Transport Malta issued an investigation report on a fall inside a Water Ballast Tank of the Maltese-registered heavy lift/pipelay vessel Pioneering Spirit, in January 2020. The investigation highlighted that there was no immediate barrier system around the opening in the deck, which could have prevented the fall.
The incident
A welder helper was tasked to assist in the mounting of two stiffeners as reinforcement to the newly installed jacket lifting system onboard, inside a Water Ballast Tank (WBT).
Upon entering the WBT, the welder helper and the welder walked different routes to reach the work site. Rather than crossing directly from the access ladder and onto the cable trunk, where the welding job was due, he followed the access ladder down to the tween deck level, crossed a guardrail, and walked alongside the cable trunk where unexpectedly, he fell through a large opening in the deck.
The welder, who was already on top of the cable trunk preparing for the job, did not see the accident and he was not in contact with the injured welder helper at the time of the occurrence.
After the fall, the injured welder helper was located, and evacuated from the space. A rescue helicopter took the injured crew member to the local hospital.
Conclusions
-Immediate safety factors
1. It could not be established what caused the fall of the injured person (IP) through the opening in the deck as he crossed underneath the tank access pathway. Although the lighting in the water ballast tank at the time of the accident was adequate, it was not excluded that:
- the IP was looking up in the direction of the work site while walking ahead, failing to see the opening;
- the bag he was carrying may have obstructed the opening on the tween deck; or
- the IP noticed the opening ahead of him but, while circumnavigating it, slipped and fell through the opening. .
2. There was no immediate barrier system around the opening, which could have prevented the fall.
Latent conditions and other safety factors
- There was no determined pathway to the work site, neither by crossing over the trunk nor on the tween deck below, as was the case during previous work at the site.
- While it could not be established exactly why the IP chose the particular route to the work site, the fact that he was not part of the planning of the work, and had not taken the route to the work site together with his peers during the preparatory work, suggests a potential lack of clarity or alignment with the IP’s team mates as to how to best reach the work site once inside the WBT. This may have prompted him to take the different route that he did.
- All crew members viewed the work in the WBT as a minor task, due to which, a number of safety precautions were deemed unnecessary.
Actions taken
During the course of the safety investigation, the managers of Pioneering Spirit have carried out the following safety actions:
- The tripod for recovery of persons from a confined space, which was installed by the manhole as a standard procedure for tank entry, was after the accident changed to a scaffolding construction instead. Moreover, it was decided that the scaffolding personnel on board would be included into the rescue team processes;
- The work risk assessment for confined space entry onboard was amended to include additional controls which identify the safe route to the work site in large tanks;
- The confined space awareness training was amended to include the specific risks in large tanks. All crew which were required to work in confined spaces had received the updated training;
- Safety session were held with the entire crew of Pioneering Spirit, to explain what had happened and any immediate and preventive actions that will have to be undertaken from that day onwards;
- During the safety session the crew was reminded to redo the Step Back 5×5 when anything changes, including people. The procedure was revised to include the need to review in case of any changes including persons.
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