Spirit of Tasmania engineer’s serious fall blamed on lack of defined safety routes
An investigation has uncovered the reason behind a Spirit of Tasmania engineer suffering a significant leg injury after slipping just 15 minutes before the ferry was due to depart for Devonport.
A Spirit of Tasmania engineer who required knee surgery after slipping from an engine during an oil change was operating in an area that lacked defined safety routes, an official investigation has found.
The Australian Transport Safety Bureau report also found that additional work to replace a turbocharger housing cover was not assessed for risk due to perceived time pressures immediately prior to the TT-Line vessel’s departure.
The ATSB probe was ordered following an incident which took place on board the Spirit of Tasmania I, soon after it docked in Geelong on the morning of 6 March this year.
The report found the “significant” change in scope of work required access to the top of the engine, which the vessel’s second engineer climbed on to several times.
At 8.15am, and just 15 minutes before the Spirit was due to sail back to Devonport, the engineer slipped and fell heavily onto catwalk grating, resulting in serious injury to his knee.
“The ATSB investigation found that, while access to the top of the engine was regularly required, there was no access ladder or platform nor was a standard safe route defined or used,” the published report read.
“Consequently, the injured second engineer used an unsafe access route along the engine rocker covers at the time of the accident.
The investigation also identified that although the shipboard safety management system required that the change of work scope necessitated a review of the Job Safety Analysis and/or completing a new pre-start safety checklist (Take 5), neither was undertaken due to perceived time pressure and a perception that the work was low risk, resulting in the risk of a fall not being properly considered.
“In addition, the ATSB found that the JSA procedure was not effectively implemented on board. This resulted in there being no JSA in place for the work being done at the time of the incident.
“Further, the JSAs covering other work on top of the engine did not address the risks involved in accessing the engine top.”
While the engineer was able to complete their work, an on-board medic referred the crewmember to a doctor ashore, who subsequently diagnosed a serious injury requiring surgery and an extended period of recovery.
The report found that TT-Line had responded proactively to the incident, by installing removable work platforms for safe engine access on both Spirit I and Spirit II vessels, and restricting routine maintenance of equipment during short-duration port calls.
The ATSB report found that continuing factors to the incident included the lack of a defined safe route to the top of the engine; and engineers failing to conduct an additional safety analysis of the additional job of replacing the housing cover.
“Spirit of Tasmania I’s safety management system procedure for Job Safety Analyses was not effectively implemented,” the report read.
“As a result, the JSA required for replacing the main engine turbocharger bearing housing cover plate was not in place.
“In addition, JSAs covering other work on top of the engine did not address the risks involved in accessing the work site.”
Originally published as Spirit of Tasmania engineer’s serious fall blamed on lack of defined safety routes
