Page 10 - 2022 - Q2 - Minerva in Focus

SAFETY & SECURITY Case study:
Fatality inside the elevator shaft
Οccurred on board a vessel of another company
Figure 1:
Emergency door tool.
Source: Investigation report by
Transport Malta - Marine Safety
Investigation Unit
by Slav Ostrowicki
Britannia P&I Club
10 MINERVA IN FOCUS – ISSUE 20 / Q2 2022
While at anchorage, an electrician did not appear for dinner, and consequently, a search
was initiated. He was later found trapped inside the vessel’s elevator shaft between the
elevator’s counterweight and a protective beam, where he had been working earlier that
same day. His fellow crew members managed to get him out of the elevator shaft, but the
electrician was pronounced dead at the scene despite receiving first aid.
What happened? On his way to the changing room on the
upper deck, the EET noticed that the elec-
During the voyage, a potential problem trician had not followed him. That did not
was identified with the stopping position raise any concerns at the time, as the EET
of the vessel’s elevator car. It was thought assumed that the electrician had gone to
that the problem might be related to the his cabin to change for dinner. At about
elevator’s control cabinet overheating 17.45 local time, the electrician had still not
and possibly also to the adjustment of arrived for dinner, and the ETT expressed
the elevator’s limit switches. Checks were his concerns to the C/E. They both went to
carried out, but the problem persisted, and look for the electrician, but when they were
as a result, the elevator was taken out of unable to locate him, the C/E asked the
service until further investigation could be ETT to point out where he had last worked
carried out at the next anchorage. On the with the electrician. They proceeded to
morning of the incident, a tool box meeting the elevator door on B deck, which was
was conducted prior to starting the work. closed. Upon opening the door using an
The meeting record indicated that the emergency tool (Figure 1), they found that
electrician and electro–technical trainee the elevator car had moved downwards.
(ETT) would inspect the elevator’s speed They could see the electrician inside the
governor and limit switches. elevator shaft with his right leg draped
Signs were posted on each deck and the over the counterweight and his upper torso
control panel, stating that the equipment
was out of service due to maintenance.
Similar signs were posted at the elevator’s
call buttons on each deck, and a public
announcement was made to make the crew
aware of the ongoing work on the elevator.
As the work involved working in the elevator
shaft, a ‘working aloft’ permit was issued.
The electrician and the ETT started check-
ing and adjusting the limit switches work-
ing from deck E downwards. The electrician
was working inside the elevator shaft,
while the ETT was located outside to act
as a safety/communications contact point.
At 16.45 local time, the electrician and ETT
stopped working and went for dinner. The
elevator car was parked on Deck B, and the
ETT watched the electrician come down
through the escape hatch in the roof of
the car and exit through the open elevator
Figure 2: The area where the electrician was
door on Deck B. The electrician informed
found inside the elevator shaft.
the bridge that both the ETT and himself
were out of the elevator shaft and would Source: Investigation report by Transport
continue the work the following morning. Malta- Marine Safety Investigation Unit