B SAFE Onboard Safety BSAFE INCIDENT CASE STUDY 12: FATALITY INSIDE THE ELEVATOR SHAFT Published: 27 October 2021 While at anchorage an electrician did not appear for dinner and consequently a search was initiated. He was later found trapped inside the vessel’s elevator shaft between the elevator’s counterweight and a protective beam, where he had been working earlier that same day. His fellow crew members managed to get him out of the elevator shaft, but, despite administering first aid, the electrician was pronounced dead at the scene. Figure 1 Emergency door tool Source: Investigation report 06/2018 by Transport Malta – Marine Safety Investigation Unit Figure 2 The area where the electrician was found inside the elevator shaft Source: Investigation report 06/2018 by Transport Malta – Marine Safety Investigation Unit WHAT HAPPENED? During the voyage a potential problem was identified with the stopping position of the vessel’s elevator car. It was thought that the problem may be related to the elevator’s control cabinet overheating and possibly also to the adjustment of the elevator’s limit switches. Checks were carried out, but the problem persisted, and as a result the elevator was taken out of service until further investigation could be carried out at the next anchorage. On the morning of the incident a tool box meeting was conducted prior to starting the work. The meeting record indicated that the electrician and electro–technical trainee (ETT) would inspect the elevator’s speed governor and limit switches. Signs were posted on each deck, and on the control panel, stating that the equipment was out of service due to maintenance. Similar signs were posted at the elevator’s call buttons on each deck and  a public announcement was made to make the crew aware of  the ongoing work on the elevator. As the work involved working in the elevator shaft, a ‘working aloft’ permit was issued. The electrician and the ETT started checking and adjusting the limit sw