May 012011

This tragic report comes from a concerned MAC subscriber and is a good case to use when discussing confined spaces with crew. Break it down into events and ask “what would you do in this situation”, the determined brother-in-law being a situation that you may havee to deal with.

M/V Melanie is a small inter island containership that is worked in the non-union section of the port of Miami FL USA using a gantry or shore crane. She is worked in the Caribbean using ship’s gear for the most part.

A 20′ ISO standard container of liquefied air-conditioning propellant came to the gate.  The tank was venting gas through an obviously altered relief valve.
The driver explained to the clerk at the gate, who had no HAZMAT training, that the venting was normal and harmless.  As the tank had the proper label and the documentation showed that it was a non-hazardous “green” gas in liquid form the clerk accepted the container into the terminal.

O2 shows as a “green” gas when it is clearly an “Oxidizer”.  Any gas that can displace O2 due to its density should have a “hazardous” label and be “on deck stowage only”.

The tank was placed on the ground in the terminal for three days awaiting the vessel.  It vented the entire time and none of the untrained employees
thought anything of it.

When the vessel arrived the tank was pre-stowed below deck on the bottom tier of the #1 hold.  Due to the sheer of the vessel the bottom tier was only 1 X 20′ container slots wide forward and 3 X20′ slots wide aft, with tiers above widening out to 5 X 40′ containers wide by the top height. Containers could be stowed 3 deep in the hold.

The tank was loaded at night in the position where it was supposed to go at the forward end of the lowest tier, center, 40′ slot which placed the tank at the foot of the access trunk and ladder coming down from the main deck.

At the time of loading an able seaman noticed the tank venting and reported it to the mate on watch as a leaking tank.

The mate located the supercargo and instructed that the tank be removed. After some discussion it was agreed that the tank would be stowed on deck.

The supercargo informed the terminal’s vessel superintendent that the tank had to be discharged.  At this time # 1 hold had just been filled and the gang was moving aft to allow the crew time to close the hatch cover.

The terminal superintendent informed the labor foreman that the tank had to be dug out of the hold.  This operation would involve the removal and replacement of 5 containers plus a substitution for the venting tank.

The terminal superintendent left to perform other duties.

The foreman, it is speculated, decided to climb into the hold and see if he could stop the venting by tightening the relief valve.  He did not know that the valve had been altered.

The venting gas had displaced the O2 in the lower tier in the interval between loading and when the foremen entered the hold.  The man climbed down into and odor free, zero O2 environment, quickly passed out, and was asphyxiated.

The foreman did not tell anyone that he was entering the hold and his going missing was not realized until the supercargo called the terminal superintendent 45 minutes later to ask why the gang was not re-arranging the stowage in # 1 hold.

The superintendent quickly realized that the foreman was nowhere to be found and a search was began.  A crew member shone a torch (flashlight) into the Number One ladder trunk and it reflected off the foreman’s orange safety vest.  The crewman gave the alarm.

Before the terminal superintendent or mate on watch arrived the hatch boss pulled his shirt up over his mouth and nose and descended down the ladder. He was the ranking person at the top of the ladder.  It should be noted here that the space at the bottom of the ladder was very small and was entirely taken-up by body of the foreman.

Before descending the ladder the hatch boss gave orders to begin removing sufficient containers, including the leaking container, to allow access to the bottom of the hatch trunk.

Once at the bottom of the ladder, within seconds the hatch boss was overcome and became unconscious.

The mate and terminal superintendent arrived at the same instant.  This was when local Emergency Medical Services were called using the regional 911 telephone system.

Another man was preparing to climb down the ladder and had to be physically restrained.  He was the brother-in-law of the hatch boss now lying atop the ship foreman.

There was both bottled O2 on the vessel as well as two self contained breathing apparatus.  In the excitement the mate did not send for these items.  The mate also did not have the captain or chief officer awakened.

The land crane started to discharge the containers to get to the men while the mate and terminal superintendent ordered and essentially pushed the longshoremen back to the gangway area.  This area was well aft by the ship’s accommodation.

With this done they waited for the responding fire department and medical crew from shore.  Sirens could be heard.  They also planned to enter the hold using the crane’s manlift basket if the containers could be cleared.

In the midst of setting up the manlift basket the hatch boss’ brother-in-law somehow was able to circle aft around the accommodation and sneak back forward on the offshore side of the main deck.

He entered the hold and became the third man to perish.  This man died as the leaking container was removed.  All three deceased tumbled into the space the container had occupied.

Everyone was deeply shocked to see this third man tumble out.

As soon as the leaking container was removed the man lift basket was affixed
to the crane.  Also at this time the fire department and emergency medical services arrived.  Firemen wearing breathing apparatus entered the hold by the crane basket.

The three victims were all placed in the basket, filling it, by firemen in breathing apparatus.  The basket was brought to then dock where efforts to revive all three proved fruitless.  Two men left young children.

The Coast Guard and US Occupational Safety and Health Departments listed many issues:

  • No HAZMAT training for anyone involved.
  • No maritime background of anyone on the terminal.
  • No procedures for the receiving, terminal storage, or loading of venting tanks.
  • No emergency action plan (ship and terminal)
  • No basic safety training (evidenced by the fatal acts of two supervisors)
  • No first aid trained individual on the terminal Improper stowage.
  • No confined space rescue plan or equipment available.
  • No confined space training.
  • Improper use of personal protective equipment (the shirt pulled over the
    mouth and nose).
  • Improper documentation (bill of lading and dock receipt)
  • No terminal safety program. In the US if the supervisors break the rules it means that there is no effective program.

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