Expelled part from hydraulic system causes a leak of hydraulic oil

TIN news:   IMCA has reported an incident in which a part was expelled from a hydraulic system under pressure, causing a leak of hydraulic oil.
The incident occurred when the hydraulics were activated to turn the winch drum to install a new wire rope. There was a loud bang from the hydraulic pack as a sensor was forced out of the unit. The sensor hit the bulkhead to the right. Approximately 2 litres of hydraulic oil was also expelled from the winch onto the deck and bulkhead.
Findings

Company safe system of work had not been followed – there had been no permission or sanction to test this equipment;
The hydraulic system had not been commissioned properly. The hydraulic hoses had been fitted the wrong way around;
The handover between technicians following crew change had not identified these issues.

Recommendations

Improve communication between crews at handover especially at crew change;
Formal “sanction to test” should be completed before it is handed over to the responsible person in charge;
Suitable and sufficient risk assessment and pre-use check list to be created and used for this work and equipment;
Status and condition of equipment should be clearly defined before planned maintenance is carried out