of the plates being handled.
  • Carry out detailed work planning and conduct toolbox meeting at the worksite to discuss work plan, assess and highlight the risk and contl measures required.
  • Assess equipment available to handle the steel plates and their SWLs. (Crane/overhead davits/pad eyes/chain blocks/ spreader bars/ slate clamps etc.)
  • Assess intended route for transfer of the plates, positions for attaching lifting devices to the plates, position of the crew while handling the plates.
  • Ensure that the crane or hoist used is positioned directly over the load to prevent the load from swinging as it clears the floor or ground. Use steadying lines to assist the safe maneuvering of loads during lifting.
  • When removing/adding a plate to an existing stack, ensure that the entire stack is not left unsecured, as it may fall or shift causing severe injuries. Take extra care when handling plates which are not stowed horizontally.
  • If moving the plates over long distances, where overhead lifting arrangements are not available, consider use of a suitable trolley.

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Caution: In another similar incident, the fitter on our ship broke both his fore arms while shifting metal plates in the engine room.

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