Lessons learned: Conduct risk assessment prior to the operations

The incident

While a vessel was at anchor, the crew received spares for the main engine and planned to move them into the engine room through a large hatch on deck. The weather was good and seas were calm.

The Chief Engineer led a discussion about loading the spare parts and put the 2nd Engineer in charge of the operation which included the 4th Engineer and an AB.

As seen in the figures below, the hatch to the engine room was large and mounted on a raised coaming and fitted with a counterweight to make it easier to open. Once it was open, the hatch could be secured in the upright
position using a pin.

The hatch was reported to be in good operating condition and well maintained. Stanchions with ropes surrounded the hatch to prevent someone from falling in when the hatch was open.

The 4th Engineer and the AB lifted the hatch by first unscrewing the dogs, then lifting the front of the hatch with help from the counterweight.

The 2nd Engineer noticed they had difficulty lifting the hatch; partly due to its weight and partly because it was difficult to work through the safety ropes strung between the stanchions.

To help get the hatch open, the 2nd Engineer sat on the on the counterweight to increase its effect. The hatch still did not open so he then stood on top of the counterweight hoping it would then open with his full weight applied.

The hatch then opened but as a result, the 2nd Engineer lost his footing and fell with his left leg sliding between the counterweight and the hatch coaming breaking a bone in his lower leg.

At the time of the injury, the 2nd Engineer was wearing a boiler suit, hardhat, gloves and safety shoes. The shoes were in good condition with good tread but were ineffective on the cylindrical smooth surface of the counterweight.

Potential Risks

While a broken leg is serious, he easily could have suffered a more serious injury or additional injuries especially if they had lost control of the hatch.

Lessons learned

• The vessel’s crew knew that the counterweight was insufficient by itself to open the hatch and would require the assistance of several crew members. It was also clear to the crew that opening the hatch would have to involve several personnel and rigging of safety ropes. These issues alone should have triggered those responsible and those engaged in the operation to consider a risk assessment prior to the commencement of the operation.
• Such a risk assessment should consider additional safer options that might have been available. For example, the same crane being used to lift the spare parts and lower them into the engine room could have been used to lift the hatch first. A block and tackle or chain fall could also have been used to help lift the hatch until the effect of the counterweight took over.
• Adding physical body weight to the counterweight by sitting or standing on it seemed a simple idea but was found to be a poor decision as well as an unsafe one. The 2nd Engineer failed to assess the risks to his own safety.
• Further, any of the other crewmembers involved in the operation could have and should have stopped the operation for safety reasons when they saw the 2nd Engineer sit and eventually stand on the counterweight. The counterweight had not been designed for either sitting or standing for any reason.