Safety Flash

11/23 – May 2023

IMCA Safety Flashes summarise key safety matters and incidents, allowing lessons to be more easily learnt for the benefit of all.
The effectiveness of the IMCA Safety Flash system depends on members sharing information and so avoiding repeat incidents.
Please consider adding [email protected] to your internal distribution list for safety alerts or manually submitting
information on incidents you consider may be relevant. All information is anonymised or sanitised, as appropriate.

1 Inspection notice from Crosby on certain products

The Crosby Group has asked that IMCA circulate the following information as part of a Safety Flash. Crosby has been
made aware (March 2023) of a few instances of hoist rings that have an important assembly component missing.
In those instances, the retaining pins used to secure the hinge pins were not in place and allowed a hinge pin to
come out during unloaded condition. Internal testing has confirmed that these hoist rings can sustain the working
load limit with only one hinge pin in place. However, Crosby recommends the listed hoist rings be immediately
inspected to confirm the retaining pins are in place. The inspection is simple and can be completed quickly with the
hoist rings installed and unloaded.

Crosby requests you perform the inspection on the above listed products with the listed production identification
codes (PICs) found on the body. Crosby has prepared the below instructions to perform the necessary inspection.
The inspection uses a small flat tool to gently pry the hinge pins outward, to confirm they are positively secured. If
any hoist rings are found with inadequately secured hinge pins, please remove from service, and notify Crosby
Technical Support at 1-800-220-8509 or [email protected] for immediate replacement.

Please inform your customer(s) of this Inspection Notice, or if you know of other users of the HR-125/125M Hoist
Rings, please pass this notice on to that user, company, or firm. To ensure further circulation of this inspection notice
to potential users of the products, it is being provided to safety minded industry organizations for posting on their
safety notification sites.

We regret the inconvenience this may cause you and your organization and thank you for your cooperation. We are
committed to providing you with the absolute best in Crosby quality.

Sincerely,

THE CROSBY GROUP

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© 2022 Page 1 of 6
Inspection Procedure: HR125 & HR125M Hoist Ring

Hinge Pin Check

NOTE: The inspection for the presence of the hinge pin retaining pins can be completed without disassembly of the
HR-125 / 125M Hoist Ring. The inspection can be completed with the hoist ring installed while threaded into the
work piece and fully torqued or uninstalled. The bail must be in unloaded condition, and the bail should be free to
pivot easily on the hinge pins.

Video Demonstration of this inspection can be found at this link: Hinge Pin Inspection.mp4

Locate hoist ring assembly and visually inspect for any issues.

Note: It is recommended to periodically inspect per Crosby Hoist Ring

Warnings and Applications Instructions, and ANSI B30.26 Rigging Hardware

The inspection can be accomplished by taking a small flat rigid object (such
as a thin pry bar) that can be inserted under the head of the hinge pin and
prying outwardly on the hinge pin.

Alternately, the inspection can be accomplished by grabbing the head of the

hinge pins (with small pliers) and pulling outwardly while twisting.

A small amount of axial movement of approximately 0.04” (1mm) may be

detected, but the hinge pins should not come out of the bail and body of the
hoist ring. Additionally, the hinge pins should not rotate relative to the body.
Perform the inspection on both hinge pins.

After the inspection, the hoist rings should have an identifier added, that
indicates the inspection was performed and found to be acceptable.

In this case we placed a blue paint pin dot next to the E-Clip.

If any hoist rings are found with inadequately secured hinge pins, please remove from service, and notify Crosby
Technical Support at 1-800-220-8509 or [email protected] for immediate replacement.

IMCA Safety Flash 11/23 Page 2 of 6

2 Uncontrolled movement of spreader bar
What happened Applicable
Life Saving
A vessel was set up alongside a barge in preparation for the subsea deployment of a 16" Rule(s)
(40cm) spool. The spreader bar sea-fastenings were removed by the deck crew and as the Line of Fire
crane raised the rigging, the spreader bar rotated uncontrollably causing it to fall from its
supports, with the forward end landing on deck and aft end landing
on the spool.

The potential for rotation was unforeseen; a rigger who was nearby
had to move quickly to get out of the line of fire. There were no
injuries.

Underlying causes
• The roll potential was identified by the onshore mobilisation
team; however, it was not communicated to the offshore team;
• The procedure and lift plan did not detail the correct sequence
for sea-fastening removal and lifting;
• There was a failure to identify and manage change
requirements;
• The design / drawings presented at the risk review were not
detailed enough to allow robust assessment of associated risks;
• The hazard of roll potential was not identified at design stage
and was not detailed in design requirements.

Learnings
• Emphasise requirement to carry out a tool-box task before starting a task, and after a worksite inspection, so
that all participants are made aware of all foreseeable hazards and implement suitable and sufficient control
measures;
• Perform post-task debriefs, considering the following:
̶ What went well?
̶ What was different than planned or expected?
̶ What could have gone better?
̶ What surprised you?
̶ What changes were made to address the issue or condition discovered?
̶ What hazards/safeguards/issues still require follow up?
̶ What would you change or do differently next time?
• Ensure sea fastening design requirements and the need for suitable technical review of full lifting operation is
communicated.
Members may wish to refer to:
• Uncontrolled movement of a riser
• UK HSE: uncontrolled movement of fabrication caused injury
• Uncontrolled movement of crane block and pennant during lifting operations at sea

IMCA Safety Flash 11/23 Page 3 of 6

3 Equipment starts unexpectedly
What happened
Applicable 0

Life Saving
Three mechanics obtained a Lock-out/Tag-out (LOTO) for a High voltage AC
Rule(s)
unit, and were performing routine maintenance on the unit. As one of them Energy Work
went to lubricate the bearings, the machine started unexpectedly. Work was Isolation Authorisation
stopped and a review was conducted. It was discovered that a linkage
was broken in the circuit breaker handle and the breaker did not actually
shut off when arranging the LOTO. The plant electricians repaired the
linkage, the LOTO was rehung, and the work was completed.

What went right and/or wrong?

• What went right: no one was in the line of fire when the machine
restarted and there were no injuries;
• What went wrong: equipment failure - the linkage in the breaker
handle was broken.
Lessons learned
• Carefully check that equipment is de-energized before working on it
– prove that it is “dead”;
• Ensure a full and thorough understanding of isolation and ensure the
proper sources of energy are isolated when equipment is upgraded
or modified.

IOGP Life-Saving Rules applicable

• Energy Isolation: the mechanics did not:
̶ Identify all energy sources;
̶ Confirm that hazardous energy sources were isolated, locked,
and tagged;
̶ Check there was zero energy; did not test for residual or stored
energy.
• Work Authorisation: the mechanics did not:
̶ Confirm that hazards were controlled or that it was safe to start
Members may wish to refer to:
• LTI: person crushed in watertight door
• Serious injury caused by energy isolation failure
• Agitator started moving during mud tank cleaning – leading to injury

IMCA Safety Flash 11/23 Page 4 of 6

4 Near Miss: steam and water released from filter
What happened?

A mechanic was given a work order to clean out strainers from a boiler circulation pump. The mechanic was got to
loosening the last two bolts, and stopped to wait to hear a “pop”
indicating the lid coming up. The “pop” was a little bit more than was
expected. As the mechanic waited for approximately 10 seconds, it
was noticed that the pressure started getting more volatile with
more air and water coming out. The mechanic moved out of the way,
and called the control room to let them know what was going on. An
operator and a supervisor responded and went to a valve that they
thought might still be partially open. They attempted to try and close
it. The supervisor tried with a bigger valve wrench and was able to
turn the valve two more turns to close it off.

What went right

• The employee moved out of the way when they noticed
increased pressure from the filter;
• The supervisor was able to close the valve two more revolutions
after the incident.

What went wrong?

• The valve did not fully close when operations attempted to
isolate it.

Lessons learned
• Procedures were changed so as to open the bypass on the filter first, then isolate the inlet and outlet of the
filter. Open drain valves upstream and downstream and then open the purge upstream and downstream,
ensuring zero energy is exhausting.
Members may wish to refer to:
• Crewman badly scalded during tank cleaning
• LTI: person crushed in watertight door

IMCA Safety Flash 11/23 Page 5 of 6

5 Maintenance and control of fire doors
What happened?
Applicable
A member has discovered instances of mandatory fire doors onboard their vessels being Life Saving
in a poor state of maintenance, and in some cases modified to alter the closing mechanism Rule(s) Bypassing
or tied back to prevent closing. Safety
Controls
Our member notes that in recent months there have been repeated internal and external
audit findings related to inadequate maintenance, unapproved modification and the incorrect functioning of fire
doors onboard their vessels. This has included Port State Control Inspection deficiencies that have raised safety
concerns and been communicated to the Flag State Authorities.

What was wrong

Inadequate maintenance and unapproved modifications reduce the effectiveness of fire and smoke boundaries
significantly, with potentially serious consequences during a fire and increased risk to crews and assets.
• Fire doors have been found to not close and seal properly;
• Fire doors have been modified to alter the speed of closure;
• Fire doors have been tied back to prevent closure.

Actions to take
• Ensure that no fire doors are modified or tied back to prevent closure or modify the speed of closure;
• Ensure all fire doors close automatically, by the self-closing mechanism and seal completely, including any hose
ports;
• Ensure that routine maintenance and inspection regimes are followed;
• Ensure that where any defects are found, these are reported immediately.
Members may wish to refer to:
• Fire door left wedged open
• Incidents relating to hatches and doors
• Disabled audible alarm on fire alarm panel
• Watertight doors left open at sea

IMCA Safety Flash 11/23 Page 6 of 6