Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2207
Initial Report
Our reporter stated that they were asked to open a vessel’s elevator doors so that a cleaning crew could ride to the top of the elevator for cleaning purposes.
The reporter explained to the cleaning crew why this would not happen and how they must plan to do the work. The reporter provided a copy of a flag state incident report highlighting a severe injury to a crew member, which is produced here:
A senior engineer on a large yacht was preparing the passenger lift for a service technician to undertake remedial work on the decorative coverings in the lift shaft. The technician was not affiliated with the lift manufacturer or any lift servicing supplier and was on board solely to attend to the decorative coverings in the lift shaft.
The senior engineer called the lift car to the bridge deck and then entered the lift shaft onto the car top by manually opening the door on the Sun Deck and stepping onto the car top. When the lift doors on the sun deck closed, the lift rose to the sun deck position, crushing the engineer between the car top and the top of the lift shaft. The engineer sustained severe injuries to his legs and ankles and was off work for a considerable time.
The reporter is confident that similar practices are taking place on other ships with elevators and wanted to draw our attention to this. Although nothing happened in this case, there have been incidents where people have been crushed to death when working on the top of an elevator that wasn’t properly isolated.
CHIRP Comment
Our reporter stated that they were asked to open a vessel’s elevator doors so that a cleaning crew could ride to the top of the elevator for cleaning purposes.
The reporter explained to the cleaning crew why this would not happen and how they must plan to do the work. The reporter provided a copy of a flag state incident report highlighting a severe injury to a crew member, which is produced here:
A senior engineer on a large yacht was preparing the passenger lift for a service technician to undertake remedial work on the decorative coverings in the lift shaft. The technician was not affiliated with the lift manufacturer or any lift servicing supplier and was on board solely to attend to the decorative coverings in the lift shaft.
The senior engineer called the lift car to the bridge deck and then entered the lift shaft onto the car top by manually opening the door on the Sun Deck and stepping onto the car top. When the lift doors on the sun deck closed, the lift rose to the sun deck position, crushing the engineer between the car top and the top of the lift shaft. The engineer sustained severe injuries to his legs and ankles and was off work for a considerable time.
The reporter is confident that similar practices are taking place on other ships with elevators and wanted to draw our attention to this. Although nothing happened in this case, there have been incidents where people have been crushed to death when working on the top of an elevator that wasn’t properly isolated.
Key Issues relating to this report
Culture- Capability for this work could be improved, given the high risk associated with lift operations.
Complacency- A casual attitude to the work was displayed, which has probably been evident in the past and has been accepted as the norm. Does your SMS have procedures for lift maintenance? If so, are these made known to contractors working on the lifts?
Capability- Are there introductory safety training courses for the ship’s staff in lift maintenance? This is usually left to a qualified lift technician from the lift manufacturers to carry out. Do you involve your lift manufacturer?