UK MAIB presents a case from its most recent Safety Digest, to provide lessons learned from an incident in which a crew member was injured by a rotating crank handle.
The incident
A winch drum, with cranking handle still attached, began to spin uncontrollably. The spinning cranking handle violently struck a crew member, fracturing their wrist. The incident occurred when the crew of a pusher tug were disconnecting lines from a cargo barge. The cargo barge ahead of the pusher tug was made fast with connecting lines that were attached to small manually operated coupling winches on the aft deck of the tug and passed forward to secure the barge.
Under the Master’s guidance, two crew members were operating the starboard coupling winch to release the lines securing the barge; however, they contravened the vessel’s standard operating procedure by not removing a cranking handle connected to the winch drum. When the winch brake was released the tension in the line connected to the cargo barge caused the winch drum, and still attached cranking handle, to spin. Someone was stood in the way; the spinning cranking handle hit that person and injured them, causing a fractured wrist. They were taken ashore to hospital for treatment. The crew member was unable to return to work for several months due to the severity of the injury.
What went wrong
- The tug’s design limited visibility of the aft deck from the wheelhouse – no line of sight – and the Master and crew used handheld radios to communicate;
- The crew failed to follow the vessel’s standard operating procedure by not removing the cranking handle.
Lessons learned
- Take a moment to undertake a dynamic risk assessment rather than rush to complete the task – stop and think;
- The Master could not safely undertake the simultaneous tasks of steering the pusher tug and trying to control the aft deck operations from a position of limited visibility – installing CCTV could help;
- “Task seen as routine” – it can be easy to overlook health and safety responsibilities while undertaking or routine duties. How can we make it easier to work safely, rather than easy to work unsafely?
- Toolbox talks can provide an opportunity to remind those involved of the correct process for the task, why it is important, and how to complete it safely.
