A purifier was being reassembled after routine overhaul by an engineer and a rating. The bowl was being lowered on to the shaft by the rating using a chain block. While the engineer was aligning and guiding the bowl, his fingers inadvertently entered one of the ports. As the rating proceeded to lower the bowl, the engineer's finger got crushed between the bowl and the casing. After first aid on board, the engineer had to be discharged from the next port on medical grounds.
Root cause/contributory factors
- Lack of proper risk assessment or work plan;
- Momentary lapse in concentration on the part of both the engineer and rating.
Other lessons learnt
- A 'toolbox' meeting must always precede such routine maintenance tasks, when a fresh appraisal of the risks must be done by all those taking part in the task.
- Whistle signals are very useful where voice instructions in a high-noise environment may not be heard or misheard.
- Where there is a risk of fingers inadvertently being used as 'alignment tools', any exposed holes must be temporarily closed by temporary plugs, masking tape or other similar means. A proper tool must be used for aligning components.
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