Page 11 - 2022 - Q2 - Minerva in Focus
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“                                                                                   Figure 3:                   SAFETY & SECURITY



        Τhe electrician was pulled out from the ele-
                                                                                            Top of elevator car
        vator shaft and the 2nd Officer, who was the                                        showing maintenance
                                                                                            box and safety cage
        ship’s medical officer, confirmed that the

        electrician had no pulse.                                                           Source: Investigation
                                                   ”                                        Malta – Marine Safety
                                                                                            report by Transport
                                                                                            Investigation Unit


        trapped between the counterweight and one of the counterweight   blocks, were rigged, which allowed the elevator car to be hoisted
        guard beams  (Figure 2). It was noticed that the electrician was   and the counterweight to move down and free the electrician. At
        wearing a safety harness, and he was outside the safety cage on   18.15 local time, the electrician was pulled out from the elevator
        top of the elevator car (Figure 3).                 shaft and the 2nd Officer, who was the ship’s medical officer, con-
        The C/E notified the master immediately, who raised the general   firmed that the electrician had no pulse.
        alarm and then went to the bridge to inform the company. He also   The body was later taken ashore by boat, and a post-mortem con-
        radioed the local authorities for medical assistance. A member of   firmed the cause of death to be a blunt compressive trauma to the
        the onboard medical emergency team entered the elevator shaft   trunk. The company arranged for an authorised expert to carry out an
        and confirmed that the electrician was not breathing and he could   inspection of the elevator. The inspection did not indicate any failure
        not detect a pulse. Hoisting arrangements, using wires and chain   of the elevator’s machinery related to this particular incident.


           Lessons Learned                                  •   While the onboard Safety Management system provided

                                                               a risk assessment for ‘Electrical Workshop Activities on
           The following lessons learned have been identified. These are   Elevator Cage,’ this only covered the use of Personal Pro-
           based on the information available in the investigation report   tective Equipment.
           and are not intended to apportion blame on the individuals or
           company involved:

           •   A safety cage is provided on top of the elevator car to
               safeguard the person(s). The electrician was found out-
               side the safety cage, which may have exposed himself to
               additional danger.
           •   Earlier, the electrician had left the elevator shaft through
               the emergency escape hatch of the car into the elevator
               cabin. This would have triggered the latch-out system and
               isolated the power on the system. To reactivate the elevator,
               you would have to close the emergency escape hatch and
               then physically reset the system at the control cabinet on
               deck D.
           •   From the position in which the electrician was found, the   Figure 4: Position of lubricators and plastic oil bottle left in the
               investigation hypothesised that he likely re-entered the ele-  elevator shaft
               vator shaft to retrieve a plastic bottle containing oil used to
                                                              Source: Investigation report by Transport Malta- Marine Safety
               top up the guide rail lubrication boxes (Figure 4). While trying
                                                              Investigation Unit
               to retrieve the bottle, it appears that he got trapped between
               the counterweight and the counterweight guard beam.   The source of this case study is an investigation conducted by the
           •   The maintenance switch located at the safety cage was   Transport Malta – Marine Safety Investigation Unit
               found in the “ON” position, meaning that the elevator   The purpose of this case study is to support and encourage re-
               could only be operated from there. The electrician was   flective learning. The details of the case study may be based on
               wearing a safety harness, which due to its attachment,   but not necessarily identical to facts relating to an actual incident.
               would have made him unable to reach the operation   Any lessons learned or comments are not intended to apportion
               panel, indicating that the elevator was not intentionally   blame on the individuals or company involved. Any suggested
               operated from inside the shaft at the time of the incident.   practices may not necessarily be the only way of addressing the
           •   The manufacturer’s instructions state that if the elevator   lessons learned and should always be subject to the requirements
               is not levelling at any floor, then it should be taken out of   of any applicable international or national regulations, as well as a
               service and a technician consulted.            company’s own procedures and policies.



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