OPTIMISM Training Platform

The International Safety Management (ISM) Code, adopted by the International Maritime Organization (IMO), provides a structured framework to ensure safe ship operation and protect personnel and the environment. It requires shipping companies to implement and maintain effective safety management systems, including procedures for safe entry into enclosed spaces. In this case, a bulk carrier was carrying soya beans—a fumigated cargo that can emit toxic gases such as phosphine. Despite the presence of a gas-free certificate, the vessel’s enclosed space entry procedures and risk assessments were incomplete or inadequately applied, particularly concerning the detection of phosphine gas, which was not monitored by the onboard gas detection equipment.

While the bulk carrier was at anchor, an ordinary seafarer entered the cargo hold containing soya beans and collapsed due to exposure to lethal phosphine gas levels. Upon hearing the alarm, the chief officer entered the hold to assist but also collapsed. Both individuals were subsequently rescued by a team wearing breathing apparatus and transferred to shore-based medical care. The chief officer recovered fully, but the ordinary seafarer succumbed to the toxic exposure. The investigation revealed that procedures for enclosed space entry were not followed, and essential risk assessments and proper gas detection were missing prior to entry.

The primary root cause was procedural error and unsafe assumptions. Although the cargo holds were identified as enclosed spaces, the mandatory enclosed space entry procedures were not followed. The crew assumed the holds were safe because the vessel possessed a gas-free certificate, leading to the omission of phosphine gas detection. The vessel’s multi-gas meter lacked sensors for phosphine, a critical oversight given the fumigated nature of the cargo. Furthermore, key risk assessment forms (S-18 and SM-15-01/02) were not completed as part of the risk management process. These failures in risk assessment, hazard identification, and monitoring created conditions that led to the fatal exposure.

This accident was preventable. Strict adherence to enclosed space procedures, including comprehensive risk assessments and verification of the presence of hazardous gases, would have mitigated the risk. Specifically, carrying and using appropriate gas detection equipment with phosphine sensors prior to entry is essential for fumigated cargoes. The gas-free certificate should be reassessed to reflect the specific hazards associated with fumigated cargoes. Company policies on mandatory use of breathing apparatus when entering holds where pesticides have been applied were subsequently implemented. Enhanced training on enclosed space risks and safety culture for all personnel before joining vessels is critical to prevent recurrence. Additionally, improved oversight of risk assessments through ISM audits by Flag State authorities and Recognized Organizations will further reduce such incidents.

The patterns of procedural neglect, inadequate risk assessments, and poor safety culture identified in the preceding case studies serve as the direct blueprint for VR Emergency @ Sea which is utilised in this chapter. The hard-learned lessons are transformed into a fully functional and immersive VR training application. The ultimate goal is to deliver a high-fidelity tool that enhances the preparedness of maritime professionals for emergencies in high-risk environments, such as enclosed spaces, engine rooms, and cargo holds, ultimately contributing to improved safety in maritime operations.