Britannia P&I Club released a case study focusing on an incident onboard a bulk carrier nearing the completion of loading corn cargo, which caused two fumigation contractors to asphyxiate and the death of one contractor.
What happened
On 3 December 2021, a 33,000 GT bulk carrier arrived in Chennai, India, to load 53,000 tonnes of yellow corn. Fumigation contractors boarded to install ducting for fumigating the cargo. Loading began that day but was intermittently halted due to rain. By 15 December 2021, cargo hold four was loaded and its hatches and accessways were sealed. Loading continued in other holds as weather allowed.
On 21 December 2021, as loading neared completion, 21 fumigation contractors boarded at 0948. While their equipment was being loaded using the ship’s crane, a team of four contractors prepared to fumigate cargo hold four. At 1212, two workers entered the booby hatch of hold four with gas masks and a phosphine gas detector. Shortly afterwards, worker A emerged onto deck feeling breathless and noticed that worker B had fallen over within the cargo hold. He re-entered to assist.
Other team members, realising the danger, attempted to help but quickly retreated due to breathlessness. One team member then informed the ship’s crew at the gangway. At 1217, the officer of the watch alerted the master, who then called for an enclosed space rescue via the public address system. The chief officer, upon hearing the call, rushed to the booby hatch. Upon seeing the two collapsed workers inside the hold, he donned an emergency escape breathing device (EEBD) and entered the hold, retrieving worker A at 1222. He re-entered (still wearing the EEBD) and, using a rope, retrieved worker B onto the deck.
Both workers were given first aid and oxygen until 1240 when they were transported to a local hospital by car. Worker A was declared dead at 1425, while worker B recovered. Toxicology reports indicated no gaseous poison in the blood or lungs of either worker.
Meanwhile, ship A arrived at the Holme Hook anchorage initiating its anchoring procedures. However, due to adverse weather, the planned bunkering operation was aborted, and the master was advised by the local Vessel Traffic Services (VTS) to anchor at the Hawke anchorage. Before leaving Holme Hook anchorage, the master of ship A noticed his ship had also dragged anchor.
Ship A then proceeded to the Hawke anchorage and anchored at around 23:00. Prior to disembarking, the pilot advised the master to remain vigilant, and to keep the ship’s engine on standby. However, soon after the pilot disembarked, the master ordered to stop the engine and handed over the bridge anchor watch to the second officer without any specific instructions to be alert of the weather situation.
Upon assuming the watch, the second officer went on to complete administrative tasks. At this point, a research and survey ship (ship B) was anchored three cables to the northwest of ship A.
At 02:46, ship A started dragging anchor however, the second officer failed to recognise this until nine minutes later. The second officer notified ship A’s master immediately and the duty engineer was called to start the main engine. The duty able seaman was then directed forward to inspect the anchor cable.
The chief officer took over watch from the second officer at 03:00 and the second officer went down to hasten the engineer. Ship B cautioned ship A on Very High Frequency radio that it was dragging anchor directly towards ship B. Ship A acknowledged the call and informed ship B that they were preparing to start their engine. Thereafter, the bridge watchkeeper on ship B also instructed their duty engineer to start the main engine and informed the master of the situation. Humber VTS also transmitted a warning to both ships and enquired on their current engine readiness situation.
Despite ship A’s attempts to start the main engine and utilising its bow thruster for avoidance, the collision occurred at 03:12, with ship A’s stern colliding with ship B’s bow.
Following the collision, ship A managed to start its main engine. However, the vessels remained entangled due to ship B’s anchor chain and attempts to disentangle were complicated by wind and tidal forces, causing the entangled vessels to drift towards Ship C, anchored nearby.
Ship C was advised by the VTS to weigh its anchor as soon as it became apparent the two ships were unable to arrest their ship’s drift. The master of ship C immediately engaged astern propulsion but shortly afterwards, at 03:20, ship A’s port quarter collided with ship C’s bow.
Britannia commentary on incident
The investigation and case study identified several contributing factors and lessons learned. These are based on the information available in the investigation report and are not intended to apportion blame on the individuals or company involved.
As per Section 10.5 of Resolution A.1050(27), grain cargoes (e.g. corn) can cause oxygen depletion. Corn kernels absorb oxygen and excrete carbon dioxide, which can cause oxygen depletion in a cargo hold that is closed for a long time. The Occupational Safety and Health Administration (OSHA) considers any atmosphere with an oxygen content below 19.5% by volume to be oxygen-deficient and immediately dangerous to life or health. After the incident, tests of the atmosphere in cargo hold 4 showed an oxygen content of 2.6% by volume.
Unauthorised entry into cargo hold
The cargo hold had been shut for six days, and the oxygen in the hold had been depleted by the corn cargo. Therefore, the cargo hold should have been considered an enclosed space. The involved parties did not recognise the danger of the cargo hold, loaded with grain and closed for a long time, so they did not consider it an enclosed space. Entry into an enclosed space should only occur after the ship’s master authorises it and completes the entry permit system. Although the booby hatch for accessing the hold could be locked to prevent unauthorised entry, it was not locked, possibly because the final loading was incomplete, and they did not anticipate oxygen depletion or unauthorised entry. Since 21 fumigation contractors boarded the ship, the crew could not monitor every action of the contractors.
Impulsive rescue
Enclosed space incidents regularly involve a person entering or re-entering a dangerous space to rescue a fallen colleague and then subsequently becoming unwell and also requiring rescue. Worker A’s attempt to help his colleague cost him his life. The chief officer’s action to rescue contractors was brave, and he managed to save the life of one worker, but he jeopardised his own safety. As per paragraph 8.5 of Resolution A.1050(27), ‘only properly trained and equipped personnel should perform rescue operations in enclosed spaces.’ The chief officer was not properly equipped to enter the space for rescue as the EEBD worn by him supplies only 10-15 minutes of air and is designed to be used for escape from a compartment with a hazardous atmosphere. It should not be used for fighting fires, entering oxygen-deficient voids or tanks, or worn by firefighters. Instead, a self-contained breathing apparatus (SCBA) should be used.
Equipment and training for fumigation contractors
The fumigator’s unauthorised entry into the cargo hold suggests they were not trained on the hazards of cargo holds and general conduct on board. Due to the nature of their work, fumigators should have been trained on the dangers of oxygen deficiency and the presence of other toxic gases that can be present in cargo holds. External visitors should not have entered any cargo space or other space on board without authorisation from the ship’s crew. They should ensure that the atmosphere is tested, safe to enter, and that all necessary precautions are in place. The contractors were carrying a phosphine detector and a gas mask, anticipating hazards relating to phosphine; however, all contractors tasked with entering the cargo hold to set up fumigation arrangements should have been provided with a personal multi-gas detector. This would have enabled them to swiftly identify the lack of oxygen in the hold and exit quickly.
Enclosed space training and drill
The circumstances that led to this incident and the shortcomings in the rescue operation highlight the need for continuous and ongoing training on enclosed space entry, emphasising the points from IMO ‘Resolution A.1050(27).’ SOLAS Ch III regulation 19 states, ‘crew members with enclosed space entry or rescue responsibilities shall participate in an enclosed space entry and rescue drill to be held on board the ship at least once every two months.’ Regular enclosed space rescue drills should be conducted in a safe and realistic manner. The master should conduct drills in all enclosed spaces on the ship to practice and address the specific procedures and equipment needed for each space.
Conclusion
Enclosed space-related accidents on board ships are mostly caused by insufficient knowledge or disregard for necessary precautions, rather than a lack of guidance. Shortcomings in the attempt to rescue and the use of improper equipment highlight the need for more awareness, training, and drills. When a large number of shore workers board, it is difficult for the ship’s crew to monitor all their actions. However, this should be discussed with the person in charge of the shore workers, and a system should be agreed upon for control of work. Access control to all dangerous spaces on board is paramount. In an emergency rescue, the atmosphere of an enclosed space should be considered unsafe unless confirmed otherwise, and proper procedures should be followed. Rescue operations should only be conducted by properly trained and equipped personnel.
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Source: Britannia P&I Club
