The incident

On 31 August 2018, Key Fighter berthed alongside Crude Passion at Averøy, Norway, where it discharged its remaining cargo of Rapeseed oil.

Before sailing for Erith, UK, 58 m³ of slops, reported to contain a mixture of tank wash water and vegetable oils, were transferred from Crude Passion to Key Fighter.

The slops, which were being loaded in cargo tank no. 5 port, were noted by the crew members to have a pungent odour of ‘rotten egg’.

He (the chief officer) stated that he had advised the AB and the painter to be very careful with the entry into cargo tank no. 5 port, due to the ‘rotten egg’ smell reported earlier. He recalled that he had also requested that the cargo tank is well ventilated, to keep the bridge informed and use personal gas detectors. He wrote down these instructions on a sheet of paper, which was left in the CCR, and then went to bed.

Following departure and while on passage, the slops were pumped out at sea and the crew started cleaning the cargo tanks.

The second officer remained alone on the bridge. He confirmed that from the bridge, he could see the floodlit deck area and the cargo tank entry lids, including those fitted on cargo tank no. 5 port.

However, he neither saw the watch changeover nor any crew member on deck; he actually assumed that if there was no one to be seen on deck, then everyone must be in the CCR. During the duration of his watch, there were no communication checks between the bridge and the cargo tank cleaning team. Moreover, the section in the cargo tank entry permit was filled neither with cargo tank entry nor exit details for the remaining time of the navigational watch.

The following morning, at about 0405 , two crew members involved in the cleaning and washing of cargo tanks were found lying motionless inside cargo tank no. 5 port.  The crew members were airlifted to a hospital in Norway.

 

Probable cause

The immediate cause of the accident was a fall from a height which led to fatal injuries, according to the Accident Investigation Board of Norway.

It was considered unlikely that both crew members would have fallen in a similar manner without the presence of additional factors. The MSIU was informed that post mortem tests could not confirm the presence of H2S gas.

The injuries may have been fatal, but based on the circumstances of the accident, the autopsy report indicated that it was possible that the cause of death was either intoxication by Hydrogen Sulphide (H2S), or suffocation due to lack of oxygen.

 

Conclusions

  1. There were neither management directions nor guidelines available for the loading of slops;
  2. Key Fighter undertook to receive a considerable amount of slop from Crude Passion without slop specific MSDS and without management directions or guidelines;
  3. Audit records indicated that the loading of slop was neither raised by the master nor identified during the audit;
  4. There were no records of pre-cleaning meeting and it is likely that the atmosphere monitoring of cargo tank no. 5 port during the cleaning process was not addressed in the toolbox talk;
  5. There was no effective supervision of the cargo tank cleaning and ventilation operations / ongoing atmosphere monitoring for toxic gas were not carried out;
  6. The general risk assessment document was not signed by the deceased crew members;
  7. Personal gas detectors were not worn by the crew members who accessed the cargo tank;
  8. Ventilation of cargo tank no. 5 port was carried out using portable gas freeing fans rather than the fixed Novenco type centrifugal fan;
  9. The officer responsible for ensuring that all parts of the entry permit were properly completed, was available neither on deck nor in the CCR during the cargo tank cleaning;
  10. The cargo tank entry permit was approved without all parts of the permit completed;
  11. The loading of slops ‘routine’ per se, and the related success (in terms of achievable goals) may have led to informal ways on how to complete the job;
  12. Given the success of past procedures and given that there were no disconfirming cues where being received by the crew members which would have suggested not to access the cargo tank, the decision to access the cargo tank was not rejected.

 

Other findings

  • Analysis of the record of rest hours of the crew members involved in the cargo tank cleaning operations indicated that the documents were in compliance with the MLC and STCW Convention requirements;
  • The tank entry procedure and the tank entry permit were in line with IMO recommendations and the guidance offered in ISGOTT Chapter 10;
  • Although the SMS recommended pneumatically powered lights for a satisfactory level of illumination inside the cargo tank, these were not available on board;
  • There was no dedicated look-out on the bridge during the hours of darkness;
  • The pungent odour of H2S gas coming from the slops did not trigger a realisation of the potential hazard to the crew and the loading of slop was not terminated;
  • The loading of slops and its discharging at sea, was not recorded in the vessel’s Cargo Record Book;
  • There were no management guideline and the carriage of slops was not authorised in the vessel’s Certificate of Fitness.

 

Actions taken

During the Course of the Safety Investigation During the course of the safety investigation, the Company adopted the following safety actions:

  • Frequent visits on board by Company representatives to observe and discuss shipboard operations;
  • Additional training offered to crew members;
  • Analysis of all Company procedures; and
  • Crew conferences on board, aiming to improve on safety.

 

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