Safety Flash

05/22 – March 2022

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 Permit to Work and Isolation procedure not followed

What happened?
Applicable 0

An electrician installed fuses on a 930V DC electrical system while the system Life Saving
was live. Under deck carousels were mechanically and electrically isolated as Rule(s) Bypassing
Energy
a precaution for maintenance work. Several other important vessel systems Safety
Isolation
Controls
were powered from the same drive cabinet. The electrical isolation was
conducted by removing the fuses for the carousel drive unit.

When the fuses were originally removed, the vessel was in port and none of the other vessel systems driven from
this same drive cabinet were powered up. The electrician isolated the power to the entire drive cabinet by isolating
the breakers and removing the fuses. The electrician then left the fuses at the bottom of the cabinet. Tags were not
applied, and the cabinet was left unlocked. On completion of the maintenance work another electrician re-installed
the fuses, believing the power to the cabinet was isolated. He opened the cabinet, removed the protective mesh,
and installed the fuses using a fuse insertion tool rated to 1000V. When inserting the second fuse, an arc flash
occurred, and the fuse blew. The electrician was not injured.

What went wrong?

• There was no Permit To Work (PTW) in place to control, communicate and co-ordinate the activities;
• Persons holding several different roles within the work team failed to understand and apply the company-
required level of controls for electrical works and isolations – the isolations were incorrectly applied;
• The vessel Standard Operating Procedures (SOP) for work on the equipment powered by this drive cabinet did
not consider the isolations as long-term with a requirement to protect several people working in the area;
• Procedures were not followed: the security of the electrical cabinet was not in accordance with company
procedures; the electrician did not lock and tag the cabinet while the fuses were removed;

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© 2022 Page 1 of 5
• Additional work team requirements with regard to the isolations had been discussed in the Toolbox Talk (TBT)
but were not carried out;
• The electrician re-installing the fuses did not check if the power to the drive cabinet was isolated before starting
work - failing to follow the instructions written on the cabinet and the work instructions given him.
Actions
• Review of procedures, work instructions, task risk assessments etc. with regard to Permit to Work and electrical
isolations;
• Review of Toolbox Talks to ensure they cover all aspects of the work including PTW and isolations;
• Check that the system you are going to work on is isolated – BEFORE you start work;
• Follow the instructions and warnings signs posted in the workplace. If in doubt, ask!
Members may wish to refer to:
• Electrician suffered flash burn to hand
• Fault in high voltage equipment
• Agitator started moving during mud tank cleaning – leading to injury

2 MSF: LTI – Fall from Height (control of work during SIMOPS)

The Marine Safety Forum published Safety Alert 21-18 relating to
an incident where someone fell from the bridge deck to the deck Applicable
below. Life Saving
Rule(s)
Bypassing
Working at
What happened Safety Line of Fire
Height
Controls
Four crew in two teams were working on maintenance of the vessel
superstructure. One of the teams was on the monkey island; the
other, on the bridge level gantry, removing gratings and working on
the steel frame of the gantry. When the team finished on the
monkey island, they went down to the bridge level, and one of
them removed his safety harness. He spotted an old paint drip that
needed dealing with, and considered that a check around the
bridge to finish off the job before break was a good use of time.

During this task he found it necessary, owing to restricted space,

to work moving backwards, not looking behind to see if there were
any obstacles. He was aware of the other team working on the
same level and that they had been working on gratings, but he did
not check to confirm where exactly they were at this moment.
Whilst working he took a step backwards and fell 3m through the
opening left by the lifted section of grating down to the boat deck.
The MSF’s member does not report what happened then but the
incident was considered an LTI.

What went wrong/what was the cause?

• Control of Work and Permit to Work Systems weren’t correctly and effectively implemented on board;
• There was a lack of situational awareness and risk perception, a lack of awareness of SIMOPS, and inadequate
communications between deck personnel in charge and deck crew;
• There were no barriers or signage in the area of the incident. A fall hazard was introduced by removing the
bridge gantry gratings.

IMCA Safety Flash 05/22 Page 2 of 5

Actions
• More effective and thorough toolbox talks and pre-task risk assessment, particularly for non-routine tasks;
• More thorough approach to SIMOPS:
̶ During scope of work planning, identify any combined operations and any additional hazards introduced by
the SIMOPS. Can SIMOPS be avoided, and tasks executed at different times?
̶ Assess the relevant level of risk associated with the SIMOPS.
̶ Are the planned control measures enough to keep things safe? If not, identify additional risk reduction
measures and update the relevant risk assessments.
̶ Whatever happens, make sure a record is kept so the same mistake doesn’t happen again - provide input
to the Permit to Work / Control of Work process and “embed” any changes identified.

Members may wish to refer to:

• IMCA M 203 Guidance on simultaneous operations (SIMOPS)
• Equipment on quay damaged when vessel started listing [uncontrolled SIMOPS]
• SIMOPS – Smoke from hot work task enters confined space
• Unsafe lifting operations [Uncontrolled SIMOPS]

Members may also wish to refer to the following incidents involving the word “grating” where someone has fallen
through grating or otherwise grating has played a role in an incident: www.imca-int.com/safety-
events/?searchitem=grating

3 UK HSE: Poor control of work - worker suffered serious injuries

An individual supervisor – not the company - has been sentenced
for safety breaches after a worker became entangled in a conveyor
belt sustaining serious injuries to his hand and arm. Applicable
Life Saving
Rule(s)
What happened Bypassing
Work
Safety Line of Fire
Authorisation
A worker was working on a conveyor belt when it became damaged Controls

and needed repair. The worker started work to repair the conveyor line, when it started moving and his arm became
entangled, which caused muscle and tissue damage.

What was the cause?

Investigation found that the site supervisor, who had control of the site in the absence of the site manager, was
responsible for completing a Permit to Work for the repair work and isolating the line. However, on his way to
complete the Permit to Work he became distracted by another matter and the Permit to Work and isolation were
not completed. This meant that the conveyor belt restarted during the repair work injuring the employee.

The inspector said: “The site supervisor failed to implement company policy and procedure in respect of Permits to
Work and isolation. This incident could so easily have been avoided by simply carrying out correct control measures
and safe working practices.”

Members may wish to refer to:

• IMCA “Are you prepared to work safely?” short video – Permit to Work
• Near miss: engine room hatch left open without barriers [A crew member who was on the deck left the area for
an urgent task forgetting to implement the control measures identified.]
• Electrician fatally electrocuted [Inadequate risk assessment, the electrician was in a hurry and distracted, there
were no competent personnel reviewing and approving electrical Permits to Work.]

IMCA Safety Flash 05/22 Page 3 of 5

• Electrician suffered flash burn to hand [the need for improved control of work was a clear lesson]

4 Fractured finger while handling metal plates

What happened Applicable
Life Saving
While working on deck, a crew member suffered a pinch injury to his right hand baby Rule(s)
finger, resulting in a distal fracture to the tip of the finger and a significant laceration Line of Fire
requiring sutures to the finger above the nail bed.

What went wrong?

Heavy weather had caused damage to welded plates on deck. While manually handling the plate back into position
with another crew member, the injured person suffered a pinch injury to his finger which was trapped between the
plate and frame. Following a medical review, the vessel headed into port to permit further diagnosis at hospital.
An X-ray showed a distal fracture to the tip of the finger and the wound required stitches.

What was the cause?

• The design of the plate did not allow for safe manual handling;
• The installation of the plate had a permanent risk of finger entrapment;
• The risk assessments and toolbox talk used were generic in content and not task specific;
• The JSA used was for hot work only and did not include manual handling at all.
Lessons learned
• Safety by design: the plate was subsequently modified to have a pair of temporary handles to keep fingers away
from the pinch points;
• Magnetic lifting handles sourced as a long term solution;
• Take care with generic risk assessments – ensure they are either modified to suit the task, or use a dynamic risk
assessment or toolbox talk specifically for a full and thorough review of the task.
• If the task is slow, uncomfortable or inconvenient, can we use the toolbox talk or JSA to better define and
understand these areas of risk? Can we remove the risk or reduce its likelihood or severity?

Members may wish to refer to:

• Update to SF 08/21: fatality – person crushed when secured material fell on him
• Secured material fell against crewman causing injury
• Crush injury to hand while attempting to secure crane hook

IMCA Safety Flash 05/22 Page 4 of 5

5 UK HSE: Liquid petroleum gas (LPG) leak
The UK Health and Safety Executive (HSE) reports that the operator of the UK’s largest oil
refinery has been fined for health and safety breaches after a leak of liquid petroleum gas Applicable
(LPG) was discovered by a worker cycling home at the end of their shift. See press release Life Saving
Rule(s)
here. Bypassing
Safety
Controls
What happened?

There was an uncontrolled release of around 15 tonnes of LPG through a valve near to the main roadway used by
LPG road tankers visiting a refinery in Fawley, Hants, UK. The leak went undetected for around four hours before
being discovered by an employee on his way home. It took a further hour to establish the source of the leak with
on-site emergency personnel having to enter the area to reset the valve.

What went wrong?

An investigation by the Health and Safety Executive (HSE) found that the leak occurred because:
• LPG was put through the pipe work at too a high a pressure for the valve;
• There was no process in place to detect the discrepancy in the flow in the pipe;
• The company had failed to take all measures necessary to prevent a major incident.

The inspector said “The measures required to prevent incidents should be proportionate to the risks. Where
companies handle large quantities of substances that can cause major incidents, such as LPG, they are required to
have layers of protection in place to prevent incidents.

In this incident a number of those layers either failed or were not in place resulting in a significant leak. Even though
there was no fire or injury on this occasion, there was potential for a major incident. The prosecution has been
brought to highlight the importance of maintaining the layers of protection and preventing this kind of major leak.”

(IMCA emphasis)

IMCA Safety Flash 05/22 Page 5 of 5