M2084

Go back

19th January 2023

Entrapment in running equipment causes serious personal injury

Initial Report

“On the dock, pulling on the running backstay requires someone pulling the block forward to keep lines off the teak deck. The supervising officer operated the winch at high speed, and the crew member on the block got their hand caught in it. As the block lifted, it hoisted the crew member roughly 5m high. It suddenly stopped, catapulting the crew back to the deck, missing the mainsheet track by 10cm. The casualty suffered a broken wrist, required stitches to the lip and chin, and was knocked unconscious for 5 minutes. The crew member had to pay for their flights home and was off work for a month.”

CHIRP Comment

There needed to be better coordination between the supervising officer and the person working the block. Clear verbal warnings that the hoist was about to start would have alerted the crew member to keep their hands clear. The use of closed-loop communications in such circumstances should be considered, e.g., the crew person responding “Clear!” to the officer’s alert of “Operating winch!” or similar.

Large super yachts are fitted with powerful equipment items, and understanding their power must be part of the familiarisation process for all crew. CHIRP also asks whether the crew person was even needed. If the concern was that the block might scratch the teak deck, wouldn’t a canvas cover or other covering have sufficed?

Use the hierarchy of controls diagram-eliminate the hazard.

Toolbox talks are not standard in the super yacht sector of this industry, but CHIRP recommends adopting them, including Stop Work authority.

CHIRP feels the owners have a duty of care to look after and support the injured crew until they fully recover.

Key Issues relating to this report

Communications: Use closed-loop communications for safety-critical evolutions such as lifting.

Teamwork: Better coordination between the winchman and the block handler would have reduced the risk of entrapment.

Local practices: Where possible, reduce entrapment risks by looking for alternative methods to achieve the aim. A floor covering would have been a safer option.

Culture: The report that the casualty had to pay to repatriate themselves suggests poor personnel and welfare standards on board, which is also an indicator of a poor safety culture.

poor_communication, teamwork, normalisation_of_deviation