OPTIMISM Training Platform

The incident took place on board a cargo vessel during routine preparations for loading at the next port. The Chief Officer (C/O), tasked with ensuring that the ship’s empty tanks were clean and ready, inspected one of the tanks and found traces of dampness and residue. Determined to have the tank ready in time, he decided to remove the remaining material with the assistance of the bosun and two ordinary seamen (OS), referred to here as OS A and OS B.

The decision to enter the tank was made quickly. No gas freeing was carried out. No checks were performed to assess oxygen levels or detect the presence of hazardous gases. The crew carried neither a portable gas detector nor the required personal protective equipment (PPE). It was a breach of the most fundamental safety protocols for working in enclosed spaces—a high-risk environment known for oxygen depletion and toxic gas accumulation.

As the work began, OS A started feeling drowsy and light-headed, early warning signs of oxygen deficiency. Looking around, he saw OS B lying motionless on the floor at the bottom of the tank. Alarmed, he left the tank to alert the bosun, who in turn reported the situation to the C/O. In the course of the rescue attempt, the C/O himself was exposed to the same hazardous atmosphere. OS B eventually regained consciousness after receiving assistance, but tragically, the C/O did not survive.

The investigation revealed a chain of failures that allowed this fatal accident to occur. First and foremost was non-compliance with enclosed space entry procedures. The C/O and crew bypassed critical safety measures such as atmosphere testing, ventilation, and the use of PPE. The ship’s Safety Management System (SMS) contained policies and procedures for enclosed space entry, yet these were either inadequately enforced or ignored entirely.

The culture on board appeared to prioritise operational efficiency over safety. There was insufficient supervision to challenge unsafe decisions, and the team composition lacked a designated safety watch or competent person to assess the hazards. Knowledge gaps and inadequate training were also evident—particularly regarding the dangers of oxygen depletion and the correct use of gas detection equipment.

This accident was entirely preventable. If the SMS had been strictly followed, gas levels would have been checked before entry, ventilation would have been carried out, and PPE—including breathing apparatus—would have been worn. Crew training should have reinforced the fact that even experienced officers are not immune to the dangers of enclosed spaces. Shipping companies must take proactive steps to provide regular, scenario-based training, carry out unannounced safety drills, and maintain rigorous internal audits to ensure compliance.