VERY SERIOUS MARINE CASUALTY
Death of a crew member and injury of three crew members onboard Ro/Pax “HORIZON” due to toxic gas contamination from the sewage tank in ship’s void space, on 7th June 2015
Report date: 17/07/2015
FOREWORD
The sole objective of the safety investigation under the Marine Accidents and Incidents Investigation Law N. 94 (I)/2012, in investigating an accident, is to determine its causes and circumstances, with the aim of improving the safety of life at sea and the avoidance of accidents in the future.
It is not the purpose to apportion blame or liability.
Under Section 17-(2) of the Law N. 94 (I)/2012 a person is required to provide witness to investigators truthfully. If the contents of this statement were subsequently submitted as evidence in court proceedings, then this would contradict the principle that a person cannot be required to give evidence against themselves.
Therefore, the Marine Accidents and Incidents Investigation Committee, makes this report available to interested parties, on the strict understanding that, it will not be used in any court proceedings anywhere in the world.
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GLOSSARY OF ABBREVIATIONS AND ACRONYMS USED IN INVESTIGATION REPORTS
AIS - Automatic Identification System AB – Able –Bodied seaman ARPA - Automatic Radar Plotting Aid B/C - Bulk Carrier COLREGS - The Int/nal Regulations for Preventing Collisions at Sea 1972, as amended DO - Diesel Oil DOT - Diesel Oil Tank ECDIS - Electronic Chart Display and Information System ETA - Estimated Time of Arrival ETD - Estimated Time of Departure FO - Fuel Oil FOT - Fuel Oil Tank FPT - Fore Peak Tank DBT - Double Bottom Tank GPS - Global Positioning System IFO - Intermediate Fuel Oil IMO - International Maritime Organization LT - Local Time LOT - Lubricant Oil Tank m - metre MT - Metric Ton NM – Nautical Mile OOW - Officer of the Watch O.S – Ordinary Seaman PSN - Position QM - Quartermaster / Helmsman RPM - Revolutions per Minute SAR - Search And Rescue S.B.E. - Stand By Engine SOLAS - Safety of Life At Sea Convention
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STCW95 - International Convention on Standards of Training, Certification and Watchkeeping for Seafarers 1978, as amended VDR - Voyage Data Recorder S-VDR - Simplified Voyage Data Recorder VHF - Very High Frequency VTS - Vessel Traffic Services UTC - Universal Time Co-ordinated ZT - Zone Time
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1.0 - SUMMARY
On 07 June 2015 the Ro/Ro passenger vessel HORIZON sailed in ballast condition from the port of Shengjin, Albania towards a shipyard in Bijela, Montenegro for a scheduled drydock inspection.
At around 16:30 LT four crew members were found unconscious inside the ship’s void space no. 3 where the sewage tank is located. Apparently the crew members went inside the void space in order to dismantle and clean the sewage pump suction filter.
When the filter cover was dismantled, poisonous toxic gases escaped from the sewage tank line and contaminated the void space causing the death of one crew member by asphyxia and the injury of the other three crew members.
The physical and documentary evidence that was gathered during our investigation, lead to the following conclusions.
The direct cause of the accident (death) was asphyxia. The contributing causes of the accident were:
“Work risk assessment” for entering into enclosed spaces was not performed. The Safety Management System procedures for entering an enclosed space were not followed, nor were any pre-entry form completed and entry permit given. No safety measures were taken before and after the crew entered the void space for work. The void space is suspect of being already contaminated in some degree due to the poor maintenance of the sewage waste discharge pump
The following recommendations were made to the Management Company:
The Managers to review the casualty within the scope of the SMS and provide a relevant circular to the vessel
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The Managers should review IMO Resolution A.1050(27) (and SOLAS III, Reg. 19.3.6) and implement to the Company’s SMS the new requirements which entered into force in 01.01.2015. The Managers to arrange for thorough cleaning of the void space floor from any sewage waste contaminants. Managers also to overhaul the sewage discharge pump.
The following suggestions were made for consideration by the Department of Merchant Shipping, Cyprus:
A permanent mechanical ventilation system to be installed in such enclosed spaces containing sewage tanks or plants. A piping line of permanent backwash with sea water to be installed on sewage filters, which should be used every time before dismantling of the filter cover is to take place. Tank lines to be required to be equipped with a double suction filtering system with isolation valves. The sewage treatment plants to be subjected to annual surveys by the Classification Societies in order to promote better maintenance by the shipowners.
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2.0 – FACTUAL INFORMATION
2.1 – SHIP’S PARTICULARS
The ship’s main particulars are the following:
Name of ship : HORIZON IMO no. : 7203637 Call sign : 5 B B V 4 MMSI No. : 210899000 Year of build : 1971, Japan Flag State : Republic of Cyprus Port of registry Limassol Type of ship : RoRo Passenger Gross tonnage : 7707 Net tonnage : 3483 Deadweight : 1433.11 tons Class : Polski Register Registered Owner : Ionisus Maritime Co Ltd, Msida, Malta Ship’s Manager : European Seaways Inc, Athens, Greece Length overall : 112.80 m Breadth : 20.40 m Draught : 5.25 m 4 internal combustion - Nigata Shipbuilding & Main engines : Repair Inc. Crew onboard at the time : 38 of the casualty Crew onboard at the time : 38 of the survey Without passengers: 17 Minimum safe manning : Up to 250 passengers: 24 document More than 250 passengers: 30
Passengers capacity : 758
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The Class and Statutory certificates of the vessel are as follows:
Class and Statutory Certificates Issued Expiry
Class 31.07.2014 15.06.2016
Safety Management System - Safety Management (SMC) 09.02.2015 14.10.2019 - Document of Compliance (DOC) 27.11.2014 20.08.2019 Loadline (ILL) 31.07.2014 15.06.2016 International Oil Pollution Prevention 31.07.2014 15.06.2016 (IOPP) International Air Pollution Prevention 31.07.2014 15.06.2016 (IAPP) International Sewage Pollution 31.07.2014 15.06.2016 Prevention (ISPP) Passenger Ship Safety Certificate 14.06.2015 13.11.2015
2.1.1 – CHARACTERISTICS OF THE INTERNATIONAL SEWAGE POLLUTION PREVENTION CERTIFICATE
The ISPP certificate certifies that the ship is equipped with a sewage holding tank and a discharge pipeline in compliance with regulations 9 and 10 of Annex IV of the MARPOL Convention.
The holding tank has a total capacity of 14.40 m3 and is located between frames 108 – 120 on the starboard side of the ship. The ship is also equipped with a pipeline for the discharge of sewage to a reception facility, fitted with a standard shore connection. In addition the certificate provides the information that the ship has been surveyed in accordance with regulation 4 of Annex IV of the MARPOL Convention.
The survey shows that the structure, equipment, systems, fittings, arrangements and material of the ship and the condition thereof are in all respects satisfactory and that the ship complies with the applicable requirements of Annex IV of the MARPOL Convention.
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The certificate was issued by the Polski Register on 31 July 2014, was based on a survey carried out on 17 April 2014 and expires on 15 June 2016.
2.2 – VOYAGE PARTICULARS
We were informed by the Master that the vessel was laid up for some time before commencing her voyages in early June which were intended to be the liner service between the ports of Shengjin, Albania and Brindisi, Italy. The distance between these two ports is about 102 nmiles.
At the time of the casualty the vessel had sailed in ballast from the port of Shengjin to destination Bijela, Montenegro for the purposes of a scheduled drydock inspection in the shipyard of the area. The distance between Shengjin and the shipyard is about 73 nmiles.
The vessel was manned with 38 crew members.
After the casualty we were informed that the vessel is intended to make the liner service between Vlore, Albania and Brindisi, Italy. The distance between these two ports is about 80 nmiles.
2.3 – MARINE CASUALTY OR INCIDENT INFORMATION
Type of marine casualty / incident: Very Serious Marine Casualty – Loss of life of one crew member and injury of three crew members
Date and time: 07/06/2015 16:30 LT
Position: Not recorded – previous entry on same day at 15:05 LT: Lat.: 41°56’6” N Long.: 019°07’3” E
Location: About 6 nmiles off Montenegro coast, Adriatic Sea
External and internal environment: Wind direction SW 3, slight sea, day, good visibility
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Ship operation and voyage segment: Vessel in ballast condition on course to shipyard for scheduled drydock survey
Place on board: Inside void space no. 3. Entrance of the void space is from the main garage. Capacity of void space approx. 670 m3
Human factors: Yes / Human Error / Decision
Consequences: Death of one (1) crew member, injury of three (3) crew members
2.4 – SHORE AUTHORITY INVOLVENMENT AND EMERGENCY RESPONSE
2.4.1 – Upon dealing with the emergency situation the Master informed the company’s DPA and the local agent in Bijela. The Master tried to contact with the local port authorities but the pilot station responded and gave him information that all parties concerned were informed and asked for immediate assistance.
2.4.2 – A shore medical emergency team carried by a fast rescue boat came onboard the vessel and provided emergency medical assistance to the injured crew members and confirmed the death of the forth crew member. The emergency medical team decided to transfer the three injured members as soon as possible to the hospital.
2.4.3 – The Port State Control of Montenegro embarked the vessel on 08 June 2015 at anchorage of port Zelenika (near Bijela). They collected some documents regarding the casualty and took some statements from the crew members.
The Port State Control inspectors suggested that the dead crew member (who was still kept onboard at the time of the inspection) was to immediately be taken ashore.
2.4.4 – The vessel was re-inspected by the Port State Control of Montenegro on 14 June 2015 and was found with 0 deficiencies.
2.4.5 – The vessel was inspected by the Port State Control of Brindisi on 17 June 2015 (more detailed inspection) and was found with 3 deficiencies.
The second deficiency is relevant to the casualty and encoded with code 99.
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It states that “Although the presence of safety procedure to access in dangerous enclosed space, on 07-06-2015 one crew member death in void space no. 3 and three others were hospitalized during maintenance of the sewage filter – no evidence of permission required (note: the wording here is probably mistaken, the intended word was “requested”) or granted to access in this space. Master instructed to put in place all possible action to avoid in the future crew accident.”
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3.0 – NARRATIVE
The following sequence of events is extracted from the vessel’s bridge log book and from the various statements obtained by the vessel’s Managers or directly from the seafarers during our investigation.
3.1 – SEQUENCE OF EVENTS
1. On 07 June 2015 the Ro/Ro passenger vessel HORIZON completed her voyages on the liner service between Shengjin, Albania and Brindisi, Italy, and sailed in ballast (without cargo or passengers onboard) from the port of Shengjin towards a shipyard in Bijela, Montenegro for a scheduled drydock inspection.
2. At the recorded time of 15:05 LT the vessel was in position Lat.: 41°56’6” N Long.: 019°07’3” E, 48 nmiles away from the port of Bijela.
3. According to the staff Engineer’s statement, at around 16:10 LT the staff Engineer was looking for the Chief Engineer but could not find him. He then remembered that he had heard that he would go to the sewage tank in order to empty it before the vessel arrived at the drydock. According to the C/E’s statement, the staff Engineer instructed the C/E to prepare the sewage line in order to deliver the sewage to the shipyard. Nevertheless which statement is valid, it is extracted that the C/E together with the Engine Superintendent went inside the void space no. 3 (details of this void space are in the next chapter) where the sewage tank, pump, filter and pipings are located. Together with them went two oilers for assistance.
3. At 16:30 LT the vessel was proceeding to Bijela (we were not informed of the exact position – but it is assumed that the vessel was closing to the port of Bijela and was about 6 nmiles from the coast of Montenegro). At that time the staff Engineer, looking for the C/E, went at the entrance of the void space and saw the C/E in a semi-unconscious state and the other 3 crew members laying down unconscious.
4. The Master and the rest of the crew were notified immediately as well as the company’s DPA and the local agent. The ship’s emergency team was activated and headed towards the void space no.3 in the main garage. The Master tried to contact with the local port authorities but the pilot station responded and gave him
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5. Some of the rest of the crew members immediately entered the void space in order to pick up the unconscious crew members and drag them out of the void space. It is noted that according to depositions of the crew members, none of the crew members who went to rescue took any safety measures before entering the void space.
6. The four crew members were dragged out of the void space and were offered emergency breathing assistance (CPR). The C/E was conscious, the Supt. Engineer and the one oiler were breathing but still unconscious, but the second oiler was not breathing.
7. A shore medical emergency team carried by a fast rescue boat came onboard the vessel and provided emergency medical assistance to the injured crew members and confirmed the death of the fourth crew member. The emergency medical team decided to transfer the three injured members as soon as possible to the hospital.
8. The vessel dropped anchor in a position just outside of the Bijela port until the situation with the authorities was clear and the vessel was then allowed to enter the drydock.
9. The dead crew member was transferred to the “Klinicki Centar Crne Gore” clinical centre in Podgorica, Montenegro where the autopsy took place on 08 June 2015 and the relevant certificate of death was issued. The reason for death was determined to be ASPHYXIA.
10. A Non Conformity report was issued as per company’s SMS during the same day of the casualty in which it was stated that the root cause of the casualty was that “the engine crew tried to check the sewage valve (and filter) without informing the Master and the valve was leaking and created the problem.” The crew then planned a Safety Committee meeting the next day in which it was decided that “in any case from now on, not any work to be carried out without informing the Master and without following correct company’s SMS procedures.” It was also decided that an emergency drill for rescue from enclosed spaces should be done in the near future.
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4.0 – ANALYSIS
The purpose of the analysis is to determine the contributory causes and circumstances of the accident as a basis for making recommendations to prevent similar accidents occurring in the future.
The following analysis draws on documentary evidence obtained from the vessel’s Master and Managers and from statements received from crew members onboard. It must be noted that the three injured crew members were repatriated before we could obtain a statement from them. All their documents (diplomas, health certificates etc.) were absent from the vessel and no copies were held onboard.
4.1 – PROXIMATE CAUSE OF CASUALTY The direct cause of the crew member’s death and the injury of the other three crew members is inhalation of toxic gases which originated from inside the sewage tank. It is extracted from the depositions of the crew that a team of four crew members went inside the void space no. 3 in order to make some works on the sewage tank. It is believed that one crew member (most possibly the deceased one) attempted to open the pump suction filter, which is connected to the piping system of the sewage tank, in order to clean it as it was possibly blocked with wastes and the discharge of the tank was not feasible. When the filter cover was opened, poisonous gases escaped from the sewage tank system and were concentrated inside the void space. This caused the death of the crew member and the injury of the other three crew members.
Sewage line filter
Filter cover
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4.2 – CONTRIBUTORY FACTORS
4.2.1 – Ship A description of the main characteristics of the ship is shown in chapter 2.1 of this report. An investigation on the validity of the ship’s certificates indicated that all the certificates issued by the Polski Register and the Republic of Cyprus were up-to- date. Based on this information only, and without having conducted any detailed condition survey on the vessel, the investigation found no evidence of any defect or malfunction of the ship itself that could have contributed to the accident.
4.2.2 – Manning The ship was manned with crew licensed, qualified and medically fit in accordance with the requirements of the International Convention on Standards of Training Certification and Watchkeeping (STCW) Convention as amended. At the time of the casualty the crew onboard consisted of 38 crew members while the minimum safe manning certificate of the vessel provides minimum manning of 17 crew members when the vessel is without passengers.
The crew members in the engine room (our investigation was concentrated to them) are following a work / rest hours schedule in accordance with regulations, which does not seem to have affected towards the casualty. The specific circumstances of the fatigue of each crew member involved in the accident are discussed in chapter 4.2.5. (14)
4.2.3 – Void space no. 3
A diagram of the void space no. 3, inside which the sewage tank is located, is shown below.
The void space no. 3 is an area located below the main deck of the vessel between frames no. 108 – 120. The dimensions of the void space are about 9 m in length, maximum breadth about 20 m and 5.7 m in height. Below the void space are located various double bottom tanks and above the void space is located the main garage of the vessel.
Inside the void space and along its full length, are the limits of the refrigerator machinery room with dimensions about 7 m in breadth and 2.95 m in height. The refrigerator machinery room has watertight limits from the void space. Next to the walls of the refrigerator machinery room is located the sewage tank with dimensions 4 m length, 2 m breadth, 1.8 m height, 14.4 m3 capacity. The total net capacity of the void space is calculated to be about 670 m3.
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Refrigerator machinery room
(underneath)
Sewage tank
The only entrance to the void space no. 3 is via a manhole, with dimensions of about 0.5 m x 0.5 m, which is located on the main garage of the vessel. The pictures below shows the manhole.
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The only machinery associated with the specific void space is the sewage tank and all its piping/accessories. The void space is naturally considered as an enclosed space and was marked with the following notifications: “RESTRICTED AREA – DO NOT ENTER WITHOUT MASTER’S PERMISSION”. It was noted that the phrase “DO NOT ENTER WITHOUT MASTER’S PERMISSION” was painted on the cover of the manhole after the accident occurred.
This is considered a correct action by the vessel’s Master who on top of the obligations of the ISPS code that are provided by the “RESTRICTED AREA” sign, he voluntarily took additional safety measures so that whoever schedules to enter the void space in the future to request permission from the Master first. It is noted that the specific manhole should be kept closed at all times.
As the void space is considered an enclosed area, all the relevant safety measures should be taken before entering such spaces. These should be the following according to “CYPRUS CODE OF SAFE WORKING PRACTICES FOR SEAFARERS” (Cyprus Flag Circular No. 20/2005).
a. A competent person should make an assessment of the space and a responsible officer to take charge of the operation should be appointed. b. The potential hazards should be identified c. The space should be prepared and secured for entry d. The atmosphere of the space should be tested e. A “permit – to – work” system should be used f. Procedures before and during the entry should be instituted g. Where the procedures listed at a to d have been followed and it has been established that the atmosphere in the space is or could be unsafe, then the additional requirements including the use of breathing apparatus should also be followed.
It was evident from the information gathered that:
a. A “work risk assessment” for entering into enclosed spaces for inspection, test or maintenance was not performed. (17) b. The Safety Management System procedures for entering an enclosed space were not followed, not was any pre-entry form completed and entry permit given. c. No safety measures were taken before and after the crew entered the void space for work. In particular:
- The void space was not thoroughly ventilated before entering and no arrangements were done for continuous ventilation while the works were in progress. Even if the atmosphere of the void space was tested and found to be acceptable, the correct procedure would be for the crew members to wear oxygen masks while working on such potentially hazardous equipment as the sewage tank. - The void space atmosphere was not tested for oxygen sufficiency before entering nor was it tested in frequent times while the work was in progress - No rescue (lifelines and rescue harnesses, torches or lamp, a means of hoisting an incapacitated person from the confined space) and resuscitation (breathing apparatuses, fully charged spare cylinders of air) equipment was positioned near the entrance of the void space - No stand-by person was instructed to remain at the entrance to the space whilst it was occupied - No system of communication with outside of the void space nor any emergency signal was therefore established - The Master or the Safety Officer (who is the Chief Officer in this case) were not informed of the work to be done d. After the casualty no safety measures were taken by the ship’s crew before entering the void space for rescue of the unconscious crew members. In particular:
- No EEBD (Emergency Escape Breathing Devices) were used by the crew members who rescued the injured persons from inside the void space. This was a risk that could have lead to even more casualties.
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- No plan or communication procedures were established between the entrants and the designated people outside of the enclosed space. - The atmosphere and oxygen sufficiency were not tested before entering for rescue
A temporary ventilation system, which was found during our investigation, was installed by the vessel’s crew after the accident. This consisted of a flexible hose which received air from the refrigerator room and was used in order to properly ventilate the void space.
4.2.4 – Sewage tank A diagram of the sewage tank was not provided by the ship’s crew or Managers, but it was physically observed as follows. The ship’s sewage tank is a tank with dimensions 4 m x 2 m x 1.8 m and capacity of 14.4 m3.
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Sewage piping
Sewage tank
Inspection door
The tank was observed to be in an acceptable condition without any major deficiencies that could have contributed to the casualty.
The piping that was of interest for our investigation was the sewage discharge piping system, which is shown below.
Washing pipe Pump suction filter
Gate valve
Sewage waste discharge pump motor
The sewage wastes are discharged from the tank through a gate valve which is followed by a filter. The piping then continues towards the discharge pump which (20) disposes the sewage wastes either overboard or to shore facilities. After the accident, the crew installed a washing pipe on top of the filter cover which will be used in the future in order to wash the filter with sea water before any future attempt to open it. This is considered to be a good and efficient idea which reduces the risk of contact with poisonous gases during cleaning of the filter.
Shore connection and overboard discharge connection
We noted that the sign on the overboard discharge connection states that “UNTREATED SEWAGE DISCHARGE OVERBOARD AT DISTANCE OF LESS THAN 12 NAUTICAL MILES FROM THE NEAREST LAND IS PROHIBITED”.
The tank’s exhaust piping was found to be in good a condition and the exhaust (which is located on the ship’s right funnel) was free from any obvious blockage.
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4.2.5 – Discharge pump The sewage discharge pump (which is used to discharge the sewage wastes from the pump to overboard or to shore facilities) was found to be in a poor condition with various leakages evident. The area below the pump and the sewage tank was found to be with many wastes / sludges.
It is possible that sewage wastes concentrated on the bottom of the void space were a contributing factor on the creation of a toxic atmosphere inside the void space, which was re-enforced by escape of toxic gases during the dismantling of the filter cover. This situation was not rectified and it appears that it did not get noticed or did not cause any concern to either the Class or to the Port State Control inspectors.
4.2.6 – Air breathing apparatuses and gas meters The compressed air breathing apparatuses certificates were examined and found to be in order. The vessel is equipped with 11 air breathing apparatuses and with 23 spare air cylinders.
The medical oxygen resuscitator was used for the breathing assistance of the injured crew and was thereafter replaced with a new one. The relevant certificate was provided.
The vessel is equipped with one gas meter, of which the relevant certificate was examined and found in order and duly calibrated.
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Despite the fact that the vessel was adequately equipped with air breathing apparatuses, none of them was used neither before entering the void space for works, nor before entering the void space for rescue.
4.2.7 – On board familiarization check list The onboard familiarization check lists of the four crew members who were involved in the accident were checked and found in order. The onboard familiarization check lists for the Chief Engineer and the 3rd engineer consist of the following sections:
A. Applicable to all newly joining crew and other persons to sail with the vessel B. Elementary basic safety familiarization (STCW A-VI/1 PAR 1) for crew C. Elementary environmental familiarization for crew D. Elementary basic security familiarization (STCW A-VI/6 PAR 1-3) for crew E. Familiarization with key company documents F. Familiarization with safety procedures G. Familiarization with environmental procedures H. Familiarization security procedures I. Familiarization with job routines and equipment J. Introduction to ISM code K. Company’s safety and environmental protection policy L. Drugs and alcohol policy M. Seafarer’s training and familiarization N. Communications O. Safety management P. Forms reporting requirements
The onboard familiarization check lists for the two oilers consist of just the points A – I in the list above.
It is also noticed that the full familiarization of the crew members of all the above procedures took place in just some hours just after the seafarer’s embarkation to the vessel.
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4.2.8 – Records of hours of work / rest The records of hours of work / rest for the crew members who were involved in the casualty were examined. It must be indicated that the hours of work / rest were not completed for 7th June due to the emergency of the casualty. Hence, we can only assume from the previous records, identify the pattern of work / rest schedule of each crew members and extrapolate the following:
a. For the Chief Engineer (injured) the records indicate that he did not have a casual work / rest schedule. b. For the Engine Supt (injured) the records indicate that he was on duty at the time of the casualty. c. For the first oiler (injured) the records indicate that he was probably supposed to be resting at the time of the casualty (off duty). d. For the second oiler (deceased) the records indicated that he was probably supposed to be resting at the time of the casualty (off duty).
The records indicate that two of the crew members (one deceased and one injured) were probably supposed to be off duty during the works in the void space. It is reminded that in cases of emergency or drill the above schedules can be changed.
4.6 – Emergency drill’s evaluation The latest emergency drill evaluation for rescue of incapacitated person from enclosed space (dated 30/04/2015) was inspected and found to be in order. Two of the seafarers who were interviewed during our attendance on the vessel took part in the emergency rescue operation of the injured crew members during the day of the casualty. As per the records of this emergency drill, the two seafarers took successfully part in the specific drill.
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5.0 – CONCLUSIONS
The physical and documentary evidence that was gathered during our investigation, lead to the conclusion that there were various contributory factors which, all of them combined, lead to the casualty.
These factors are summarized below:
1. “Work risk assessment” for entering into enclosed spaces was not performed. If there was a proper work risk assessment done before the crew members entered the void space, then the possible dangers would have been identified and addressed and the corresponding safety measures taken. Risk management is a vital part of every ship’s operation, and if performed properly, it could minimize the possibility of such casualties occurring.
2. The Safety Management System procedures for entering an enclosed space were not followed, nor was any pre-entry form completed and entry permit given. If the procedure was performed adequately, then the possible hazards would have been identified and preventative measures taken.
3. No safety measures were taken before and after the crew entered the void space for work. In particular, the void space was not thoroughly ventilated before entering, was not tested for oxygen sufficiency. In addition, no rescue and resuscitation equipment was positioned near the entrance of the void space. No stand-by person was instructed to remain at the entrance to the space and no system of communication with outside of the void space was established. Finally, the Master or the Safety Officer were not informed of the work to be done.
4. The void space is suspect of being already contaminated in some degree due to the poor maintenance of the sewage waste discharge pump
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6.0 – RECOMMENDATIONS
The scope of this report is not to apportion blame or liability but to determine the contributing factors of the casualty and recommend ways to improve the safety of life at sea and the avoidance of such accidents in the future.
Our recommendations to the Managers of the vessel:
1. The Managers should review the casualty within the scope of the Safety Management System (SMS – as per ISM Code IMO Res. A.741 (18) as amended) and provide a circular to the vessel informing the crew of the SMS discrepancies that took place and emphasizing to the crew members of the necessity that the correct safety procedures are followed in such cases in order to avoid future loss of human lives. The Managers to provide copy of this circular within 3 months.
2. The Managers should review IMO Resolution A.1050(27) (and SOLAS III, Reg. 19.3.6) and implement to the Company’s SMS the new requirements which entered into force in 01.01.2015. In particular Managers to pay special attention to the following paragraphs and provide within 3 months proof of implementation of the following:
a) 3.3 - The company should elaborate a procedural implementation scheme which provides for training in the use of atmospheric testing equipment in such spaces and a schedule of regular onboard drills for crew (note: The Managers are reminded that enclosed space entry and rescue drills are required at least once every two months to ensure that crew members are familiar with the actions to be taken).
b) 4.1 - The company should ensure that a risk assessment is conducted to identify all enclosed spaces on board the ship. This risk assessment should be periodically revisited to ensure its continued validity.
c) 6.4 – Only trained personnel should be assigned the duties of entering, functioning as attendants or functioning as members of rescue teams.
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Ships' crews with rescue and first aid duties should be drilled periodically in rescue and first aid procedures. Training should include as a minimum:
1. identification of the hazards likely to be faced during entry into enclosed spaces; 2. recognition of the signs of adverse health effects caused by exposure to hazards during entry; and 3. knowledge of personal protective equipment required for entry.
3. The Managers to arrange for thorough cleaning of the void space floor from any sewage waste contaminants. Managers also to overhaul the sewage discharge pump. Photographic evidence to be provided within 3 months.
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ANNEX NO. A – VESSEL’S LOG BOOK EXTRACT
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ANNEX B – SMS NON CONFORMITY REPORT
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ANNEX C – SAFETY COMMITTEE MEETING
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ANNEX D – CREW LIST AT THE DATE OF THE CASUALTY
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