Page 11 - 2022 - Q2 - Minerva in Focus

“ 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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