Unit 1: Introduction

1.3. Case Study 3

The International Safety Management (ISM) Code, established by the International Maritime Organization (IMO), sets a structured framework to ensure the safe operation of ships and the prevention of marine pollution. Under the Code, ship operators must maintain a Safety Management System (SMS) that includes procedures for the safe entry into enclosed spaces, which are widely recognised as one of the most dangerous environments on board. In this case, the accident occurred on a vessel carrying logs, where the cargo hold presented a hazardous enclosed space. The Code of Safe Working Practices for Merchant Seafarers requires all unattended dangerous spaces to be locked or otherwise secured against entry, and for any access points to be clearly marked as dangerous spaces. The hatch in question was marked only with “Restricted Area Authorized” – a designation that did not meet the Code’s requirement for explicit “Dangerous Space” signage, nor was it secured to prevent entry.

Two stevedores, while engaged in operations on board, approached and entered the cargo hold without authorization from ship officers. The ship management failed to prevent this by ensuring both the physical security of the hatch and the clarity of its hazard markings. With no physical barriers in place and an ambiguous warning sign, the stevedores proceeded inside, unaware or unmindful of the enclosed space risks. The cargo hold, containing logs, was oxygen-deficient and presented an immediate threat to life. Tragically, both stevedores succumbed shortly after entry, with emergency response efforts unable to save them. The sequence revealed both procedural breakdowns and inadequate hazard communication.

The investigation concluded that the accident was the result of two primary failures. Firstly, ship management acted recklessly in not fully complying with the Code of Safe Working Practices, failing to lock or secure the cargo hold access hatch and not marking it with the mandatory “Dangerous Space” warning. Secondly, the two stevedores made a critical procedural error by disregarding shipboard enclosed space entry protocols, entering without authorization or a permit-to-work. The inadequate signage – “Restricted Area Authorized” instead of the required “Dangerous Space” designation – compounded the risk, as it did not clearly communicate the life-threatening hazard inside. These errors collectively created an environment where the fatal entry could occur without intervention.

This tragedy could have been entirely avoided had the shipboard enclosed space entry procedures been followed and enforced. Securing the access hatch, in compliance with the Code, would have physically prevented unauthorized entry. Additionally, correct hazard markings would have provided a clear warning, reinforcing the need for adherence to the permit-to-work system. Proper crew training, frequent safety drills, and vigilant enforcement of SMS procedures would have ensured that both ship crew and visiting workers understood and respected the dangers of enclosed spaces. With these measures in place, the likelihood of recurrence is negligible.