Lapse in judgment almost costs a man his finger

Lookout! Issue 30, December 2014

A man working on a fishing trawler at sea sustained a serious injury to his finger when he tried to adjust a heading machine without stopping it first.
Heading machine
Maritime New Zealand ©2020
The heading machine with a glove showing where the man’s hand was when his finger was injured.

The man, who was processing catch on the machine, said a drive belt that runs around three rollers had come off three times in quick succession. On the first occasion, he called the supervisor over to reset the belt – as company procedure required – but the second and third times it happened he decided to reset the belt himself, leaving the machine running. On the third occasion, he injured himself.

Instead of turning the machine off, as was standard practice by the supervisor, the worker lifted the tensioner arm with his right hand and reached into the machine. He put his left hand between two tensioners to pull the running belt forward from where it had lodged behind the tensioner gears, leaving one finger sticking out.

The belt grabbed and ran the man’s hand towards the blade, cutting his index finger about three-quarters of the way through. At this point, the man hit the emergency stop button on the machine.

The vessel returned to port and the man was transferred to hospital for emergency treatment. Luckily, his finger eventually healed and there was no lasting damage, apart from some scarring.


  • The incident, which happened towards the end of the operator’s shift, illustrates the dangers of a lapse in judgment or making a hasty decision in order to save time.
  • Company policy was that in the event of a belt coming off a roller, the machine was to be shut down and the shift supervisor or watch engineer – the only people trained and authorised to replace the belt on the roller – called over.
    • The worker was trained and experienced in operating the machine, but was not trained or authorised to make any repairs or adjustments to it. He chose not to follow company procedure, and suffered a serious injury as a result.
  • Health and safety must be treated as a priority by both employees and employers. In this case, the company immediately acted to ensure the machine was safe for other workers to use. The company completed a detailed internal investigation into the incident and issued a report.
  • All crew on the vessel were required to review the crew handbook, and particularly the section on machinery and factory safety. The vessel’s training and training records were also reviewed to ensure the systems were up to date and ongoing refresher training is being provided.
  • A specialist technician reviewed all types of this heading machine in all of the company’s vessels to prevent this kind of incident happening again. An engineering inspection revealed no reason for the belt to come off as it had. The belt remained in place after the incident and didn’t cause any further problems.
  • A side panel had been removed so that the operator could view the cutting blade’s position from where he stood and, if needed, adjust the position of fish on the in-feed belt. The risk of injury with the panel removed was considered to be low, except that it meant untrained workers had access to the belt when it came off its rollers.
    • Appropriate safety measures need to be taken for any modifications to equipment used on board a vessel, taking into account the obvious risks as well as those not so easily predicted. After the incident, side covers were reinstated on all of the vessel’s processing machines and an electronic switch was installed to automatically cut power to the unit when the cover is opened. Procedures for reinstalling the belt were also revised, so that the machine doesn’t need to be powered in order to feed the drive belt on.

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