The Marine Department of the Hong Kong Special Administrative Region (SAR) presents an incident in which a fatal accident happened on board a bulk carrier during a fumigant removal operation.
The incident:
The ship arrived at the Urmston Road Anchorage to discharge cargo, which had been fumigated with aluminum phosphide in sleeves. A fumigant removal team from shore, including the worker, was hired to remove the fumigant residues. Two deck crew members of the ship were assigned to assist with the removal operation, including the opening and closing of the relevant cargo hatch covers. When the removal operation was shifted to cargo hold no. 6, the worker was found missing onboard. After searching around the cross deck area between hold no. 5 and hold no. 6, the aft booby hatch of hold no. 5 was found open, and the worker was found lying unconscious in the spiral ladder space of hold no. 5. The ship crew quickly organized to rescue the worker and applied first aid. The worker was subsequently airlifted by a rescue helicopter and transferred to a shore hospital for medical treatment. Unfortunately, the worker was eventually declared dead at the hospital.
The investigation identified that the contributory factors leading to the incident were that the ship crew did not fully follow the requirements of the Shipboard Safety Management Manual to properly monitor enclosed space entry and take appropriate actions to prevent unauthorized entry into the ladder space; the ship crew did not adhere to the requirements of the Operational Manual for Bulk Carrier for safe entry into the fumigated space onboard; and the worker lacked safety awareness on the high-risk fumigant removal operation, especially concerning enclosed space entry.
Lessons learned:
- Strictly follow the requirements of the shipboard procedures to properly monitor enclosed space entry and prohibit personnel from entering into enclosed spaces unless authorization and a valid permit are given;
- Strictly follow the requirements of shipboard procedures for safe entry into fumigated spaces onboard, i.e., a gas-free certificate should be issued before personnel are permitted to enter the fumigated space onboard;
- Conduct necessary internal audits from time to time to ensure that the crew members strictly follow the shipboard procedures to monitor enclosed space entry and enhance crew training to ensure strict adherence to the shipboard procedures. The attention of shipowners, ship managers, ship operators, masters, officers, and crew is drawn to the lessons learned above.
