The American Club published lessons learned from an incident where an engineer failed to notice a missing section of deck plate and fell into the opening.
The incident
The engineers on a bulk cargo vessel were doing routine repair work replacing insulation on a piping system under the deck plates in the engine room. They held a toolbox meeting to assign the work and discuss specific details about the insulation and how it should be properly secured. The insulation they were replacing was not old but had been incorrectly installed and had fallen off the piping in several locations.
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At the same time, other engineers were tasked to replace a worn bearing on a main engine lube oil pump. Both groups would be working in the engine room at the same time, but only a portion of the piping insulation work was near the lube oil pump. A separate toolbox meeting was held by the engineers assigned to replace the worn bearing.
Both groups got to work first thing in the morning. The engineers working on the pipe insulation removed the deck plates so they could easily access the piping. They decided to remove most of the deck plates right away so they could install the insulation more continuously. They stacked the deck plates in a location that was out of the way in the exact order they had removed them so they could get them all back in the correct locations when the insulation work was done.
At approximately 10:00, the entire crew took a coffee break including both groups of engineers. As they were all heading back into the engine room after the break, one of the engineers working on the lube oil pump bearing failed to notice a missing section of deck plate and fell into the opening. He severely injuring his knee and had to be sent ashore for medical treatment. He was not able to return to the vessel.
The investigator interviewed all of the engineers. He learned that the discussion at the pipe insulation toolbox meeting was primarily focused on how to install the insulation correctly. The only safety item mentioned was that they should be careful when standing on the framing for the deck plates. The toolbox meeting for the lube oil pump bearing replacement included no mention of the other work being done in the engine room or any risks associated with that work. Similar to the other toolbox meeting, it focused on how the specific work should be done.
The investigation noted that no caution tape or physical barrier was in place around the areas where the deck plates had been removed. The investigator also determined that the engineers working on the lube oil pump had been talking with each other as they returned to their work site and had forgotten about the missing deck plates. The engineer walking in front saw that the deck plate was missing and quickly side-stepped the opening, but the engineer following close behind him did not see the opening and stepped into it.
Lessons learned
- In addition to the work to be done, toolbox meetings should address all safety aspects of the work including other hazards in the area. Those other hazards can be from other work taking place nearby.
- Caution tape or physical barriers should be used whenever there is a risk of falling and whenever there is a change to the normal working environment that creates a safety hazard.
- Mariners should always be aware of the risk from distractions. Distractions can come from external sources such as other people or activities, or they can come from internal sources such as loosing focus or inattention.
