Sep 262008

<img style=”margin-left: 5px; margin-right: 5px;” title=”safespace” src=”” alt=”” />MAC makes no apology for bringing such frequent attention to enclosed/confined space incidents. The release of the joint investigation into two fatalities in the forward store of the general cargo ship Sava Lake by Britain’s Marine Investigation Branch and the Division for Investigation of Marine Accidents of Latvia’s Maritime Administration again highlights these avoidable tragedies and the systemic shortfalls of which they are the result.

Sava Lake was carrying steel turnings, a cargo liable to self-heating and spontaneous combustion, reducing oxygen levels through oxidation. In this case the atmosphere in the ship’s single cargo hold was 6 per cent oxygen. Human life requires 20 per cent oxygen. The result is evident in the incident which followed.

The vessel’s document of compliance forbade carrying this cargo but it had done so before. Different terms had been used to describe the cargo in documentation and discussion rather than the appropriate Bulk Cargo, BC, code.

Due to confusion, the ship was carrying a forbidden cargo which produced a hazard atmosphere in the cargo hold.

Some time previously, bellows in the cargo hold ventilation ducts had been cut to allow seawater and cargo residues to drain away. Cutting the bellows create a direct link for oxygen-depleted atmosphere to enter the ship’s forward store.

These ducts were poorly designed and, although not directly stated in the MAIB/Latvia report, it can be questioned as to whether they were fit for purpose.

Normal practice aboard ship meant the there was little natural or forced ventilation functioning in the forward store.

The ship’s SMS system included appropriate procedures and a permit to work system which functioned in space normally considered dangerous, such as the water ballast tanks, but which was not considered to apply to the forward store.

The forward store was not identified as a hazardous space and no precautions were taken regarding entering it, despite the presence close by of a hazardous cargo. No permissions were sought by the two Ukrainian Abs to enter the space and it is not known why they entered it. The speed at which they were overcome by the oxygen depleted atmosphere is evident in that they were found, dead, at the bottom of the ladder.

On discovery of the men, and despite clear indications of hazard, including the odour of the cargo in the hold coming from the access to the forward store, the Chief Officer entered the space and was affected by the lack of oxygen. It is only by good fortune that he survived long enough to exit the space. Had he collapsed, it is almost certain that the watch engineer who was present would also have attempted a rescue and also been overcome.

It is only by luck that there were two rather than four fatalities. As case, after case, after teeth-grinding case shows, such luck is usually absent and would-be rescuers usually become victims.

This is an example of an incident which occurred due to systemic processes: A poorly designed ventilation system installed when the vessel was built led to adaptions that turned the forward store into a potential gas chamber. The adaptions were not considered in relation to their effects on other parts of the ship; confusion over the nature of the cargo led to a cargo being taking on that the ship was not permitted to carry, a cargo that turned the forward store into a killing bottle; the effect of the cargo on neighbouring space was not considered and it was not appreciated that the forward store was now a hazardous space; as a result, no appropriate procedures were in place; those immediately responding to the incident, in particular the Chief Engineer, were not appropriately prepared or trained to deal with such a situation, put their own lives at risk, and the lives of others.

We won’t repeat what we’ve written elsewhere, follow the links below, suffice it to say that such incidents remain both unacceptable and seemingly resilient to solution.

A survey by the Maritime Accident Investigators International Forum shows that from just six administrations covering 15 flag states, few of them covering major tonnage, some 44 deaths and 63 incidents in enclosed/confined spaces have occurred since 1993, a disturbing number of them in spaces not normally considered hazardous, as in the Sava Lake incident. It is self evident, from the relatively small sample available to MAIIF, that the true situation is far, far worse.

This is unacceptable.

Sava Lake Report

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