Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2102
Initial Report
The engineer on a fish processing vessel needed to conduct maintenance on a conveyor belt used for moving boxes of fish. When work on the processing deck was temporarily stopped for a crew break, the engineer activated the emergency stop so that the conveyor belt would not be reactivated while they worked on it. They should have informed the crew of their maintenance intentions.
After the coffee break and once processing had restarted, the engineer wanted to check whether the tension on the chain was correct. While the engineer was checking the chain’s tension by hand, an approaching box of fish activated a sensor that instantly switched on the conveyor belt, causing the sprockets and chain to start moving. The engineer’s startled reaction was to pull their hand back because their fingers were trapped under the belt, tearing off part of a fingertip.
CHIRP Comment
The engineer failed to isolate the system completely and thought activating the emergency stop would prevent the system from operating. CHIRP contacted the company and received very positive feedback on how they would ensure that this type of incident would be prevented from happening again.
CHIRP was informed that the risk had been identified in the risk assessment for this work; it did not include Lock Out, Tag on, Tag off (LOTOTO) procedures which were only available for work on electrical systems and not on equipment with moving parts. The company have made changes to include this safety procedure for all equipment with moving parts.
Everyone must be briefed on planned maintenance work at the daily work planning meeting to ensure that conflicting work activities can be rescheduled and that adequate time and resource is allocated to the task. Because no one else was aware of the engineer’s intentions, the incident outcomes could potentially be even more severe.
Key Issues relating to this report
Communications – Does your vessel have daily and weekly work planning meetings and is the work communicated to the rest of the crew? Would you display a notice board showing daily and weekly work activities?
Pressure – Self-imposed time pressure led to shortcuts being taken. Planned maintenance should not be rushed.
Design – It should have been impossible for the conveyor to restart until the emergency stop button was reset. Emergency cut-off systems are not an acceptable alternative to the established pre-work isolation routines.
Everyone must be briefed on planned maintenance work at the daily work planning meeting to ensure that conflicting work activities can be rescheduled