Hong Kong Merchant Shipping has issued an information note to draw lessons learned from a fatal accident happened on board a Hong Kong registered general dry cargo ship during discharging fumigated logs at Zhangzhou, China.
The incident
A Hong Kong registered general dry cargo ship (the vessel) berthed at the port of Zhangzhou, China for discharging the fumigated logs. In the morning of the day of the accident, a stevedore (the stevedore) entered the spiral ladder space (the ladder space) of the almost fully loaded No.1 cargo hold (the hold) from the access entrance on the main deck to unhook the lifting slings of an excavator which was transported from No.2 cargo hold to the hold by the shore crane.
After that, another stevedore on the main deck near the opened hatch of the hold observed that the stevedore did not show up to work inside the hold, nor did he respond to calls via walkie-talkie. The duty crew members, including the chief officer of the vessel (C/O), were informed of the incident.
The C/O came to the scene and wore a mask respirator which could only filter toxic gases but not able to provide survivable oxygen, then entered the ladder space for rescue. About one minute later, the C/O also became untraceable inside the ladder space.
The master of the vessel immediately raised the shipboard alarm to muster all crew members in response to the emergency situation and reported the accident to the management company of the vessel. The stevedore and the C/O were eventually rescued from the ladder space by onshore fire-fighting team, but unfortunately both of them were declared dead by the doctor onshore on the day of the accident.
The investigation identified that the contributory factors leading to the accident were that the vessel:
- failed to comply with the requirements of the “Code of Safe Working Practices for Merchant Seafarers” (the Code) and the shipboard safety management system (SMS) to properly control the entry into enclosed spaces;
- failed to follow the shipboard SMS procedures for entry into cargo holds by conducting a full risk assessment and issue an entry permit before entering
the ladder space; - failed to comply with the requirements of the Code and the shipboard checklist to properly plan the cargo handling, including safe entry into cargo holds;
- the shipboard safety training and drills, including enclosed space entry and rescue as well as knowledge of the limitations on the use of mask respirators, were ineffective; both of the stevedore and the C/O lacked safety awareness of the fatal risk inside the ladder space; and
- the foreman/terminal failed to identify the risk in the hold to prevent the accident.
Lessons learned
In order to avoid recurrence of similar accidents in the future, the ship management company, all masters, officers and crew members should note:
- strictly follow the requirements of the Code and the shipboard SMS to properly control the entry into enclosed spaces;
- strictly follow the shipboard SMS procedures for entry into cargo holds by conducting a full risk assessment and issue an entry permit before entering
enclosed spaces; - strictly follow the requirements of the Code and the shipboard checklist to plan cargo handling operation in a safe and proper manner, mutually agree with terminal operators for the procedures involved before and during cargo loading or unloading operation;
- enhance shipboard safety training and drills, including enclosed space entry and rescue as well as knowledge of the limitations on mask respirators;
- enhance the safety awareness of crew members on the risk of cargo holds containing fumigated cargoes in case of oxygen depletion and/or emission of toxic gases; and
- the management company should ensure crew members strictly follow the requirements of the shipboard SMS when handling fumigated cargoes and entering enclosed spaces.
