LTI: Person crushed in watertight door
- Safety Flash
- Published on 16 February 2023
- Generated on 26 December 2024
- IMCA SF 05/23
- 2 minute read
An electrician was crushed and severely injured while working on a watertight door on a vessel.
What happened?
The electrician was evacuated by helicopter.
The incident happened when the door opened unexpectedly, during adjustment of a proximity sensor for the door.
Just before this adjustment, the electrician had closed a ball valve in the hydraulic system, believing this was a safety valve which would prevent the door from opening.
Once working on the system, the selector switch on the primary operating system, which is used to open and close the watertight door, did not return to the neutral position enabling a signal to be sent to the programmable logic controller (PLC).
When the electrician manually aligned the sensor which he had to repair, a signal went to the PLC and the door opened unexpectedly crushing him between the door and the deck.
Fig. 1: Vertical watertight door
Fig. 2: Watertight door opening on dummy (DEMONSTRATION)
What went wrong?
- The system was not isolated at the time of the incident – no Lock Out / Tag Out system was in place.
- There was no request for a Permit To Work (PTW) nor was a Job Safety Analysis (JSA) prepared for the activity.
- The ball valve did not isolate the hydraulic system:
- The ball valve was not a safety valve.
- The ball valve was leaking.
- The ball valve was not a safety valve.
- The door opened when the command “open” came in from the PLC. This command came in because the selector switch was damaged and did not return to the neutral position once released.
- When the door is operated, visual and audible alarms are initiated. The alarms and signals were not fully operational nor working.
Fig. 3: Selector switch was damaged and did not return to the neutral position once released
Lessons learned
- Ensure there is a Permit To Work in place, a Lock Out / Tag Out procedure, and a suitable and sufficient job safety analysis before you start.
- Hydraulic system ball valves are not “safety valves”. Take care that you fully understand what you’re working on, and ensure systems are fully de-energising before putting yourself in the line of fire.
- The switch on the primary operating system was not in working condition but there were not sufficient spares on board to replace them. Sufficient spare parts should be on board, so these can be replaced immediately.
Related safety flashes
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IMCA SF 06/19
5 April 2019
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IMCA SF 25/17
19 October 2017
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IMCA SF 03/16
27 January 2016
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