200802 Pumproom incident

Following the completion of maintenance tasks in the pump room of a tanker in port, portable equipment and tools were being removed for securing. While the crew on the top were engaged in manually hauling up a portable hydraulic pump with a ployprop 'heaving' line, the chief officer began to ascend the access ladder. The hauling line was led through a portable grating section at the top of the pumproom lifting trunk. The grating consisted of four quadrants overlaid on a cross frame made out of steel angle bars, the frame and the gratings being supported on a extending lip in the trunk (see Figure 1). For convenience, the four grating sections had been removed, with the hauling rope leading through one of the open quadrants.

 

Fig. 1 - Detached cross frame

 

During the operation, due to contact with the moving hauling line, the cross frame dislodged and tilted sufficiently for it to fall through the trunk opening. The chief officer, who was still below the top level, was struck by the falling cross frame, weighing about 30 kg. He was given first aid by the ship safety officer before being transferred to a hospital ashore where, besides multiple lacerations, a fracture in his right hand was detected, necessitating his repatriation.

Root cause/contributory factors
Inadequate leadership and/or supervision;
Incorrect design;
Inadequate work planning;
Inadequate risk assessment;
Failure to identify and secure loose cross frame;
Inadequate monitoring of lifting.

Results of investigation
Before the work began, appropriate safety checklists had been properly used and all personnel had been properly briefed. However, no one was aware that the grating support frame was not fixed securely to the trunk and that it was only sitting on the narrow lip with a minimal overlap. During a recent lengthy drydocking, the cross frame and grating were removed to facilitate the lowering and raising of objects to and from the bottom of the pump room. Unfortunately, the hazard posed by an unsecured cross frame that supported a regularly-used grating atop a very deep trunk had not been identified either by ship or shore personnel.

Corrective actions
Two safety awareness meetings were held in the aftermath of the incident with all shipboard personnel.
A company letter was issued requesting all vessels to inspect grating supports and report any deficiencies to company. (It was interesting to note that the cross frames in other vessels with similar arrangements had already been bolted into place by the shipbuilder.)
A copy of the internal investigation report was forwarded to other company-managed vessels with instructions for the report to be discussed at subsequent vessel safety and vessel management team meetings.
A review of planned maintenance routines relating to grating and supports to be carried out.
The report to be circulated to industry, as important lessons were to be learned.
Provisions to be made to fix the cross frame securely to the ship's structure to prevent accidental removal or displacement.
All vessels instructed to fit a lifting lug to the centre of the cross frame to facilitate safe handling.
Company to implement a behavioural based safety (BBS) programme.