UK MAIB Investigation: Three seafarer lives lost in cargo hold

The incident 

On 27 June 2022, three unconscious stevedores were recovered from a cargo hold access space on board the Isle of Man registered bulk carrier Berge Mawson at Bunyu Island Anchorage, Indonesia. Despite prompt medical attention by ship and port staff, the three men died.

Berge Mawson was loading a bulk cargo of coal from barges using a floating crane. The coal in cargo hold No.7 was being levelled by a bulldozer when loading was paused and all hatches were closed due to heavy rain. Once the rain stopped, a stevedore made several attempts to gain access to the bulldozer. Unsupervised, the stevedore mistakenly descended into cargo hold No.8 access space where he collapsed. As Berge Mawson’s crew were collecting rescue equipment, two stevedores also collapsed in cargo hold No.8 access space as they attempted to rescue their stricken colleague.

Investigation 

Safety issues directly contributing to the accident that have been addressed or resulted in recommendations

1. The three stevedores entered a cargo access space adjacent to the coal cargo that had a noxious atmosphere deficient in oxygen and high in hydrogen sulphide.
2. It is highly likely that the noxious atmosphere in the cargo access space caused each of the three stevedores to lose consciousness and die.
3. Atmosphere testing was not carried out before entries into cargo holds or cargo access spaces, contrary to international guidelines and Berge Mawson’s procedures. Consequently, personnel were at risk of exposure to an unsafe atmosphere.
4. The stevedores working on board Berge Mawson were ineffectively supervised and their safety was not managed.
5. The access points to Berge Mawson’s enclosed spaces were not secured while the stevedores were working on board, so unauthorized access into cargo hold access spaces was not prevented.
6. The stevedores had little or no understanding of the safety warnings and enclosed space signage. They were unaware of the inherent risk of entering the cargo hold access spaces.
7. The on-board permit to work system was not used for cargo hold access while Berge Mawson was loading cargo. The stevedores were therefore unprotected from the inherent risk associated with enclosed space entry.
8. The Ship-Shore Safety Checklist applied only at the start of cargo loading, and the agreed requirements were neither followed nor promoted safe cargo work on board Berge Mawson.
9. The port authority had not followed international guidelines. Consequently, the stevedores had not received basic safety training, did not have correct PPE, and had no risk assessments to enable them to work safely on board Berge Mawson.
10. Industry guidance on personnel safety during loading operations was not followed at the terminal, resulting in compromised stevedore safety due to the lack of a safe system of work.

Safety issues not directly contributing to the accident that have been addressed or resulted in recommendations

1. The enclosed space entry/rescue drill scenarios practiced on board Berge Mawson did not consider that stevedores might be working on the vessel during a rescue from a cargo hold.
2. The COSWP did not include the possible presence of third parties during an enclosed space entry/rescue.
3. It is likely that a bulk carrier industry initiative that requires ports to implement safety training and an SMS could improve the level of safety for stevedores working on board bulk carriers.

Actions taken

Actions taken by other organisations

Isle of Man Ship Registry has issued Technical Advisory Notice 005-24: Enclosed Space Entry – Gas Detection and CO2 Hazards, highlighting the gas detection requirements and safety management systems for entry into enclosed spaces.

Berge Bulk Maritime Pte. Ltd has:

• Updated its SMS procedure for cargo hold access to include a physical safety barrier within the booby hatch access.
• Revised its training matrix to ensure all ranks receive enclosed space training, incorporating lessons from the accident.
• Enhanced its SMS procedure for cargo hold access, with clear instructions for warning signs and identification markings on enclosed space entry points and safeguards against wrongful entry during ventilation.
• Amended its cargo hold entry checklist to record atmosphere testing before entry.
• Revised its Ship-Shore Safety Checklist to include warnings against unauthorized opening/closing of enclosed spaces; clear procedures; 72-hour checklist validity; and a stevedore familiarisation section with emergency procedures.
• Added a requirement in its cargo operations checklist to monitor Ship-Shore Safety Checklist conditions every watch and ensure compliance with cargo hold entry procedures.

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