Mistakes and Ladders

Mistakes and Ladders

Report Text

A crew member was working in the engine room using a step ladder.  He was standing on the third step when, without warning, the ladder suddenly gave way.  He fell backwards onto the adjacent platform. Fortunately his injury was limited to bruising.

The incident was investigated by the ship’s staff. ¬†Examination of the step ladder showed that the plastic hinges at the top of the ladder had failed, resulting in its collapse. It was noted that a previous breakage of the hinges had been repaired using glue, a steel plate and pop rivets. ¬†This set of step ladders should have been disposed of prior to this incident, as they were clearly not fit for purpose. ¬†Pre-use inspection of the ladder took place but the obvious defect was not noticed. ¬†With no traceable record of purchasing the ladder it is assumed that this was part of the vessels original outfit. ¬†The ladder has been removed from service and marked as broken. ¬†A new more suitable ladder is being purchased at first opportunity. ¬†The cause of this incident was the fact that the ladder had previously failed, and then fixed, when disposal was more appropriate. ¬†It has also been decided onboard that all portable ladders will be inspected for suitability and structural integrity. ¬†Any ladders found to be in poor condition or are unsuitable for shipboard use will be condemned and disposed of. Also as the crew member did not notice the poor condition of the ladders, it raises the possibility that pre-use equipment checks are not being carried out thoroughly enough. ¬†The Chief Officer is in the process of briefing the crew and officers on importance of proper pre-use equipment checks.¬† This should in turn result in any defects being noted and reported before an incident occurs. In the future all portable ladders will be included in the ROLA (Register of Lifting Appliance) and will be subject to regular recorded inspections to ensure incidents such as this can be avoided. ¬†The inspection of ladders is also going to be part of the Shipboard Safety Officer’s inspection regime to ensure deterioration of appliances doesn’t get over looked.

The Company also added that ladders with plastic hinges are not well suited for shipboard use.

CHIRP Comment:

Whilst at first sight this incident may appear to have been a technical failure of a simple piece of equipment, it was the result of non-conformities in applying procedures. ¬†Could the outcome have been worse? ¬†In slightly different circumstances someone may have fallen off the ladder and toppled over the rail to the deck below. ¬†So the ship’s safety team is commended for investigating the incident thoroughly, taking remedial action and sharing the learning through the company’s reporting scheme. ¬†We thank the company for sharing it with a wider audience.

CHIRP endorses the point that care must taken when purchasing equipment to ensure that it is fit for use in a marine environment.

Another company has advised that it has a Ladder Register. Ladders are checked quarterly in conjunction with the checks on Personal Protective Equipment.