Inadequacies in training and risk awareness, lack of appropriate equipment, and impractical safety rules developed by shore-based personnel, rust and a noisy anchor chain all contributed to the deaths of three seafarers aboard the Viking Islay on 23rd September last year reveals a report released by the UK’s Maritime Accident Investigation Branch.
Robert Ebertowski and Robert O’Brien, were day work seamen aboard the ERRV Viking Islay, managed by Vroon Offshore Services and owned by Viking North Sea Finlay MacFadyen was an 8/12 seaman, he worked the 8 to 12 am and pm watches, on the same vessel. All were very experienced. Viking Islay was servicing the ENSCO 92 rig.
The anchor chain locker was virtually airtight prior to it being opened by Ebertowski and O’Brien. It is estimated that rusting bulkheads and anchor chain had, over time, depleted oxygen to as little as 4 per cent, about a quarter of that needed for the men to stay alive.
Ebertowski and O’Brien were tasked with securing a noisy anchor chain in the starboard anchor chain locker. MacFadyen was on watch on the bridge. Ebertowski entered the chain locker and collapsed almost immediately. O’Brien alerted MacFadyan by VHF radio then went into the locker to rescue Ebertowski and became unconscious almost immediately.
MacFadyen rushed to the chain locker carrying an emergency escape breathing device, EEBD, with 10 minutes air time, presumably to assist one of the victims, and wearing a breathing apparatus, BA. He could not enter the locker with the BA so he abandoned it and used the EEBD instead. At some stage he either removed the EEBD or it was dislodged and, exposed to the atmosphere in the locker, he immediately collapsed. All three were dead when recovered by a team from the ENSCO 92 rig wearing breathing apparatus.
Among the issues raised is that shore-based personnel had banned work in dangerous spaces unless the vessel was in port and attended by appropriate specialists. While the policy made sense to those on shore, says MAIB: “..it did not take account of scenarios that could require crews to enter confined spaces while at sea.” Crew aboard the Viking Islay and other vessels in the Vroom fleet entered anchor chain lockers from time to time to secure noisy anchor chain.
For that reason there was no equipment aboard Viking Islay for safe entry of confined spaces and no means to test whether the atmosphere was oxygen deficient. Without such equipment it is not possible to tell whether the atmosphere can support human life until seafarers start dying.
The policy did not clarify which spaces were to be regarded as dangerous. The MAIB report says: “…the policy was unrealistic and provided the crew with insufficient practical guidance for the conduct of day-to-day operations.”
Vroon’s SMS did not clarify its policy and individual vessels could amend their own risk assessments for confined space entry. There was also a mismatch between risk assessment and equipment actually available onboard.
A toolbox-talk risk identification card system was in place as a safety measure but was regarded onboard as merely an administrative function rather than a safety device and often signed after work was complete rather than before.
Other safety management systems, including audits, failed to identify shortcomings aboard the Viking Islay.
Confined Space Rescue drills were carried out using the ship’s laundry and were not appropriate for entering access ways as small as those to the anchor chain locker and the difficulties did not become apparent until MacFadyen attempted to enter the locker wearing a BA which he subsequently abandoned. Effective drills would have identified the problem and means found to work around.
It is notable that the team from the ENSCO 92 had drilled for such an eventually and were able to enter the anchor chain locker safely and recover the bodies using breathing apparatus.
An Emergency Escape Breathing Apparatus, as used by MacFadyen, is just that. It is a one-way ticket. He may have assumed that 10 minutes would be enough to rescue someone, he was courageous in trying to attempt the rescue but was horribly wrong in his assumption.
It is worrying that the Master did not appreciate that the anchor locker was a dangerous or confined space. Says the MAIB report: “..crew members on Viking Islay were found to have mixed perceptions of the hazard posed by the chain locker, and one of the risks faced when entering that compartment. Some were clear that the chain locker was a dangerous space; while some other crew members, including the master, were not aware that the chain locker was a dangerous enclosed/confined space. Some crew members had done similar tasks in similar spaces (both on the Viking Islay and other ships) and admitted that they would have continued to do so had it not been for this accident.”
Indeed, the report goes on to say: “More than one crew member expressed shock and surprise that three men could die simply by entering a chain locker.”
Of course they can, and do. It’s even possible for the victim to remain undiscovered for a year afterwards.
For the families of Robert Ebertowski, Robert O’Brien and Finlay MacFadyen it’s been a lesson at the cost of someone close, yet a lesson that, as MAIB in this case and the Isle of Man investigator whose report was the basis of The Case Of The Silent Assassin, point out has yet to be learned.
Confined Space episodes:
The Case Of The Silent Assassin (also available on video)
The Case Of The Electric Assassin
The Case Of The Acidic Assassin
The Case of The Lethal Lampshade
MAC Articles and Posts:
Enclosed space Entry Deaths – The Shipping Industry’s Shame
Chancing the Chain Locker Assassin
A Grand-Daughter’s Grief
Granny’s Bloomers and Safety In Confined Spaces
Confined Space Casualties – Worse Than Expected
Grinding teeth, staying alive in Enclosed Spaces
Enclose Space Entry – Complacency Cannot Be Allowed To Grow
Headwind Of “Huh?” And Death In Spaces
Enclosed Space – Two Lucky People – The MAIB PE For Panguric II
Marine Safety Forum Flash – Enclosed Space Entry