MARS 200968

Loss of hand

A crew member, assisted by a cadet, was ordered to unlash and lower a pneumatically-powered accommodation ladder. Due to unfamiliarity with the procedures and equipment, instead of slowly ‘breaking out’ the ladder safely by means of the manual winch provided, the seaman attempted to combine both the swing-out and lowering movements by tentatively opening all the air valves and moving all the control levers to maximum.

As the winch paid out the wire rope with the ladder still in the stowed position, a number of loose turns came off the drum, coiling around the crew member’s right hand, which was still gripping the main operating lever. Suddenly, when the ladder swung out and dropped, the loose turns instantly pulled tight, severing his right hand from the base of the thumb and shearing away the control handle. Reconstructive surgery was done, but it is likely that the crew member will have a permanent disability which will prevent him from continuing a seafaring career.

Root cause/contributory factors

1. The crew member had not been properly familiarised in the preparation and operation of the accommodation ladder and failed to communicate this fact to the bosun when the task was assigned to him;
2. The accommodation ladder operation was not supervised by an experienced person and was conducted in an unsafe manner by the crew member, who did not follow the correct ‘breaking out’ and control valve operational procedures;
3. No operating instructions were displayed locally;
4. No risk assessment for the operation of the accommodation ladder appeared to have been conducted; and 
5. Improper design – the control levers were located very close to the rotating wire rope drum, which had no protective guard fitted.

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