The incident

A Navigation was alongside in Port Kelang, Malaysia, discharging a cargo of steamed coal. At approximately 1000 on 01 April 2018, whilst the chief mate and the shore foreman were conducting their routine inspection of the cargo holds, a burning smell was noticed coming from the entrance hatch to cargo hold no. 3.

On investigation, they discovered the body of one of the stevedores, lying on the upper platform of the access ladder to the cargo hold. The stevedore had severe burns to his upper body and without any personal protection equipment (PPE).

Although the exact reason for the accident could not be accurately ascertained by the safety investigation, it was suspected that a pocket of methane gas and coal dust ignited at the top of the ladder for cargo hold no. 3.

Cause of death

Although the investigation did not have access to the post mortem examination results, it was suspected that the casualty is likely to have died from third degree burns and asphyxiation.


  1. The immediate cause of the accident may have been a deflagration of a mixture of methane and coal dust;
  2. The lower ladder access became an enclosed space because of the height of the cargo inside the cargo hold;
  3. The cargo was liable to emit methane;
  4. The presence of coal dust was not excluded in view of the ongoing cargo operations in the other cargo holds;
  5. Although no cigarette butts were found on site, the safety investigation did not rule out smoking taking place inside the space;
  6. The deflagration may have caused the stevedore to fall from the position where he lifted the grating to where his body was finally located.

Actions taken

The Company took the following safety actions:

  • published an Information Notice to raise awareness on the hazards related to working alone and on the importance of communication in enclosed spaces;
  • reviewed and improved where required the ship’s patrolling during port operations and the supervision of activities by shore personnel on board;
  • disseminated the findings of the internal investigation carried out in terms of Section 9 of the ISM Code to the fleet; and
  • reviewed the ship / shore checklist with the aim of including the requirement for a shore representative in charge of the safety of workers on board, and their safe entry into / exit from enclosed spaces.

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