Case study: Crew member dies after entering cargo hold under fumigation

The incident highlighted inefficient compliance with safety procedures and crew unfamiliarity with the proper safety equipment when entering an enclosed space.

The incident

The bulk carrier, transporting timber logs, was on a voyage. The logs in the cargo holds were under fumigation by using aluminum phosphide tablets under the supervision of a fumigator-in-charge onboard.

The Bosun of the vessel identified an exceptionally high bilge level in a cargo hold under fumigation by referring to its sounding pipe reading. It was quite sure that the sounding reading was false as the bilge level alarm of that cargo hold showing no high water level, which suggested that the sounding pipe might be blocked.

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After multiple failed attempts to clear water from the pipe, the Bosun informed the Chief Officer that he would wear a mask respirator and enter the cargo hold through the aft access hatch to conduct a physical inspection of the bilge level.

Later, the Chief Officer arrived at the aft access hatch, through which he saw the Bosun lying unconsciously on the upper stool shelf plate of the cargo hold. A rescue was immediately organized to pull the Bosun out from the cargo hold, but he was declared dead subsequently on board.

Findings

The investigation revealed that the main contributory factors of the accident were as follows:

1. the crew lacked safety awareness and did not follow the safety procedures of carrying out a proper risk assessment before allowing the Bosun to enter the cargo hold, and
2. the fumigator-in-charge was also not informed of the Bosun’s entering into the cargo hold in advance.

The investigation also identified the following safety issue: The daily measured phosphine gas readings at the accommodation and shipboard personnel working areas were not recorded in the vessel’s logbook in accordance with IMO circular MSC.1/Circ. 1264.

Lessons learned

1. All officers and crew onboard ships should strictly follow the established procedures in shipboard safety management manual to conduct a full risk assessment before entering an enclosed space and the issuance of the entry permit. Prior advice of the fumigator-in-charge onboard must be sought before opening sealed cargo holds under fumigation.
2. Crew members should be familiar with the limitation of the use of mask respirator and wear a correct type of respiratory protection in entering enclosed space. Gas concentration safety checks at the accommodation and shipboard personnel working areas must be conducted throughout the voyage at eight-hour intervals at least or more frequently with the readings recorded in the ship’s log-book in accordance with IMO circular MSC.1/Circ.1264.