RMI investigation: Cadet’s death in enclosed space associated with failure to identify hazard

A Deck Cadet lost his life in an enclosed space onboard the RMI-registered bulk carrier LA DONNA I, in August 2018. The Republic of the Marshall Islands issued its investigation report on the accident, identifying lack of familiarity with procedures as contributing factor to the fatality.

The incident

The Republic of the Marshall Islands-registered bulk carrier LA DONNA I, managed by FML Ship Management Ltd., arrived in the Port of Paradip, India on 12 August 2018 to discharge a cargo of 61,557 metric tons (MT) of coal.

At approximately 17301 on 14 August 2018, during cargo discharge operations, the Deck Cadet was reported to have been incapacitated due to oxygen deficient conditions in the enclosed Australian ladder trunk of Cargo Hold No. 6.

In response to the incident, the Chief Officer (C/O) entered the space to assist the Deck Cadet and subsequently lost consciousness.

The Deck Cadet and C/O were rescued from Cargo Hold No. 6 by the ship’s crew.

The C/O regained consciousness and recovered, however, the Deck Cadet did not survive.

Probable causes

The RMI marine safety investigation concluded that the causal factors that contributed to the Deck Cadet’s loss of life include:

• asphyxiation due to insufficient oxygen levels within the space where he was working;
• the C/O’s failure to properly identify the Australian ladder trunk as an enclosed space when he entered, and subsequently directed the Deck Cadet to enter, the cargo holds;
• the failure of the C/O to identify the potential hazards despite the warning statement present on each access hatch cover;
• the failure of the Deck Cadet to follow the OS’s advice that a self-contained breathing apparatus (SCBA) should be used when entering the enclosed trunk;
• the failure of the Deck Cadet to identify the potential hazards despite the warning statement present on each access hatch cover; and
• the C/O’s failure to follow and enforce enclosed space entry and rescue procedures.

Additional causal factors which likely contributed to the Deck Cadet’s loss of life include:

• lack of familiarity with ship design characteristics in relation to design of the enclosed Australian ladders within the cargo holds;
• inadequate onboard implementation of pre-task risk identification, assessment, and control procedures;
• inadequate supervision of trainee crew members during high-risk or non-routine work assignments;
• ineffective communication amongst crew members related to the transfer of duties and responsibilities;
• delays in effecting a properly organized rescue of the Deck Cadet due to the C/O attempting a rescue alone and without raising the general alarm; and
• ineffective onboard implementation of “Stop the Work” policy when crew members observed unsafe actions or conditions

Actions taken

In response to this very serious marine casualty, the Company has taken the following preventive actions:

1. All managed ships having similar enclosed Australian ladder designs were identified, and ship-specific entry plans developed.
2. Within 24 hours, a safety alert was sent to all managed ships which detailed the findings and lessons learned from the incident. In addition, all ships carrying coal were reminded of the requirement to keep access hatches for loaded cargo holds locked.
3. The Classification Society was requested to review the Australian ladder design and recommend modifications to increase ventilation of the enclosed areas.
4. For ships fitted with enclosed type Australian ladders, an overview of the design will be added to initial crew member orientation.
5. Safety training was conducted for all crew members regarding the precautions to be taken when entering the enclosed Australian ladders for the cargo holds.
6. All superintendents will be provided with the findings and lessons learned for their awareness and for use as a training aid on board their ships.

Additionally, the Administrator has taken the following action:

1. Issued Marine Safety Advisory (MSA) 23-18 on 30 August 2018 reporting preliminary findings based on the Administrator’s marine safety investigation of the enclosed space entry incident that occurred on board LA DONNA I and ones that occurred on board other Republic of the Marshall Islands-registered ships. The MSA also included recommendations for ship managers and Masters regarding enclosed space entry and enclosed space rescue procedures.

Recommendations

The following recommendations by RMI are based on the above conclusions and in consideration of the actions taken:

1. It is recommended that the Company review its “Stop the Work” policy and take positive steps to encourage appropriate use of this policy onboard managed ships via additional crew training, crew seminars, and other appropriate measures. It is further recommended that this incident be used as a practical case study in such training.
2. Due to the similarity of this incident with other recent incidents occurring on Republic of the Marshall Islands-registered ships, the previous safety recommendation for the Administrator related to enclosed space entry training is reaffirmed.

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See also: RMI investigation: Fatality in enclosed space