Jan 012012


Some accidents make one wonder whether Mr. Bean wrote the script. A recent safety alert for the Marine Safety Forum is an example. It could, of course, have been much worse, and did potentially put others in danger.

The MSF safety alert goes thusly, in its own words: “During preparation for tank cleaning onboard a PSV, one of the AB’s fell from the main deck down in starboard methanol tank. The fall height was 4,30 m. The AB was securing the area with blocking (barrier) tape and while moving backwards, he stepped into the tank. The injured person (IP) fractured his femur.

The vessel splanned start tank cleaning later that night, and the deck crew was removing the hatches from the man-holes in the cargo-rail in order to measure the content of oxygen, and ventilation of the tanks below main-deck. In total, 16 hatches were to be opened. After opening each tank, the Chief Officer measured the oxygen, and safety barriers were arranged around each tank. In
addition, a plastic grating was laid over each man-hole.

The job (removing hatches for ventilation before tank-cleaning) was considered as a routine job, and due to that, they agreed that the procedure for Confined and Enclosed Spaces was not applicable for this part of the job.

When starting to arrange safety barriers around tank no 9 stb (starboard methanol tank) with barrier tape, the IP moved slowly backwards. Apparently he had forgotten that he just a few minutes earlier had removed the hatch cover from the tank, and no grating placed over the hole.
He stepped into the open hole, and fell down to the bottom of the tank. The Chief Officer alarmed the rest of the crew, and a person with breathing apparatus was sent down in the tank to measure the O2 content. In the meantime the Captain called for an ambulance. The IP was then examined by the ambulance team, before he was brought to the local hospital.

Investigation Findings – Immediate causes
Immediate cause was that the IP stepped backwards into an open man-hole, and fell from decklevel and 4,3 m down to the bottom of the methanol tank.

Basic causes
 Lack of safety barriers in place. Grating not covering the manhole prior to putting the barrier tape in place.
 Lack of safety awareness. IP walking backwards when putting the barrier tape in place.
 No Risk Assessment or Toolbox talk was carried out before starting the job. The job (removing hatches for ventilation before tank-cleaning) was considered as a routine job. All involved crewmembers were well aware of the procedure for the tank-cleaning job, but they considered this as just a preparation for tank cleaning, and due to that, the procedure was not applicable for their job.
Root cause
 Not effectively controlling identified hazards. Wrong prioritisation of safety barriers.
 Confined space entry procedure was not fully implemented onboard, as a permit to work for removing tank hatches was not issued.
 Supervisor failed to initiate a formal Risk Assessment process for the work.
The IP has fractured his right femur. The IP was hospitalized for 3 days. He will be on sick-leave for another 2-3 months. The vessel crew responded extremely well and managed to recover the injured person effectively and safely from the tank. The rescue equipment was easily available and the vessel crew was well trained in rescue from tanks. Under slightly different circumstances the incident could have resulted in a more severe injury.
Investigation Recommendations and Actions
 Experience transfer internal and external. The experience transfer must address the requirement of formal Risk Assessment and supervisor responsibility for all activities.
 Revision of procedure for “Confined and enclosed spaces”, to clearly address the PTW requirement for preparations for tank work/entrance. I.e. if tanks are to be prepared/ventilated for later inspection or cleaning, a separate PTW shall be issued for the removal of hatches/covers etc.
 Risk Assessment for Tank Entry to be reviewed in Safety Meetings onboard.
 A separate Risk Assessment for removing tank hatches for ventilation to be implemented in the management system.

 All vessels to review the on board arrangements for each tanks wrt. safety measures, e.g. gratings, safe barriers and other relevant arrangements.
 All vessels to prepare a tank rescue plan and ensure relevant rescue equipment is available on board.

Download the safety alert

See also:

Oraness: Fall Injury Due To Unexpected Open Grating

Spirit of Tasmania I Fall: Observing the Obvious In Catwalk Capers

Bulk Carrier Polska Walczaca Fatality: Work At Height + Confined Space

Watch Your Step When Mooring

Bow Cecil – Don’t Forget: You Can Fall From Height In a Confined Space

One In Three Claims Slips, Trips Falls Says UK P&I