Accident in Australia involving an ACC with a superseded rope cover

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An ACC built in 2008 (first generation) was in April 2013 involved in an accident in Australia . The ascender had not undergone annual inspection nor been upgraded due to our instructions -it was equipped with a superseded rope cover. The operator seriously injured his left hand fingers. The index finger was treated for severe rope burn and nail bed reconstruction and the middle finger and the ring finger tip was amputated at the first joint.

The predominant contributing factor for this incident was that the ACC I powered ascender was fitted with a superseded rope cover. The design of the rope cover was changed early 2009, and this particular machine was not modified. Though ActSafe took the correct actions and sent a safety alert to all of their importers and distributors, however the independent Australian distributor at the time did not pass on the information and the replacement part to all users. ActSafe also offered the replacement part at no cost to the end user.


The Safety Alert sent out by ActSafe in March 2009 can be viewed here: March 2009 Safety Alert ACC

The full report issued by High Point Access and Rescue can be found under "Related files and documents" below.

Background

At the time of the incident, the Rope Access Supervisor was working approximately 50m above ground level. While ascending with the powered ascender, the rope spooled abnormally out of the device. The operator noticed a loop (approximately 200mm long) had formed between the rope grab and the rope guide. The operator immediately stopped ascending. While attempting to rectify the issue, the device came off the rope and the loop pulled through the rope guide. It is assumed that the loop of rope was wrapped around 3 of the operators fingers at the time, pulling them through the rope guide. The operator fell a short distance onto the safety system. After confirming the integrity of the rope and the ascender, the operator was able to install the rope back into the ascender, reset the safety device and ascend to the walkway above.

Contributing factors

1. Abnormal spooling of the rope out between the rope grab and the rope guide.

-The powered ascender had a superseded rope cover fitted.

-It is assumed that the tail of rope exiting the device was blocked, causing the rope to spool abnormally.

2. Rope coming off the rope grab allowing the device to fall.

-The device was not supported / suspended by an alternate system while rectifying the abnormal spooling.

-The manual / emergency descent pin was left in the receptacle as it was being used for descent to preserve battery life (Note, this will not preserve the battery life).

-It is assumed that another rope (used to hoist equipment) caught on the manual / emergency descent pin, engaging the manual descent and allowing the rope grab to rotate. This would have wound the rope off the rope grab allowing the device to fall.

Remedial actions

-Notify end users of the incident details.

-End users to inspect their equipment to identify if their unit has a superseded rope cover. This applies to ACC 1 models manufactured prior to Mars 2009

-If a unit is found to have a superseded rope cover, it must be immediately removed from service and the user contact the Manufacturer.

-All devices to be sent to the authorized service agent at least annually for inspection.

-Users to only insert the emergency descent pin when necessary for emergency descent and to remove the pin at all other times. The emergency descent manually disengages the brake, and will function even when the electrical system is isolated.

Related Files & Documents

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