During 2018 and 2019, AMSA received notification of two separate accidents that involved crew members being trapped and crushed by a moving elevator. In both instances, the elevator moved while the crew members were working between the elevator casing and the cage, resulting in fatal crush injuries.
In this regard, AMSA issued a marine notice highlighting shipowners’, operators’, masters’ and crews’ obligation to ensure safe working arrangements are in place for any work involving a ship’s elevator.
Incidents resulting in crush injuries caused by an elevator are not new, with a similar fatality investigated by the Australian Transport Safety Bureau (ATSB) in 2007.
In this instance, a crew member was crushed in the elevator while conducting repairs. Elevator related fatalities have also been reported on multiple ships in other parts of the world.
AMSA believes that such incidents are avoidable through the application of simple and effective risk controls.
Systemic failures related to fatal crushes in elevators on ships
Similar systematic failures have been identified in all of these fatal accidents. The following were considered to be some of the key safety issues:
- Elevator instruction manuals lacked unambiguous and usable safety guidance.
- No proper risk assessments were in place for elevator maintenance as part of the safety management system.
- Risk assessments that did exist were not effectively implemented.
- Crew were not aware of—or did not consider—all of the hazards associated with working in the elevator. An example of this is the counterweights that moved down as the lift cage moved up, causing harm.
- Untrained personnel were used to carry out maintenance and repairs on the ship’s elevators.
- No appropriate safeguards were in place—such as isolation lock-out—to ensure that the elevator cage did not inadvertently move while the crew were working in the elevator shaft.
See also: Fatality on elevator onboard highlights work hazards in enclosed spaces
Expectation
Potential dangers associated with elevator shaft involve:
- height risk
- injury by falling object(s)
- noise
- electrocution from live electrical circuits
- unanticipated movement of the elevator cage.
Recommendations
AMSA cannot stress enough the importance of conducting a proper risk assessment and implementing relevant procedures, which are applied in practice to ensure the safety of crew working on a ship’s elevator.
In addition, AMSA recommends planning for elevator maintenance or deferring elevator maintenance work until the vessel is in port and utilising a trained manufacturer’s technician.
Effective risk assessment
Meanwhile, AMSA has earlier provided guidance on tools and methods that can be adopted to support risk identification and the implementation of risk controls.
The aim of risk identification is to generate a comprehensive list of risks. This is important, as a risk that is not identified at this stage will not be included in the risk management process.
It is also important to ensure that people with different experience and expertise are involved in identifying risks.
In this way, differing perceptions can help in getting a richer understanding of risks.
Both the identification and implementation of risk controls are most likely to be successful when different perceptions are recognised and taken into consideration.
It is important that personnel on board are consulted and that their views together with other knowledge of risk are taken into account in the risk management process.
People’s individual perceptions may influence:
- willingness to consider new information
- confidence or trust in such information
- the relative importance given to information.
Effective communication and consultation will ensure everyone involved understands the basis on which decisions are made and the reasons why particular actions are requested.
Such communication and consultation further provides an opportunity for people to raise issues, for example regarding conflicting goals and competing tasks.
