This incident summary is based on an investigation report detailing a fatal accident involving toxic gas exposure on a bulk carrier during cargo loading operations. The report highlights how unauthorized entry into an enclosed space and inadequate safety controls resulted in multiple fatalities.
What Happened
While at anchor and loading coal from barges using a floating crane, a bulk carrier experienced delays due to weather and barge availability. On the eighth day of operations, routine atmospheric testing identified hazardous conditions in cargo hold No.8, including oxygen deficiency and the presence of flammable and toxic gases.
Later that day, the bulldozer operator was observed entering cargo holds multiple times without authorization. At approximately 1305, the operator was found unresponsive inside cargo hold No.8. Before the ship’s rescue team arrived, two stevedores entered the same hold without protective equipment in an attempt to assist and also collapsed. The rescue team, using breathing apparatus, recovered all three individuals within minutes, but none could be revived.
Why It Happened
A combination of safety breaches and hazardous conditions caused the incident. The primary factor was the unauthorized entry into an oxygen-deficient, toxic environment inside the cargo hold. None of the victims had received enclosed space awareness training, leaving them unaware of the severe risks involved. Access control measures were inadequate, and enforcement of entry restrictions was insufficient to prevent unauthorized access. Inside the hold, hazardous gases such as hydrogen sulfide, methane, and carbon monoxide were present at dangerous levels, alongside critically low oxygen concentrations. Additionally, ineffective scene control during the emergency allowed untrained personnel to enter the hazardous space, which resulted in further casualties.
Actions Taken
The report emphasized the need for stricter access control to enclosed spaces, mandatory training for all personnel (including stevedores), and improved emergency response procedures.
Lessons Learned
- Enforce strict access control to enclosed spaces using physical barriers and formal entry permits.
- Ensure all personnel, including shore-based workers, receive enclosed space entry and hazard awareness training.
- Maintain caution even during routine operations; safe conditions in previous days do not eliminate ongoing risks.
- During emergencies, control the scene to prevent untrained or unequipped personnel from entering hazardous areas.
- Use appropriate personal protective equipment and atmospheric testing before any entry into an enclosed space.
Did you subscribe to our daily Newsletter?
It’s Free Click here to Subscribe!
Source: Nautical Institute
