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Is that duct tape weight tested?

I wonder if anybody really expected a safety chain, held in place by duct tape, to prevent someone from falling through an opening in the upper level deck, to the middle level below.

Apparently, that's exactly what somebody expected recently on one of our submarines. It didn't take long, however, to discover that a safety chain held in place by duct tape would be no match for the weight of an unsuspecting Sailor who happened to wander into it. The results were very painful for both the Sailor and his command.

You see, the 24-year-old machinist mate second class (auxiliaryman), after falling through the opening in the upper level deck, suffered a concussion, with amnesia, soft tissue injuries to his left shoulder, a broken right wrist and left ring finger, and dislocations of the right ring and little fingers. The injuries could have been much worse. His command, meanwhile, has lost a valuable asset. An experienced technician and watchstander is out of commission. His watches will be filled by his shipmates. Duty sections may need to be altered to fill the void. Some watchstanders may go port and starboard until a replacement for MM2 is trained and qualified.

How did this mishap occur?, you ask. Well, the ship had been handling weapons on the day of the mishap. During weapons handling evolutions, deck plates must be removed in upper level of the forward compartment. Safety chains are installed and available for use to prevent personnel from getting too close to the edge of an opening in the deck and falling through. In this case, the weapons handling evolution had been suspended for the day, to be resumed the following morning. Instead of replacing six of the seven upper level deck plates (one left open where the piston goes through), only three of the seven deck plates were installed. This left a much bigger area open to the middle level below, and no installed safety chains near the edge of the opening in upper level. A makeshift safety chain was placed near the edge of the opening along with a sign warning "Decks Removed." The safety chain was held in place using tape. There were two other safety chains in place on installed chain hooks. One was across the passageway at the forward entrance to control. The other was across the entrance to the CO's stateroom. This left the rest of the passageway open. Personnel coming into upper level from the middle level ladder had unrestricted access to the area where the deck plates were missing. The only physical barrier to the opening in the deck they would encounter would be the makeshift safety chain across the passageway.

The MM2 was conducting a system inspection on a piping system located in the overhead in upper level. His attention was focused on the piping system overhead. He did not see the safety chain, the warning sign or the opening in the deck. By the time he made physical contact with the chain, which didn't stop his momentum, he was at the edge of the opening. With nothing to stop him and nothing to grab, he fell through the opening to the deck in middle level. And you know the rest of the story.

Of course, the MM2 could have been more aware of his surroundings, or maybe even had a shipmate walk the path of the piping system with him to ensure that he didn't walk into a hazardous situation. However, for a safety chain to be effective, it must be installed in such a way as to withstand the weight of a person walking into it, and it must be far enough away from the opening that it prevents someone from falling through. This safety chain didn't do either of those things.

We have to be sure to ask ourselves, "What could go wrong here, and how can I prevent it?" especially when operating in a mode you're not accustomed to. It doesn't cost much to go the extra mile and prevent a mishap. But it's very costly to lose a valuable member of your crew when it's preventable.
COPYRIGHT 2002 U.S. Naval Safety Center
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Copyright 2002 Gale, Cengage Learning. All rights reserved.

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Title Annotation:submarines
Date:Apr 1, 2002
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