CAKE Session no. 2 You can contribute to an accident – or stop it

We are impressed CAKE session no. 1 went well. Involvement from all units Reflections on Care, Awareness, Knowledge and Engement are collected and will be published on posters CAKE has been presented to our clients and their feedback is positive

Work shop Three lifting related incidents They are all about blind lifts They are all about series of broken procedures Several personnel have either participated in, or observed procedures not being followed All personnel chose to contribute to the incident – and not stop it

”MÆRSK GALLANT”, March 8th Man caught up in tag line during lifting operation Slinger/signaller gets caught up in the tag line and is lifted from the deck during a blind lift. No personal injury

”MÆRSK GALLANT”, March 8th Man caught up in tag line during lifting operation The following was said of the incident: A Slinger/Signaller was caught up in the tag line and lifted up ca. 2 m, during an operation where furniture, strapped to a pallet, was lifted from the deck to the living quarters on the forward starboard side. The lifting operation entailed blinfd lifts from both the deck and the living quarters. Despite this, the operation was carried out with only one person (combined Slinger/Signaller) on the living quarters. Just before the incident, the Signaller on deck went for a cup of coffee, leaving only one person to carry out the combined Slinger/Signaller role. This is against regulations and several points in the Maersk Contractors Norge AS procedures. The incident was not reported by the person who was caught up as he regarded this as non-critical. The operation continued after the incident.

”MÆRSK INSPIRER”, March 19th, 2008 Man gets arm crushed between tool and container under lifting operation Roastabout climbs into the container under a blind lift and get his arm caught between the container wall and a tool which tips the wrong way Absence from work

”MÆRSK INSPIRER”, March 19th, 2008 Man gets arm crushed between tool and container under lifting operation The following was said of the incident: The tool, which was to be lifted to the main deck, was lifted vertically with a lifting cap at one end. The Roustabout, who was later injured, fastened the hook to the lifting cap, which was allready attached to the the tool on the drillfloor. He then went onto the main deck in order to receive the tool there. On the way down, he contacted the other Rousabout on the crew and asked if he could assist with the lift. It was a blind lift. The first Roustabout directed the Crane Operator to the tool, which was placed approximately 50 m over the bottom of the basket into which it was to be lowered. He climbed into the basket. This was observed by the other Roustabout who stood outside the basket and was to pull the tool out towards the edge of the basket before it was to be lowered in completely. The Crane Operator did not observe that anyone was in the basket. The first Roustabout then instructed the Crane Operator to lower the tool into the basket. The end of the tool reached the bottom of the basket and the rest of its length began to lower down. When the tool reached an approximately 45 o angle, it swung across to the Roustabout in the basket, and his arm was crushed between the tool and the container wall as he tried to prevent the tool from hitting him. This resulted in him breaking his arm.

Gyda, November 1st., 2002 Man crushed to death between containers under lifting operation The crew was in the process of moving a chemical container. It was a blind lift and the hook was lowered too far. When the hook was lifted again, it got stuck and tilted the container. The Roustabout was caught between the falling container and another. Death

Gyda, November 1st., 2002 Man crushed to death between containers under lifting operation The following was said of the incident: A person was killed on Gyda the when he was crushed between a falling chemical container, weighing approximately 1400 kg, and another container. Two chemical containers were stacked ontop of each other. The top chemical container was accidentally lifted by the crane, when the hook or splice clamp (presskopling) wedged itself between the tank and the tank’s transport frame. The deceased was working on the top of the chemical container, and was to fasten the hook, when it was lifted and the container toppled off and against another container. A series of breaches of regulations, procedures and good pratice was uncovered in connection with the planning and execution of lifting operations, both of previous lifts and the lift in question.

Work shop 1.What did these accidents have in common? 2.What must be done so that we can learn from these accidents? 3.Hom can increased focus on CAKE prevent another accident from happening?