MSF: Routine task – Badly cut finger changing mop head

The crew member was in the process of changing a sponge mop head. Whilst attempting to fit a new mop head he saw that one of the retaining channels had glue in it which was preventing it from fitting the holder. He tried to clear out the glue with his pocket knife and in doing so he slipped and sustained a cut to the left index finger. The cut was quite deep, partially severing the flexor tendon and damaging the associated nerve. A surgery was required to repair the damage.

The incident highlights failure to manage change properly. The injured person deviated from the original intent to carry out ‘routine’ cleaning duties, and instead attempted to fix a new problem with the mop head with the tools and facilities to hand, without recognizing the inherent risks of the new task.

Members may wish to refer to the following similar incidents (key words: knife slipped):

• Lost time injury (LTI): Severed tendon
• Finger and hand injuries

Our member’s investigation noted the following:

• A preliminary on-site investigation of the failure by the manufacturer was conducted with no conclusive root causes identified. The failed winch brake was shipped to the manufacturer for a detailed analysis to determine root cause(s).
  
  
• Following extensive testing and analysis, the manufacturer identified the most likely root cause of the run-off was probably a blockage in the winch secondary brake release line.
  
  
• Given the damage to the winch the incident investigation could not determine a definitive root cause but were able to establish through elimination a probable cause for the occurrence. A series of actions to prevent occurrence had been established these were included in the manufacturer’s technical bulletin.