Jun 092011

Nothing was learned from the report by New Zealand’s Transport Accident Investigation Commission on two fatalities aboard the TPC Wellington bulker except that lessons are not being learned about the dangers of confined space entry. A chief officer with plentiful experience in the particular cargo loaded, logs, entered a confined space, collapsed, followed by another member of the deck crew. Both died in less than 10 minutes.

Neither the ship’s owner, nor those in command of the vessel, had equipped the crew with the awareness or training to enter the space safely or to be rescued should an incident occur.

The scenario is frustratingly familiar. It is one that will continue to kill seafarers in large numbers until the maritime industry as a whole, from those working on deck to those commanding multi-million dollar enterprises, in the public and private sectors, as well a professional organisations and labour unions come together to make forceful efforts to reduce this unacceptable toll.

In its summary of the report TAIC says: “On the afternoon of 3 May 2010, the bulk log carrier TPC Wellington was loading logs in Port Marsden, Northland. When the chief officer entered a cargo hold that was full of logs that had been loaded at a previous port, he rapidly lost useful consciousness (lost the ability to hold on to the ladder) and fell from the ladder onto the cargo below.

The ship’s bosun had accompanied the chief officer to the cargo hold access and when the chief officer fell he alerted nearby deck crew before leaving to collect rescue equipment. One of the nearby crew members went to the hold access and on seeing the unconscious chief officer below, entered the hold with the intention of rescuing him. He too rapidly lost useful consciousness and fell from the ladder onto the cargo below.

The two crew members lost useful consciousness owing to the combined effects of an oxygen-depleted atmosphere and the likely presence of toxic gases, both consequences of the organic decomposition of the logs in the closed cargo hold. The oxygen levels in the cargo hold were as low as 1% to 3%, which would cause loss of effective consciousness within 3 to 9 seconds, and total unconsciousness very soon afterwards, followed by death within 5 minutes. Both crew members were pronounced dead at the scene after they had been rescued from the hold access.
The dangers of the organic decomposition of logs and other organic cargos in enclosed spaces are well known in the international maritime community, and were documented on board the TPC Wellington, but in spite of this the high risk this posed to the crew had not been identified, no specific training had been given to the crew members to heighten their awareness of the risk, and no emergency drills had been conducted in recent times for rescue from enclosed spaces.

It is noteworthy that the Bosun had warned the Chief Officer against entering the space.

The report adds: “The emergency response by the ship’s crew to the accident was not well co-ordinated, which reduced the possibility of saving the lives of the two men in the cargo hold.

Internationally a disproportionately high number of deaths attributable to entry into enclosed spaces has prompted a review by the International Maritime Organisation of what can be done to improve safety in this area. The Commission has not been able to make any new and meaningful recommendations to address this well known safety issue. The Commission will, however forward this report to the IMO and invite the appropriate committee to note the contents of the report for any future programmes to improve awareness of the dangers associated with entry into enclosed spaces.

Key lessons:

– Enclosed (confined) spaces can kill.
– Never enter an enclosed (confined) space unless you have checked the atmosphere.
– Always follow the correct procedures for entering enclosed (confined) spaces.
– Manuals and written procedures alone will not prevent accidents, but training and audit that ensures they are understood and are followed, probably will.

Hazards presented by log cargoes are well-known, from oxygen-deficient atmospheres to the generation of carbon monoxide, hydrogen sulphide and, in this case, phosphine gas.  Quite simply, those hazards were ignored and even the most basic safety procedures, such as ensuring the immediate availability of rescue equipment were not followed.

Says the report: “The accident sequence started when the chief officer entered an enclosed cargo space without checking that the atmosphere was suitable for entry and without following the appropriate safety precautions. In this case, there was insufficient oxygen in the hold to sustain life for more than a few minutes. The presence of other toxic gases such as CO and H2S would of themselves have been likely to cause similar incapacitation through intoxication.

However, the effects of such severe hypoxia would be supervening in a short time period. With such a rapid onset of loss of useful consciousness, the crew would have been unlikely to recognise the effects of hypoxia in time to self-rescue from the oxygen-depleted area“.

This sort of unsafe situation occurs every day throughout the world.

Further, the report observes: “Having rules, regulations and guidelines does not in itself ensure compliance with them, nor does simply repeating the rules and regulations in on-board documentation ensure compliance. The responsibility for ensuring compliance with legislation and company operating procedures firstly rests with the ship owner or operating company, then with senior staff on board who have the responsibility for ensuring compliance on board, then lastly with the crew who are performing the procedure. It is this chain of responsibility that is espoused in the ISM Code, and if the chain is broken in some way the crew who are most likely to encounter an enclosed space scenario are at higher risk of having an accident”.

What does come firmly from the report is the need for competency assessment to ensure that crew actually understand and are aware of the hazards. Compliance is not enough to ensure safety.

Full report

See also:

The SafeSpace Project

Swedish report on the Saga Spray Incident

Hong Kong Report on Saga Spray

Deadly Wood

Watch Out For Wood