Unit 6: Additional Micro Analysis of Accident Reports – Reviews 11 to 20

6.2 An Investigation into Root Causes of Accident – Enclosed Spaces

Reference Number

RZ/JU1

Description

A bulk carrier was at anchor when an ordinary seafarer collapsed in a cargo hold containing soya beans. The alarm was raised and the chief officer who entered to help also collapsed. Both the chief officer and ordinary seafarer were recovered from the hold by a team wearing breathing apparatus. Both were transferred to hospital ashore where the chief officer made a full recovery. The ordinary seafarer died as a result of exposure to lethal levels of phosphine gas.

Key Root Causes

ISM non-conformity (The cargo holds were identified as “enclosed spaces” but enclosed space procedures were not followed). It was assumed the space was safe, and PPE was not required, as the vessel was in possession of a gas free certificate hence Phosphine gas detection equipment which was onboard was not considered necessary. The vessel’s multi-gas meter used for “enclosed space” entry did not have phosphine sensors. No risk assessment form S-18 nor SM-15-01/02 Enclosed spaces (General) were completed as part of the management of risk protocols).

Management fault (Inadequate procedures and inadequate training, safety culture issues).

Casualties

I fatality and 1 injury

Action-Recommendation

Reviewed and amended procedures regarding enclosed and dangerous spaces and circulated and implemented a series of additional safety training on working in enclosed or dangerous spaces for all persons prior to joining vessels. Training on safety culture onboard. Implemented a company policy on the donning of Breathing Apparatus when entering holds where fumigant has been present.   Reviewed IMO recommendations on safe use of pesticides on ships and provided new forms for the appointment of responsible person in charge. The Flag State should also consider a review of the effectiveness of the ISM audits carried out by ROs pertaining to the adequacy of risk assessments for the safe carriage of fumigated cargoes.

Would it happen again

No if there was discussion around the assessment for potential hazards, risks or testing the spaces prior to entry. Gas free certification for the type of cargo needs reassessment.  

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

Accident Investigation Review 12 - 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

The bulk carrier was at port when an ordinary seafarer collapsed in a cargo hold containing soya beans. The alarm was raised and the chief officer who entered to help also collapsed. Both the chief officer and ordinary seafarer were recovered from the hold by a team wearing breathing apparatus. Both were transferred to hospital ashore where the chief officer made a full recovery. The ordinary seafarer died as a result of exposure to lethal levels of phosphine gas.

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

Procedures regarding enclosed and dangerous spaces have been reviewed and amended. Additional safety training on working in enclosed or dangerous spaces have been implemented for all the personnel before joining the vessel as well as a training on safety culture onboard. Moreover, company policy has been implemented on the donning of breathing apparatus when entering holds with presence of chemical pesticides. To align with the International Maritime Organization (IMO) recommendations, new forms have been provided for the appointment of the person in charge (PC). It is recommended to The Flag State to review the effectiveness of the ISM audits carried out by ROs with a focus on assessing the adequacy of risk assessments for the safe carriage of fumigated cargoes.

5. Observations 

The investigators' review uncovers a significant mistake and recklessness in handling enclosed spaces. Although the cargo holds were identified as "enclosed spaces," proper procedures were not followed. Assumptions were made about the space's safety due to the possession of a gas-free certificate, and personal protective equipment (PPE) was not considered necessary. However, the vessel lacked phosphine gas detection equipment, which was crucial for ensuring safety. Moreover, essential risk assessment protocols, such as forms S-18 and SM-15-01/02 for enclosed spaces, were not completed.

6. Comments

The accident investigation report identifies mishandling of enclosed spaces and the absence of safety precautions as the root causes of the incident. The report recommends revised procedures, enhanced safety training, and improved risk assessment protocols to prevent similar accidents as discussion around the assessment for potential hazards, risks or testing the spaces prior to entry could avoid the incident from occurring. The company has promptly taken essential actions, aligned with IMO recommendations. Further, the report highlights the need for the Flag State to review ISM audits' effectiveness, particularly in assessing risk assessments for safe cargo carriage.