Even the most experienced officer might not have identified the area around the P10 cargo tank inboard Butterworth hatch of the 12,249 gt chemical tanker Jo Eik. This confined space in plain sight on an ‘open’ deck led to an AB being overcome by fumes from Crude Sulphate Turpentine then to a chief officer and second AB also being affected while attempting a rescue.
Says Britain’s Marine Accident Investigation Branch: “Some areas on the deck of Jo Eik fell into the category of enclosed spaces as defined by the International Maritime Organization (IMO). This was not recognised by the crew, so the appropriate safety precautions were not taken. There was also a complacent attitude regarding the need for respiratory protection during cargo operations. The requirement was not enforced and this put the crew at risk.”
IMO Resolution A.864(20), adopted in 1997, has the following:
2.1 Enclosed space means a space which has any of the following characteristics:
.1 limited openings for entry and exit;
.2 unfavourable natural ventilation; and
.3 is not designed for continuous worker occupancy
Even though the space around the P10 cargo tank inboard Butterworth hatch was open to the atmosphere the ship’s structure and prevailing wind conditions meant that hazardous heavier-than-air fumes being expelled from the Butterworth hatch during tank cleaning with a portable washing system could gather and not be dispersed.
Of particular note: “Before the AB went down the ladder to shut off the valves supplying hydraulic power to P10 deepwell pump, he noticed a very strong pungent smell. He did not consider the need for respiratory protection because he did not recognise the risks and had not been warned of the cargo hazards. As he descended the ladder, climbed over the deep deck longitudinals and was adjacent to P10 inboard Butterworth hatch, he could no longer smell the vapours. Immediately afterwards he slipped into unconsciousness.”
It is characteristic of these type of toxic fumes that the sense is smell becomes disabled.
Several other issues led to the incident:
The portable washing machine was used because the fixed washing system was unreliable with only seven of the vessel’s 65 Gunclean 7000S fixed tank washing machines working.
The cargo specific MSDS which was passed to the chief officer of Jo Eik in Savannah identified H2S as a constituent part of the CST cargo, and warned of the potentially fatal effects of inhaling the cargo vapours. This important information was not passed on, so no-one involved in dealing with the StS transfer was aware of the true dangers of the cargo; therefore the risk assessments and safety control measures were not based on accurate information. In addition, there were no specific instructions on board Jo Eik for handling H2S cargoes.
A ship to ship transfer scheduled to take place at Bayonne was preceded by a pre-arrival conference but the transfer was delayed for six days and was not reviewed before the transfer at Teesport.
Checklists were not properly used. Says the MAIN report: The SMS on Jo Eik incorporated a comprehensive set of checklists covering all phases of cargo loading, unloading and washing. The use of checklists is long established and helps to ensure that operations can be conducted safely. However, to be effective, each check should be diligently undertaken, and this was not the case prior to, during or post the StS operations.
”It is clear that the discipline of correctly completing the checklists was given
scant attention. Despite all checks being confirmed to be correct the dangers
posed by the presence of H2S were not identified, no one was advised to
wear respiratory protection and only 7 out of 65 fixed washing machines were