The Swedish Accident Investigation Authority published its report on the death of a casual labourer from oxygen deficiency when he entered an unventilated spiral ladder leading down to one of the cargo holds.
The incident
The bulk carrier Declan Duff, loaded with coal, arrived to the Port of Oxelösund on 14 March 2018. When the vessel was moored, a production coordinator from the port came on board to go over the discharging plan and safety checklist with the ship’s chief officer.
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During the briefing, the ship’s master entered and underlined that the vessel had enclosed spiral ladders that end at the bottom of the cargo holds, and that there was a risk of oxygen deficiency in these spaces. The entry hatches to be used, i.e. the vertical ladders, would be opened by the crew of the ship at the request of the port personnel.
The hatch foreman and the dockworker that would be operating the loader in the cargo hold (worker A) boarded the Declan Duff to prepare and start the work before the remaining team members arrived. They went to the fore edge of cargo hold 7, and the hatch foreman told worker A how he was to operate the loader inside the cargo hold.
After their conversation, worker A left to enter the cargo hold. The hatch foreman did not think about which entry hatch worker A would use.
The hatch foreman looked down into the cargo hold to see when worker A would enter the space. When he did not appear, the shift leader called him on the radio, but there was no response. The hatch foreman then went to the entry hatch to the spiral ladder and went down. On the platform before the spiral ladder begins, he found worker A, who appeared to be lifeless.
The hatch foreman tried to get a response from worker A by shouting and slapping him, while he was calling for help on the radio. Suddenly, the hatch foreman felt that his legs started to tremble and he felt dizzy. He started to climb out of the hatch, but while doing so, he fainted on the upper platform. Another colleague (worker B), who had arrived on the site, helped the hatch foreman out of the hatch and up on the deck.
Worker B then went into the hatch, but fainted and in doing so hit his head. Another colleague (worker C) arrived with an emergency escape breathing device (EEBD2 ), which he had collected from the onshore office, as they had brought none on board. The hatch foreman and worker C were unsure how the breathing device worked, but worker C put the mask on and went down into the hatch.
After a short while, worker C started feeling dizzy. However, he managed to wake worker B so that he could get out. Worker C then also exited the hatch.
There were several efforts to enter the hatch to retrieve worker A, but none were successful. It was only when the ship’s crew brought an oxygen mask that one of the dockworkers, equipped with the oxygen mask, climbed down and tied a rope around worker A, pulling him out of the hatch.
Probable cause
According to the Swedish Accident Investigation Authority, the reason why the dockworker went down a hatch to the cargo hold where there was a lack of oxygen was likely a combination of being unaware of the risks, because of lack of training and experience in discharging coal, and not being given the information regarding the spiral ladder being enclosed and the risks that this entailed.
The circumstance that the entry hatches to cargo hold 7 are in reversed order in comparison to the other cargo holds has likely contributed to the choice of the hatch in question.
Underlying factors also included a lack of sufficiently structured methods for provision of safety-critical information and robust systems for discovering and rectifying procedural drifts.
Recommendations
Against the background of the extensive action programme that the Port of Oxelösund is planning to implement, and which SHK believes to be enough in order to eliminate the identified faults, SHK is not issuing any specific safety recommendations to the Port of Oxelösund.
However, SHK assumes that the findings of this report will be taken into consideration in the work with the action programme.
The Work Environment Authority is recommended to:
- Review and, if necessary, develop its inspection procedures for dock work in terms of how the ports work to prevent and discover risky procedural drifts. Refer to section 2.7. (RS 2019:01 R1)
SHK requested to receive by 13 May 2019 at the latest, information regarding measures taken in response to the recommendations.
See further details in the PDF below