Case Study: Unseen Danger – Unguarded Conveyor Drum and Communication Lapse Lead to Serious Injury
- Home
- Latest updates
- News
- Case Study: Unseen Danger – Unguarded Conveyor Drum and Communication Lapse Lead to Serious Injury
The Incident
Whilst undertaking fishing operations, a conveyor belt carrying frozen fish became blocked after several boxes were placed unevenly on the belt, causing one to jam against the side and the others to pile up. The belt was stopped by the crew to assist in clearing the obstruction. Once the blockage was cleared, the crew returned to their respective workstations, in the processing area, in order to resume operating the conveyor line.
The 2nd Engineer, who was not involved in the processing work but happened to be walking past the conveyor belt, noticed some pieces of rope stuck on the conveyor drum. Noting the conveyer belt to be stopped, he attempted to clear the pieces of rope by hand. As the conveyor drum was unguarded, the 2nd Engineer was able to reach into the exposed moving parts, a space that should have been physically protected. At that moment, unaware of the presence of the 2nd Engineer, the conveyor was restarted by one of the processing crew. This resulted in the arm of the 2nd Engineer being drawn into the unguarded drum, resulting in a traumatic amputation of his left forearm.
The vessel diverted to the nearest port where the 2nd Engineer underwent emergency surgery ashore. Whilst the 2nd Engineer’s life was saved, the incident resulted in the permanent loss of his arm.
Observations
- The absence of guarding on the conveyor drum created a major safety hazard.
- Although daily technical status reports to the office were in place, no crew had previously raised this hazard. It appears the exposed drum had become a routine sight on board and was therefore not recognised as a risk, reflecting a degree of normalisation of deviance regarding this unsafe condition.
- The 2nd Engineer showed a lack of situational safety awareness by attempting to remove pieces of rope from the drum area without confirming that the conveyor was safely isolated.
- There was a breakdown in communication between the 2nd Engineer and the crew who were operating the conveyor.
- Following the incident, a protective shield was installed at the drum. This measure was adopted fleetwide.
- This case underlines the critical role of appropriate machinery guarding, the undertaking of regular safety inspections, clear communication and ongoing crew training/toolbox talks on areas such as the isolation of machinery during maintenance.
Recommendations
- Install Guards – Fit protective shields on conveyor drums and other rotating parts of appropriate machinery to prevent contact with moving parts.
- Lock-Out/Tag-Out – Always isolate and tag machinery before working on them, either to carry out repairs or when performing maintenance.
- Communication – Establish clear procedures requiring crew to notify the supervising officer or the crew member in charge of the machinery and obtain confirmation before working on or near machinery.
- Hazard Awareness, Inspections & Near-Miss Reporting – Build a strong safety culture where all crew are encouraged to identify unsafe conditions, such as missing guards, and report them promptly as near misses or hazard observations. Members should also ensure regular inspections are carried out, so hazards are identified and corrective actions implemented fleetwide.