Page 9 - 2022 - Q1 - Minerva in Focus

“ SAFETY & SECURITY

On arriving at the LGSP
cabinet, the cadet found the
unconscious and unresponsive Figure 3:
electrician lying on the deck IG scrubber pump
starter contacts and
with his head and hands the missing star
contactor spring
inside the lower section. Source: Investigation
” report by Republic of

the Marshall Islands
Maritime Administrator

The door for the IG scrubber pump starter panel was fully open, The ship diverted to a nearby port, where the electrician was trans-
and the lower panel covering the 440V power terminals had been ported ashore the same day and pronounced dead. The cause of
removed and placed to the left of the cabinet (Figure 1). death was consistent with electrocution.

The cadet alerted the third engineer (3/E) and motorman working The main circuit breaker supplying power to the pump starter
nearby. They then moved the electrician further away from the (inside the IG scrubber pump starter panel) was found in the off
open LGSP cabinet, found he had no pulse, and started cardiopul- (open) position. The star contactor for the pump starter was miss-
monary resuscitation (CPR). ing a spring and cover locking pin (Figure 3). These were found on
the cabinet’s lower framing and deck. The investigation presumed
The master was subsequently advised, a general alarm was raised, that the electrician inadvertently touched the energized 440V pow-
and emergency medical equipment was brought to the scene. er terminals in the cabinet’s lower section while retrieving the star
Despite continued CPR, the electrician could not be resuscitated. contactor spring or the cover locking pin.

Lessons Learned member to be present, which could have resulted in an ap-

propriate challenge and stopped the unsafe work.
• The Company’s Stop Work Authority (SWA) policy required
The following lessons learned have been identified based on that all crew members take action to prevent observed
the information available in the investigation report and are unsafe acts or conditions. Using this authority, the 2/E and
not intended to apportion blame on the individuals or company engine cadet could have prevented the electrician from un-
involved: dertaking the task.
• An effective and timely scheduled maintenance would have
• A formal risk assessment, as required by the SMS, should resulted in recording and rectifying the missing physical
have identified the hazards of working in the cabinet with safety barriers within the LGSP cabinet and prevented the
440V power cables and terminals, and would have resulted electrician from accidental contact with energized circuits.
in adequate risk mitigation. • Although it did not contribute to the incident, the cadet
• Completing a PTW, as required by the SMS, would have result- could also have been electrocuted when he immediately
ed in the LOTO procedures being applied and ensured that pulled the electrician from the LGSP cabinet, as he had not
the circuits and equipment in the work area were de-ener- ensured that the power was isolated or that the electrician’s
gized. They would have also prevented the electrician from body was not energized.
accessing the cabinet while the 440V power input was not
secured.
• A work-specific Toolbox Talk could have helped with appro- The source of this case study is an investigation conducted by the Re-
priate pre-task hazard identification. The engineering officers public of the Marshall Islands Maritime Administrator.
were reportedly unaware that the electrician was completing
this work, and a Toolbox Talk had not been held with him. The purpose of this case study is to support and encourage reflective
• The Company’s SMS required that all scheduled work be learning. The details of the case study may be based on, but not neces-
planned at least one day in advance to allow time for com- sarily identical to, facts relating to an actual incident. Any lessons learned
pleting the required safety procedures. During the morning or comments are not intended to apportion blame on the individuals
planning meeting, the electrician was not questioned or or company involved. Any suggested practices may not necessarily be
prevented from undertaking the unplanned work. the only way of addressing the lessons learned and should always be
• The electrician was working alone when the incident oc- subject to the requirements of any applicable international or national
curred. A completed PTW would have required another crew regulations, as well as a company’s own procedures and policies.

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