Lessons learned from elevator fatality
Safety procedures are there to protect people. They should be kept simple and straightforward, and they should be known to all and always enforced. Bypassing them must not be an option, however quickly the job ‘needs’ to be done.
The followingMARS report on elevator maintenance decribes an incident where the company safety procedures were not followed and one man died.
The Incident
Routine inspections and maintenance of shipboard equipment hadbeen scheduled while the vessel was at anchor. A tool box meeting washeld in the engine control room where the assistant electrical officer(AEO) said he wanted to check the ships elevator that day to try and findthe cause of an abnormal noise. The second engineer instructed thathe should be assisted by the fourth engineer and told him to take allnecessary precautions as per the procedures.
The men posted red hand-written warning tags Elevator UnderMaintenance on every elevator doorhandle on each floor. Then,using the emergency key to open the landing door on B-deck, thefourth engineer changed over the AUTO-MANUAL selector switch onthe elevator control panel mounted on the cage top from AUTO toMANUAL position. This meant pressing the individual buttons on eachdeck would not cause the elevator to function.
After that, the AEO joined the fourth engineer on the elevator top;he proceeded to control the movements of the cage by pressing theup and down button switches on the control panel to detect any noiseduring running. This caused the elevator to slowly move in the desireddirection, but after about 10 minutes they came out without havingdetermined the cause of the noise.The two men then proceeded to other duties, but the AEOreturned alone to the elevator.
Shortly thereafter, loud screamingwas heard coming from the elevator location. Crew quickly came tothe elevator and found the AEO trapped in the space between theelevator cage and the shaft.With some difficulty the AEO was pulled out of the cage andtransferred to ship hospital. Throughout the operation, the crew triedto communicate with the AEO but got no response. He was later pronounced dead.
Lessons Learned
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The company investigation found it probable that the switch on the control panel at the time of the accident was set to AUTO. Other safetydevices were most probably bypassed; as such, any calls from decksabove B-deck would cause the elevator to move up automatically ata speed of 30 metres per minute, which is the nominal speed of themachine. The investigation into the accident revealed that the maincontributing factor to the accident was that the elevator safetyprocedures issued by the company were not closely followed by thepersonnel. Additionally, the work was prepared without sufficientlyappraising the associated risks. |
One of the principal contributing factors to manyaccidents is crew NOT following procedures. How ironic, andunfortunate in this case, that companies try and limit risk by writingprocedures yet have crew bypass them in order to get the job done.But in many instances this is not just a manifestation of individual roguebehaviour. The leadership has probably tolerated procedural shortcutsand telegraphed to crew their implicit acceptance of these unsafe acts.
Source:Mars Reports/ The Nautical Institute
