The Case Of The Acidic Assassin

 

Oceanic Angel

 

What you don’t know can kill you

Listen to the podcast

His name was Job Deolopez, he was a 47 year old Filipino AB. He’d worked aboard the Panama-flagged bulk dry cargo carrier Oceanic Angel for a year . The task he carried out on 8th August 2007 was one that he knew well. He hadn’t got into trouble before, but in Job’s case the first time was the last time.

The Voyage

Oceanic Angel left Tuticorin, India, at 1300 on 6th August, 2007, in ballast. She was bound for Mistaken Island, Dampier, Western Australia, to take on a cargo of salt. Once clear of Tuticorin, hold cleaning began using a 31 per cent dilute solution of Hydrochloric Acid to remove corrosion from the steelwork that could contaminate the next cargo. Exposure to Hydrochloric Acid fumes can cause dizziness. That’s mentioned in the Material Safety Data Sheet but only the Master knows it exists. Nobody else has seen it.

The seas were rough, with a two to two and a half metre swell. She headed roughly south east under cloudy skies and occasional brief showers, with the seas and swell on her starboard beam inducing a moderate roll.

Since hold cleaning was such a routine activity there were no toolbox talks or job safety assessments. It was assumed that everybody knew what the hazards were and didn’t need reminding.

At 0800 on 8th August, the crew completed cleaning Hold No. 1 and move on to Hold No. 2. After lunch they continued cleaning hold no 2 and when nearly finished, Job and another AB, we’ll call him Anthony, moved on to Hold 3.

They were fairly heavily dressed with wet weather gear over their normal work clothes, sea boots, nitrile rubber gloves, face masks and hard hats and started spraying at around 15.15.

The outside air temperature was 29 degrees.

Working In The Hold

Hold 3 had two access points, one aft served by a ladder with an angled mid-section, called an Australian ladder, the other, forward, by a vertical ladder without safety hoops. There were three platforms, one near the base of the ladder, a second a little less than halfway up and a third almost at the top.

It’s impossible to be sure of every detail of what happened to Job Deolopez but from the available evidence and the conditions at the time it’s most likely it went something like this:

Apart from the lunch break, Job’s been working continuously in hot, humid conditions since 8 o’clock that morning. The hard work’s made harder by the layers of clothing and protective gear he’s wearing. He’s sweating profusely as he works, losing water from his body.

Water in the humid air has taken up some of the hydrochloric acid spray. It isn’t enough to cause a burn, but enough to cause mild irritation.

He’s fatigued because of the ardous conditions. He can’t wait to get out of there.

Job and Anthony spray the aft end of the hold, then spray forward along the port side.

They finish about half the port side at 16.30 when the bosun, who’s on deck controlling the pump for the hydrochloric acid wash, calls down to tell them to leave the hold so the hatch lids can be closed for the night.

Anthony takes the safer ladder aft, but Job is in a hurry, he chooses to use the unguarded vertical ladder forward.

Job’s Ladder

Before he climbs he takes off his hard hat, removes his face mask, then puts the hard hat on his head without fastening the straps and begins climbing. He’s carrying the face mask and possibly holding his breath.

Something happens as he gets near the top platform, nearly 12 metres up. Perhaps he’s feeling dizzy because of the hydrochloric acid, or that and the effects of mild dehydration. His skin is itchy, and he’s struggling to hold his breath. Sweat may have carried hydrochloric acid into his eyes, causing irritation. The face mask he’s carrying interfers with his climbing. He reaches for another rung of the ladder but the sweat inside his glove makes his hand just slip off, or his heavy, clumsy seaboots loose purchase as the ship moves, or his hand slips because the rain showers have made the rungs slippery.

He slips off the ladder, the unfastened hard hat falls from his head and he plummets to the deck headfirst.

There was little chance of Job surviving the fall and he didn’t.

Anthony heard the sound of the fall when he was near the top of his own ladder, turned and saw Job lying on the tank top below, on his side, slumped forward with his face down. Wisely, Anthony used his handheld radio to call for help and exited the tank.

The chief officer, wearing self contained breathing apparatus, climbed into the hold and checked Job for breathing and eye dilation, both were negative and there was a lot of blood from Job’s head. A second crewman wearing emergency escape breathing apparatus entered the tank and Job’s body was lifted out by rope.

The Master called Australia RCC for advice and spoke with the Flying Doctor Service. After getting details, the Flying Doctor Service advised wrapping Job in plastic and placing his body in a freezer.

Don’t Be Freezer Fodder

How do you avoid ending your career, or someone else’s, in a freezer? Make sure your hard hat is properly fitted and chinstraps in place, otherwise you might as well not wear one at all. From the height he fell, Job might still have died even if he’d worn his hard hat correctly, but not doing so turned might into a certainty.

Removing the face mask while still in a hazardous atmosphere was not a good idea, trying to carry it as he climbed was a worse one. If it really was necessary to remove the face mask, it might have been better to find some other way to recover it rather than carry it.

One investigator believes that Job held his breath as he climbed, if so, that was a bad idea, too. The heavy weight of his clothes, his boots, his gloves, means that the effort of the climb up the ladder used up the oxygen in his blood quicker and he’d have been distracted by the growing need to take another breath. He’d have hurried, and that’s when mistakes happen. Having taken off his facemask, of course, he didn’t have much choice.

Climbing a ladder is something we’ve done so often that’s it’s not actually a task any more. The first time we climbed a ladder, maybe to get up a tree or paint the ceiling, we made sure that we held on firmly with one hand before moving the other hand, that one foot was stable before we moved the other. Our task was to get up the ladder safely. After a while, we get so used to climbing the ladder that it’s no longer a task – the task is what we’re going to do once we’re at the top. That’s when accidents happen, when we forget the task that we’re carrying out at that moment.

If Job had focussed on climbing the ladder, rather than getting out of the hold, he might just had climbed more safely.

The ladder was not designed for safety, there were no safety hoops, for instance, to stop someone from falling. It would have been wise to use a safety harness or some sort of fall restraint.

Know Your Enemy

Every chemical used aboard a ship has a Material Safety Data Sheet, MSDS, which outlines the hazards and how to avoid them. The crew aboard Oceanic Angel were probably aware that hydrochloric acid is corrosive, but didn’t know the other effects because the master had kept it to himself – no-one else even knew what an MSDS was.

If you’re doing the job, make sure you know and understand what’s in the relevant MSDS. If you’re giving the job to someone else, make sure both of you know and understand the hazards of the material you’re dealing with.

Check the Safety Management System on your ship and follow the procedures outlined there. It isn’t just another document, it’s there to keep you alive.

Of course, there should be a job safety analysis which involves looking at every aspect of the job and identifying what can go wrong and either removing or lessening the threat. In this case it would have covered the possible effects of exposure to hydrochloric acid and the danger presented by the forward ladder, the hindering effects of wearing multiple layers of clothing in hot, humid conditions and so on.

There should be a Job Safety Analysis for each job carried out on board. It’s something that should be occasionally reviewed and changed if any aspect of the job changes.

A job safety analysis might have identified the danger of climbing the forward ladder when the ship is rolling and how to reduce the danger.

A toolbox talk should be carried out before every job. It covers what the job involves, how it will be done, the personnel and tools needed and, especially, safe working practices. That toolbox talk might have reminded Job about the dangers of climbing an unprotected ladder and to make sure one hand is secure before moving the other, use one limb at a time.

As a seafarer you have a right to working condition that are as safe as they can be but you also have a duty, to yourself, to your family, to your fellow crewmembers, to work safely. Be pro-active: look at the jobs you carry out, get together with other crew members and identify and discuss the hazards and how to deal with them, don’t wait for someone else to tell you.

This is Bob Couttie wishing you safe sailing.

Official ATSB Report

Official Panama Report

  7 Responses to “The Case Of The Acidic Assassin”

  1. […] Maritime Accident Casebook has the next entry in his original series: “The Case Of The Acidic Assassin“. […]

  2. […] the Oceanic – The Case Of The Acidic Assassin – the body of the victim, who’d fallen two dozen metres, was found several feet from his […]

  3. sad incident that could of been prevented.
    Most hard hats are for the protection for bumps and scrapes to the head, but primarily to protect from dropped objects.
    Bob makes good reference to the use of chinstraps
    However V guard type helmets are not best suited for fall from height.
    Climbers helmets that rope techs( absaelers ) use are best suited for working at height, they have a better fix to the head of users.
    They also offer superior side protection in the event of a fall.
    Petzl make the best ones I have seen in use, BP have a safe operating procedure for this (SOP 33) I t makes reference to this issue of helmets for working at Height
    Maybe we should share this knowledge?

  4. After many years of being coached , instructed, trained, I am of the reluctant belief that enforcement is the one of the best ways forward, I say this because we seem to change things after something goes wrong( Reactive)
    This is true even for most issues were we have the answer from other past incidents.

    Self regulation in the form of company procedures is good ; only if applied consistently
    It saddens me that after over 20yrs working for a client like BP, we still saw a massive tragic accident at BP Texas city Refinery, after all the good work of others in the same company had applied it on their sites and platforms.
    What is more tragic is that, it was no accident, it was deliberate, the directive by the top honcho to cut costs was criminal, yet he walked away, free,
    There has to be a consequence, a proportionate consequence
    Until we have this we WILL have some who make decisions with no thought to those who it affects, NOT THEM!!!

    • I share the sense of teeth-grinding frustration. It’s probably fair to say that BP, as a corporate entity, has taken its responsibilities seriously and it is to be hoped that a forceful message is going down though the line-managers. The new ‘corporate manslaughter law’ may have an effect in the UK and on UK-flagged ships. It would be nice to see someone from the corporate side comment on this. As a bit of trivia, ship’s masters and print newspaper and magazine editors bear a similar personal responsibility for their ‘ship’ in most jurisdictions.