Confined Space Replay: The Case Of The Rose Assassin


Saga Rose

A busy cruise liner in port, a safety management audit, a class society survey and a second bosun who doesn’t notice that his job has changed.

The Silent Assassin goes to work. Again.

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We’ll call him Lito. He was 43 years old and a Filipino. On 11 June, 2008, he was Second Bosun on the passenger liner Saga Rose when it docked at berth 101 in Southampton on Britain’s southern coast.

A week earlier surveyors from the classification society Det Norske Veritas inspected the vessel but three double bottom tanks remained to be examined: Number 5 port inner tank, which was an oily bilge tank, and Numbers 4 and 7 port outer tanks, which were recorded as being permanently filled with ballast. These were scheduled to be looked at when Saga Rose next made a port call in Southampton, 11 June, but on arrival the staff captain expected to empty and refill the 4 and 7 double bottom tanks with fresh water, so only the No 5 outer double bottom tank could be inspected.

Tank layout of Saga Rose

Because port outer tanks 4 and 7 hadn’t been opened for a long time nobody knew for sure what was in them: fresh water, salt water or grit. Before emptying and refilling the staff captain wanted to find out what was in them but sounding pipes for the tanks were blocked. so decided that both tanks would have to opened.

With the safety officer, the staff captain inspected the access to the tanks to assess the risks and decided there were none. The check could be done just with the manhole covers removed. Nobody would have to actually go inside the tanks so they considered that no safe entry permits were needed.

Lito and an AB started work on the manhole covers of the port and starboard No 7 outer tanks just after Saga Rose docked, even though only the port tank was scheduled to be inspected by the DNV surveyor.

Opening the tanks took longer than expected because the manhole bolts were badly rusted but finally they were opened and at 1130 the chief officer, safety officer and the DNV surveyor arrived to inspect the number seven port outer double bottom tank.

The tank was full of water so the safety officer reached in, dipped a finger in the water and tasted it. It was fresh water.

Just after lunch Lito set to securing manhole covers on the opened tanks while two other crewmen opened the covers of number 4 port and starboard outer double-bottom tanks. With that job complete they reported to Lito and told him that there was water in the port tank and grit in the starboard tank.

Meanwhile, the bosun was overseeing the loading and unloading of passenger luggage. One of the crewmen who had opened the number 4 tanks told him there was water in the port tank. The Bosun tried to reach the staff captain by the UHF radio but reception was bad so he used the ship’s telephone instead.

The staff captain asked whether the water in the port tank was fresh or salt and the Bosun went off to find out.

Purifier Room, Saga RoseBy now, at around 1410, Lito was in the purifier room, where the Bosun found him and said that the staff captain wanted to know the status of the water in the port tank. Lito said he would find out by sticking his finger in the water and tasting it.

A lightening hole led from the purifier room to an open cofferdam where the manhole access point to the port tank was located. Lito went into the lightening hole as the bosun went to check on the starboard tank.

entry to the ballast tank

We can’t be exactly sure what happened next but it must have gone something like this:

Looking through the tank access Lito realised that the tank was not full, or even half full as he expected, Even though it was supposed to be a permanent ballast tank it probably had not been full for several years. He climbed through the manhole, down the ladder, stretched out his hand to get a sample of the water to taste, and knew nothing more.

When the bosun returned to the purifier room there was no sign of Lito. He called out but there only an ominous silence

The bosun was too big to crawl through the hole so Paul went through.

The bosun was too big to fit through the small lightening hole so he went to the engine room and found the watchkeeping motorman, another Filipino who was a close friend of Lito’s. We’ll call him Paul. The Bosun wanted him to check whether Lito was still in the tank.

Paul was small enough to pass through the lightening hole and slid into the coffer dam . He looked through the open manhole. Lito lay face up on the bottom of the tank, unconscious, one of his legs between the lower rungs of the ladder.

Immediately, Paul told the bosun, who ordered him out of the cofferdam and the two men went to the engine room. There the Bosun telephoned the officer of the watch on the bridge who raised the alert, notifying a rapid response team by bleeper and instructing the team to go to the Number 4 port tank in the engine room.

To Paul, with his friend in danger, the rescue probably seemed to be taking a long time. He spoke to a mechanic about what he’d seen and the two men decided to attempt a rescue.

Paul climbed down the ladder into the tank as an AB arrived. Lito still wasn’t moving. Paul prepared to lift him, took a deep breath and collapsed over Lito, semi-conscious and confused.

The mechanic and the AB returned to the engine room to wait for help.

The rapid response team arrived with SCBA units and an airline breathing system. The staff captain arrived, too, and told the officer of the watch to alert the ship’s medical team. As it happened, the Saga Lines fleet director of operations was on the bridge and used his cellphone to alert emergency services shoreside.

Meanwhile the ship’s safety officer and staff chief engineer equipped themselves with breathing gear, made their way through the lightening hole and into the cofferdam. The safety officer went down into the tank. Paul was alive, just, but Lito showed no signs of life, his eyes glazed and half-closed, his mouth open.

With the staff chief engineer helping from outside, the safety officer tried to manoeuver Paul out of the tank. Even with a rope around Paul it became clear that there was no way to rescue these two victims quickly. He put SCBA masks on both victims before leaving the tank.

Confused, Paul tried to rip the SCBA mask from his face. The staff chief engineer managed to get a forced air ducting tube over Paul’s head as the safety officer poured water over him head to keep him cool.sagaba

After several minutes, Paul began to respond and the safety officer and staff chief engineer were able to persuade and help him to climb the ladder out of the tank into the cofferdam, through the lightening hole and into the air purifier room where the shore-based emergency teams were waiting.

Shortly before 1600 Lito was pronounced dead. It was not until 1910 that his body could be removed from the tank.

A post mortem showed that he had died because there wasn’t enough oxygen in the tank.

What Killed Lito?

What killed Lito was what wasn’t there – oxygen. It had been three years since the tank was last opened and it wasn’t ventilated enough to mix the atmosphere with fresh air. We need air with around 21 per cent in order to live. Steel in the tank’s structure effectively sucked oxygen out of the air until it reached as low as 8 per cent. That’s not enough to stay alive and just taking one breath, as Paul later did, is enough to incapacitate you.

You can’t see a lack of oxygen which is why every enclosed or confined space must be tested before entry, safety equipment be put in place and a safety watch kept while someone is in the space.

Of course, Lito hadn’t expected to have to go into the tank at all. It was assumed that he’d be able to test the water from the outside, it was a wrong assumption. The nature of the job had suddenly changed from one in which the water would be tested from the outside to one which required entry into an enclosed space.

Lito was well aware of the procedures for entering an enclosed space. He’d followed those procedures before. He did not appreciate that the job had changed. when a job changes, so do the hazards and the risks.

When a job changes, stop, step back, and review what you’re doing.

Assumptions and expectations were also this assassin’s handmaidens. The safety officer found Tank No. 7 to be full of water so, when told by the bosun that outer tank 4 also had water, the staff captain assumed that it was full and the water could be tested from outside the tanks. Both assumptions were wrong, as were the ship’s records for the tanks.

Add the unreliability of the UHF radio and the risk of communications breakdowns increased dramatically.

About one in four maritime incidents involve communications failures.

Be aware of the difference between information and communication.


Why wasn’t the work onboard being monitored by responsible officers? Good question. They were busy, and, ironically, one of the reasons they were busy was because the ship was undergoing a safety management audit.

And the ship’s safety officer was to leave the ship at Southampton and was carryin g out familiarisation of his replacement.

And the DNV tank inspections and safety audit distracted the staff captain.

And the chief officer was, quite properly, resting in preparation for taking his watch later that day.

Add to those the usual busyness of a newly docked ship on a port visit and you have all the ingredients for a systemic safety breakdown.

There were symptoms of such a breakdown on Saga Rose. Two other tanks had been opened up by mistake, and, of course, were closed without further thought.

Error are like cockroaches, mice and termites – where you find one, there will almost certainly be others.

Accident happen not because of one mistake but several that work together to bcreate a tragedy.

If the wrongly-opened tanks had been regarded as a red flag, a reason for a quick review of what was happening, a questioning of ‘do we know what’s going on’, if Lito had treated the mistake regarding the status of the ballast tank as an alarm bell, then prehaps he would still be alive.

When you see one error, look for others. Review safety issues.


A Deadly Rescue

One of the most difficult messages to get across is ‘don’t rush to rescue’. It’s a natural reaction, when a friend or shipmate is in trouble, to throw caution aside and rush in without the proper equipment or training.

Consider this: We do not know whether Lito could have survived, whether he could have been revived. True, when the safety officer, wearing the right gear, entered the tank, Lito showed no signs of life, his chances were marginal, but the safety officer did not have the opportunity to work that margin because of Paul.

Triage is the process of making hard decisions about who lives and who dies. Those who have the best chance of survival get treatment first. It’s a cold reality of saving lives. It’s not a hard decision to make, but it can be a hard decision to live with.

With Lito showing no signs of life and Paul alive but semi-conscious, the safety officer had no choice but to concentrate on saving Paul.

We do not know whether Lito could have been saved and it’s too late to find out.

True, many of us are willing to put our lives on the line to save a friend or shipmate. It’s part of what we are, but if we do that without the equipment or training to keep ourselves alive then we may well be responsible for the death of the person we’re trying to save.

This is Bob Couttie wishing you safe sailing

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