Inappropriate risk assessment leads to serious injury from rotating winch


The incident

A person was about to spool a wire onto the main crane forward tugger winch drum. To do the operation, he got into a restricted space inboard of the winch and opposite to the supporting riggers on the crane tugger platform.

When he decided to leave this location, he placed his left foot on the winch frame to help step over a protrusion. This led in his foot to be placed directly into a line of fire position, extending beyond the handrail.

The anchor block, fitted to the outside of the still rotating winch drum, hit the extended boot which caused five toes to be amputated.

Probable cause

According to IMCA the following played an important role in the incident:

  • The task risk assessment (TRA) was not appropriate for the work and did not recognise dangers regarding rotating equipment during the spooling operation;
  • The TBT did not consider positioning for the personnel involved in the task, and did not emphasise the rotating block as a hazard;
  • The rotating anchor block was unguarded as it was thought to be safe and barriered by the handrail;
  • Safer options were available to the work team but not taken;
  • There had been no time pressure to complete the task.

Lessons learned

In order to prevent similar accidents from happening in the future, the operator took the following measures:

  • Carried out a ‘hazard hunt’ on winches to identify further potential line of fire hazards;
  • Re-assessed the effectiveness of the existing safety controls, barriers, implemented required improvements and reporting findings back to shore-side management;
  • Reinforced importance of specific risk assessments, effective TBT preparation and delivery for every activity, and the importance of last-minute risk assessment at work-site to ensure that all hazards have been identified prior to work starting;
  • Reiterated importance of ‘Stop Work Authority’.


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