DESCRIPTION OF THE LAUNDRY ROOM AND THE WASHER-DRYER INSTALLATION

Transcription

1 LOUISIANA OFFICE FLORIDA OFFICE 3501 HOLIDAY DRIVE, SUITE #314 OCEAN-OIL P. O. BOX NEW ORLEANS, LA ST. PETERSBURG, FL CELL (24 HOURS): (504) EXPERT WITNESS, INC. 566 VILLA GRANDE AVE. S. FAX: (504) ST. PETERSBURG, FL NAVAL ARCHITECTS and MARINE ENGINEERS PH: (727) MARINE CONSULTANTS FAX: (727) CELL (24 HRS): (727) DANGEROUS LAUNDRY ROOM ON A PASSENGER VESSEL By: Hector V. Pazos, P.E., Naval Architect, Marine Engineer and Registered Mechanical Engineer ( Copyright 2015 All Rights Reserved BACKGROUND During a very nice seven-day cruise on a large passenger vessel in the Caribbean, a lady passenger decided to use a coin operated laundry room, available aboard the vessel, which was available to the passengers. The washers and dryers were heavy-duty stackable units, with the washers resting on the deck or floor of the laundry room, and the dryers mounted on a steel frame just above the washers. After drying the clothes just washed, the passenger was pulling clothes out of one dryer when the dryer fell on her resulting in serious injures. DESCRIPTION OF THE LAUNDRY ROOM AND THE WASHER-DRYER INSTALLATION The laundry room where the accident took place measures approximately 15 feet in the athwartship direction and 6 6 to 7 0 in the fore and aft direction. There are four heavy-duty washing machines and four commercial dryers in this room besides a sink, a permanently mounted folding table opposite dryer #2, two chairs and an ironing board. Each dryer is mounted on top of a coin collection box about 6 in height (Money Acceptors). The coin collection boxes appear to be an integral part of the dryers and have matching dimensions with the base of the dryers. The dryer/coin box units have an approximate weight of 140 pounds. The dried clothing in the dryer weighed approximately fifteen pounds. Thus, the total weight of the dryer unit involved in this accident was approximately 155 pounds, along with the accumulated weight of coins in the coin collection box. It appears that the dryers are rigidly connected to the coin collection boxes, therefore, both items reacting as a single unit to any force or vibration applied either to the dryer or to the coin collection box. Each washer and dryer/coin box pair are mounted on individual steel structures which support both units, with the washer on the lower portion of the structure and the dryer/coin box above it. The flat floor pads and the square base washer support: The steel structure is welded on top of steel flat floor pads which are welded to the laundry floor towards the athwartship bulkhead, which is to the rear

2 of the steel structure and on the right side of the laundry as one enters the room. Each steel structure has a square base approximately 27 deep x 27 wide x 4 high at the bottom to which the washer is mounted. This square base is welded to the flat floor pads, which in turn are welded to the steel deck. The steel bases for the washers were not welded directly to the floor apparently because the vessel s steel deck has substantial deformations. The flat floor pads are not as long as the square base they support. The pads terminate 8 ½ short of the front of the square base. Hence, the square base and therefore, the washer that is resting on the square base is cantilever and overhang the flat floor pads. Because of the irregularities in the floor (which undulates throughout the laundry room), there is an irregular gap between the floor and the bottom of the square bases the washers are mounted on. The dryer support frame: The square base supporting the washer has two vertical steel channel posts welded to its back corners. These two posts are approximately 35 ¾ high. The posts are the only support for the dryer support frame. The back of the frame is formed by a piece of 1 ¼ x 1 ¼ x ¼ angle iron connecting the two vertical posts. The sides of the frame are formed by two arms approximately 18 1/4 long made of 1 ¼ x 1 ¼ x ¼ angle iron. The arms are connected by a flat piece of steel welded horizontally to the bottom of the two arms. The dryer/coin box unit rests on this support. Since the dryer/coin box unit measures approximately 27 deep, and the arms are only approximately 18 1/4, approximately 9 of the front part of the dryer/coin box unit is supported. In other words, the dryer/coin box unit is partially cantilevered off the dryer support frame, and 9 of the dryer coin box hangs over the end of the dryer frame completely unsupported. The safety tether wires intended to restrain the dryer were not installed: In order to restrain the dryer/coin box from falling forward onto the dryer s user, the manufacturer designed, manufactured and installed safety tether hardware on the dryer s casing. All of the four heavy-duty commercial dryers have factory equipped wire safety tether (approximately 30 long). The wire safety tether is secured to the left and right upper rear corners of each dryer and passed through a stainless steel clip. The clip was intended to be secured by four screws to the athwartship bulkhead of the laundry room located 12 behind the dryers, thereby preventing the dryer from moving or tilting forward. Despite clear instructions in the manufacturer s installation instructions and the clear purpose of the safety tether hardware to any maintenance person, the safety tether hardware was never attached to the bulkhead, as evidenced by the complete lack of holes in the steel walls of the laundry room behind the four dryers. This hardware was intended to restrain the dryers from sliding or tilting on the dryer support frame towards the front, where the person using the dryer would be standing when loading or unloading the dryer. During the inspection performed by the author of this case study, it was found that the clips were never secured to the bulkhead and each wire and each clip was hanging loose from the top of each dryer. Hence, unless otherwise restrained, the dryer can slide or tilt towards the person using it due to deformation of the supporting frame, motions of the vessel vibrations created by the washer, and/or the dryer, vibrations created by the machinery of the vessel, or in normal use when the user pulls outwards on the door handle to open the door of the dryer, or pulls clothes from the dryer. If this factory installed safety tether had been properly attached to the wall rather than left unused, the accident would not have occurred as it did. Bolting dryer to the dryer support frame: Another system intended to hold the dryer/coin collection box units in contact with the dryer support frame consisted of two holes (about ¼ inch in diameter) drilled on the backside of the dryer support frame and two matching holes in the back of the coin collection boxes. 2

3 These holes purpose was to allow the installation and tightening of two bolts to secure the dryer/coin collection box units to the dryer support frame. During the inspection performed, it was found that bolts were missing and the ones that were visible, were loose or were the wrong size, such as having a bolt 2 ½ long with a loose nut midway. Obviously, on the day of the accident, there were no bolts securing dryer #2 to its frame, since the dryer was relocated more than 3 when it fell on the lady passenger. It appears that the only items providing a small force to restrain the dryer from falling completely off the dryer support frame were the electric cables and the dryer exhaust hose. During the inspection it was noted that the sheathing protecting the electric cables of the electric wires for dryer #2 had about 2 of visible separation from its attachment point to the dryer, indicating the dryer had been pulled towards the front with the electric wires being forcibly pulled through the sheathing. At the time of the inspection, dryer #2 had 2 bolts of different characteristics both completely loose, one 1 long inserted from the outside of the frame and the other 2 ½ long and less than 3/16 in diameter, inserted from the inside of the frame. These characteristics indicate that it was not an original installation. The electric panel boxes: Each heavy-duty commercial dryer has an electric panel box installed close behind it on the athwartship bulkhead located approximately 12 behind the dryers. The electric panel boxes behind dryers #1 and #2 cannot be accessed without removing or relocating the dryer, as the support structure is permanently welded to the laundry floor. It is obvious that from time to time the dryers need to be relocated or removed to access the electric panel box, and, in order to move a dryer, the bolts intended to secure the dryer to their frame had to be removed. The repair or maintenance personnel acted negligently by not replacing missing bolts and by not tightening the bolts. During the inspection of August 7, 2004, the door of the electric panel box behind dryer unit #1 was closed but in tight contact with the back of the dryer unit #1. The door of the electric panel box behind dryer unit #2 was open at the time of the inspection because it appears that if the door were closed, dryer #2 would not be able to be pushed back to the back completely onto the dryer support frame, causing dryer #2 to hang out over the end of the dryer support arms even more. In other words, the electric panel boxes behind dryers #1 and #2 are in the wrong location. DESIGN AND FABRICATION DEFICIENCIES OF THE STEEL STRUCTURE SUPPORTING THE WASHER AND DRYER 1. General The steel structure supporting the washer and dryer was improperly designed and fabricated because, among other deficiencies, it allows elastic and permanent deformations of the structure towards the front where the user would be located, without positive means of restraining the dryer from falling towards the user. The center of gravity of the washer and the dryer are not in the center of each unit, but are most probably towards the front of each unit because of the following: 3

4 a). The coin collection device and storage of coins are at the bottom front of the dryer; b) When the washer is in operation, the clothes and water in the washer would move the center of gravity towards the front; and c). When clothes are being removed from the dryer, the clothes will be pulled and accumulated towards the front. The above magnifies the effect of having 8 ½ of the entire frame structure cantilevering from the floor pads welded to the deck. Furthermore, the dryer is resting on a dryer support frame that is supported by just two vertical posts originating at the back of the square base frame supporting the washer. Therefore, the entire weight of the dryer, with a center of gravity towards the front, along with the weight of its supporting frame, is creating a cantilever deformation resulting in tilting the frame supporting the dryer towards the front where the user of the machine would be located. In an unloaded condition, the front end of the partial frame supporting the dryer was found during the inspection to be permanently deformed about ½ downwards. When the dryer is loaded and the clothes are being moved toward the door to remove them from the dryer, it can be expected that the front of the dryer could become 1 ½ to 2 lower than the back of the dryer due to permanent and elastic deformations of the partial dryer support frame, the deflection of the two posts in the back of the partial frame, and the deficient connection of the steel structure to support the washer and dryer previously discussed. The arms supporting the dryer/coin collection unit were also only attached at one point to the structure. A bracing arm should have been included. The arms supporting the dryer/coin collection unit should have been the same length as the unit and should have incorporated a piece of angle iron at the front to create a frame into which the unit would rest. 2. Deficiency regarding the elevation of the door of the dryer: The bottom of the opening through which clothes are placed in the dryer or removed from the dryer should be lower than the height of the eyes of the persons that are expected to use the dryer, in order to allow the user to look inside the dryer for remaining clothes, and to avoid the possibility of the user to attempt to pull herself or himself up using the opening of the dryer as holding structure, to look inside the dryer for remaining clothes. A survey of several-stacked installation of washer dryers available to the general public, revealed that the bottom of the opening from which clothes are taken had heights above the floor between 50 to 54 inches. A chart developed by Dr. Steven B. Halls, MD, FRCPC and John Hanson, MSC (see footnote), indicates that 50% of the women, white race of about 65 years of age had an average height of 63 inches. The average distance from the eyes to the top of the head of women is about 5. Hence, the bottom of the opening from which clothes are removed should be several inches lower than 58, which indicates that the 50 to 54 found during the survey represents a reasonable industry standard. Footnote: Article entitled: Women s average height chart, stature gradually declines, can be found at: 4

5 FRCPC: Fellow of the Royal Colledge of Physeceans and Surgeons of Canada. During the inspection of the cruise ship, it was found that the bottom of the opening from which clothes are taken was about 61, which is 7 to 11 higher than reasonable industry standards. Due to deficient design of the base frame supporting the washer (4 height), the space between the top of the washer and the underside of the coin collection box (approximately 2 ½ to 3 ) and the thickness of the coin collection box (approximately 6 ), the dryer is several inches higher than it would have been if the following improvements to the design would have been applied: The washer could have been mounted closer to the floor by eliminating the 4 base and using a flat plate foundation (if necessary) and four vertical clips, reducing the height by 3 ½ to 4. The dryer/coin box could have been stacked on the washer as shown in the Installation Instructions for coin operated stacked dryers, reducing the height approximately 3. The above improvements would have required some provisions for securing and repairing the units, somewhat different than the present design. MAIN DESIGN DEFICIENCY AFFECTING DRYER #2 BESIDES THE LACK OF INSTALLATION OF THE RESTRAINING WIRE In addition to the design, fabrication and maintenance deficiencies common to the four pair of units, dryer #2 has a peculiar location that makes it more susceptible to fall from its supporting bracket. Dryer #2 is positioned between unit #1 and unit #3, and the space between unit #1 and unit #2 and between unit #2 and unit #3 is only 5 ½. Hence, the back of the unit #2 cannot be accessed thru the sides of unit #2. Unit #1 has limited access thru one side and back because there is about 12 space on the side and on the back of the unit. A similar condition exists for unit #3. Unit #4 has reasonable access through either side. Because the 5 ½ space between units, unit #2 can be only accessed by a maintenance mechanic thru the 12 space on the back of the unit #1 or unit #3, after crawling on the side of either unit #1 or unit #3, and stretching his arm about 33 to reach the edge of the supporting frame of dryer #2, and stretching about 36 to reach the location of the bolts intended to secure the dryer to the structural supporting frame. In view of the above, it can be expected that most maintenance people would not apply the effort necessary to install and tighten bolts to secure dryer #2 to its supporting frame. The above dangerous condition is the explanation for the absence of the restraining wire and the absence of bolts in the frame securing dryer #2 to the dryer support frame. The absence of bolts probably existed off and on several times since the laundry room was placed in operation. In other words, every time that a circuit breaker trips on the electric box in the back of dryer #2, the bolts on the back of the dryer needs to be removed to relocate the dryer forward, and then, the bolts must be reinstalled and tightened again, an effort that is doubtful was normally applied. 5

6 PLACEMENT OF THE FOLDING TABLE The laundry room table located in front of dryer #2 contributed to this accident in that a user was unable to move away from the falling dryer. The folding table should have been located elsewhere. The space allocated to the laundry room was insufficient. CORRECTIVE MEASURES It should have been obvious to the vessel s personnel during installation as well as during routing maintenance and/or at the time the vessel started operating. Hence, corrective measures should have been applied a long time ago. Some corrective measures could have been: 1. Install the safety tether restraining clip as per the installation instructions. 2. Install proper bolts at the rear of the dryer support frame. 3. Extend the dryer support frames of the dryers by 9 to create a full restraining frame to prevent the dryer from tilting or sliding. The lengthened arms should be connected, not by a flat piece, but rather with another piece of angle iron, which would serve to create a complete frame across the front to better hold the dryer unit. Also, the entire frame was too high, the vertical posts should have been shortened and a support brace placed at an angle (approximately 45 degrees) between the vertical posts and the horizontal arms. 4. Relocate the electric boxes of units #1 and #2 to an accessible location not requiring the removal of dryer #1 and dryer #2. 5. Put all of the dryers out of service until these various modifications are accomplished. 6. Placement of warning signs to advise users the dryers are not secured. 7. Replacing the current folding table with a narrower table. COMMENTS REGARDING THE CRUISE LINE S ACCIDENT REPORT The accident was reported to the ship s nurse shortly after the accident occurred, and was investigated by a ship s officer, who prepared a report signed by the ship s Captain, indicating, on page 2, that the passenger s action did not contribute to her injuries, by checking NO in the corresponding location. In the Investigative Report, the accident is described as follows: During the investigation the passenger claimed that on the date of the accident, while she was getting her clothes out from dryer #2 inside guest laundry on main deck, the dryer was about fall from its original position. In order to keep it from falling on her pushed the dryer back in its position thus causing sprain on her back. Guest claimed injury on her back. Regarding deficiencies that caused the accident, the Investigative Report indicates: (1) The place of accident was inspected along with the guest and noticed two nuts and two bolts missing from the clamp, which is holding the dryer. (2) The defect was immediately rectified by a crewmember to avoid similar accident. 6

7 (3) All dryers were inspected in the main deck guest laundry to ensure that it is properly fixed on the clamp and noticed some of the bolts and nuts were missing. Replaced all the missing nuts and bolts immediately. It should be noted that the Investigative Report mentions the word clamp, presumably referring to the tether bracket located at rear at the top dryer, provided with the dryer, which is described on page 4 of this report and identified as a stainless steel clip. The clamp or tether bracket was not installed as of the date of the inspection. Hence, the clamp was not bolted or secured, and therefore, could not have been holding the dryer when the accident took place. This deficiency still existed as of the day of our inspection, although the Investigative Report asserts that this deficiency was immediately rectified. The Investigative Report also indicates that also, some of the bolts and nuts were missing, presumably referring to the bolts and nuts intended to secure the dryer/coin collection box unit to the dryer support frame. In summary, the vessel s investigator found that the clamp (tether bracket or clip) was not connected and bolts and nuts were missing, and, as a result the dryer was free to slide on the dryer support frame due to vibration and ship motions. CONCLUSIONS AND OPINIONS In the maritime environment, where vessels, including passenger ships, must be prepared to meet all manner of weather conditions, all heavy equipment, including the dryer/coin box in this case, must be properly secured properly anticipating that if one manner of securing fails, a redundant manner will already be at work. Routine inspection and maintenance must be carried out on all heavy equipment, especially where passengers are involved. The carrier in this situation, the vessel s personnel, has the experience to know that this equipment would be a danger if not properly secured. The following are my preliminary conclusions and opinions: 1. The primary cause of the accident was the fact that dryer #2 was installed and maintained in a negligent, unsafe and hazardous manner without positive means of restrain. 2. The installation should have included the restraining wire properly attached to the athwartship bulkhead and two appropriately sized bolts with spring washers intended to secure the coin collection box attached to dryer #2 to the partial supporting frame. At the time of the accident the wire was not installed and the two bolts could only have been missing. 3. Even if the two small bolts in use on dryer #2 on the date of inspection have been installed and initially tightened, this method of anchoring the dryer is unsafe and hazardous because the nuts will become loose due to vibrations and due to the deficient design of the supporting frame. 4. The two small bolts intended to secure dryer #2 to its partial frame were missing as a result of a very deficient overall and detail design, installation and maintenance of the laundry room and its components as follows: 7

8 a). b). c). Dryer #2 is located between unit #1 and unit #3, with very little space between units, an arrangement that makes it extremely difficult to reach the back of dryer #2 to secure the two bolts that were the only hardware that were used to keep the dryer in its intended position. The design is unsafe because the two bolts need to be removed every time that it is needed to reach the electric box of unit #2, because dryer #2 is blocking the electric box. Hence, the dangerous condition of the dryer not being secured or restrained from sliding and falling existed at least since last time that an electrical problem needed to be corrected on unit #2. The design of the supporting structure is unsafe because, due to the motions and vibrations of the vessel and the vibrations originated by the washer underneath the dryer, it would not take long for the dryer to move towards the edge of the partial support frame (when the two bolts are missing) and fall off the partial support frame because the partial support frame has an inclination or slope towards the front of the dryer due to permanent and elastic deformations of the supporting structure. 5. A contributory cause of the dryer falling off the partial dryer support frame is the improper design and construction of the frame, which not only allows large permanent and elastic deflections towards the front where the user of the dryer will be located but also is too short, allowing the dryer to fall off the supporting frame when the canter of gravity of the clothes is relocated towards the front of the dryer or when a light pulling force is applied to the front of the dryer, or a combination of both factors. The frame should have been the entire length of the unit and the arms connected with another piece of angle iron, not a flat piece. This would have formed a frame to help restrain the unit. A support arm at a forty-five degree angle from the vertical posts to the horizontal arms should have been incorporated into the dryer support frame. Additionally, the entire frame was too tall, increasing the likelihood of a user having to use pulling force to remove clothes from the dryer, and the danger associated with the dryer falling from a higher position. 6. The vessel s personnel were aware of the danger of the dryer falling off the partial support frame as the dryers came equipped with safety tether wires secured to the top back corners of each dryer. Not only do installation instructions come with the dryers, the intended use of the safety tether wire is obvious. The attachment of the wires to the athwartship bulkhead of the laundry room compartment was never done, so a superior factory installed restraint system for the dryers was eliminated. This condition existed since the laundry room was placed in operation. No warnings were provided to the passengers that the safety equipment had not been installed. 7. In order to gain access to the electrical boxes, the dryers had to be moved forward at least one or two feet. To do this would require the maintenance staff to either have equipment to hold the dryer up in the air or have another person to hold the dryer up. Thus, the vessel s personnel had actual knowledge regarding the dangers of the dryer falling from its support frame when the restraining bolts were not in place, especially in light of the failure to install the safety tether. 8. The vessel s supervisory personnel most probably decided not to secure the wires to the bulkhead because they realized that this action will create one more obstacle for maintenance personnel to reach the electric boxes, so negligently decided to cancel the installation of the wires. 9. The vessel s personnel was negligent in failing to adequately inspect the dryer. Even a cursory inspection by a safety officer of the retaining systems used on the dryer would have revealed the failure to use the safety tethers and the inadequacies of the securing bolts and the shortness of the support arms. 8

9 10. The vessel s personnel was negligent to design, install and put in operation a laundry room that was overcrowded, with laundry machines blocking access to the electric boxes, with not enough space to reach the back of the dryers to install two small securing bolts, by not installing the factory installed safety tethers provided with the dryers, and having a folding table too close to the laundry equipment, not leaving adequate space for a user of the equipment to move out of the way to avoid injury should the dryer fall from its elevated position. Also, the supporting structural frames were improperly designed. The two arms supporting the dryer are too short to prevent the dryer from falling, if the dryer is moved slightly from its designed position, despite the fact that the dryers are removed from their designed position every time that the electrical boxes need to be serviced. The vessel s personnel had actual knowledge of this dangerous condition having moved the dryers to service the electric boxes. The above deficiencies most probably existed since the vessel was put in operation. 11. Regarding the bolts to secure the dryer to the frame and the bolts to secure the clamp, both set of bolts were missing at the time of the accident. Although the vessel s Investigative Report Ascertains that the defect was immediately rectified, at the time of the inspection, the clamp was still NOT secured to the bulkhead of the vessel and the bolting system to the dryer s support frame was inadequate. The litigation regarding the injuries sustained by the passenger was settled out of court. About the Author: Hector V. Pazos is a Naval Architect, Marine Engineer and a Registered Mechanical Engineer and has been engaged in Accident Investigation/Reconstruction for more than 40 years. He has been retained as an Expert Witness in over 1,200 Maritime cases, related to both commercial vessels and pleasure crafts, for both defense and plaintiff. He has offices in St. Petersburg, FL and New Orleans, LA. He can be reached by phone at (727) or (504) or by at: hectorpazos75597@aol.com and oceanoilpazos@bellsouth.net. For more information, please visit our website at: 9