The incident

On 05 April 2017, the electrician had been working with the electro-technical trainee when work was stopped for the day. However, at about 1745 (LT), when the electrician had not shown up for dinner, the trainee engineer became concerned and informed the chief engineer.  A search of the area where the electrician was last known to be working was carried out and he was eventually found inside the elevator shaft, trapped between the counterweight and a protective beam.

The alarm was raised and the crew rushed to release him and administered first aid, including resuscitation, but he did not respond. He was pronounced dead at the scene. The master immediately informed the company Designated Person Ashore (DPA) and the local authorities.

Probable cause

The immediate cause of the death was the downward powered movement of the elevator car, causing the counterweight to move upwards and entrapping the electrician between the counterweight and one of the counterweight guard beams.

Safety issues

  1. The electrician stepped out of the safety cage;
  2. The position of the elevator car would suggest that the electrician probably reset the latch-out system in the machinery room on deck D and thereafter called the elevator car to deck A, prior to entry into the elevator shaft through the elevator door on deck B;
  3. From the position in which the electrician was found, the only logical explanation appears to be that he returned to retrieve a plastic bottle of oil, either to prevent an oil spillage or to top it up and return it on the following day;
  4. The actual risk taken by the electrician to access the elevator shaft on his own is suggestive of an efficiency-to-thoroughness trade off (ETTO);
  5. The re-entry inside the elevator after the day’s work was over must have been perceived to be trivial and did not require the entry of a second person.

Other findings

  • Both fatigue and alcohol were not considered to have contributed to the accident;
  • Whilst the elevator was put out of service, the responsible expert was not called or informed of the problem as required by the manufacturer’s manual;
  • It was evident that up until the electrician and electro-technical trainee finished work for the day just before dinner on the evening of 05 April, the on board procedures in accordance with the safety management system were complied with;
  • The position in which the electrician was found indicated that he would not have been able to operate the elevator manually, as he would have been unable to reach the maintenance buttons due to the attachment of the safety harness;
  • The elevator was not intentionally moved from the inside of the shaft at the time of the accident;
  • The only way the elevator could have moved mechanically would be if the maintenance switch was not in the ‘ON’ position at this time;
  • Subsequent checks by a qualified person found the elevator brake to be in good working order.


In view of the conclusions reached and taking into consideration the safety actions taken during the course of the safety investigation,

-the Merchant Shipping Directorate is recommended to:

  • publish an Information Notice to raise awareness on the hazards related to working alone and the importance of communication in enclosed spaces.

-Augustea Tecnoservice srl is recommended to:

  • disseminate the findings of this safety investigation report to the fleet regardless of whether they have elevators or not, in order to highlight the importance of communication when working alone or in confined spaces;
  • review the risk assessment for ‘Electrical Workshop Activities on Elevator Cage’, with a view to include electrical isolation, and safe entry and
    exit of the elevator shaft;
  • provide specific training to personnel involved in elevator maintenance;
  • review the maintenance, inspection and test operational procedures so as to specifically exclude all adjustment of limits by ships personnel unless supervised by an expert.

Further details may be found herebelow: