In 2019, two seafarers died and two were seriously injured in an enclosed space entry incident on an RMI-registered bulk carrier. With this respect, the RMI reiterated once again the need to maintain vigilance with regards to enclosed space entry and rescue training.

The cases were:

Cadet’s death in enclosed space associated with failure to identify hazard

The incident

The Republic of the Marshall Islands-registered bulk carrier LA DONNA I, managed by FML Ship Management Ltd., arrived in the Port of Paradip, India on 12 August 2018 to discharge a cargo of 61,557 metric tons (MT) of coal. At approximately 17301 on 14 August 2018, during cargo discharge operations, the Deck Cadet was reported to have been incapacitated due to oxygen deficient conditions in the enclosed Australian ladder trunk of Cargo Hold No. 6.

In response to the incident, the Chief Officer (C/O) entered the space to assist the Deck Cadet and subsequently lost consciousness.

The Deck Cadet and C/O were rescued from Cargo Hold No. 6 by the ship’s crew.

The C/O regained consciousness and recovered, however, the Deck Cadet did not survive.

 Probable causes

The RMI marine safety investigation concluded that the causal factors that contributed to the Deck Cadet’s loss of life include:

• asphyxiation due to insufficient oxygen levels within the space where he was working;
• the C/O’s failure to properly identify the Australian ladder trunk as an enclosed space when he entered, and subsequently directed the Deck Cadet to enter, the cargo holds;
• the failure of the C/O to identify the potential hazards despite the warning statement present on each access hatch cover;
• the failure of the Deck Cadet to follow the OS’s advice that a self-contained breathing apparatus (SCBA) should be used when entering the enclosed trunk;
• the failure of the Deck Cadet to identify the potential hazards despite the warning statement present on each access hatch cover; and
• the C/O’s failure to follow and enforce enclosed space entry and rescue procedures.

Additional causal factors which likely contributed to the Deck Cadet’s loss of life include:

• lack of familiarity with ship design characteristics in relation to design of the enclosed Australian ladders within the cargo holds;
• inadequate onboard implementation of pre-task risk identification, assessment, and control procedures;
• inadequate supervision of trainee crew members during high-risk or non-routine work assignments;
• ineffective communication amongst crew members related to the transfer of duties and responsibilities;
• delays in effecting a properly organized rescue of the Deck Cadet due to the C/O attempting a rescue alone and without raising the general alarm; and
• ineffective onboard implementation of “Stop the Work” policy when crew members observed unsafe actions or conditions

The Administrator has taken the following action:

1. Issued Marine Safety Advisory (MSA) 23-18 on 30 August 2018 reporting preliminary findings based on the Administrator’s marine safety investigation of the enclosed space entry incident that occurred on board LA DONNA I and ones that occurred on board other Republic of the Marshall Islands-registered ships. The MSA also included recommendations for ship managers and Masters regarding enclosed space entry and enclosed space rescue procedures.

 Recommendations

The following recommendations by RMI are based on the above conclusions and in consideration of the actions taken:

1. It is recommended that the Company review its “Stop the Work” policy and take positive steps to encourage appropriate use of this policy onboard managed ships via additional crew training, crew seminars, and other appropriate measures. It is further recommended that this incident be used as a practical case study in such training.
2. Due to the similarity of this incident with other recent incidents occurring on Republic of the Marshall Islands-registered ships, the previous safety recommendation for the Administrator related to enclosed space entry training is reaffirmed.

Fatality in enclosed space

The incident

The Republic of the Marshall Islands-registered oil/chemical tanker LINUS P was cleaning cargo tanks while underway off the west coast of the US on 24 November 2018.

At about 0030, an Able Seafarer Deck (ASD) 1, together with the Pumpman, was supplying fresh water to the No. 2 Port (P) Cargo Tank using a fire hose through the open tank dome.

During this work, he dropped his portable radio into the tank. The Pumpman reported that the ASD1 told him he was going to retrieve the radio from the tank after getting a flashlight.

The Pumpman reported that he tried to stop the ASD1 from entering the tank.

The ASD1 entered the inerted cargo tank to retrieve the radio without following onboard enclosed space entry procedures and the lack of oxygen quickly rendered him unconscious.

During the enclosed space rescue operation, the Second Officer (2/O) and ASD2, lost consciousness when they removed their self-contained breathing apparatus (SCBA) face masks while inside the cargo tank.

As a result, the ASD2 fell from the second platform of the tank access ladder to the tank top. All three individuals were subsequently removed from the tank.

The 2/O and the ASD1 recovered; however, the ASD2 did not survive the injuries sustained from his fall.

 Findings

RMI marine safety investigation concluded that the causal factors that contributed to the death of the ASD2 and the injury to the ASD1 were:

1. failure of the ASD1 to properly secure his radio while working on deck;
2. failure of the Pumpman to take firm actions to “Stop Work” when the ASD1 advised him that he was going to enter the tank;
3. failure of the ASD1 to comply with the Pumpman’s warning;
4. failure of the ASD1 to follow enclosed space entry procedures when he climbed into the No. 2P Cargo Tank to retrieve his radio;
5. failure to follow enclosed space entry procedures when the 2/O entered the tank alone; and
6. failure to follow enclosed space rescue procedures when the 2/O and the ASD2 removed their SCBA masks while inside the enclosed space.

Probable causes

The causal factors that likely contributed to the fatality and injury include:

1. improper decision making by the Chief Officer (C/O) when he directed opening the domes of inerted tanks for cleaning procedures;
2. improper supervision by the Master when he failed to ensure the appropriateness and accuracy of the tank cleaning plan and the risk assessment developed by the less experienced C/O;
3. inadequate onboard implementation of pre-task risk identification, assessment, and control procedures;
4. inefficient organization and execution of the enclosed space rescue procedures;
5. ineffective onboard implementation of “Stop Work” policy when crewmembers observed unsafe actions being taken; 6. ineffective enclosed space entry training; and
6. lack of understanding of nitrogen (N2) inhalation dangers

Recommendations

Following investigation, the RMI provided the following recommendations:

1. The Company incorporate the lessons learned from this casualty into a pre-joining training program, which should also be completed by current crew members to raise awareness.
2. The Company implements a pre-joining training program pertaining to the hazards of N2 and the relevant safe work practices, which should also be completed by current crew members to raise awareness.
3. The Company review, and update as necessary, the process for addressing and disseminating safety recommendations issued by the Administrator.
4. The Administrator considers submitting a proposal to IMO to amend Resolution A.1050(27) to amend the emergency response section in order to better detail the fundamental actions that should be taken during an enclosed space rescue in order to ensure a safe and effective response.

The Republic of Marshall Islands (RMI) with MSA 23-20 issued on 24th June 2020, reminds all managers of RMI-registered vessels and Masters the need to maintain vigilance with regards to enclosed space entry and rescue training. In 2019, two seafarers died and two were seriously injured in an enclosed space entry incident on an RMI-registered bulk carrier. The continued loss of life due to improper enclosed space entry and rescue serves as an unfortunate reminder of the dangers associated with the improper entry into shipboard enclosed spaces.

The Administrator has noted some similarities between enclosed space entry incidents, including:

• the lack of awareness by crewmembers of the potential hazards posed by the improper entry into enclosed spaces;
• senior crewmembers failing to ensure that ship management’s enclosed entry procedures are adhered to prior to directing junior crewmembers to enter an enclosed space; and
• the Master of the ship not being notified that an enclosed space was going to be entered.

Safe entry into enclosed spaces has been the focus of extensive industry discussion and crewmember training recently. However, shipboard incidents relating to the improper entry into enclosed spaces continue to occur. This highlights the need to increase the awareness of all seafarers in the recognition of enclosed spaces, the hazards posed by improper entry, and the procedures for safe enclosed space entry.

The Administrator also strongly recommended that ship managers send a notice or bulletin to all ships in their managed fleet addressing:

• the dangers of improperly entering an enclosed space;
• how to recognize an enclosed space and examples of the different types of enclosed spaces a seafarer might encounter while performing their day-to-day shipboard tasks;
• that all seafarers, regardless of rank, must not enter an enclosed space without permission and then, only in accordance with ship management’s established procedures;
• who on-board is authorized to permit entry into an enclosed space; and
• that the best way for a seafarer to assist a fellow seafarer in trouble inside an enclosed space is to immediately raise the alarm so that an organized rescue can be conducted in accordance with ship management’s established procedure.

On the same subject the company has carried out a relevant Vision Zero  "Enclosed space - The silent and invisible killer onboard vessels" HSE Campaign along with respective material that was in effect fromAugust to December 2019.

Campaign material contain:

1. Gard’s former surveyor Alf Martin Sandberg’s real life experience in video. He entered a void space onboard a barge, without checking the atmosphere inside the space first - a mistake that could easily have cost him his life. Alf Martin’s story serves as a real-life reminder that any enclosed space is potentially life threatening, that every precaution should be taken both prior to entry and while inside an enclosed space - and that even trained professionals make mistakes;
2. Two posters provided by Gard and the Shipowners Club which shall be printed and posted in the area(s) the presentation will held to crew;
3. A case study by Gard to be used so at to trigger engagement of participants and discussion
4. Latest email exchanges on VS-06 enclosed entry form revision, proper ESE form completion and the actual form itself.

The Administrator with the issuance of this MSA also strongly recommends that Masters:

• hold a special safety meeting to review the notice or bulletin issued by ship management and share the information provided in this MSA, with particular emphasis on enforcing the responsibility that all seafarers have to prevent enclosed space entry related incidents and the need for crewmembers to resist their natural urge to immediately enter an enclosed space in order to try to assist a fellow crewmember in trouble;
• review the ship’s enclosed space entry procedures with the ship’s officers and crew and then conduct enclosed space entry training; and
•  conduct an enclosed space rescue drill.

MSA 20-23 has been circulated to the fleet with relevant guidelines for compliance with above expectations.

Souce: Z. Lempesi / HSQE Manger & https://www.register-iri.com/