Cause & Consequence
- Moving, flying or falling object
WHAT CAUSED IT:
- The grinder had no emergency stop system in place. Therefore the grinder continued its rotational movement once it was not under the control of the AB Seaman. This rotation resulted in cutting the seafarer and the wood deck;
- Improper position to perform the activity (on top of a ladder) and ladder was not properly secured;
- Deck space was not sufficient to perform the maintenance activity and was reported as being slippery;
- The condition of the crash-bar and this planned activity did not justify the urgency to perform this specific maintenance activity during the stand-by position at an offshore platform.
Procedural and/or Organizational Findings
- No evidence of Planning the Activity/Toolbox Talk;
- No evidence of Permit to Work issued (Hot work Permit/Working at Heights);
- The two seafarers working on deck (AB Seaman and Bosun) were working independently (not as per PTW requirements –supervisory needs);
- No evidence of a Task Risk Assessment being performed;
- General Risk Assessment (RA) Document/Manual was available onboard that vessel that incorporates a general RA sheet pertaining to surface preparation for painting.
Human Factor Findings
- The Able Seaman had been trained in accordance with the Safety Management System (SMS) in place and was competent in using of the specific tool;
- The Captain and Crew have proper knowledge of the SMS in place and of safety law requirements;
- No enforcement of Company rules by the crew;
- Lack of Risk Awareness & judgment by the crew.
CORRECTIVE ACTIONS: To address this incident, this company did the following:
- Conducted an inventory of the portable power tools available onboard all vessels and replaced the ones without an emergency stop system;
- Issued an instruction/circular aimed to control certain non-urgent maintenance activities on deck in particular circumstances (e.g. potential vessel instability/unpredictable movements);
- Reinforced instruction to personnel regarding the Stop the Job Authority;
- Reinforced instruction to personnel about the importance of Permit To Work, Risk Assessment and Toolbox Talk system to identify risk so as to become aware and reduce them;
- Issued instruction/circular aimed to limit the use of electrical tools under particular circumstances