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During weighing anchor, the open gears of the windlass were being greased with the aid of a short-handled brush by a seaman. Due to the fixed gear cover, grease was being applied by poking the brush through the inspection hole with the winch operating lever secured in the 'heave' position.
Due to a momentary lapse in concentration, the seaman's hand got caught in the gears and was severed. Even though the chief officer was present on the forecastle deck, he was not directly supervising the operation.
Root cause/contributory factors
- A momentary lapse in concentration on part of the seaman;
- Inadequate risk assessment by the chief officer and crew member;
- Inadequate supervision and control over operation;
- Failure to comply with the Code of Safe Working Practices for Merchant Seamen, which requires that a powered appliance should always have a (suitably experienced) person at the controls while it is in operation.
Other valuable lessons
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Every anchor party should be made up of at least three persons, including a responsible officer or team leader. In this case, where an additional task was being performed, there should have been an additional crewmember, or the very least, an operator on the winch controls.
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A detailed risk assessment must be carried out and documented and crew members properly briefed before every operation involving working on or near moving gears / machinery. Appropriate sections of on-board procedures, work instructions in company manuals / planned maintenance systems should be reviewed or rewritten.
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Under no circumstances should the operating control of any machinery be left unattended and secured in the running mode.
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The persons involved in such critical operations must at all times be supervised by a responsible person and must always have visual contact and/or other reliable means of communication.
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Work on open gears must not be attempted when the gears are moving, unless alternate safer means can be employed, eg spraying grease pneumatically from a safe distance, or at least using a long-handled brush.
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If gears are to be lubricated while the machinery is rotating, it should be carried out in a safe and controlled manner, at a slow speed, with the rack and pinion gears turning outwards, so that it would have an effect of throwing out, instead of pulling in a foreign body.
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