An engineer and an oiler were undertaking maintenance on the ship’s elevator. They had opened the inspection cover to the reduction gear of the elevator winch and were inspecting the gears while turning them manually using the turning handle.
At one point, other crew enquired via UHF radio whether the elevator work had been completed as they wanted to use the elevator. Since the inspection had just been finished, the engineer responded in the affirmative and requested the assisting oiler to switch on the breaker of the elevator. The oiler saw that the turning handle was still inserted in the gearbox, and asked the engineer to confirm whether it was OK to switch on the breaker. The engineer said yes and accordingly, the oiler switched on the breaker of the elevator.
At about the same time, the elevator was activated by the other crew, causing the turning handle to quickly turn; it hit the engineer in his face and arm causing injuries.
- The engineer made an error; he had a lapse, forgetting to remove the turning handle before having the elevator motor energised via the breaker. Everyone makes errors but teamwork and procedures should eliminate single point failure and reduce the consequences of an error. For example, had the oiler specifically pointed out to the engineer that the turning handle was still in the gearbox, rather than just asking for confirmation that it was OK to turn on the breaker, the engineer would surely have removed it.
- Always follow procedures when undertaking specific jobs. In this case, allowing activation of the elevator while still in the elevator machinery room was most certainly against procedures.