Safety Flash

18/23 – July 2023

IMCA Safety Flashes summarise key safety matters and incidents, allowing lessons to be more easily learnt for the benefit of all.
The effectiveness of the IMCA Safety Flash system depends on members sharing information and so avoiding repeat incidents.
Please consider adding safetyreports@imca-int.com to your internal distribution list for safety alerts or manually submitting
information on incidents you consider may be relevant. All information is anonymised or sanitised, as appropriate.

1 Restricted air supply to diver

What happened?

During a diver recovery drill, a contracted subsea company encountered significant issues that led to the standby
diver momentarily losing his main air supply. This restriction in the air supply resulted in the diver going on bailout
and the drill being aborted. Both divers were safely recovered to the surface.

What went right

Both divers worked together during the recovery to

amend the issues after the incident. When the primary
air supply was restricted, Diver 1 was attentive and
assisted Diver 2. Both divers were recovered to the
surface safely.

What went wrong

A review of both divers’ videos showed difficulties in

recovery, primarily caused by improper umbilical
management and communications.
• Human error: Diver 2 moved his umbilical Subsea camera still of twisted umbilical
restriction from the handle of Basket-2 to the
handle of Basket-1, leaving just 2m of slack between this connection and the ring on Basket-2 main wire. This
led to his umbilical becoming strained between the baskets due to uneven recovery, causing a restriction in his
main air supply;
• Inadequate supervision: The task plan for the drill lacked detailed and specific instructions, leaving gaps. That
caused further issues when coupled with the umbilical placement, uneven recovery of the baskets, and
communications issues;
• Communication breakdown: The placement of Diver 2 umbilical between the baskets was not apparent to the
Diving Supervisor. The Diving Supervisor was unaware of the uncoordinated basket movement and there was
inadequate communication between the divers and the diving supervisor, exacerbating the situation.

What were the causes of the incident?

• Improper umbilical management: Prior to the recovery of the divers, Diver 2 moved his umbilical restriction
from the handle on Basket-2 to the handle on Basket-1. Leaving Diver 2 with his umbilical connecting between
Basket-1 and the ring on Basket-2 wire, causing a strain on his umbilical when Basket-1 raised before Basket-2.
This led to a kink in the umbilical resulted in the loss of the main air supply to the diver;
• Communication issues: There were initial misunderstandings between the divers and the diving supervisor
regarding the issues, resulting in delays in levelling the baskets to remove the strain from Diver 2’s umbilical;

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© 2022 Page 1 of 6
• Coordination problems: When the instruction was given to recover both baskets together, LARS-2 began lifting
Basket-2 while Basket-1 was not lifted. This led to Diver 2 umbilical stretching between the two baskets as
Basket-2 pulled it.
Lessons
Our member took the following lessons:
• Communication: Establish clear communication protocols before the operation and ensure all team members
understand their roles and responsibilities. Ensuring that the crew understand their roles prevents
misunderstandings and enhances overall coordination during operations;
• Supervision: Ensure adequate instructions, communications, and supervision during all operations. Particular
attention should be paid during the planning, execution, and oversight of regular emergency drills;
• Umbilical Management: Proper umbilical management during all diving operations is critical. Poor umbilical
management can lead to serious diver incidents and injuries;
• Continuous Improvement: Besides annual reviews, lessons learned from incident findings should be included
in updates to operational procedures, manuals, and guidelines – helping to ensure that good practices are
formally implemented and providing guidance to reduce potential risks in future operations.
Actions taken
• Ensure that lessons learnt is shared with the entire workforce and with IMCA;
• Reviewed and updated company diving procedures, training and diving manuals to include learnings outlined
above.

Members may wish to refer to:

• High potential near-miss: Failure of both divers’ breathing air supply and dive stage recovery winch
• Diver experienced an air flow restriction
• Near miss: diver reports tight gas

2 LTI – crew member fell down open hatch

What happened
Applicable
During mooring, a crew person was attempting to secure the rope on the aft Life Saving
section of the vessel. While performing this task, the person stumbled and fell Rule(s) Bypassing
into a hatchway which had been left open. The fall caused the individual to Safety Line of Fire
Controls
suffer three broken ribs, which led to a Lost Time Injury (LTI).

Right-hand image is a re-construction!

IMCA Safety Flash 18/23 Page 2 of 6

What went wrong
• Lack of communication: The engineer had failed to communicate the fact that the hatch was open and
unprotected. No toolbox meeting had taken place to facilitate communication among crew members;
• There were no barriers nor warning signs;
• Inadequate hazard identification and risk management: No-one spotted this…crew members failed to identify
and manage the risk. A toolbox meeting could have helped address this issue;
• Lack of toolbox meeting: Without a toolbox meeting, the crew couldn't discuss hazards, precautions, and
communication strategies. Toolbox meetings should be considered essential for promoting safety awareness.
What can be done
• Discuss requirements for using barriers and warning signs when hazards are present, such as open hatches or
other potential risks. Make sure signage and equipment are readily available on board to facilitate these safety
measures;
• Ensure toolbox meetings are held before starting work, and that they focus on task-specific hazards, safety
measures, and crew member responsibilities. Encourage open communication and active participation from
everyone involved.
Members may wish to refer to:
• Medical treatment: Person fell down unprotected hatch
• LTI: step into open deck hatch causes fall
• Crewman falls down open hatchway during simultaneous operations

3 Fire in diesel generator following tests

What happened

There was a small fire in the engine room on a vessel in port. The incident occurred when a diesel generator was
being maintained by a third-party maintenance team. On completion of a change of alternator bearings, the
generator was tested at idling speed, and no problem was found. But when the generator was tested at operational
speed, after a few minutes fire came out of the non drive end exciters. The alarm was raised; the diesel generator
was brought to an emergency stop and the fire was put out with an extinguisher.

IMCA Safety Flash 18/23 Page 3 of 6

What went wrong

There was a misalignment of the internal cover of the non drive end bearing. This misalignment caused friction
against the shaft and subsequent sparking. The root cause was considered to be insufficient supervision of the third-
party personnel conducting the maintenance.

Lessons
• Whilst there was only a burnt alternator in this case, the potential was for the fire to have spread throughout
the engine room;
• Ensure full and thorough supervision of the personnel of third-party contractors;
• Check carefully the status and readiness of any equipment after maintenance and test – in this case, it was as
well that they tested it at operational speed rather than only when idling.

Members may wish to refer to

• Engine room fire on a ferry [bearing failure and a fire caused by friction]
• Fire alarm activation in engine room
• Near Miss: Fire blanket caught fire during third-party hot work
• Small fire following hot work

4 Chain caught and broke

What happened
Applicable
Crew were removing a hydrogen gland from a generator using a lifting attachment, two Life Saving
chain falls, and an overhead crane. One of the chain fall’s pull chains caught on a bolt and Rule(s)
Safe
broke. The bolt was on the top of the generator and was there to hold a protective cover Mechanical
Lifting
sheet in place. There were no injuries.

What went wrong

• There was a general job briefing done for the day’s work,
but not specifically for this task;
• The crew had started lifting the load with chain falls and
were beginning to lift with the crane. There are two distinct
lifts to be considered - the manual lift (with the chain fall)
and the power lift (with the crane). The transition is the
critical time;
• Everyone was focused on the load and not watching the
chain falls or the crane.
Actions
• A Safety stand-down was held to discuss this incident with
all involved and lessons from it were to be included in future training material for apprentices and new hires;
• Have an increased awareness of ensuring chains are free when moving loads;
• Keep the “bigger picture” in mind – don’t get so focussed on the detail that something obviously potentiallly
unsafe escapes your attention.
Members may wish to refer to:
• Dropped load and failed chain
• Crewman fatally injured during mooring operations [chain snapped]

IMCA Safety Flash 18/23 Page 4 of 6

• Near-miss: Safe use of chains in rigging

5 BSEE: Overhaul Ball falls to deck resulting in High Potential near miss
What happened
Applicable
The United States Bureau of Safety and Environmental Enforcement (BSEE) has published Life Saving
Safety Alert 460 relating to a dropped object during lifting operations. While conducting Rule(s) Safe
crane operations during decommissioning/well abandonment, a 350kg crane “headache Mechanical
Lifting
ball” fell 8m to deck and landed less than 60cm from one of the riggers.

A crane was moving a 200kg (400 lb) well cap when a wedge socket on the auxiliary line snagged on the flange of a
C-channel located at the edge of the platform’s rig deck. The lift required running the crane’s auxiliary line within
centimetres of the edge of the platform. It was a “blind lift,” directed by a rigger using radio communications. The
rigger was standing on the pipe deck and had a clear view of the load, line, pedestal crane, and crane operator. His
location put him approximately 9m from the load line.

The wedge socket above the headache ball snagged on the C-channel flange that ran across the length of the edge
of the deck. This snag temporarily held all the weight of the load and rigging, resulting in a false reading on the
auxiliary winch - the load cell sending a weight signal to the operator was below the snagged wedge socket.

The crane operator did not detect that the auxiliary winch was no longer holding the weight of the load. The rigger
did not realize that the line had snagged on the C-channel and continued giving directions to keep lowering the
load. As the load cell was positioned below the snag, there was no change in the load signal, even though the weight
of the load was now being supported by the C-channel and not the auxiliary winch.

The rigger, not seeing any movement, repeated a request to lower the load. Because the crane operator could not
see the winch drum behind the crane cab, he did not see that the load was not moving and responded that he was
still lowering the load. As the crane operator continued to unwind the auxiliary line at the winch drum, the wedge
socket slipped off the flange of the C-channel, releasing the snag. The headache ball fell 8m and hit the deck less
than 60cm from one of the riggers guiding the load.

What went wrong?

BSSE identified several contributing factors
• The rigger and crane operator should have noticed the auxiliary winch was no longer detecting the weight of
the load;
• The engineered controls (i.e., weight indicator) provided an inaccurate representation to the crane operator of
the weight on the winch due to the wedge socket snagging above the load cell;
• The crane operator and rigger failed to recognize something was wrong after repeated requests to lower the
load and after receiving the response that the line was being lowered and not seeing any movement in the load
position;

IMCA Safety Flash 18/23 Page 5 of 6

• The rigger did not check the path of the auxiliary line for potential snags;
• The work team ought have noticed the potential hazards of working close to the C-channel at the edge of the
platform rig, and should have recognized the potential snag points;
• No formal risk assessment was conducted. However, a review of the task was performed.
Lessons and actions
• Ensure a secondary device (e.g., weight indicator, camera) is accessible to detect any slack on the load line;
• Identify all potential rigging contact or snag points and include them in worksite instructions, risk assessments,
and toolbox talks – particularly when working close to other equipment or structures;
• Ensure fully agreed, understood and practiced/tested communication between crane driver and rigging crew;
• Ensure a full and thorough lift plan is place before the job is started;
• What would you have done to avoid this situation? Discuss what key controls are in place to remove yourself
and your team members from the potential “line of fire”.
Members may wish to refer to:
• Snagged load, a sling snaps, dropped objects: persons injured [a focus on “snagging”]
• Near miss: winch wire snagged and released suddenly [The driller failed to notice that the winch wire had
become snagged and continued to…]
• Snagged lift during deck cargo operations (MSF)

IMCA Safety Flash 18/23 Page 6 of 6