The Republic of the Marshall Islands Maritime Administrator has released an investigation report into the death of a crewmember from tanker TRF Kashima after the sailor and two other crewmembers had entered an enclosed space and fell unconscious.
What happened
On 14 July 2024, the Republic of the Marshall Islands-registered oil/chemical tanker TRF Kashima, managed by Anglo Eastern Shipmanagement (Singapore) PTE. LTD., was underway in the South China Sea en route to the Republic of Singapore, where the ship was due to arrive on the morning of 16 July 2024. Work being done on board included cleaning of the ship’s cargo tanks.
At 1646, either the Pumpman or OS2 reported by radio that the C/O had collapsed inside No. 6 S CT. The Master immediately directed the OOW to sound the general alarm and to make an announcement for crewmembers to proceed to No. 6 S CT for an enclosed space rescue.
The Master and other crewmembers arrived at the No. 6 S CT dome at 1649. They found the access hatch open and saw the C/O lying on the upper platform and the Pumpman lying on the second platform inside the cargo tank. The OS2 could not be seen.
A rescue was conducted in accordance with the ship’s enclosed space rescue plan. By 1705, the C/O, Pumpman, and OS2, who had been found lying under the Pumpman on the second platform, had been removed from the cargo tank. When they were each removed from the cargo tank, all three were unconscious but were breathing and had a pulse, however the OS2’s pulse was weak. Crewmembers started administering CPR and medical oxygen to the OS2 before moving him to the ship’s hospital, where crewmembers continued to administer CPR and medical oxygen. The C/O regained consciousness within a few minutes after being administered medical oxygen before being taken to the ship’s Hospital. The Pumpman remained unconscious after being administered medical oxygen and was also moved to the ship’s Hospital where crewmembers continued administering medical oxygen.
The Master sought shoreside medical advice and then diverted the ship toward the nearest port so that the C/O, Pumpman, and OS2 could be disembarked for medical treatment. By 1750, the Pumpman had regained consciousness but was continuing to have difficulty breathing and, by 1755, the C/O was determined to be in stable condition. The OS2 remained unresponsive and at 2000, crewmembers stopped administering CPR after the shoreside medical doctors determined he was deceased.
TRF Kashima rendezvoused with a SAR vessel shortly before 0300 on 15 July 2024. A rescue team, which included a medical doctor and a police officer embarked the ship. The rescue team members examined the C/O, Pumpman, and OS2 and at 0322 confirmed that the OS2 was deceased. The rescue team, along with the C/O and Pumpman, safely disembarked to the SAR vessel, which immediately proceeded to shore, where the Pumpman was admitted to the hospital for medical treatment.
The marine safety investigation conducted by the Republic of the Marshall Islands Maritime Administrator determined the C/O had entered the No. 6 S CT to take pictures required by the Charterer and that the OS2 and Pumpman entered the cargo tank to aid the C/O after they saw him lying on the upper platform. The entry into the cargo tank by the three crewmembers was not conducted in accordance with the ship’s enclosed space entry procedures and without taking any required precautions. It was also determined that the C/O had previously made multiple entries into the ship’s cargo tanks, also to take pictures required by the Charterer, while cargo tank cleaning operations were conducted on 9–11 and 13–14 July 2024. Evidence of a lack of oversight by the Master, crewmember fatigue, and that records of work and rest hours were not being accurately maintained were also identified.
Lessons learned
The following lessons learned were identified:
- Enclosed spaces should never be entered for any reason, including to assist a fellow crewmember, without implementing established shipboard procedures.
- Masters and other senior officers must place safety above all else, and through both their words and actions, provide a positive example for junior officers and ratings.
- Deviations from established procedures increase the risk of accidents.
Conclusion
Causal factors that contributed to this very serious marine casualty included:
the C/O’s entry of No. 6 S CT and subsequent entry by the OS2 and Pumpman without implementing the Company’s enclosed space entry procedures or otherwise taking necessary precautions;
the lack of oversight by the Master and Company of the cargo tank cleaning operations that were conducted on the ship on 9–11 and 13–14 July 2024;
onboard normalization of deviation from established procedures and requirements during the cargo tank cleaning operations that were conducted on board on 9–11 and 13–14 July 2024 as evidenced by:
- the C/O making multiple entries into the ship’s cargo tanks to take pictures without implementing the Company’s enclosed space entry procedures;
- opening cargo tank access hatches without cargo tanks being gas freed, using cargo tank access to add the citric acid solution to the cargo tanks, and the cargo tank tagging system which was not implemented; and
- the deviation from the Company-approved plan for cleaning the cargo tanks.
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Source: IIMS
