Slips, Trips, and Falls On Domestic Passenger Vessels

Transcription

1 Slips, Trips, and Falls On Domestic Passenger Vessels EXECUTIVE SUMMARY: Slips, trips, and falls (STF) continue to be a leading cause of injury in commercial passenger vessel operations and account of a vast majority of the reportable marine casualties aboard these vessels. Why is it that, given all the modern technological advances in the maritime industry, the risk of STF has not been eliminated or significantly reduced? In general, risk management is a key factor, and the keen ability to identify potential risk and knowing how to effectively control them is extremely important to the safety of both passengers and crew. The Passenger Vessel Association (PVA) and the United States Coast Guard (USCG) understand that a majority of personnel injuries onboard domestic passenger vessels are the result of a STF. In May 2015, the President of the PVA and the U.S. Coast Guard s Director of Prevention Policy signed a joint charter, establishing the Natural Working Group (NWG) to provide direction and procedures for the PVA in partnership with the Coast Guard to develop recommendations to mitigate STF incidents on domestic passenger vessels. The goal of the working group as well as the focus of this white paper was to describe and analyze the risks involved STF on domestic passenger vessel and to point out areas for preventative measures and actions. DISCUSSION: On average, nearly 36% of all personnel injuries were associated with STF. Specifically, out of the 1,223 personnel casualties associated with a Reportable Marine Casualty, 436 were directly associated with a STF. The high percentage of STF incidents indicates that preventative measures and actions could have a significant impact on overall casualty rates. Slips, trips, and falls are their own unique classification because they represent such a large portion of personnel injuries onboard commercial passenger vessels. Additionally, compared to other incident classifications, the numbers of STF are somewhat consistent year to year, with little variation in number of reported incidents. A proactive and precautionary approach can go a long way in reducing the potential of an incident occurring. Often, STFs occur because no one has thought that the operations being conducted are hazardous. For instance, passengers and crew onboard ferry vessel, who take the ferry as part of their normal every day commute, might not think twice about the hazards that may be present, simply because they do the same thing day in and day out, without incident. Something as simple as identifying potential hazards can be crucial in preventing incidents. When investigating a STF incident, it may be easy to chalk it up to human error or neglect, but an in-depth analysis of the incident may reveal other causal factors. Things such as training 1

2 (inadequate or missing), environmental factors, and/or corporate cultures may all be causal factors when investigating STF incidents. METHODS: Data for this analysis was extracted from the Coast Guard s Marine Information for Safety and Law Enforcement (MISLE) for calendar years 2010 to Analysis of this valuable data yielded the following: There were 1,223 Reportable Marine Casualties 1 involving a personnel casualty. Of those, there were a total of 821 incidents in which the personnel casualty was the single event (not caused or initiated by another event). Personnel Casualty Accident Type Total Dead Contact Injury - Fall onto surface Contact Injury - Line handling/caught in lines 1 1 Noncontact Injury - Asphyxiation Noncontact Injury - Diving Noncontact Injury - Other Other Injury Type Overexertion Injury - Strain or sprain 1 1 Unknown Injury Type Injured Contact Injury - Collision with Fixed Object Contact Injury - Crushed between objects Contact Injury - Fall into water 1 1 Contact Injury - Fall onto surface Contact Injury - Line handling/caught in lines Contact Injury - Other Contact Injury - Struck by Moving Object Noncontact Injury - Asphyxiation Noncontact Injury - Burn Noncontact Injury - Diving Noncontact Injury - Electric Shock 1 1 Noncontact Injury - Exposure Noncontact Injury - Other Other Injury Type Overexertion Injury - Strain or sprain Unknown Injury Type Total Further analysis of the 821 personnel casualty events showed 385 were not related to slip, trip, and/or fall events (collisions, crushing, overextension, exposure, burns, diving, electric shock, line handling, etc.). The remaining 436 incidents can be directly related to a STF incident. 1 As defined in Title 46 CFR

3 Personnel Casualty Accident Type Total Dead Contact Injury - Fall onto surface Injured Contact Injury - Collision with Fixed Object Contact Injury - Fall into water 1 1 Contact Injury - Fall onto surface Total Further breakdown of the data indicated the following as these casualties relate to passengers versus crewmembers: Reported Passenger Injuries: 320 (76%) Reported Crewmembers Injuries: 116 (23%) Total STF Injuries: 436 (100%) Anecdotally, many more incidents likely occurred that are below the reportable threshold established in current regulations 2. Furthermore, we analyzed the type of STF and location of the occurrence. Incident Involves type: Slip: 120 Trip: 98 Fall: 238 Location on vessel: Deck: 225 Stairwell/Staircase: 185 Unspecified: 36 Analysis of the data revealed that the highest proportion of STF injuries occurred on vessel decks and gangways. This is primarily due to the fact a majority of traffic activities occur on decks and passageways, as well as embarkation/de-embarkation points onboard the vessel. Conversely, the lowest amount of STF injuries occurred in engine room spaces, which could be explained by a heightened sense of awareness in such spaces and the limited number of people accessing these spaces. 2 Title 46 CFR (a)(6) defines an injury as one that requires professional medical treatment (treatment beyond first aid) and, if the person is engaged or employed on board a vessel in commercial service, that renders the individual unfit to perform his or her duties. 3

4 Summary of STF that resulted in deaths: 1. Crewmember was walking on deck when he slipped and fell, hitting his head on the corner of the superstructure. He was taken to the hospital for stitches and was sent home, as passed away several days letter due to complications from the injuries. 2. Passenger onboard sailing vessel fell from the rigging and landed on the deck of the vessel. The passenger was taken to the hospital, where he passed away due to head trauma. 3. Passenger slipped and fell on the deck while trying to embark the passenger vessel. He was taken to hospital for treatment and passed away the next day due to injuries suffered in the fall. 4. Passenger fell down a ladder well, suffering a laceration to her head. The passenger was transported to hospital where she passed away due to injuries suffered in the fall. 5. Passenger lost her balance during a sharp turn by the vessel and fell, striking her head on the upper deck ladder. The passenger was taken to the hospital where she passed away from injuries sustained in the fall. 6. Passenger onboard casino vessel was departing the vessel when he fell down the vessel s staircase and suffered a head injury. He was treated in the hospital for approximately 1 month before passing away due to injuries associated with the fall. 7. Passenger lost her balance and fell backwards down an interior ladder, resulting in blunt force trauma to her. She was transferred to the local hospital where she passed away due to injuries associated with the fall. DATA QUALITY: Efforts to fully analyze incidents associated with STFs onboard passenger vessels were limited due to data quality within the Coast Guard s MISLE database. Required reports of personnel injuries, in particular those associated with STF, were found lacking specific details that could prove beneficial in risk management analysis. Any attempt to mitigate the number of incidents related to STFs must have complete, detailed records of past incidents to analyze. During the course of this project, there were several initiatives introduced that are intended to improve the quality of such data for future analysis, including the revisions to the CG-2692 forms and its addendums, particularly the newly created CG-2692C (Personnel Casualty Addendum). In order to classify injuries on a comparable scale, CG-INV developed a series of categories, ranging from Minor (the least severe) to Major (the most severe) injuries. 4

5 Injury Classifications Minor: The injury is minor or superficial in nature. No professional medical treatment beyond first aid is required Example: Minor scrapes/bruises/cuts/sprain/strain Moderate: Exceeds Minor level, but did not result in any major broken bones (other than fingers, toes, or nose), loss of limbs, muscle, nerve, or tendon damage or internal organ damage. These may require professional medical treatment beyond first aid. Example: Broken fingers/toes/nose; amputated fingers/toes, burns on less than 10% of body; concussion/seizure/severe sea sickness Serious: Exceeds the Moderate level and requires medical/surgical management. The person was not hospitalized more than 48 hours within 5 days of the injury Example: Broken bones (other than fingers/toes/nose), partial loss of limb, burns on 10-30% of body, bruised organs, or hyperbaric chamber use. Severe: Exceeds the Serious level and requires significant medical/surgical management. The person was hospitalized more than 48 hours within 5 days of the injury. Example: Internal hemorrhage; punctured organs, severed blood vessels, burns covering more than 30% of the body; loss of entire limb Critical: The worst injury, which requires significant medical/surgical management. The person was hospitalized and in intensive care for more than 48 hours within 5 days of the injury Example: Spinal cord injury, extensive burns, severe crushing injury, concussion with severe neurological symptoms Careful analysis of this data set revealed that, in a majority of the cases, the injury severity data was not entered correctly into the MISLE system. This is due in part to the fact that the severity scale is very subjective, and the classification varies between Investigating Officers (IO). One IO may classify an incident under one classification, while another IO may classify the same incident under another classification. To that end, CG-INV is currently working on methods to improve the injury severity classification system in order to standardize data entries for improved future analysis. 5

6 IMPROVEMENT INITATIVES: New Report of Marine Casualty Form (CG-2692): In July 2016, the Coast Guard released a new version of the CG-2692, Report of Marine Casualty) form. The new form is the result of an extensive overhaul of the previous form, which has remained unchanged for nearly 40 years. The new version contains a revised addendum form for reporting personnel casualties, and is streamlined to align with statutory and regulatory language. The new form, the CG-2692C, is utilized to report data on persons who were injured 3, killed, or missing as a result of a marine casualty. Specifically, the form is designed to capture more robust data, including the activity of the person at the time of the casualty, the location on the vessel or facility where the injury occurred, and the extent of the injuries (part of the body and type on injuries). These changes are not yet reflected in 46 CFR Part 4; however, CG-INV is working to incorporate the necessary non-substantive changes into the current regulatory initiative that increases the property damage estimate dollar thresholds for reportable marine casualties and Serious Marine Incidents. New MISLE database: MISLE is the primary operations support system for capturing and reporting the information to support Coast Guard marine safety programs. In September 2015, the Coast Guard released an updated version of MISLE. The new version, MISLE 5.0, was an upgrade to both hardware and software that improved reliability, processing speed, and future expandability. With the release of MISLE 5.0, functionally was streamlined to enhance the Coast Guard s ability to capture critical information to ultimately meet mission requirements. Specifically, MISLE 5.0 increased data quality by requiring a more robust description of the incident that occurred, as well as the events/occurrences that required the incident to be investigated. Improved data quality will directly lead to improved data analysis of STF events. ANALYSIS: An analysis of data collected by the group revealed several issues that warranted further examination. One statistic that stood out was the number of reportable STF incidents involving crewmembers onboard ferry boats, which accounted for over 43% of total incidents. In fact, STFs by crewmembers onboard ferry boats was the highest percentage of crew incidents compared to other inspected vessel types. As a result, the group reached out to a select group of PVA members that operate ferries, soliciting feedback through a series of questions about their specific operations. See Enclosure (1) for the list of questions. The question that received the most responses and useful feedback was In your opinion, is there anything inherent in the design of your vessel, the nature of your 3 Interpreted by USCG as damage or harm caused to the structure or function of the body as a result of an outside physical agent or force to a passenger, crewmember, or non-crewmember. 6

7 specific ferry operation, or any other conditions that could lead to more slips, trips, or falls for your crewmembers versus any other excursion operations? The responses can be summarized in few main points: Schedule and Volume: Operators expressed a sense of pressure from the general public to operate, with little regard to the operating conditions. Additionally, they expressed concern over the sheer volume of operations that they conduct. For example, the Staten Island Ferry in New York Harbor operates 24 hours a day, 7 days a week, 365 days a year. On a typical weekday, a fleet of five boats can make over 120+ trips, carrying approximately 77,000 passengers. During rush hours, the ferries operate on a four boat schedule, with departures every 15 minutes. Between rush hours, the ferries are fueled and maintenance work is performed. Human Error: In a vast majority of STF incidents, there is some sort of human error involved. Human error, by common definition, can be described as an incorrect decision, an improperly performed action, or lack of attention. To this point, several PVA member vessels have camera monitoring devices installed onboard. These surveillance systems provide valuable data for both the safety improvement process as well as in the claims and litigation process. Operating Conditions: Given the nature of their business, many ferries are often required to operate in adverse conditions, including rain, fog, snow and/or ice. In order to meet the ever increasing scheduling demands. Ferry vessels from the public, ferry vessel often get underway in conditions that excursion vessels would not operate in. Additionally, many ferry operators expressed that they felt that their routes may be longer and more exposed than the routes of typical excursion vessels. Clearly visible engine room STF hazard 7

8 CAUSAL FACTORS: Passenger Demographics: It is not common for passengers who have never been onboard a vessel to have trouble getting their sea legs (getting adjusted to being on a moving object on the water). For example, on any given day, there are many people aboard vessels that may have never been onboard a boat before, and therefore may be unaware of the physical instability that can be associated with being onboard an underway vessel. Suddenly, they find themselves in an unfamiliar environment with unfamiliar surroundings, meaning they are likely not as aware of the potential risk as the routine commuter who takes the ferry to work five days a week. Furthermore, other physical characteristics that can increase risk of STF incidents are failing eyesight and/or visual perception, physical condition, fatigue, and/or illnesses. Modern Society: In today s fast paced society, commuting has become a way of life. In certain parts of the world, commuting by passenger vessel is a routine daily practice. In New York and Seattle, for example, there are thousands of passengers who commute to and from work on a daily basis. Such passengers are seasoned commuters, who have grown accustomed to the risk associated with traveling onboard a passenger vessel. Conversely, think about a charter fishing boat in a coastal tourist town. In this scenario, the typical passenger is on vacation and wants to get out and enjoy a day on the water fishing and/or sightseeing. Distractions: Recent studies have shown that the number of accidents involving people being distracted by personal electronic devices is skyrocketing. More than 1,500 pedestrians were estimated to be treated in emergency rooms last year for injuries related to using a cell phone while walking 4. While people are using their devices, their ability to remain focused on their surrounding is significantly diminished. This lack of focus is compounded when put in a maritime environment, where many passengers may already be outside their normal environment. Weather: despite all the technology available, weather prediction is still not an exact science Tight scheduling along with suddenly changing weather can significantly increase the likelihood of a personnel casualty associated with STF. Often, particularly passenger ferry vessels get underway in adverse weather conditions. While the operators may seem seasoned and accustomed to operating in such conditions, the inherent risk.still exists. Alcohol Consumption: Excessive alcohol consumption is known to cause poor judgment, coordination problems, and/or a lack of balance, all significantly increasing risk of a STF incident. Alcohol is frequently consumed aboard passenger vessels. Attire: Specifically, the shoes an individual wears can play an important factor in preventing STF incidents. The slickness of the soles and type of heels worn can factor into STF incidents. Crewmembers should be expected to wear appropriate footwear for the duties they are performing onboard the vessel

9 Actual shoes worn by a passenger onboard a passenger vessel who experienced a STF incident. PREVENTION: A majority of STF injuries can be prevented with proper safety precautions in place. Shoreside, particularly in shipyards, OSHA regulations found in 29 CFR mandate that all walkways and working surfaces be free of all STF hazards. However, OSHA regulations do not apply to passenger vessels in most situations. Passenger vessel owners and operators are responsible for establishing and maintaining good housekeeping practices to minimize hazards to crew and passengers. Hazards causing STF require no special skill to be identified and exist on virtually every passenger vessel. The mitigation and prevention of such hazards are often simple and require little to no cost to correct. In May 2014, the Coast Guard issued Marine Safety Alert discussing slip, trip, and fall hazards. 5 This alert outlined a STF investigation in which Coast Guard investigated an accident involving a passenger onboard a catamaran vessel who fell into an unprotected stair well and received significant injuries. As a result, the Safety Alert was prepared and widely disseminated to provide education on the inherent risk of STF and increase overall risk awareness. AREAS OF MOST CONCERN ABOAD VESSELS: Walkways and Passageways: Eliminate slippery conditions, such as rain, snow, ice. When such conditions cannot be eliminated, consider alternatives such as restricting crew and/or passenger access to such areas

10 Photo of the deck of a passenger vessel that was not properly maintained after a rain storm. Gangways: Gangways should be properly maintained to avoid STF incidents. Careful attention should be paid to the mounting brackets used to attach the gangway to side of the vessel, as they are subject to potential failure and presenting a serious safety risk to persons utilizing it. Under OSHA regulations, 29 CFR (e) requires that When the gangway overhangs the water so that there is danger of employees falling between the ship and the dock, a net or suitable protection shall be provided to prevent employees from receiving serious injury from falls to a lower level. Photo of a very steep gangway leading to the vessel. Such excessive incline could lead to STF incident 10

11 Ladders/Stairwells: Immediately remove ladders with known defects from service. Such defects would include broken and/or missing step/rungs, broke or split steps, corroded parts, damage to or loose handrails, missing nonskid, etc. RECOMMENDATIONS: Operators should identify potential hazards and secure them in a manner that will prevent slips, trips, and falls. Make routine risk awareness part of the operational culture; ensure crewmembers are frequently assessing the vessel s material condition with the sole purpose of identifying and mitigating hazards. When a hazard cannot be completely eliminated, bring the hazard to the attention of passengers during the safety brief and crew prior to the commencement of work. Operators should track and analyze all of their incident data no matter how minor they seem. By analyzing all STF data available, owners/operators could develop trend analysis for development of mitigation strategies. Operators should consider installation of CCTV security cameras to monitor high risk areas such as stairways, gangways, and outer decks. Operators should incorporate safety reminders into their orientation/safety brief. Passengers should be reminded of the following: o Passengers should be reminded to pay attention to where they are walking. Look for spilled liquids, extension cords, changing surface levels, and be aware of vessel movement. Pay special attention to surfaces that may be covered with ice and/or snow. o Passengers should be reminded to be careful on stairs and ladder ways. Passengers should not run up or down stairs. Additionally, they should refrain from carrying large loads when transiting up or down stairs. Operators should properly maintain all transition areas, and utilize contrasting colors of carpet and/or paint to serve as a warning. Additionally, operators should ensure that there is proper signage and adequate lighting to minimize risk of STF injuries. 11