201333 Lack of 'Safety Leadership' leads to a confined space close call

Report edited from a Health and Safety Executive (HSE) Press release, March 2013.

Two men, one aged just 17 and both untrained in enclosed space entry, had been tasked to carry out cleaning and welding work prior to repair work going forward in a small vessel’s fuel tank. The tank, 4.5m long and 2.25m deep, was accessed through a small manhole from the vessel’s net store. The two men were told to use buckets to empty the tank’s residual seawater and diesel (approximately 600 litres), and then rags to clean the inside in preparation for the welding repair.

On the first day, the two workers wore normal work overalls and had no face masks. In order to provide some respite from fumes and the cramped working space they swapped roles regularly in the tank. One recalled having a heavy feeling in his chest and finding it difficult to breath when he was in the tank. He said he felt dizzy and faint.

The next day, the two men prepared the inside of the tank for welding work. One man used a grinder, causing sparks to fall on his workmate, who was holding a lamp to illuminate the work. This grinding created significant amounts of fumes. At one point the two men, finding the working conditions less than adequate, abandoned the job and contacted staff at the port harbour office for advice. The Harbourmaster visited the vessel and halted further work after the company failed to provide documentation and permits to show the tank was safe to work in.

Findings:
1 A gas monitor was not used before and during the work to measure available oxygen in the tank and no gas-free certificate was obtained before beginning the task.
2 An ordinary electric fan was used inside the tank to blow the fumes out (on the second day) but was ineffective. A second fan was also put outside in the net store. Neither of these fans had an extraction hose fitted, so were ineffective and just blew the fumes about.
3 Both men were unsupervised, largely untrained and unfamiliar with the tank work they were undertaking.
4 The company had not considered the need to provide any rescue equipment such as harnesses, lifelines or lifting equipment or other appropriate emergency arrangements.
5 No safety watchman was stationed at the entrance of the confined space while work was ongoing.

Lessons Learned
1 Lack of preparation for the work could have led to tragedy. The tank should have been thoroughly steam cleaned or jet-washed instead of being bucketed out and mopped with rags.
2 Only good luck had prevented an accident in this case. Had the diesel fuel residues been sufficiently heated they would have created fumes which could have led to an explosion or fire.
3 All employers involved in confined space working must consider their activities properly, train and equip staff sufficiently, and reduce and control risks as much as possible. Any confined space work should be considered high risk.
4 One of the workers was a young man just beginning his working career. Young people at work need extra training, supervision and guidance and sometimes restrictions on what they are allowed to do. When in doubt, stop work and seek help and advice. If your direct supervisor is not of any help, try and consult his boss or an outside authority. In this case it was the Harbourmaster but on a vessel at sea, the Master or DPA can be consulted.

 Editor’s Note: In this case no serious consequences resulted but confined space casualties continue to be a blight on marine activities - yet they are entirely preventable. By following the enclosed space best practices found below risks will be reduced to levels as low as reasonably practicable (ALARP level).
http://www.hse.gov.uk/pubns/indg258.pdf
http://www.maritimenz.govt.nz/Publications-and-forms/Commercialoperations/Shipping-safety/Safety-updates/Issue21-mnz-safetybulletin-september-2009.pdf
http://www.imo.org/KnowledgeCentre/IndexofIMOResolutions/Documents/A%20-%20Assembly/1050(27).pdf

Two conditions, each complementing the other, should be in place to prevent an event such as that described above.
1 Workers should be properly trained in the risks of confined spaces
2 The employer must demonstrate due diligence and safety leadership when planning and assigning tasks.