The second engineer was unable to open the lift shaft doors
A large container vessel was in port, undergoing a preliminary environmental compliance inspection, which, among other items, required the pit of the lift shaft (lift trunk) to be checked for oil residues. The lift car (elevator cage) was at the designated position on the lowest deck, but the second engineer was unable to open the lift shaft doors to gain access to the lift pit.
The chief engineer intervened to resolve the problem. Without stating his intentions, he entered the lift car, climbed through the escape hatch on the top, and shut the hatch behind him.
The second engineer reset the lift controls, incorrectly assuming that the chief engineer had taken manual control of the lift from the panel on top of the lift car. However, the chief engineer had not done so, and when the second engineer reset the system, the lift was returned to its normal automatic operating mode.
Suddenly, possibly in response to a random call from a higher deck, the lift car moved upwards at its usual operating speed and trapped the chief engineer against the door sill of the deck above, asphyxiating him. It is not known what the chief engineer had intended to do, but it is likely that he was leaning over the car, attempting to open the door locks manually.
Root cause/contributory factors
- On board SMS did not adequately address all hazardous tasks and risk assessment techniques. Lift maintenance and inspection was not included in the list of activities that required risk assessments;
- All the safety systems that could have prevented the accident had been ignored, reset or circumvented;
- Contrary to the manufacturer’s manual, which specified that at least two people were needed for work outside the lift car, the chief engineer was the sole person in the lift shaft at the time of the accident;
- No familiarisation, training or guidance was provided to the ship’s engineers for working on the lift. Working methods were developed informally and passed verbally from officer to officer.
Lessons learnt
- As general good practice, before any work is commenced inside the lift shaft, it must be ensured that:
- Reliable two-way radios are used for communications;
- The local stop switch/controls are engaged to prevent the lift responding automatically to calls from other stations;
- The emergency hatch on top of the lift car (that usually activates a safety interlock) is kept open for the duration of the work.
Recommendations
The MCA publication Code of Safe Working Practices for Merchant Seamen provides guidance on how to conduct an initial and detailed risk assessment. It also provides detailed information on the specific risks associated with working on lifts, in Section 21.22 Ð Personnel Lifts and Lift Machinery (Annex G). The most relevant points are summarised below:
- Regular examination of lifts must be carried out by a competent person at intervals not exceeding 6 months and a certificate or report issued;
- Any work carried out on lifts must only be performed by authorised persons familiar with the equipment and the appropriate safe working procedures;
- A formal risk assessment must be made to identify hazards associated with work on the installation, including work requiring access to the lift trunk;
- After the hazards have been suitably controlled, a permit-to-work system must be drawn up and all persons who are designated to carry out work on, or inspection of the lift installation, must comply with the stated procedures;
- Appropriate safety signs must be prominently displayed in the area and also on all remotely located controls and lift call buttons;
- Barriers must be used when it is necessary for lift landing doors to remain open to the lift trunk;
- Before attempting to gain access to the trunk, whenever possible, the mains switch should be locked in the OFF position.
Source: Mars/Nautical Institute
