201571 Three deaths in an enclosed space

 

Edited from official BSU (German Federal Board of Accident Investigation) report 140-14

A general cargo ship was in port to discharge a cargo of moist, partially impregnated and freshly sawn timber. Two crew were instructed to begin removing the tarpaulins protecting the timber stowed on deck. At one point, the chief officer and another deck rating lost sight of the two crew detailed to remove the tarpaulins. They went forward to try and locate the two persons. The chief officer called down to the forecastle tweendeck and then entered the space. The deck rating who was also searching arrived at the forecastle tweendeck access hatch soon after, just in time to see the chief officer collapse on the tweendeck, next to the two missing crew who had also collapsed.
The rating quickly switched on the ventilation to that space and ran aft to raise the alarm. Emergency procedures were enacted and help was solicited from stevedores. The three victims were eventually brought out by rescuers using breathing apparatus (BA) and other gear but they were later pronounced dead.
The investigation later found that halfway down the ladder to the forecastle tweendeck, oxygen concentrations were in the order of 10% and only 5-6% at floor level. The victims had succumbed to oxygen starvation. Since the forecastle tweendeck had an access way to the hold, the timber cargo had reduced the oxygen content of forecastle space to below life sustaining levels.

The carriage of wood products was a common practice for this ship and crew and all were apparently well versed in the risks of such a cargo. Additionally, the forecastle tweendeck access hatch was clearly labelled as a confined space that must be ventilated and a permit to work issued before entry. Nonetheless, three people entered without taking these precautions and died.

Lesson learned
- Placards and signs are a good safety measure but they are never enough. Training, awareness and procedural integrity are needed to ensure safety.
- Never descend into a confined space to save a victim unless you are equipped with proper breathing apparatus and have support from other personnel.
- A confined space untested for adequacy of oxygen or the presence of harmful gases is a death trap.