Summary of WHE Accidents
First Quarter FY03

RMKS/1. THE PURPOSE OF THIS MESSAGE IS TO DISSEMINATE SHORE ACTIVITY WEIGHT HANDLING EQUIPMENT (WHE) ACCIDENT LESSONS LEARNED TO PREVENT REPEAT ACCIDENTS AND IMPROVE OVERALL SAFETY.

2. REF A REQUIRES COMMANDS TO SUBMIT TO THE NAVY CRANE CENTER (NCC) A FINAL, COMPLETE ACCIDENT REPORT (INCLUDING CORRECTIVE/PREVENTIVE ACTIONS) WITHIN 30 DAYS OF AN ACCIDENT, REGARDLESS OF SEVERITY OR TYPE. IN ADDITION, CONTRACTING OFFICERS ARE REQUIRED TO FORWARD TO
NCC REPORTS ON ALL CONTRACTOR ACCIDENTS.

3.  FOR THE FIRST QUARTER OF FY-03, 51 NAVY WHE ACCIDENTS AND 3
CONTRACTOR WHE ACCIDENTS WERE REPORTED.  SEE PARAGRAPH 8 FOR CONTRACTOR WHE ACCIDENTS.  SERIOUS ACCIDENTS THIS QUARTER INCLUDED 1 INJURY, 5 DROPPED LOADS, 5 OVERLOADS AND 5 TWO-BLOCKINGS.

4.  INJURY:
A MACHINE SHOP SUPERVISOR WAS BRIDGING A CRANE WHILE PERFORMING THE OPERATOR'S MONTHLY CRANE INSPECTION.  AS THE CRANE TRAVELED ON THE RAILS IT COLLIDED WITH A CEILING MOUNTED HEATER DUCT THAT HAD RECENTLY BEEN EXTENDED INTO THE CRANE'S TRAVEL PATH.  THE COLLISION CAUSED SOME PARTICLES TO FALL INTO THE SUPERVISOR'S EYE, DAMAGING A
BLOOD VESSEL.

LESSONS LEARNED:  AFTER INSTALLING NEW EQUIPMENT IN THE VICINITY OF OVERHEAD CRANES, THE CRANE TRAVEL PATH MUST BE CHECKED CAREFULLY TO VERIFY THAT THERE ARE NO INTERFERENCES.

5. DROPPED LOADS:
A.   IN SEPARATE LIFTS AT DIFFERENT LOCATIONS DURING INCLEMENT WEATHER A CATEGORY 4 CRANE WITH A POWER BLOCK CABLE REEL ASSEMBLY WAS USED TO PLACE SHORE POWER CABLES ONTO TWO SHIPS.  DURING BOTH OF THESE LIFTS, THE POWER CABLE SLIPPED FROM THE POWER BLOCK REEL AND FELL ONTO THE PIER.  A REVIEW OF THE ACTIVITY'S ACCIDENT DOCUMENTATION REVEALED THAT THE CABLES HAVE A TENDENCY TO SLIP OUT OF POWER BLOCK REEL ASSEMBLIES DURING WET CONDITIONS.

LESSONS LEARNED: OPERATING PROCEDURES FOR THE USE OF POWER BLOCK REEL ASSEMBLIES FOR THE PLACEMENT OR REMOVAL OF SHORE POWER CABLES MUST BE REVIEWED.  IF A POWER REEL HAS A TENDENCY TO LOSE THE CABLE DURING WET CONDITIONS, ALTERNATIVE MEANS SHOULD BE USED WHENEVER RAIN OR INCLEMENT CONDITIONS ARE A POSSIBILITY.
B.  A CRANE TEAM WAS PRACTICING THE REMOVAL AND REINSTALLATION OF A MOCK-UP ONTO A STAND.  THESE LIFTS WERE ASSUMED TO BE SIMPLE IN NATURE SO THERE WERE NO PRE-LIFT BRIEFS CONDUCTED.  PRIOR TO THE ACCIDENT, THE REMOVAL AND REINSTALLATION OPERATION WAS CONDUCTED NUMEROUS TIMES WITHOUT INCIDENT.  DURING THE LAST PRACTICE RUN, THE LOAD SHIFTED AND FELL WHEN THE OPERATOR LANDED THE MOCK-UP AND
RELEASED THE TENSION ON THE HOISTING AND RIGGING LINES.  THE
ACTIVITY'S REVIEW OF THE ACCIDENT REVEALED THAT THE MOCK-UP WAS NOT PROPERLY SEATED AND ALIGNED ON THE SUPPORT STAND.  THE CRANE TEAM WAS UNABLE THE SEE THE IMPROPER POSITIONING DUE TO OBSTRUCTIONS IN THEIR LINE OF SIGHT.

LESSONS LEARNED:  THERE ARE INHERENT HAZARDS IN EVERY LIFTING OPERATION.  PRIOR TO ANY LIFTING OPERATION, TIME SHALL BE DEVOTED TO ASSESSING THE HAZARDS.  ONE OF THE CONTROL ELEMENTS IN THE LIFTING OPERATION IS THE RESPONSIBILITY OF MAKING SURE THAT THERE IS AN UNOBSTRUCTED SIGHT LINE MAINTAINED BETWEEN THE LOAD AND SUPPORTING STRUCTURE.

C.  A MOBILE CRANE WAS BEING USED TO LIFT A PUMP WEIGHING 350
POUNDS. THE CYLINDRICALLY SHAPED PUMP WAS RIGGED IN THE VERTICAL POSITION. THE OPERATOR WAS INSTRUCTED TO RETRACT THE BOOM.   WHEN THE BOOM HIT THE FIRST SECTION OF THE BOOM STOP IT SHOOK THE LOAD AND THE LOAD SLIPPED THROUGH THE SLINGS AND FELL TO THE PIER. IMPROPER RIGGING ALLOWED THE PUMP TO SLIP AND FALL TO THE PIER DURING THE LIFT.

LESSONS LEARNED: CARE SHALL BE TAKEN TO USE THE PROPER RIGGING CONFIGURATION WHEN HOISTING CYLINDRICALLY SHAPED OBJECTS.  OBJECTS OF THIS TYPE SHOULD BE HOISTED IN THE HORIZONTAL POSITION WHEN POSSIBLE.  USING A DOUBLE CHOKER HITCH SLING CONFIGURATION WILL FACILITATE A BETTER CONTROL OF THE LOAD.

D.  DURING THE LIFT OF AN AXLE ONTO A TRAILER, THE AXLE BECAME
DISLODGED AND DROPPED.  THE TWO-LEG WIRE ROPE SLING BEING USED HAD A  SAFETY LATCH MISSING FROM ONE OF THE HOOKS.  THIS ALLOWED THE HOOK TO SLIP OUT OF THE SHACKLE CAUSING THE AXLE TO DROP.

LESSONS LEARNED: PRIOR TO ANY LIFTING OPERATION, RIGGING GEAR MUST BE CHECKED FOR DEFICIENCIES.  IF THE RIGGING IS FOUND TO BE DEFICIENT, IT SHALL BE REPLACED.

6. OVERLOADS:
A.  RIGGING GEAR WAS OVERLOADED DURING THE LIFT OF A SHAFT DOLLY SECTION AND TILT TABLE THAT WEIGHED 8,500 POUNDS.  THE RIGGER ASSUMED THAT THE WEIGHT WAS 6,200 POUNDS.  THE RIGGER'S INFORMATION WAS OBTAINED FROM THE DOLLY'S LABEL PLATE BUT THE ANNOTATED WEIGHT DID NOT INCLUDE THE WEIGHT OF THE TILT TABLE.  IN ADDITION, THE RIGGING GEAR  WAS INCORRECTLY SIZED FOR THE ASSUMED WEIGHT OF 6,200 POUNDS.  THE RIGGER DID NOT CONSIDER THE FOUR-POINT LIFT REQUIREMENT
OR THE DOWNGRADE FOR THE LIFT ANGLE 

LESSONS LEARNED: WHEN LIFTING A LOAD HAVING MULTIPLE SECTIONS, THE RIGGER MUST VERIFY THE WEIGHT OF EACH INDIVIDUAL SECTION.

B.  A MOBILE CRANE WAS OVERLOADED ON FOUR DIFFERENT OCCASIONS AS A RESULT OF THE TEST DIRECTOR'S MISINTERPRETATION OF THE OEM'S LOAD CHART.  THE ORIGINAL HOIST WIRE ROPE HAD BEEN REPLACED WITH A ROTATION RESISTANT WIRE ROPE.  ALTHOUGH THE ROTATION RESISTANT WIRE ROPE HAS A HIGHER BREAKING STRENGTH THAN THE ORIGINAL ROPE, THE REQUIRED FACTOR OF SAFETY IS HIGHER, RESULTING IN A LOWER RATED CAPACITY THAN THE ORIGINAL WIRE ROPE.  THE TEST DIRECTOR DID NOT NOTICE THE LOWER RATED CAPACITY OF THE ROTATION RESISTANT WIRE ROPE AND TESTED THE CRANE ON FOUR DIFFERENT OCCASIONS BASED ON THE RATED CAPACITY OF THE ORIGINAL WIRE ROPE.

LESSONS LEARNED: DURING THE REVIEW OF THE LOAD CHART, THE TEST DIRECTOR MUST NOTE THE TYPE OF WIRE ROPE USED ON THE CRANE AND CALCULATE THE TEST LOAD BASED ON THE ALLOWABLE LOAD OF THAT PARTICULAR WIRE ROPE.

C.  DURING A LOAD TEST OF A PORTAL CRANE, THE AUXILIARY HOIST WAS OVERLOADED.  THE TEST DIRECTOR FAILED TO VERIFY THE TEST LOAD'S WEIGHT PRIOR TO HOISTING THE LOAD.

LESSONS LEARNED:  TEST DIRECTORS MUST VERIFY THAT THE TEST LOAD IS WITHIN THE TEST LOAD LIMITATIONS AS REQUIRED BY REF A, PARAGRAPH 3.7.1.

D.  A SLING WAS OVERLOADED WHEN IT WAS USED TO HOIST A LAUNCH THAT CONTAINED WATER.  DURING THE PRE-LIFT BRIEF, THE CRANE TEAM WAS TOLD THAT THE WEIGHT OF THE LAUNCH WAS 24,000 POUNDS.  SLINGS WERE SELECTED BASED UPON THIS WEIGHT.  THE ACTUAL WEIGHT WAS 36,000 POUNDS DUE TO WATER BEING RETAINED INSIDE THE HULL.  SEVERAL OTHER ERRORS OCCURRED:  THE CRANE OPERATOR DID NOT IMMEDIATELY SET THE LOAD BACK DOWN WHEN THE LAUNCH BECAME UNSTABLE DUE TO THE SHIFTING
WATER INSIDE THE HULL; THE CRANE OPERATOR DID NOT STOP THE OPERATION AFTER SEEING THAT THE CRANE'S LOAD MOMENT INDICATOR READ MORE THAN 24,000 POUNDS; THE RIGGER-IN-CHARGE DID NOT VERIFY THE SLING CERTIFICATION DATES (ONE SLING WAS NOT CERTIFIED); THE CRANE TEAM MEMBERS DID NOT KNOW THAT THEY COULD HALT A LIFT IF THEY SUSPECTED A PROBLEM; AFTER THE CRANE ACCIDENT, THE RIGGING SUPERVISOR DID NOT PRESERVE THE ACCIDENT SITE, NOR DID HE WAIT FOR THE INVESTIGATION TO BE COMPLETED BEFORE CONTINUING WITH THE LIFTING OPERATION.

LESSONS LEARNED: IF A LOAD BECOMES UNSTABLE, THE CRANE OPERATOR MUST RE-ESTABLISH CONTROL OF LOAD BEFORE CONTINUING WITH THE LIFT.  THE OPERATOR MUST SET THE LOAD DOWN WHEN AN OVERLOAD IS SUSPECTED.  THE RIGGER-IN-CHARGE MUST INSPECT THE RIGGER GEAR PRIOR TO USE AND VERIFY THAT THE GEAR HAS A CURRENT CERTIFICATION.   DURING PRE-LIFT BRIEFINGS, MEMBERS OF THE CRANE TEAM SHOULD BE REMINDED THAT ANY
MEMBER OF THE TEAM CAN HALT A LIFT IF THEY SUSPECT A PROBLEM.

E.  WHEN TAKING UP THE SLACK ON A JIB CRANE THAT WAS BEING TIED DOWN TO A PIERSIDE CLEAT, THE FORCE APPLIED OVERLOADED THE CRANE.  THE SHACKLE ATTACHED TO THE CLEAT HAD BREAKING STRENGTH WAS HIGHER THAN THE RATED CAPACITY OF THE CRANE.

LESSONS LEARNED:  WHEN TYING DOWN HOOKS, ONLY ENOUGH TENSION SHOULD BE APPLIED THAT WILL HOLD THE HOOK IN PLACE.  A WEAK LINK CONNECTION SHALL BE USED TO SECURE THE CRANE'S HOOK AS PRESCRIBED IN REF A, PARAGRAPH 10.17.

7.  TWO-BLOCKINGS:
A. A MONORAIL AND A BRIDGE CRANE WERE TWO-BLOCKED AT DIFFERENT NAVY ACTIVITIES WHEN CONSTRUCTION CONTRACTORS PERFORMING WORK IN THE BUILDINGS ACCIDENTALLY REVERSED THE PHASE CONNECTION IN THE POWER PANEL THAT FED THE MONORAIL AND BRIDGE CRANE. 

LESSONS LEARNED: WHEN ELECTRICAL WORK IS COMPLETED IN AN ELECTRICAL DISTRIBUTION PANEL BOX, THE EQUIPMENT ENERGIZED BY THAT PANEL BOX MUST BE TESTED FOR PROPER OPERATION.  SUCH OPERATIONS MUST BE PERFORMED VERY SLOWLY IN ORDER TO AVOID TWO-BLOCKING THE HOIST.

B.  A MOBILE CRANE OPERATOR INADVERTENTLY ACTIVATED THE MAIN HOIST HOISTING CONTROL LEVER WHILE ROTATING THE BOOM, WHICH RESULTED IN TWO-BLOCKING.  THE OPERATOR STATED THAT HE FELT PRESSURE TO COMPLETE THE TASK AT HAND AND TO MOVE QUICKLY TO THE NEXT ASSIGNMENT.  THIS PRESSURE MAY HAVE DIVERTED THE OPERATOR'S ATTENTION FROM THE SAFE COMPLETION OF THE CURRENT ASSIGNMENT.

LESSONS LEARNED: CRANE OPERATORS SHALL BE ALERT WHEN OPERATING CRANES, ESPECIALLY MOBILE CRANES.  THE COMPLEXITY OF MOBILE CRANE OPERATIONS MAKES THE OPERATOR'S ATTENTION TO DETAIL IMPERATIVE. OPERATORS SHOULD REPORT TO THEIR SUPERVISORS ANY UNDUE PRESSURE TO COMPLETE THE JOB QUICKLY.

C.  A PENDANT CONTROLLED BRIDGE CRANE WAS TWO-BLOCKED AS A RESULT OF AN UNAUTHORIZED ALTERATION, WHICH INADVERTENTLY DISABLED THE UPPER LIMIT SWITCH.  THE CRANE WAS MANUFACTURED WITH A 110 PERCENT TORQUE LIMIT SWITCH.  THE ACTIVITY INSTALLED AN OVERRIDE SWITCH TO PERMIT THE CRANE TO BE TESTED AT 125 PERCENT FOR THE ANNUAL LOAD TEST.
HOWEVER, THIS SWITCH ALSO  DEACTIVATED THE UPPER LIMIT SWITCH.  THE IMPROPER ALTERATION WAS DISCOVERED BEFORE THE ACCIDENT BUT WAS NOT CORRECTED.

LESSONS LEARNED:  ALTERATIONS TO OPERATIONAL SAFETY DEVICES REQUIRE NCC REVIEW AND APPROVAL.  CRANE OPERATORS MUST BE AWARE OF THE OPERATING CHARACTERISTICS OF THE CRANES THEY OPERATE.  WHEN THE HOOK BLOCK APPROACHES THE UPPER BLOCK, OPERATING SPEEDS MUST BE REDUCED.

D.  DURING THE MAINTENANCE INSPECTION OF A MOBILE CRANE, DAMAGE TO THE BOOM TIP SHEAVES AND TO THE WIRE GUIDE WERE FOUND.  THE DAMAGE APPEARED TO BE CAUSED BY A TWO-BLOCKING.  A REVIEW OF OPERATORS' ODCL'S SUBMITTED AFTER THE ACCIDENT SHOWED THAT NO DEFICIENT CONDITIONS WERE FOUND DURING THEIR INSPECTIONS.

LESSONS LEARNED: CRANE OPERATORS SHALL BE TRAINED THAT IF A CRANE ACCIDENT OCCURS, OPERATIONS SHOULD BE HALTED AND THE INCIDENT REPORTED.  ALSO, DURING THE PRE-USE CHECK, OPERATORS MUST INSPECT CLOSELY ENOUGH TO FIND ANY DAMAGE TO THE CRANE AND REPORT THE DAMAGE TO SUPERVISION.

8.  CONTRACTOR CRANE ACCIDENTS:
 A.  A CONTRACTOR RECENTLY HAD A SERIOUS CRANE ACCIDENT
INVOLVING A CRAWLER/RINGER CRANE MOUNTED ON A BARGE.  WHILE LIFTING THE UPPER WORKS OF A SHIPYARD PORTAL CRANE, THE BARGE CRANE'S BOOM COLLAPSED AND THE LIFTED LOAD LANDED IN THE RIVER.  THE BARGE CRANE OPERATOR'S CAB WAS CRUSHED BUT FORTUNATELY NO ONE WAS SERIOUSLY INJURED.  

LESSONS LEARNED: SEE REFERENCE B.

B.  A CONTRACTOR WAS HOISTING A CRATE OF TRANSFORMERS THAT WAS HOISTED WITH PALLET BARS RIGGED ON THE OUTSIDE OF THE CRATE.  WHEN THE OPERATOR HOISTED THE CRATE APPROXIMATELY 20 FEET INTO THE AIR, THE BOTTOM OF THE CRATE FAILED.  THE TRANSFORMERS FELL ONTO A DISHWASHER UNIT STAGED ON THE PIER.

LESSONS LEARNED: CRATES SHOULD BE PLACED ON LIFTING PALLETS.  THIS WILL INSURE THAT THE BOTTOM OF THE CRATE IS PROPERLY SUPPORTED.

C.  A MOBILE CRANE WAS BEING USED TO REMOVE A WOODEN PALLET LOADED WITH A HOSE REEL WHEN THE PALLET LIFTING BEAM DISENGAGED FROM THE RIGGING GEAR CAUSING THE HOSE REEL TO SLIDE OFF THE PALLET AND FALL APPROXIMATELY 40 FEET.  THE ACCIDENT INVESTIGATION REVEALED THAT TWO OF THE SLING HOOKS' SAFETY LATCHES WERE DAMAGED AND DID NOT WORK
PROPERLY, THE HOSE REEL WAS NOT PROPERLY SECURED, SHACKLES WERE NOT USED BETWEEN THE PALLET LIFTING BEAM ATTACHMENTS AND THE SLING HOOKS, AND THE RIGGER FAILED TO THOROUGHLY CHECK THE RIGGING CONNECTION.

LESSONS LEARNED:  SEE LESSONS LEARNED IN PARAGRAPH 5.D.  ALSO,
PALLETED LOADS SHOULD BE PROPERLY SECURED.

9.  WEIGHT HANDLING PROGRAM MANAGERS AND SAFETY OFFICIALS ARE ENCOURAGED TO CONSIDER THE POTENTIAL RISK OF ACCIDENTS OCCURRING AT YOUR ACTIVITY SIMILAR TO THOSE HIGHLIGHTED ABOVE AND APPLY THE LESSONS LEARNED TO PREVENT SIMILAR ACCIDENTS.  REF C PRESCRIBES METHODS FOR ASSESSING HAZARDS AND CONTROLLING AND MINIMIZING RISKS IN HAZARDOUS OPERATIONS.  NAVY ACTIVITIES SHOULD INCORPORATE THESE
PRINCIPLES INTO BOTH TRAINING AND DAY-TO-DAY WEIGHT HANDLING OPERATIONS.

10.  E-MAIL SUBMISSION OF REPORTS OF ACCIDENTS, UNPLANNED
OCCURRENCES AND NEAR MISSES IS ENCOURAGED.  THE E-MAIL ADDRESS IS ACCIDENT@NCC.NAVFAC.NAVY.MIL.  THE REPORTS MUST INCLUDE A COMPLETE AND CONCISE SITUATION DESCRIPTION, CORRECTIVE AND PREVENTIVE ACTIONS, PROBABLE CAUSE AND CONTRIBUTING FACTORS, AND AN ASSESSMENT OF DAMAGE.  FOR EQUIPMENT MALFUNCTION OR FAILURE INCLUDE SPECIFIC DESCRIPTION OF THE COMPONENT AND THE RESULTING EFFECT OR PROBLEM CAUSED BY MALFUNCTION OR FAILURE.//

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