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It's a tragedy anytime
someone dies, but some of the sting is softened when that loss translates
into changes designed to save other people's lives.
In a recent mishap
investigation report, I read about a 19-year-old Sailor who died while
using a vertical-package conveyor. He had just finished sending down the
last box and was stowing the load-unload device with the conveyor running.
The weight and awkwardness of the load-unload device caused him to lean
too far into the conveyor trunk. A tray coming down grabbed his head and
forced his neck between two forks of the load-unload device.
Someone hit the
emergency-stop button as the victim's head became pinched at the bottom of
the device, but his neck was squeezed so tight he couldn't breathe. He
cried for help and struggled for only a few seconds before he died,
trapped there on the fourth deck.
We've all heard of
the domino effect, right? Here are the "dominoes" that fell into
place and caused this young Sailor to die:
- poor supervision and no operational risk
management
- cheated safety switches
- improper equipment-operating procedures
- lack of training and qualifications
- degraded material condition of equipment
- improper installation of a ShipAlt to add
safety devices to the conveyor.
As a result of this
tragedy, Fleet commanders have tasked each ship to ensure all required
personnel-safety devices for vertical-package conveyors have been
installed, and operate properly. These devices are identified in an
advance-change notice to the Naval Ships' Technical Manual
572 dated 18DEC99 1.
Naval Sea Systems Command
has modified the personnel-safety shield, which was part of the ShipAlt
for ships with vertical-package conveyors. The original design called for
enough room to fit a 30-inch package on the conveyor, which caused the
shield to be too high, as in the case of the latest casualty. The new
design will required the safety shield to extend down to one inch from the
load-unload device when it is in the stowed position.
Naval Sea Systems Command
is updating the Naval Ships' Technical Manual 572 1 to
require the use of portable platform or gravity conveyors during all
conveyor operations. All the additional safety requirements listed in the
advance change notice will be included in the update.
The fleetwide conveyor and
dumbwaiter improvement program (CDIP) has been re-established. This
program ensures all ships comply with the Naval Ships' Technical Manual1
and applicable technical manuals.
These changes will help
make conveyor operations safer. However, people still must use common
sense. In other words, you can't cheat safety switches, operate equipment
you're not qualified for, and use unauthorized procedures. Otherwise,
you're on a one-way trip to disaster.
Supervisors must watch all
operations closely and know how to recognize dangerous situations. Stop
and correct hazards as soon as they occur. By working together, we can
make a difference and keep our Sailors alive.
1 NSTM 572 (Shipboard Stores and Provision Handling) contains
guidance about the use of vertical-package conveyors. Download
the ACN to NSTM 572
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