IMCA draws lessons learned from an incident where a worker sustained a back injury while transiting through a lightening hole within a confined space.
What happened?
The incident occurred during completion of planned maintenance. Whilst attempting to get out of the confined space through a lightening hole by moving feet-first (face up), the worker’s hands slipped and they fell back, striking their lower back on a beam at deck level.
The worker was still able to exit the compartment and confined space unassisted. Onshore medical assessment/treatment, however, was subsequently required.
What went wrong?
The technique used for getting out of the compartment feet first, grabbing a stiffener plate or grab handle (both above the opening), dictated a body positioning facing upward. Because of that body positioning, facing upwards, the worker was reliant on hand grip, and thus unable to stop the fall when their grip was lost.
What was the cause?
- Vessel design – and hence confined space design – is centred on structural requirements, rather than ergonomics.
- Design of the access/egress arrangements meant that there was only one grab handle outside the compartment.
- The risk assessment did not sufficiently cover getting into and out of, and moving around within, the confined space.
Lessons learned and actions
- Risk assessments for confined space predominantly focus on the WORK being done – rather than on how to get in and out of the confined space.
- Design of access/egress points are normally based on structural requirements, rather than ease of access for the worker. The task risk assessment process plays an important role in identifying and mitigating associated risks.
- Normalisation of high-risk activities can occur when the same activity has been undertaken multiple times – as perhaps with planned maintenance.
- Further grab handles were installed inside the compartment, and possible installation of platforms was investigated (after evaluation) on either side of the lightening hole to help crew get in and out of the space.
- A comprehensive review was held of Confined Space Entry procedures in light of this incident, looking into such issues as:
- Getting in and out of confined spaces.
- How to move safely and position the body correctly when transiting through difficult spaces in voids and tanks and through frames and lightening holes.
