Transport Malta MSIU issued an investigation report on the serious injury of a fitter while operating the lathe onboard the vehicle carrier MV Titania, in February 2020. The report found that a rod slipped from the tailstock while the lathe was rotating at a very high speed.
The incident
On 04 February 2020, one of the fitters mounted a rod on the lathe to fabricate a new roller and shaft for the quarter gangway.
As soon as he started the lathe, one end of the rod slipped out of its securing point and struck him with significant force, knocking him down. The third engineer found him in the workshop.
Assistance was immediately provided, and the fitter was transferred to the nearest shore hospital for further medical treatment.
Immediate cause of the accident
The fitter was operating the lathe to machine a cast iron rod of 800 mm length and 35 mm in diameter. In the process, the rod slipped from the tailstock while the lathe was rotating at a very high speed. This caused the rod to bend and strike the fitter on his right shoulder region.
Conclusions
- The rod, which slipped from the tailstock end while the lathe was rotating at a very high speed, deformed and hit the fitter;
- In all probability, the fitter was focusing on the tool post when he was struck by the rod;
- The tailstock sleeve clamping lever was not secured properly, allowing the tailstock positioning handwheel to rotate under its own weight/vibration and for the rod to slip out of the tailstock;
- Evidence did not confirm that the risk assessment was discussed during the toolbox meeting;
- The fitter was not involved in the risk assessment;
- The chief engineer was neither present for the risk assessment, nor for the toolbox meeting;
- A safety helmet could have minimised the severity of the head injury;
- The fitter had no technical guidance on the speed settings of the lathe;
- No preventive symbolic barrier systems were fitted in proximity of the lathe;
- A follower rest was not provided onboard.
Actions taken
As a result of the accident, the company took the following safety actions:
- The company’s procedures were revised and a lathe training checklist compiled by the Chief Engineer whenever new fitters signed on has been introduced;
- A revision of the generic risk assessment was undertaken to include hazards related to dimensions of the workpiece and an additional control measure to determine and confirm the speed setting for the job in hand. The new assessment carried a cautionary note on excessive lathe’s rpm;
- The company confirmed that steady and follower rests have been made available on board and were being used;
- A fleet wide experience exchange was carried out to ensure that the lessons learned from this occurrence were promulgated and addressed.
Recommendations
The company is recommended to:
- Ensure that lathe operators are part of any lathe risk assessment procedure;
- Fix a cautionary notice on the importance of appropriate settings and controls in proximity of the lathe.
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