The Nautical Institute presents an incident where, a general cargo vessel was berthed and stevedores were preparing to unload logs from the holds, which had been opened several hours earlier.
During the pre-unloading meeting, the vessel’s Chief Officer (C/O) instructed the stevedores to use a work cage operated by a shore crane for accessing the holds. This was necessary because the logs were blocking the access stair trunks. The stevedore foreman insisted that once enough logs were unloaded, the stevedores should use the access entrances and fixed steel ladders on the main deck. The C/O agreed and had the safety grilles to the hold access ladders unlocked.
The stevedore foreman then asked that the ventilation be stopped. Unloading commenced about seven minutes later, after the stevedores had ostensibly conducted gas testing inside the access spaces. Testing was done without the presence of shipboard personnel and was apparently conducted with gas detectors and live chickens.
The next day, the log unloading continued. That morning, a stevedore entered the forward deck access to hold No. 2 to help move an excavator into the hold with the shore crane. Another stevedore entered the aft deck access to the same hold, not realising that the access from the ladder trunk to the hold was blocked by cargo. His goal was to release the excavator’s slings.
When the first stevedore exited the hold, he realised the other stevedore was missing. He tried to communicate with him via walkie talkie but there was no response. He then attempted to enter the hold via the aft ladder trunk to search for him, but exited shortly afterwards due to breathing difficulty inside the ladder trunk. He reported the situation to the ship’s duty officer and a few minutes later the C/O, wearing only a mask respirator (to filter toxic gases but not deliver oxygen), arrived at the scene and entered the ladder space via the aft entrance.
Within a minute, the C/O stopped responding to calls, prompting the shipboard alarm to be raised. A rescue team equipped with self-contained breathing apparatuses entered the ladder trunk and found the C/O unconscious on the ladder steps. They put an emergency escape breathing device (EEBD) on him and brought him to the deck. The fire-fighting team then arrived and quickly extracted the unconscious stevedore. Unfortunately, both the C/O and the stevedore were declared dead.
The investigation found, among other things, that the hold access trunk contained an O2 concentration of only 3%, and 1.3 ppm of phosphine (a fumigation product). The level of carbon monoxide exceeded the upper range of the gas detector. The report found that if proper access controls to the entrance to the ladder trunks had been in place, the fatal accident might have been avoided.
The investigation also found that the initial actions taken by the crew in response to the emergency in the ladder trunk were not properly organised and failed to follow recommended practices. For example, the mask worn by the C/O during his solo improvised rescue attempt was only to filter toxic gases but did not provide survivable oxygen. In short, the crew were not familiar with the limitations of the mask respirator. It could be deduced that the shipboard safety training and drills for enclosed space entry and rescue were ineffective.
Lessons learned
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Proper gas testing cannot be undertaken in six minutes using gas detectors and certainly not by using chickens.
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This accident is a prime example of a vessel’s leaders bowing to the pressures of shore stevedores. A vessel’s crew, by virtue of its company’s SMS, are bound to ensure compliance with the enclosed space procedures on their vessel. In this case gas testing, enclosed space access, and victim rescue were all either ignored, outsourced or not properly carried out.
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It would appear that the crew, notwithstanding having done enclosed space rescue exercises as per SOLAS, were unfamiliar with the limitations of the mask respirator, among other things. Another glaring deficiency was the C/O’s improvised solo rescue attempt with the wrong equipment.
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Mandatory enclosed space rescue exercises are now required by SOLAS but how do you practice something you don’t really know how to do in the first place?
