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SAFETY4SEA

Lessons learned: Closed-loop communications important for safety-critical tasks

by The Editorial Team
January 23, 2023
in Accidents
chirp lessons learned

Credit: Shutterstock

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CHIRP informs of an injury of a crew member, who while pulling the block forward to keep lines off the teak deck, was hoisted roughly 5m high.

The incident

On the dock, pulling on the running backstay requires someone pulling the block forward to keep lines off the teak deck.

The supervising officer operated the winch at high speed, and the crew member on the block got their hand caught in it.

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As the block lifted, it hoisted the crew member roughly 5m high. It suddenly stopped, catapulting the crew back to the deck, missing the mainsheet track by 10cm.

The casualty suffered a broken wrist, required stitches to the lip and chin, and was knocked unconscious for 5 minutes. The  crew member had to pay for their flights home and was off work for a month.

Probable cause

According to CHIRP, there needed to be better coordination between the supervising officer and the person working the block.

Clear verbal warnings that the hoist was about to start would have alerted the crew member to keep their hands clear.

The use of closed-loop communications in such circumstances should be considered, e.g., the crew person responding “Clear!” to the officer’s alert of “Operating winch!” or similar.

Lessons learned

  • Communications: Use closed-loop communications for safety-critical evolutions such as lifting.
  • Teamwork: Better coordination between the winchman and the block handler would have reduced the risk of entrapment.
  • Local practices: Where possible, reduce entrapment risks by looking for alternative methods to achieve the aim. A floor covering would have been a safer option.
  • Culture: The report that the casualty had to pay to repatriate themselves suggests poor personnel and welfare standards on board, which is also an indicator of a poor safety culture.
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