In its latest Safety Flashes for July, IMCA describes a case involving a crew man, who got his finger stuck between the cargo and the lifting chain, during cargo operations. IMCA highlighted an insufficient management of change (MoC) by the company.
Management of change represents an organization’s ability to deal with change and capitalize on change opportunities. Change management includes adapting to the change, controlling the change and effecting new change, while it also requires an organization to take a proactive approach to change.
The incident
The incident occurred when a vessel was discharging modules with a weight of 220 tonnes direct from the vessel to a trailer on the quay. One hook of a chain tackle which was connected to the cargo, fell off. The other hook was still connected to the trailer.
When reconnecting the hook that fell off, a sudden movement of the module meant that one finger got stuck between the module and the chain. When the module swung back the crewmember was able to remove his hand. His finger was seriously damaged, and he had to be sent to hospital for X-ray and stitches. He came back onboard some hours later.
According to IMCA, the lifting was taking place at a relatively unsheltered location; there was some vessel movement from swell, but this was considered to be within acceptable limits. Notable is that the crew were experienced in this discharge operation; it was second time the ship was discharging in this port.
Probable causes
- There had been a change of plan, for which there had been insufficient management of change (MoC). The company has a technique for use in exposed harbours where swell is an issue. It was felt that there was insufficient equipment available for that technique to be used safely, so the decision was made to land the cargo straight on the trailer, using chain tackles to reduce the horizontal motion;
- No job hazard analysis or toolbox talk took place for the alternative lifting technique; this is considered to be the cause of the incident.
Actions taken
New technique was to be developed for landing cargo in a swell port, based on tools/equipment the company used in another product group (cross learning).
