‘Routine’ task, non-routine result: A fall from a crane ladder leads to an LTI

A member has reported an incident in which a crewman fell from a fixed ladder injuring himself. The incident occurred when, after familiarising the shore-side crane operator, an Able Seaman (AB) was descending the crane ladder. His right foot slipped on the second rung of the ladder from bottom. He lost his hand grip on the ladder and fell down backward from a height of half a meter, with his buttocks touching the floor first resulting in lower back pain. He was referred to hospital for further examination of the injury and was declared unfit for duties for seven days.

Our member’s investigation noted the following:

• The ladder steps were free from oil/grease and clean;
• Correct and clean personal protective equipment (PPE) was being worn:
• the injured person’s safety shoes were in good condition with no traces of oil/grease on the soles
• the cotton gloves he was wearing were also free of any oil/grease;
• The injured person was not firmly holding onto the ladder with his hands while descending the ladder;
• He was sufficiently rested before the incident;
• The immediate cause was carelessness – right foot slipping off from crane ladder rung, a loose hand grip on the ladder while descending;
• A causal factor was improper motivation – lack of focus towards the task in hand;
• The root cause was that the risk was seen as tolerable – this was a ‘routine’ and recurring task.

The following preventative actions were identified:

• All crew to be reminded to be more safety conscious especially while going down ladders – ensure footing is secure and that there is no rush or hurry when on ladders;
• Care to be taken to ensure safety shoes and gloves are free from oil/grease stains;
• Care to be taken when conducting ‘routine’ work, especially by less experienced crew.

Members may wish to refer to the following incidents:

• ‘Routine’ task, non-routine result: Batteries stored sideways leak battery acid
• ‘Routine’ task, non-routine result: Finger injury during welding
• Recent slips, trips and falls involving stairs