On 16 July, the Malta registered dry cargo ship 'Kati' arrived in Wismar, Germany to discharge a cargo of fuel logs, stowed on deck and in the ship’s two cargo holds.
During a customs’ routine inspection, the AB, who was stationed by the gangway, did not respond when he was called by the master to unlock his cabin for inspection. An initial search onboard yielded no results.
At approximately 1335, the bosun went to have a look inside the cargo hold entrance and noticed a person lying on the deck, approximately eight metres down at the bottom of the access duct.
The bosun notified the master by VHF about his findings. Together with the chief officer, the master immediately proceeded to the forecastle.
It was the missing AB who was found on the cargo hold’s tank top. He was later pronounced dead.
The safety investigation found that at the time of the accident, the percentage of oxygen in the air inside the cargo hold was about 2.1%.
The immediate cause of the accident was exposure to an atmosphere which was deficient in oxygen. Asphyxia was determined to be the cause of death.
Wood products carried in bulk and in sealed cargo compartments are capable of depleting oxygen from the atmosphere, for instance, inside a cargo hold. There are various theories which explain the possible mechanisms leading to oxygen depletion including, microbiological activity and oxygen reactions with the constituent elements of wood.
- It was probable that the crew member had fallen off the ladder in the access duct for cargo hold no. 1 during his descent and before reaching the tank top, as a result of symptoms related to breathing oxygen-deficient atmosphere;
The AB was found with injuries to his head. Although the MSIU could not verify the cause of these injuries, it was considered that probably, he had fallen off the ladder in the access duct for cargo hold no. 1 during his descent and before reaching the tank top, as a result of the above mentioned symptoms.
- It was not excluded that the degree of knowledge which the AB had on the particular characteristics of the cargo may have not been as thorough as that of the ship’s officers;
- The entry to the cargo hold was accessible to the crew member, with no signs posted to remind of / mark the dangers which were inside as a result of the nature of the stowed cargo;
- Access to the cargo hold was due to two possible factors:
• the situation inside the cargo hold was perceived not to be dangerous and / or life threatening; or
• a perceived negative situation on board forced a reactive stance i.e., although aware of the danger, the benefits in accessing the cargo hold were considered by the crew member to overcome a perceived negative situation.
- None of the crew members had seen the AB entering the cargo hold and neither knew his intentions nor talked to him about the associated dangers immediately before his entry.
Immediately following the accident, notices cautioning of the potentially hazardous situation onboard were affixed on the access door to cargo hold no. 1. Moreover:
- A safety meeting was held with the Company’s Safety Manager with all the crew members and the preliminary findings of the internal investigation were discussed;
- Crew members were briefed on ‘Safety at Work’ and ‘Entrance in enclosed Spaces’, SMS procedures. An evaluation was also made on board on these procedures;
- Company has discussed ‘Safety at Work’ and ‘Entrance in enclosed Spaces’, SMS procedures in order to determine whether amendments were necessary (no changes affected); 18
- Evaluation of Company procedure implementation will be carried out by the Technical Superintendent / Safety Manager during their routine visits on board;
- An additional SMS audit was carried out in order to verify the implementation of corrective actions and action to prevent recurrence;
- Company Information Letters were sent to all Company vessels, emphasizing ‘Safety at Work’ and ‘Entrance in enclosed Spaces’, SMS procedures;
- Additional ship’s entry into enclosed space drills was also conducted on all ships;
- The Company’s Safety and Quality Managers, Superintendents, masters and safety/security officers were instructed to conduct relevant crew familiarization/training on ‘entry into enclosed spaces’ procedures, during all their routine visits onboard.
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