LTI – Spiral fracture to shinbone after turning awkwardly and falling in stairwell


Whilst descending backwards down the stairs a turn was required to move from the stairs though the door. In the turn the left foot caught/jammed on the stairs unexpectedly. This caused loss of balance and the IP fell with a twisting motion, causing a spiral fracture of the left shin.

Preliminary findings and possible causes:

 Stairs were well lit and in good condition with clear, non-slip coating.

 IP was descending backwards on steep stairs which is good practice (refer Safety Flash 03/2016)  IP was wearing good quality, lace-up safety boots.

 Second-last stair is roughly at level with the door step which encourages a “short-cut” rather than fully descending the stairs to the landing platform to get a good balance, turn and then move over the doorstep.

 Short delay in getting shore medical assistance – uncertainty in contact numbers.

Immediate corrective/ preventative action:

 Reminder to all crews to be fully focused and avoid “short-cuts” when using stairs/ladders even though a stair design is inadequate. Unfortunately stair incidents is still very common in Svitzer for all ranks.

 There have been numerous Safety Flashes emphasizing how Slip & Trip injuries can be avoided. Take moving around the tugs seriously and avoid injuries even though moving around is a common part of daily life onboard and not addressed by HMS Safe System of Work processes.

 Delay in shore medical assistance was caused due to site-specific emergency numbers not readily available in accommodation. HMS 11-003 specifies that vessels display a poster with DPA, DDPA and 24 hour operations number in prominent locations. Site-specific emergency contacts should also be included to ensure medical assistance can be mobilised ASAP for serious injuries. If the vessel do not have the immediate medical contact number Operations must be contacted to assist.