Gard News 207, August/October 2012
Operation of watertight doors may involve risk to human life. Some personal injury incidents found in public reports and news articles are described below.
In 1989, the newly-formed UK Marine Accident Investigation Branch (MAIB) investigated an accident on board a cross-channel ferry. A crew member had been trapped when trying to pass through a door while in "local control". He had operated the lever to close the door and tried to pass through while the door was closing (in some old systems, the operating lever can be secured in opening or closing position).
In 1990 there was a fatality on board a Canadian vessel, caused by improper use of a watertight door, resulting in a Ship Safety Bulletin being issued by Transport Canada in 1991. It underlined that most accidents happen when the doors have been closed from the bridge control and crew members pass using local control, without waiting for the door to be fully opened. The correct procedure would be to hold on to the operating lever with one hand, while with the other grab the lever on the other side, before releasing the first.
Dangerous old systems
In 1998 an engine room rating on the cross-channel Ro-Ro passenger ferry P&OSL KENT died after being trapped in a door. The vessel had 10 watertight doors with one control panel on the bridge and another in the engine control room for "local control" and "door closed". According to the MAIB accident report, the door had been in "local control", so the local operating lever had to be held for the door to close. When such a door is in any position other than fully opened, there is a hinged, 150 mm high floor plate obstructing the passage. The purpose of the plate is to cover the recess in the deck at the door frame when the door is open. The worker had been carrying a 25 kg bag of salt on his shoulder, and could possibly have tripped on the raised floor plate, hitting his head on the steelwork and falling forward on to the operating handle, causing the door to close. As the worker was found trapped in a vertical, sideways position, it was assumed that he had attempted to pass the doorway sideways, before the door was fully opened. MAIB found the doors and arrangements in good order.
In 1999 a worker was crushed to death by a watertight door on board the oil tanker NORDIC APOLLO. The case was investigated by the Occupational Health and Safety Division of the Nova Scotia Department of Labour. The converted tanker was operated as a floating, storage and offloading vessel (FSO) for Canada's first offshore oil production project. The vessel had two watertight doors, one between the engine room and the coal hopper flat, the other between the coal hopper flat and the steering gear flat. The doors had a remote control panel in the engine room and in a station on main deck. If the doors were in remote control and were opened locally, they would close automatically when the local control switch was released. The local switch had three positions: close, off and open. There were local control switches on both sides of the door, and if one was left in "closed" position, it would override the switch on the other side. If someone on that side should open the door, it would start to close immediately when the switch was released. This danger had been discussed during safety meetings whenever switches had been wrongly left in the "closed" position. It was calculated that the worker had passed through the watertight doors at least 6,000 times when the accident happened. It was found by the investigators that the worker had not been trained in the use of the doors, no operating instructions were posted and the doors had operational deficiencies due to wear of the local controls. After the accident, the remote control panel was moved from the engine room to the bridge.
In 2001 a third engineer on board the 1984-built cruise vessel ROYAL PRINCESS was seriously injured when a power-operated watertight door closed, trapping his arm. He managed to free himself and had to pass another four watertight doors to reach the control room and raise an alarm. The arm had to be amputated due to extensive crush injuries. The investigation by MAIB revealed that the door had been correctly in "local control" mode. The engineer had locally set the door to close and locked the operating lever in the "close" position and gone through the doorway while the door was closing. Somehow his boiler-suit became snagged, causing a momentary hold-up and the door closed on his arm. MAIB remarked that there were differences between the Master's standing orders/damage control manual and the notices posted on each door, as well as the accepted practice. Safety instructions on board a vessel should be consistent.
MAIB also informed that the company had experienced at least three previous accidents on board their vessels, resulting in one person killed and two seriously injured. All these three accidents had happened with the doors in "bridge control" mode and the individuals in question had attempted to pass the doorways while the doors were closing, not having been fully opened.
In 2001 there was also an unusual accident on board a small cruise vessel, the CAPE MAY LIGHT, in a Florida port, where the Master was killed by a power-operated watertight door. The vessel's owner had filed for protection from creditors due to bankruptcy and the 224-capacity passenger vessel was being prepared for lay-up. The Master and two company employees were on board to make arrangements, the Master was the only seaman. Among the securing of various systems in the engine room, their tasks were to shut down the vessel's power supply and disconnect battery terminals. From the dark engine room, the Master, torchlight in hand, made his way forward through a watertight door in the engine room bulkhead, when the door closed on him. He managed to call for help, but died by compression asphyxiation. Investigators found no fault with the door. It appears that the Master had forgotten or not been aware that power-operated watertight doors have stored energy for three movements, independent of the main power supply, and that a door having a fault, like a power cut, will go to closed position for the sake of the vessel's safety. It was not sufficient to just cut the battery power, the hydraulic pressure would also have to be taken off, by moving the door. Details of how to disconnect and immobilise watertight doors in case of lay-up or stay in shipyards can be found in instruction manuals and must be followed.
In 2002 DNV issued a report concerning a fatal accident on board a passenger vessel built in 1980. A subcontracted worker had been found squeezed to death by a watertight door while the vessel was alongside. The door was relatively small and had a closing time of only eight seconds. DNV's report mentioned the SOLAS regulations for ships built after 1st February 1992, requiring a "master mode switch" on the bridge with two modes: "local control" and "doors closed" (also known as bridge/remote control; "bridge control" only to be used in emergencies and for testing), and suggested that owners of vessels built before 1992 should consider adhering to the regulations voluntarily.
Accidents on board offshore units
In 2001 a subcontractor on the mobile offshore drilling unit DEEPWATER NAUTILUS was squeezed to death by a hydraulically- operated watertight door. When he was found, jammed in the door, the rescuers could not open the door as his body obstructed the operating lever so it could not be placed in the opening position. The hydraulic pipes had to be disconnected and the door forced open to free the body. The drilling unit had 48 such doors. For several doors the closing time was found to be far too short, down to nine seconds. All doors were in local control, except for the one in question, which due to uncompleted repairs was operating in remote control. As the local lever of the door was released, the door immediately started to close.
In 2001 a person was squeezed by a hydraulically operated watertight door on the semi-submersible offshore installation SNORRE B, resulting in moderate chest injuries. He had only partly opened the door when he went sideways through the narrow opening, releasing the operating lever. The door was in remote control mode, so it closed immediately, but he managed to grab the lever again and move it to open, before losing consciousness. A red light next to the door, signalling that the door was in remote control mode, had not been noted by the person. The offshore installation had 29 watertight doors, of which several, including the one involved in the accident, were found to close too fast.
In 2003, a crew member on board the mobile offshore drilling rig WEST ALPHA was seriously injured by a hydraulically-operated watertight door. One person had walked through the door and was closing it, having his back to the door, when another crew member tried to squeeze through and was caught. The door was immediately opened again and the seriously injured crew member taken to hospital by helicopter. Although the regulations ask for a closing time of between 20 and 40 seconds, the door in question was found to close in only four seconds.
In 2005 the semi-submersible offshore installation KRISTIN was at quay in Norway when a worker was crushed to death by a closing watertight door. The investigation concluded there had been two contributing causes to the incident: the habit of workers to pass through such doors before they are fully opened, and the unexpected closing of the door due to a spring in the opening/closing mechanism being broken. The mechanism has two springs, one for bringing the activating lever from the open position and back to neutral and one for bringing it from the closed position. As one spring for return of the lever was broken, the other may have brought the lever back, passing the neutral position and activating the closing of the door.
The practice of passing moving doors
In 2005 a crew member became trapped in a watertight door in the 1993-built Canadian Ro-Ro passenger ferry CONFEDERATION. The unconscious crew member was found and freed by a co-worker and taken to hospital with serious injuries. The vessel had three watertight doors, and the practice was to close the doors from the bridge control while in transit. In order to open the doors locally, regulations required operating levers on both sides of the door, located so that they could both be reached at the same time by a person going through. That was hardly possible for the door in question: in order to do that an operator would need a reach of 64 cm. The Transportation Safety Board of Canada (TSB) investigation found that one door on board was opened by pushing the lever, another by pulling it. For SOLAS vessels such levers are to operate in the direction of the desired movement of the door. Canadian regulations at the time did not have a requirement in that respect, but it was noted that one door closed in only 10 seconds. There was a practice on board to pass through the doors before they were fully opened.
In 2006 the Britannia P&I Club reported in its newsletter ‘Risk Watch' that a third engineer on board a 2001-built container vessel had been trapped by a watertight door between the engine room and the shaft tunnel. He suffered massive internal injuries and was found dead. The ship had an unmanned engine room and had therefore the bridge control of the doors set in "remote closing". It was assumed that the engineer had tried to pass through the doorway before the door was fully opened, and it had closed on him as soon as he released the handle.
In 2006 a passenger was injured by a watertight door in the passengers' accommodation of the 1987-built Ro-Ro passenger ferry KING OF SCANDINAVIA, then recently registered under the Danish flag. The watertight door was in closed position when the passenger opened it by activating the lever at the door. The passenger also used the palm of her left hand to push the door, and when she released the lever, the door closed on the hand and trapped the fingers. A fellow passenger assisted in the release. The Danish Division for Investigation of Maritime Accidents did not mention whether the control on the bridge was set in "bridge" or "local", but it is apparent it was in "bridge", as the door closed when the local lever was released. In the ship's forward end on the lowermost deck, Deck 1, there were cabins for crew members and two cinemas for passengers. Deck 2 had cabins for passengers. The accommodation areas of these two lowermost decks were divided into watertight sections, with a number of watertight doors. The Danish Maritime Authorities had required the watertight doors on these decks to be closed at night time, and they were therefore routinely closed at 2200 hrs every day. Passengers, used to passing through these doors during the day, did not realise the dangers involved in opening the doors at night. Following the accident, the unorthodox reaction of the Danish authorities was to make door levers less accessible by requiring them to be placed within cabinets, and warning signs "Do not try to open the watertight doors" to be attached to the doors in the passenger areas. The Danish authorities informed they were to study the problems of watertight doors further, and gave the vessel an exemption, allowing doors on Deck 2 to be left open at night during sea passages.
Lever operation obstructed by trapped person
In 2006 the offshore support vessel ISLAND FRONTIER was alongside a Norwegian port when an electrician was nearly killed as he became trapped in a watertight door in an engine control room. The worker had tried to pass through the doorway while the door was moving. His colleagues had difficulty in releasing him from the door, as his shoulder blocked the lever, so it could not be moved to the open position. It is actually not uncommon for the lever to be blocked by a trapped person. The lever had to be dismantled on one side of the door, so the door could be opened from the other side. A helicopter brought the injured electrician to hospital where he was treated for a punctured lung and broken ribs. This vessel had 18 watertight doors.
In 2008 an engine room fitter was found trapped in a hydraulically operated watertight door in the machinery space of the Ro-Ro passenger ferry EUROVOYAGER. The UK MAIB issued a report on the accident in 2009. The injured worker had been released from the door by the motorman on duty and brought to hospital and treated for crush injuries. He was not expected to be able to return to work for at least six months. It was found that the door closed in only seven seconds, three times faster than allowed on board new vessels, and that the fitter could not have followed the recommended transit procedure. The door had been in "remote control", contrary to SOLAS requirements, and thereby closed automatically once its local operating handle was released. MAIB also noted that the usual practice on board was to have the doors in "local control", but also noted that many doors were left open while at sea. "Remote control" had been chosen on this occasion, for the purpose of ensuring that all doors were closed during an inspection by a Belgian maritime inspector.
In 2008 an electrician on board the UK-flagged Ro-Ro cargo vessel ARK FORWARDER was found pinned between a watertight door and its frame, at the bow thruster compartment. The door's hydraulic system had to be dismantled to release the pressure, as the position of the engineer's body obstructed the use of the operating lever. When the door opened, there were unsuccessful attempts to revive the electrician. The door was in remote closing mode. The MAIB Safety Digest issued a warning based on this incident.
Doors in remote control mode are dangerous
In 2008 the launching ceremony of the cruise vessel RUBY PRINCESS at the Fincantieri Yard, Italy, had to be called off, as a worker died when trying to pass through a watertight door which closed on him. A scheduled blackout test was taking place at the time of the accident.
In 2009 the crew on board the Australian passenger vessel OCEANIC DISCOVERER were conducting a fire and emergency drill in the port of Napier, New Zealand, which included a test of the watertight doors. For the test the master closed the doors remotely from the bridge. Some minutes later, the chief engineer was trapped by a door to the engine room when attempting to pass through. The chief engineer was taken to hospital, but died. The investigators of the New Zealand Transport Accident Investigation Commission (TAIC) found that crew members on board the vessel were used to the doors being set in "local control" on the bridge. When releasing the lever opening a door, the door would then stop in that position until activated for closing. With the bridge control in "doors closed" mode, however, the doors would close automatically when opened locally as the lever was released. It was also found that crew members had a habit of going through the doors before they were fully opened, and that the movement of the particular door had been set at twice the permitted speed. There was also a failure to the sound alarm for the closing of the door. Maintenance of the watertight doors was not a part of the safety management system on board.
In 2011 the Maritime Authority of the Cayman Islands issued a warning concerning a near-miss on board a large yacht (above 1,000 GT). Due to a loss of power to the control of watertight doors, the doors went to their "fail safe" position closed. Hearing the local alarm for doors closing, a crew member went to investigate and tried to stop the door from closing by the use of his foot. He had to call for assistance and another crew member assisted to release him by using the local door control. The door was fully electric; had it been more powerful, like the hydraulically- operated doors are, the crew member would probably not have escaped without injury. Watertight doors on board ships will not open if an object is positioned between the door and the door frame, like doors of garages and elevators ashore.
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