Safety Flash

27/22 – December 2022

IMCA Safety Flashes summarise key safety matters and incidents, allowing lessons to be more easily learnt for the benefit of all.
The effectiveness of the IMCA Safety Flash system depends on members sharing information and so avoiding repeat incidents.
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information on incidents you consider may be relevant. All information is anonymised or sanitised, as appropriate.

1 MAIB: “pinkie is no longer perkie”

What happened? Applicable
Life Saving
The Marine Accident Investigation Branch Safety Digest 2/2022 includes an incident in Rule(s)
which a crew member on a large cargo vessel lost part of their finger while passing through Line of Fire
a hydraulically operated sliding door to an adjoining machinery space. The door was fitted
with a operating lever handle on either side. The
crew member used their right hand to operate the
lever handle and the door began to open to the
right. The crew member walked through the
doorway and placed their left hand on the lever
handle on the other side, pushing it down once
more to continue the operation.

What went wrong

The door opened fully, while the crew member kept

their hand on the handle. As the door retracted
fully, the crew member’s left hand became trapped
between the handle and the doorframe, resulting in
the little finger suffering amputation of the fingertip
and nail above the first knuckle. It could not be
reattached. Door operating handle – red circle indicates line of fire

The door was not faulty: Subsequent inspection for technical, hydraulic and electrical defects found it to be in good
working order.

Lessons learned (MAIB)

• Training: automatic or powered doors are potentially very dangerous. Hydraulic and electric power-operated
systems are unforgiving in their closing force and should be treated with respect. Crew should be provided with
suitable training on both the safe use of these doors and the dangers of their unsafe operation;
• Procedures: If we go through a powered door often, it is easy to forget the dangers and take shortcuts such as
walking through the door before it has fully opened. Previous accidents have sadly resulted in more serious
injuries than those suffered in this case, and sometimes death;
• Awareness: Entrapment is a hazard often associated with moving machinery and wariness is the watchword.
There should have been no need for the crew member’s hand to remain on the door’s operating lever and this
action indicates insufficient knowledge of the system;
• Short cuts: if the operator was attempting to take a shortcut, then a greater understanding of the system would
have been required to understand the dangers of doing so. Lack of understanding of how a system will work
when shortcuts are taken, and the potential consequences, are a good enough reason not to take short cuts.
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© 2022 Page 1 of 5
Members may wish to refer to:
• Lost time injury (LTI): Finger injury – watertight sliding door (2016)
• Fatal accident involving a horizontal watertight sliding door (2001)
• Line of fire: pinched finger between door and frame
IMCA will bring further reports from this MAIB Safety Digest in the next few Safety Flashes.

2 LTI: person suffered serious crush injuries

What happened Applicable
Life Saving
Rule(s)
During offshore drilling operations, a drilling assistant sustained serious crush injuries,
Line of Fire
resulting in several weeks away from work. He was injured when he leaned out of the
rooster box, between the guard railings, and was caught between the
compensator carriage and the rooster box.

What went wrong

• No-one STOPPED THE JOB: people on the back deck did not challenge
unsafe behaviour: people remained in the rooster box in between tool-
handling operations.
• There was inadequate management supervision – no-one verified and
monitored compliance with the applicable rules, regulations and good
practice;
• Procedures were not adequately controlled, maintained, and shared;
• Hazards associated with the tasks were not adequately identified and
assessed in the preparation onshore, nor execution offshore;
• There was a lack of means of communication and observation (such as
audio comms and CCTV) to support the management of deck activities;
• Previous lessons learned during other geotechnical drilling operations were not adequately captured in the
drilling manual, shared and/or implemented on this project.
Actions and recommendations
• Our member took the following actions and recommendations
̶ Ensured that the procedures and work instructions supporting the operations were controlled, up to date,
relevant to the operations and shared, ensuring that the team executing the operations were adequately
familiarised;
̶ Hazard identification tools such as HAZOPS, HAZID, Risk assessment, Task risk assessment or SLAM (“Stop,
Look, Analyze, Manage”) are critical in ensuring all stakeholders are aware of all the risks and mitigations,
reducing the risk to “as low as reasonably practicable”;
̶ Adequate communication is essential between employees and supervisors, and where required should be
supplemented via electronic means;
̶ Safety barriers and devices (e.g. railings) should not be bypassed or defeated;
̶ Regularly reinforce messaging to ensure that in the event of any process change or where a hazard is
identified, all of us are empowered to speak up and STOP THE JOB without fear of consequence or
retaliation.
Members may wish to refer to:
• High potential LTI: rigger ear injury
• Near-miss: Personnel almost caught between crane house and scaffold pipe

IMCA Safety Flash 27/22 Page 2 of 5

• LTI: head injury

3 LTI: burns to forearms

What happened? Applicable
Life Saving
During pipe coating application work at a third-party sub-contractor worksite, a worker Rule(s)
received serious burns to both forearms, that resulted in an LTI. The injury occurred at the Line of Fire
start of the operation when the pipe was being coated with the first layer. During this
operation the transition between pipes required the manual application of a spatula to mark the pipe cutting area,
as shown below. While marking the pipe, the injured person’s arm touched the pipe due to an unexpected
movement of the pipe assembly, causing serious burns to both forearms. This injury was seen by another employee
who activated the line emergency stop and helped the injured person away from the line of fire situation to a safe
place. First aid was given before the casualty was taken to hospital for further treatment.

Re-enactment of task (spatula) CCTV footage of the task being undertaken by the
injured person.

What went wrong

The final investigation is still to be released, but preliminary findings from this incident and other recent third-party
incidents have identified the following issues:
• The task was deemed to require manual intervention using a spatula as a marking tool, thus exposing people
to possible injuries;
• The task was seen as routine, to be undertaken on a regular basis. There was no challenge to re-engineer the
task by those performing it or supervising it;
• There was no consideration of hierarchy of risk controls, or specifically automated or engineered methods to
eliminate human exposure;
• Company management had paid a visit and had previously identified the risks associated with the task and
provided improvement suggestions to the sub-contractor.

Recommendations
• Ensure that the obligation and expectation to exercise the stop work authority is clearly communicated and
understood by all, particularly third-party and sub-contract personnel;
• Can we do the job in a safer way? Ensure we have clear expectations in respect of controlling risk and identifying
tasks that can be reengineered to remove the risk of human intervention or manual handling;
• Dare to challenge the “norm” with a fresh set of eyes as to how tasks are actually being conducted.

Our member notes an increasing need to improve human factors, risk perception and competency considerations
for personnel involved in third-party operations. Our members’ analysis of their own “top 20” incident causes to

IMCA Safety Flash 27/22 Page 3 of 5

date in 2022 confirms that inadequate engineering/design and use of tools and equipment are within the top 5
causes of incidents.
Members may wish to refer to
• Cook’s arm scalded while removing food from oven
• Flash fire in field joint coating station

4 LTI: Foot trapped between pipes

What happened
Applicable
During pipe handling operations a rigger positioned himself at the pipe’s Life Saving
bottom layer gap. A pipe from the upper layer rolled down into the space on Rule(s)
Bypassing
the bottom layer, trapping the riggers left foot resulting in a Lost Time Injury Safety Line of Fire
Controls
(LTI).

What went wrong?

The worker walked towards the pipe stack. The pipe on the top layer was still connected to the gantry crane. He
stepped forward into the gap on the bottom layer. At the same time, the pipe stack shifted, trapping his ankle,
causing an LTI. The sequence of events is illustrated here:

Crew member walked towards the Crew member stepped forward into Crew member’s left foot trapped
pipe stack. The pipe on the top layer the gap on the bottom layer. At the between the two pipes
was still connected to the gantry same time, the pipe stack shifted,
crane trapping his ankle.

What was the cause?

• This was a repetitive task which had been ongoing for two months (loading and unloading 2000 pipejoints
during this period);
• There were sufficient team members on site, but the other riggers were involved in another task elsewhere.
The crew person involved decided to continue the task on his own to get the job done;
• Temporary wedges were available during the pipe handling operations. The pipe stacking area, however, was
not set up with permanent wedges or spacers to ensure the pipes could not roll;
• A stacking plan and a risk assessment were available, but neither were being followed at the time;
• Inspections and audits had failed to verify controls and preventive measures;
• Human factors - risk perception and competency of personnel involved in operations.
Members may wish to refer to
• Serious injury during pipestalk rolling operation (2006)

IMCA Safety Flash 27/22 Page 4 of 5

• Lost time injury (LTI) during lifting operations – backloading tubular cargo (2015)
• Injury caused by shifting load of pipes (2016)
• LTI: Leg Fractured While Loading Tubulars (2020)

5 MAIB: A scalding injury

What happened Applicable
Life Saving
The Marine Accident Investigation Branch Safety Digest 2/2022 includes an incident in Rule(s)
which an engineer suffered severe scalding to his face. The incident occurred during Line of Fire
rounds, when a cruise ship’s third engineer discovered a leak on the
drain valve for one of the vessel’s four economisers. There was an
open-ended pipe running from the valve to a tundish drain in the
deck. The Chief Engineer was briefed and a decision was taken to
conduct a repair. The economiser’s circulating pump was stopped
and the inlet and outlet valves were shut; the plan was to leave the
system to cool down overnight before the repair.

What went wrong

After the isolations were in place, but before the system had cooled
down, the Second Engineer decided to check the system by opening
the drain valve. Leaning over the valve, the Second Engineer cracked
it open and pressurised hot water and steam burst out of the drain
pipe. The force of the discharge caused the hot water to deflect
upwards off the tundish, severely scalding his face. After initial
medical treatment on board, he was evacuated to a nearby hospital
for specialist burns care.

The lessons (MAIB)

• Hazard: The opening of drain lines on pressurised systems
should be undertaken with extreme caution;
• Risk: The Second Engineer leant forward over the pipework that ran to the tundish to open the drain valve. As
a result, his upper body was directly in line with the deflected water and steam. When venting or releasing
stored pressure, keep your body OUT OF THE PATH of any predictable discharge;
• Equipment: Take great care when opening valves that are infrequently used. A valve that has become seized in
the shut position may require extra force to manoeuvre it and lead to the valve suddenly and unexpectedly
opening, causing an uncontrolled fluid flow. The use of a correctly sized wheel key can provide appropriate
torque and increase the application of controlled force to the valve wheel.

Members may wish to refer to

• Scalding injury to crew member
• Crewman badly scalded during tank cleaning
• Personal injury – burns from hot engine oil to body and face

IMCA Safety Flash 27/22 Page 5 of 5