Cause & Consequence
- Handling, lifting or carrying
Any Location Type
Lifting, crane, rigging, deck operations
Incident Info Source
Specific Incident Equipment
Tugger wire, towing pins
The findings of the investigation revealed the tow pins did not have an audible alarm when operated. Due to a crew change occurring at the same time as the tow pin operation, the tow pin operator was distracted momentarily. This is considered to be a contributing factor that led to the incident occurring.
A revised set of procedures which include only raising one tow pin a time has now been implemented. A danger area around the pins has been identified to ensure no crew members are to be inside this area whilst the pins are being operated.Revision of procedures should include management of change due to the increased hazards created while crew changing during operations to ensure that these are safely and properly managed.