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Examining Fatal Shipyard Accidents - Volume
1 What went wrong? What went wrong? What went wrong? What went wrong? What went wrong? What went wrong? Examining Fatal Shipyard Accidents - Volume 2 The scenes you are about to witness depict fatal accidents that occurred while employees were working in shipyards. All identifying references have been removed to protect privacy interests. Please be advised that the depictions may be disturbing and deal with graphic subject matter. (MUSIC) Accident Examination 1 - Crane Boom Contacts Power Lines, Worker Electrocuted - 1 Fatality A crane operator and two riggers were moving
structural sections of a crane boom from a storage area to another area
of the shipyard. The riggers were positioned at both ends of the structural
sections while they were being transported. After the first section was
delivered the men noticed their original route taken to deliver the first
section was now blocked by another working crane. Rather than wait for
the crane to finish and move out of the way, they decided to take another
route to the work site. As they transported the second section the two
riggers focused their attention on keeping the load headed straight down
the narrow path. All three workers failed to see the overhead power lines.
The crane boom contacted these high voltage power lines. Seven thousand,
two hundred volts passed from the power lines through the wire rope into
the suspended structural section to the rigger who was still holding onto
the section. The rigger was killed instantly. (MUSIC) In route to their work area the crane traveling with the suspended load struck overhead power lines. A safe route was not established before the crane was moved. A designated person must establish a safe traveling route for cranes. Equipment must not be operated or positioned within ten feet of an energized power line. The rigger holding onto the load provided an electrical path to ground. Always use non-conductive tag lines to control loads. When practicable, tag lines should be clean and dry. Riggers assigned to assisting the movement of the crane and load must ensure sufficient distance as maintained between the extended boom of the crane and power lines. Ensure riggers are adequately trained to recognize crane hazards. It is recommended that power lines be clearly marked and visible as well as other overhead hazards. If work place conditions change another hazard assessment should be performed to determine whether previously unidentified hazards exist. Although not contributing to the fatality it is recommended that loads be carried no higher than necessary, normally waist high to prevent contact with any other obstruction. (MUSIC) Accident Examination 2 - Crane Operations without Adequate Clearance Crushes Welder - 1 Fatality A truck crane lifts steel shell plates from a
staging area. The crane holds them place on the vessel while they are
tack welded in position. After tack welding several steel shelf plates
the welder went back to complete the welds on each plate. As the employee
completed each weld, the crane continued moving additional plates into
position. As the welder worked on the port section, the crane moved plates
to the star board side. The crane lifted each plate and swung it over
the hull under construction. The crane operator inadvertently left the
auxiliary hoist line partially extended. As the crane swung the auxiliary
line struck the top of a shell plate, snapping it at its tack welded base.
The shell plate toppled and fell onto the welder working below. The welder
was crushed to death. (MUSIC) The crane operator did not recognize the hazards
caused by the partially extended auxiliary hoist line. Crane operators
should assess and recognize potential hazards before starting work. Unused
slings and lines must be secured prior to moving the load. The crane operator
swung the boom and load over an area where the employee was working. Crane
operators must never swing loads over employees. The work should be planned
and plates pre-positioned on both the star board and port sides, so there
is no load passing over the workers. It is recommended that riggers where
a high visibility vest and have available to them an audible device such
as a whistle to alert crane operators or nearby workers of unsafe situations.
The welder was not aware that the crane had started to swing over his
work area. Educate all workers of the hazards around working cranes. Crane
operators should keep visual contact with nearby workers. Assign a spotter
on the ground to make sure the crane will not interfere with other objects
or other work operations. (MUSIC) An inactive ship was being prepared for relocation
to another pier. Two men were rigging a chain fall to lift the last of
seven 3,000 pound mooring chains in order to secure it along the deck
edge of the vessel. One half of the mooring chain was supported part of
the way up the side of the vessel. The men were preparing to lift and
secure the unhooked end of the mooring chain near the deck edge. The men
began by attaching several short wire rope slings end to end with shackles,
creating a longer hoisting line. One end of the sling assembly was attached
to the unlinked end of the mooring chain. The other end of the sling assembly
was led through a bit on the deck edge of the vessel and then attached
to a chain fall. As the chain fall pulled its maximum distance the sling
assembly was secured to the bit by a manila rope used as a stopper. The
chain fall was then slackened so that the chain fall hook could be attached
to the next sling shackle through the bit. As the second sling was pulled
by the chain fall the sling shackle got hung up on the bit. The sling
assembly was secured with a manila rope stopper and then the chain fall
was backed off. While a waiting for instructions, the worker walked into
the area and looked over the deck edge to see what was wrong. The manila
rope stopper snapped, causing the weight of the chain to be transferred
back to the sling assembly. The slack assembly suddenly became taut and
struck the rigger in the neck with tremendous force, breaking his neck.
The rigger died instantly. (MUSIC) A hazard assessment was not performed before the
work began. Riggers were not properly trained to perform the tasks they
were assigned. The sling assembly used was not properly sized for this
hoisting operation. For this job only slings that fit through the bit
should have been used. A safety line should have been attached to the
end of the mooring chain to support it if the hoisting apparatus failed.
Always use the proper equipment for the job. The employee entered the
bite of the line while the line was under load. Never enter the bite of
the line. The crew relied on manila rope as a stopper. The load on the
rope exceeded the safe working strength of the rope. Never exceed safe
working loads of rope line or chains. (MUSIC) Two workers were assisting a crane operator who
was loading a piece of equipment from a pier onto a ship. The ship's crane
was being used to transfer a heavy delivery valve onto the ship for installation.
The workers were positioned on two unguarded cat walks that ran along
each side of the ship's open hopper. The workers used tag lines to guide
the load onto the ship's deck. As the crane swung the load from the pier
to the ship, the load disengaged from the hook, the load fell and struck
the star board side cat walk near one of the workers. The startled worker
on that cat walk quickly stepped back away from the falling load and lost
his footing and fell, hitting his head on the cat walk as he went down.
Unconscious he fell into the hopper, which at the time was filled with
water and drowned. (MUSIC) The valve was not properly rigged to the hook
of the crane. Always ensure that the load is properly rigged to prevent
the load from becoming disengaged from the hook. It is recommended that
hooks be equipped with a safety latch or moused (ph.). Actions were not
taken to ensure adequate fall protection was provided to workers along
unguarded edges. Employees working on elevated cat walks must have adequate
fall protection. In required order such protection includes guard rails,
fall arrest systems or if employees are working over water personal floatation
devices. (MUSIC) A dive team was asked to install j bolt patches
as a temporary repair for two holes in a crude oil tank barge. The two
holes were at a depth of approximately 25 feet. The dive team consisted
of two scuba divers and a diving tender to control the safety lines from
the pier. The two divers entered the water to remove a wooden plug from
the first hole and install a j bolt patch. Both divers had safety lines
attached. After installing the patch both divers returned to the pier
and exited the water. Diver number one wearing blue remained on the pier,
while diver number two wearing yellow reentered the water by himself to
tighten the first patch that was installed. Diver number two had a safety
line attached for this dive, but the line was not tended. After tightening
the patch using a pneumatic wrench diver number two exited the water.
On his third dive number two reentered the water by himself to move the
air hose, safety hose and magnets from the location of the first patch
to where the second patch would be placed. The air hose and safety lines
were attached to the hull of the ship with a magnet. Diver number two
did not have a safety line attached because he was relocating it. Diver
number two had been in the water for over ten minutes, while diver number
one was on the dock mixing epoxy. He called the tender off his break to
help him with preparing a patch for the second hole. When the tender returned
to the dive location to assist diver number one he noticed that the air
hose and safety lines were not attached to the hull, indicating that diver
number two failed to reattach the lines. He became suspicious that something
was wrong. Diver number one put his scuba equipment back on and entered
the water to find diver number two. Visibility was very poor, so diver
number one could only search by feeling with his hands. After a search
of approximately ten minutes, diver number two was found unconscious and
was removed from the water. Diver number one attempted to resuscitate
diver number two by performing CPR. His efforts were not successful. (MUSIC) While in the water scuba waters must always be
tied to a safety line and line tended from the surface or accompanied
by another diver with continuous visual contact at all times. A stand
by diver must be ready to provide assistance whenever a scuba diver is
in the water. Scuba divers must carry a reserve air breathing supply.
When line tending from the surface, a tender must never leave his post.
The designated person in charge must not let other tasks detract from
his prime responsibility, the safety and health of dive team members.
(MUSIC) Two workers were told to pump out a bow compartment
of a barge that held 12 inches of water. The on deck pump they would normally
use was being repaired, so they decided to use a smaller gasoline powered
pump inside the compartment. The compartment had only one open access
hatch that the workers used to enter the space. The gasoline powered pump
was set up inside the space and one worker remained with it to make sure
that the intake house stayed submerged. Exhaust gases from a gasoline
powered pump containing carbon monoxide built up in the space. The workers
slowly became unconscious and eventually fell face down into the water
that remained in the space. The other worker on deck did not know there
was a problem, because the pump was running continuously. Later on when
the pump ran out of fuel and stopped running the worker on deck went down
into the compartment and found is coworker face down in the water. (MUSIC)
Confined spaces must be visually inspected and
tested by a competent person to determine the atmosphere's oxygen content
prior to an employee's entry. Employees entering confined or enclosed
spaces must be trained to perform their work safely and to recognize hazards.
When using internal combustion engines, exhausted below decks the space
must be periodically tested by a shipyard competent person to ensure that
dangerous levels of carbon monoxide do not develop. Ventilation must be
provided to maintain the oxygen level and keep carbon monoxide below hazardous
levels in spaces where internal combustion engines are used. Workers in
confined or enclosed spaces or in isolated locations must be checked frequently.
(MUSIC) An electrician was working on an open electrical
panel on a ship. He needed to add a new cable and attach it to a breaker
within the panel. The electrician identified the isolation breaker that
fed the entire panel on the schematic drawing. The electrician de-energized
the breaker and properly tagged out. As the electrician was fitting the
new cable into the panel his left hand came into contact with the panel's
main bust bars. Four hundred forty volts of current passed from the bus
bars through his left hand, across his chest, and out his right hand that
braced him against the panel electrocuting him. At some point the tagged
out isolation breaker had been crossed wired with another breaker. The
electrician did not know that the panel he was working on was never de-energized.
(MUSIC) Employees should verify the location of all energy
isolation points. Employees must check or test electrical panels or electrically
powered equipment to ensure they are in fact de-energized before working
inside them or within the vicinity of exposed electrical circuits. Inform
all contractors and subcontractors of the ship's systems and/or modifications
to the systems prior to beginning work. (MUSIC) A shipyard worker was preparing to replace a high
pressure steam valve that was faulty and leaking in an engine room. The
valve was part of a 600 psi steam system on a vessel. Other shipyard personnel
had previously located all the valves and drains and isolated the steam
system according to the ship's as-built drawings. All the drains indicated
on the as-built drawings of the ship were open and depressurized. The
drains were then marked with tags. As one of the workers loosened the
bolts around the faulty valve a tremendous burst of steam was suddenly
released. The steam under high pressure, at 385 degrees Fahrenheit knocked
the worker to the ground and produced third degree burns on more than
60 percent of his body. The worker died two days later in the hospital.
Errors and omissions on the ship's as-built drawings had prevented shipyard
personnel from completely isolating and draining the steam system. (MUSIC)
Use a thermal gun or carefully place your hand
near both sides of the valve to check the temperature. Verify that the
steam system is drained and the drain valve is open. Be careful not to
touch the pipes or valve too quickly. Approach them slowly to feel if
heat is radiating from them first. If they are very hot then they may
still contain steam under pressure. Accurate drawings free from discrepancies
are essential for effective energy isolation. Shipyard personnel should
be properly trained to conduct a visual check of all drains and valves
in a steam system that is to be drained and depressurized. Drain connections
on all dead interconnecting systems must be opened and observed to ensure
effective isolation. Employees authorized to perform steam system repairs
should be directly involved in the isolation and lock out tag out of the
system. Direct involvement by workers in the lock out, tag out process
ensures their understanding of the operation or process hazards that the
lock out, tag out is designed to control and how to avoid or control these
hazards. It is essential for ship's personnel and repair contractors to
communicate and coordinate about the isolation and lock out tag out of
the ship's systems. (MUSIC) |

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