Three contract ‘sweepers’ boarded the oil and chemical tanker Bro Arthur at the Cargill terminal, Hamburg, Germany. They were behaving strangely and smelled of alcohol but allowed to enter the No. 2 cargo hold to ‘sweep’ the remains of a cargo of stearin, a waxy substance typically used in making soaps, candles and cosmetics.
The ship’s chief officer noticed the men’s odd behaviour. The ship’s chief cook and messman noticed both odd behaviour and a smell of alcohol but did not report it to the chief officer. A supercargo who was to direct the sweeping operations noticed the smell of alcohol on the worker’s breath but in Hamburg, very few companies carry out cargo “sweeping”. In the supercargo’s view, obtaining a replacement team would have been very difficult, and there was a commercial responsibility on him to discharge the rest of the cargo as soon as possible.
There was insufficient guidance in the ship’s Safety Management System about the control and management of contractors.
Only two of the men came out of cargo tank two alive.
A postmortem toxicology report identified that the casualty was under the influence of a variety of prescription and illegal drugs which would have caused severe impairment. All the evidence suggests that he fell from the vertical ladder as he lost his hand grip on the slippery surface. He had not been provided with a safety harness or fall arrestor.
Stearin is slippery and the casualty’s glove was contaminated with it. A risk assessment did not identify a potential hazard and the need for a safety harness or fall arrestor.
The atmosphere of the cargo tank was tested correctly for oxygen levels but the equipment used to test for other gases only reached half way down the tank. The supercargo noticed that one of the “sweepers”, who was the subsequent casualty, needed help to descend the angled ladders.
The vessel’s own casualty recovery equipment was too unwieldy
An MAIB investigation found that the mandatory two-monthly dangerous space casualty recovery drills had not been practised for a considerable time.
MAC notes: Very clearly these three workers, given their condition, should not have been allowed onboard. Four people were aware of their condition but did not communicate those concerns between each other. More worrying, though is the fairly obvious lack of effective and realistic safety drills that would have exposed the inadequacy of the available equipment to save lives.
MAIB give the following lessons:
• While there is a clear responsibility for a worker to take reasonable care of his own health and safety, there should be clear guidance in the ship’s safety management system regarding ship’s staff responsibilities for effectively controlling and managing contractors.
• If there is any doubt about the physical or professional ability of a person designated to carry out work, regardless of whether they are crew or a contractor, they should be confronted and, if necessary, the task should be aborted.
• Risk assessments need to be thorough if they are to be of use in identifying the most appropriate control measures. When working at height, including entering or exiting cargo tanks, due consideration should be given to the use of safety harnesses or fall arrestors.
• Crew should be equipped with correct atmosphere sampling equipment and be fully trained in its use and interpretation of results. Equipment needs to reach to the bottom of a tank.
• The crew had not been properly trained in rescue techniques and the ship’s casualty recovery equipment was unsuitable for the task. Lightweight rapid-deployment tripods and quadpods are commercially available and should be considered