Chief officer gets found lifeless on the bottom of a cargo tank
Danish Maritime Accident Investigation Board (DMAIB) issued a Marine Accident report regarding an fatal occupational accident, resulting in the death of the chief officer on board the Danish flagged chemical/products tanker SCORPIUS.
On 8 May 2014 at 1830, the chief officer on board the Danish flagged chemical/products tanker SCORPIUS was found lifeless on the bottom of a cargo tank during a tank cleaning operation.
Fifteen minutes earlier, the chief officer had been inspecting the ships port side cargo tanks. He had checked each of the tanks visually by taking a few steps down the tank access ladder. At approx.1825, the chief officer stopped responding to radio calls. The crew started to search for him and found him at the bottom of a starboard side cargo tank. The chief officer was evacuated immediately and provided with resuscitation treatment, but could not be rescued.
The marine accident report on this fatal accident centers on two topics: The construction and safety measures of the tank access ladders on SCORPIUS, and entering a tank without an entry permit.
In the report, The Danish Maritime Accident Investigation Board concludes that the fatal accident on SCORPIUS was a fall accident that connects to the ladders design, and that the entry without a permit did not have an influence on the outcome of the accident. However, the DMAIB also discuss the relation between safety procedures and operational workflow.
| Conclusions |
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The chief officer on board SCORPIUS died due to a fall from the top of a tank access ladder as he was checking the tanks visually during tank cleaning. By taking a few steps down the tank access ladder without an entry permit, he did not comply with the safety procedure on board. This, however, was not likely to have any connection to the outcome of the accident. Due to the design of the ladder, the accident could have happened on any other day even if the enclosed space procedure had been followed. The design of the tank access ladders on SCORPIUS was a combination of an inclined and a vertical ladder, which resulted in inconsistent and inefficient fittings of fall preventive measures. The person entering the tank was completely unprotected at the top of the ladder in case of fall. Furthermore, the requirement to wear fall arrestor at tank entry was not supported by designated constructive fittings facilitating the use of these. The safety procedures and risk assessments concerning tank cleaning and enclosed space entry focused on the risks of hazardous atmosphere and the theoretical ways to avoid them, which did not correspond with or cover the operational situations and problems of the workflow. A generic description cannot foresee and describe all tasks and their safety issues, because the operational situations on board are varying and complex. These varieties call for the crewmembers on board to adapt to the situation at hand and weigh out safety and workflow when making decisions. Therefore, there will always be a difference between work as described and work carried out. The chief officer on SCORPIUS most likely adapted to a given situation when he decided to enter the tank without a permit. His decision was most likely based on the assessment that the tank atmosphere was safe to enter, and in this context the risk of falling was not considered a factor. Therefore fall preventive measures were not taken. The fatal accident on board SCORPIUS was not a result of an evasion of a safety procedure, but rather points to a problematic ladder design, inconsistent fall preventive measures as well as an atmosphere-focused risk assessment. |
Further information may be found by reading DMAIB Marine Accident Report by clicking on the image below:
Source: DMAIB / Image Credit:Sirius Shipping AB
