And Then There's Coconut Killer

 casualties, enclosed space, fatality  Comments Off on And Then There's Coconut Killer
Jul 172008

Checked the oxygen? Good. Checked for explosive atmosphere? Good. But it might still not be enough. Back in 2001 the Britannia P&I Club’s Riskwatch published a cautionary tale of a ship carrying Indonesian crude coconut oil from Kuala Enok to Rotterdam.

A heater in the tank of coconut oil ensured that the cargo remained liquid n the colder climes of Europe.

After berthing and discharge six men went into one of the tanks to clean residue from the pump suction. Oxygen levels were found to be acceptable and tested with an explosimeter showed that the atmosphere was below the lower explosive limit, LEL, so the tank was ‘safe’ and the men started work.

After a while one of the men seemed to be having a problem. Four men managed to get out of the tank, two others collapsed, one of whom later died.

During the voyage from Indonesia the heating of the coconut oil led to the evolution of carbon monoxide gas, something not realised before. indeed, a chemist in the investigation was sceptical until laboratory tests revealed that heated vegetable oils could, indeed, produce carbon monoxide.

The levels in the tank were more than 1,000 parts per million, dangerously high. Carbon Monoxide is deadly because it replaced oxygen in the blood. Think of it as chemical suffocation.

In a previous post we talked of dangerous videos that suggested that it was okay to go into atmospheres of less than 21 per cent (actually, 21.9 per cent). We warned that if the oxygen level was low it was because something was displacing the oxygen and that something might be hazardous. In this case, carbon monoxide was a little more than 0.1 per cent.

New Podcast: The Case Of The Rusty Assassin – The Viking Islay Tragedy

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Jul 152008

New Podcast: The Case Of The Rusty Assassin

The Viking Islay Tragedy

Three men lay dead in the anchor locker.
What they’d need to stay alive was everywhere around them
except in the one place it could have saved them:
The air they breathed


Viking Islay: Deadly Systemic Inadequacies Revealed

 confined space, enclosed space, fatality, SafeSpace, Viking Islay, Vroon  Comments Off on Viking Islay: Deadly Systemic Inadequacies Revealed
Jul 092008

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: “ 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

Saga Rose Death: Another Candle To Light

 accident reporting, enclosed space, MAIB  Comments Off on Saga Rose Death: Another Candle To Light
Jun 132008

Five investigators from the UK’s Maritime Accident Investigation Branch spent the night of Wednesday June 11 aboard the cruise ship Saga Rose, docked at Southampton, inquiring into the death of a 43 year old second bosun, one of two Filipino crewmen trapped in one of the vessel’s ballast tanks. The ship’s 300-strong crew is devastated, they’ve been together for 10 years, they’ve lost one of their own, and yet another family in the Philippines will lit yet another candle in a cemetary at All Soul’s in November.

It will probably be many months before the MAIB’s final report is released, it would be unwise to speculate on details, but already it is evident that safe entry procedures were not followed.

Initially, the two men were thought missing and a search was conducted, which eventually found them trapped inside a ballast tank. One man had breathing apparatus and survived, the other died almost certainly because of lack of oxygen in the ballast tank atmosphere.
That reveals that no safety watch was kept at the access to the tank with a means of communication in case something went wrong.
The tank was not adequately ventilated prior to entry. If it had been, the crewman would probably not have died.
It seems unlikely that the atmosphere in the tank was tested prior to entry or during the inspection they were apparently carrying out.

None of the ship’s officers appear to have known that the two men were in the tank. If proper procedures had been followed they would have known and been able to monitor events.

Because procedures were not followed a man is dead, a close-knit crew is distraught, a family is grieving.

The unnerving consistency with which these events occur is unacceptable and indicates something deeply amiss in training, competency and safety behaviour throught the industry.

Maritime Safety News Today – 12th June 2008

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Jun 122008

Major search and rescue operation launched on cruise ship
Southern Daily Echo – Southampton,England,UK
Two crew members of the cruise ship Saga Rose are reportedly “missing” in the ballast area of the ship’s hull. Teams from St Mary’s fire station as well as

Pirates attack Aussie-bound cattle ship – Australia
By Warwick Stanley A CATTLE transport ship bound for Western Australia came under two hours of heavy fire from pirates just hours after sailing from

Again, Gunmen Attack Addax Vessel
This Day (subscription) – Apapa,Lagos,Nigeria
Immediately the hoodlums sighted the vessel, they allegedly allowed it to sail within their weapons range before opening fire on it. The vessel was under

Blaze leaves man fighting for his life
this is – Winchester,England,UK
By Chris Yandell A MAN was fighting for his life in hospital last night after he was burned in a fire aboard a former sail training vessel.

Comoran ship catches fire – Paris,France
A Comoran ship, Bushralher, caught fire at the port of Moroni on Monday, but firemen promptly brought it under control, the gendarmerie brigade at the port

NGA – special warning re operations off Nicaragua

The US National Geospatial-Intelligence Agency (NGA) issued a Special Warning that Nicaragua is strictly enforcing its waters on both the Pacific and Caribbean sides.  Small vessels, such as yachts and fishing vessels, are particularly subject to being stopped and inspected.  Vessels suspected of operations inconsistent with Nicaraguan law are subject to detention.

Posted 06/11/08 at 10:29 AM

Lloyd’s Register has developed a voluntary assessment program, designed to support the practical implementation of the forthcoming ILO Maritime Labour Convention (MLC, 2006) on new and existing ships.Not yet mandatory, the MLC, a significant development in international shipping described as a ‘bill of rights’ for maritime labor,

Accurate reporting
By Richard Meade
Addressing precisely this issue last week, IMO secretary-general Efthimios Mitropoulos issued a not so subtle reminder to member governments on the importance of their casualty investigation duties.

Valero agrees to pay penalty for 2006 oil spill – Midland,TX,USA
of the Clean Water Act. The June 1, 2006 accident involved about 3400 barrels – or nearly 143000 gallons – of oil that leaked into the ship channel.

WCO – impact of US 100% container scanning requirement

The World Customs Organization (WCO) issued a press release stating that a study of the global impact of the US 100% maritime container scanning legislation indicates that global trade, shipping, port, and Customs administrations would have to undergo pivotal and costly changes to accommodate such a requirement.  WCO members are largely of the opinion that container scanning is only one element of a more comprehensive intelligence process based on risk management and the sharing of information.

May 262008

In The Case Of The Electric Assassin I suggested that, if you’re going to enter an enclosed space without the proper equipment or precautions then dig two graves, one for yourself and one for the poor sods who’ll try and rescue you. That recommendations was validated by two virtually identical incidents, several thousand miles apart, within just 24 hours.

There’ll be little wonder that maritime casualty investigators grind their teeth in frustration when these enclosed space incidents occur, partly because they keep happening and partly because little is done to stop them happening.

On 20th May this year at Port Everglades a dock superviser, Hyman Sooknanan, entered an enclosed space aboard Madelaine, a 110 metre cargo ship, to investigate a suspected leak of argon from a container gas tank.

He didn’t return, nor did he respond to radio calls. Worried, a second docker, James Cason, wrapped a shirt around his face and entered the space to find out what happened to Sooknanan. He didn’t reappear either. Now a third man, Rene Robert Duterte did the same, with the same result.

In 20 minutes, three men were dead, the last two because they’d tried the help the first.

Argon isn’t chemically poisonous but it does displace oxygen in the air, asphyxiating the victim. It gets you almost without warning and wrapping something around your face isn’t going to stop it happening when there’s no oxygen in the atmosphere to breathe.

On 22nd May in Chongming Dadong Shipping Yard, Shanghai, 21st May in Florida, three Filipino seafarers died and 10 were injured, all from a single vessel, the Hakone, in an incident involving leakage of another suffocating gas, carbon dioxide.

As research by Don Sheetz of the Vanuatu Registry for the Maritime Accident Investigators International Forum shows, these were not isolated incidents. In just three months, Sheetz gathered reports on 120 enclosed space incidents with 228 from just 16 flag registries over a period of about 10 years. With figures from the largest registries still not available, some estimate that the true figure may be as high as 1,000 deaths.

Says Sheetz:”We are concerned that this is just the tip of the iceberg and will ultimately become a larger issue than, say, dropping of lifeboats.

The numbers are simply too high, and the incidents too frequent, to dismiss as unfortunate one-offs. It is unsatisfactory to conclude that it was the victims’ faults, because they, and their would-be rescuers, didn’t follow procedures, and close the book

What they show is that there is something deeply wrong with the system and with the industry that allows deaths on such a scale without a qualm. If there were qualms, there would be a solid drive to find a solution and there isn’t one. It’s a record of which the industry should be ashamed.

It is self-evident that training is inadequate in the first place and the necessary drills are not being carried out onboard or alongside in the procedures for safe entry and rescue from confined spaces.

Training will be ineffective unless backed-up by a positive management level commitment to managing safety, assessing competence onboard and developing a safety culture from company head-office to the master to the deputy chief assist cook’s chief assistant deputy. All too often putting a safety management system on a ship is little more than a butt-covering exercise to avoid liability when the worse happens.

Let’s look at it another way. If the estimates of deaths in enclosed spaces are reasonably accurate, and there’s every reason to believe they are, then enough lives have been lost to put crew on 40 to 50 cargo ships. Currently the industry is going through paroxysms of recruitment to fulfill manning needs of the future, maybe they should spend just a little more time trying to keep alive the ones they’ve already got.