The Japan Transport Safety Board (JTSB) has released report MA2025-4, detailing a fatal incident that occurred in May 2024 aboard a bulk carrier moored at a Japanese port. The tragedy involved two stevedores who collapsed inside a cargo hold during unloading operations one lost his life and the other sustained serious injuries. The investigation sheds light on critical safety lapses and the urgent need for stricter confined space entry protocols.
The Incident and Its Causes
According to the JTSB report, the stevedores entered the cargo hold without performing atmospheric testing. The hold contained palm kernel shells, an organic cargo that can ferment and produce carbon dioxide while consuming oxygen. Measurements after the incident revealed low oxygen and high CO₂ levels a lethal combination.
The report identified several contributing factors, including inadequate management oversight, lack of proper risk assessment, and failure to follow confined space entry procedures. The crew had assumed the operation was safe since loading and unloading were routine tasks, reflecting a dangerous level of complacency. Moreover, there was a general lack of awareness about the confined space hazards associated with organic cargoes.
Safety Oversights and Recommendations
The JTSB noted that basic confined space entry protocols such as atmospheric testing and controlled access were not implemented. The absence of a safe system of work, non-compliance with Japanese health and safety regulations, and insufficient training all contributed to the fatal outcome.
In response, the JTSB issued several key safety recommendations:
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Mandatory atmospheric testing before any entry into cargo holds, especially when handling organic materials.
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Enhanced training for stevedores and supervisors on confined space entry and related hazards.
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Development of cargo risk profiling guidelines to identify and manage high-risk cargo types more effectively.
The JTSB’s findings serve as a sobering reminder of the risks associated with confined spaces on vessels. The incident underscores that even seemingly harmless cargoes can create deadly atmospheres and that strict adherence to safety protocols must never be compromised. The implementation of JTSB’s recommendations could play a crucial role in preventing similar tragedies in the future and reinforcing a safety-first culture within the maritime sector.
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Source: IMCA
