Serious hand injury

The two 4″ pipes and umbilical were being recovered over the stern of the vessel and pulled up the deck with a tugger winch in order to cut them into 10m sections for transfer ashore and disposal. The process involved securing the pipes/umbilical bundle in a clamp at the stern of the vessel and cutting the bundle with a hydraulic cutter further up the deck. A chain stopper was then secured around the bundle just aft of the cutter in order to pull the bundle a further 10m up the deck for the next cut. This was a repetitive, continuous operation scheduled to take three to four weeks with two rigging crews working 12-hour shifts.

The injuries were sustained less than two days before the completion of this recovery operation. The injured person was preparing to fit the chain stopper immediately after a cut and was rearranging the two 4″ pipes and umbilical into a triangular configuration to ensure the chain stopper would not slip. During this process, residual tension in the pipes caused one to spring against the other. The injured person’s hand was crushed between the two pipes resulting in partial amputation of two fingers.

Investigation revealed a number of failures, particularly with reference to ‘routine’ or repetitive tasks, and identified a number of questions that project and vessel management teams could ask themselves.

• There was a lack of defined process: A procedure and risk assessment for the recovery operation was prepared onshore. However, during the course of the work (five weeks) various changes were allowed to creep in without recognition or challenge – something that is not uncommon with ‘routine’ and repetitive work. The actual work processes were no longer being defined by the procedure, nor, as a consequence, by the risk assessment.
  • How does your team ensure that work is always conducted to an up-to-date and risk assessed procedure?
  • Are all supervisory staff conscious of the tendency for ‘routine’ and repetitive tasks to creep away from original procedures and risk assessments? How do you check?
  • Do toolbox talks ‘routinely' involve using the procedure and the risk assessment to ensure personnel are familiar with the planned process, its hazards and consequent safety controls?
• There was a failure to apply the management of change process: The management of change process was not applied to changes in equipment, process or operational conditions. As a result, procedures were not updated and the changes were not subjected to risk assessment.
  • Is your team applying the management of change process correctly?
  • Are all key personnel familiar with the circumstances in which management of change must be applied?
  • Have any changes crept into ‘routine’ processes that haven’t been subjected to management of change, and therefore risk assessment?
• There was a lack of adequate supervisory control: The management team on the vessel did not ensure that the work was completed to an approved and risk assessed process. Differing approaches developed within each shift.