OPTIMISM Training Platform

Table 21: Micro Presentation of a Review of an Accident – Review 8

 

Title: An Investigation into Root Causes of Accident – Enclosed Spaces

Accident Investigation Review 8 - Enclosed Spaces

1. Introduction 

In this accident investigation was carried out by a qualified accident investigator employed by an Accident Investigation Agency. 

The investigation aimed to demonstrate the difficulties to establish the root causes of accidents. 

2. Background

The International Safety Management (ISM) Code, adopted by the International Maritime Organization (IMO), establishes a framework for safe operation and management of ships and the prevention of pollution. Shipping companies are required to implement and maintain effective safety management systems that comply with the ISM Code. The accident investigators were responsible for proposing remedies to ensure the accident does not happen again and in the process identify any other contributing root causes.

3. Methodology

The investigation by the accident Investigators involved a comprehensive review of accident using any documents forwarded to them to carry out the investigation according to the Agency rules and practice. The Investigators employed an approach to evaluate the accident and its root causes against the requirements set forth by the Agency.  C4FF reviewed the information available primarily from accident investigation report with a view to find out if ISM can be more effectively implemented or its effectiveness improved.

4. Investigation

Recklessness by the ship management and Mistake by the two Stevedores who did not follow the shipboard enclosed space entry procedures and entered a cargo hold without authorization from ship officers - The access hatch only maintained marking “Restricted Area Authorized”, which did not fully meet the requirement of the Code.

Findings

4.1 Investigation Practice

The Investigation took place in accordance with the Accident Investigation Agency procedures and practice. The Investigators examined various aspect of the accident and SMS Manual containing policies, procedures, and records/documents as well as non-Quality Assurance and Control deficiencies to ensure their findings would stop this accident from happening again. 

4.2 Accident investigator’s Report

It is the required to have the ship crew to be trained on procedures and requirements for entering enclosed space and seek permission to entry such spaces. Markings for restricted areas should be in line with requirements of the ISM code to prevent reoccurrence of the incident in the future.

5. Observations

The investigators' report uncovers a critical Error involving the non-compliance of the Code of Safe Working Practices for Merchant Seafarers. Specifically, the report highlights that the entrances to unattended dangerous spaces on the ship, such as the enclosed cargo hold loaded with logs, were not properly locked or secured against unauthorized entry as required. Additionally, the necessary markings designating these entrances as dangerous spaces were missing. 

6. Comments

The accident investigation report reveals a serious safety lapse in the compliance with the Code of Safe Working Practices for Merchant Seafarers. The failure to properly lock or secure entrances to dangerous spaces, such as the enclosed cargo hold, and the absence of required markings were key factors in the tragic incident. It emphasizes the importance of comprehensive training for ship crew on procedures and requirements for entering enclosed spaces and the necessity of adhering to ISM code regulations. Implementing the recommended safety measures is crucial to prevent similar accidents in the future and ensure the well-being of the crew onboard ships.