The incident
The incident happened after two service engineers from a subcontracted company were on a vessel for the day to install a new electronics board in a radar antenna.
The job was completed safely, and all documentation related to permit to work (PTW)and job safety analysis (JSA) done, and a service report has been issued.
Then one service engineer went back to the monkey island to collect some missing tools, without wearing any personal protective equipment (PPE) (e.g. no fall protection) and without ensuring that the lock out/tag out and PTW were still in place.
When he reached the monkey island, he couldn’t find the missing tool, and so he went to check on the mast itself.
At that moment, the Captain and the second service engineer operated the radar for a final test.
The radar antenna started to rotate and hit the service engineer. He lost balance and fell down from the mast to deck and landed on the roof of a fiberglass lifeboat.
He suffered multiple fractures and was fortunate not to have been killed. He was medevaced to hospital for surgery.
Probable causes
- Poor communication and coordination;
- Poor management of subcontractors on the part of the vessel crew;
- Weak safety culture in subcontractor;
- Insufficient job preparation and completion of checklists.
Lessons learned
- Better communication required: the vessel Master and second service engineer were not informed that the service engineer went back up onto the monkey island;
- Job preparation: more attention should be given to detail in preparation and to identification and mitigation of risks;
- Subcontractor management: better management and control of subcontractor required. Subcontractors should be more thoroughly monitored, especially when working in a dangerous area;
- Subcontractor selection: better selection should be made to focus on HSE aspects and to encourage subcontractors to improve their safety culture.
