A casualty report into the enclosed space multiple deaths on board the bulk carrier Sally Ann C in March this year has been released.
It points to an incomplete safety management system (SMS), absence of warning notices in the danger spot, and "impulsive actions" as among the causes of the casualty.
The incident, which occurred on 13 March 2015 while the Isle of Man-flagged ship was on passage from San Pedro, Ivory Coast, to Dakar, Senegal, carrying a cargo of sawn timber, resulted in the deaths of the chief officer and chief engineer from asphyxiation, and serious skull injuries to the ship's second officer.
The chief officer had entered the cargo hold where the timber was stowed, and collapsed. Finding him there, the chief engineer entered the hold to rescue him. He also collapsed. The same actions were taken by the third crew member, the second officer, but fortunately a rescue operation launched by the other crew members meant that he was successfully resuscitated.
The Isle of Man Ship Registry (IMSR) report found that the shipowner, Carisbrooke Shipping, had "failed to implement a detailed key shipboard operation into its SMS, specifically in the area of enclosed space entry procedures".
While each vessel "must produce its own list as to where all the enclosed spaces are identified", the IMSR report says that at the time of the investigation "no evidence could be found that the ship possessed a record noting the whereabouts of all the enclosed spaces on board", or indeed any note indicating the number of enclosed spaces on the ship.
IMSR notes that a simulation drill was probably practised in January, but the level of detail deployed in that drill - such as whether it had included the entry into an actual tank - could not be known as "no safe work permit or risk assessment [was] issued for that day or exercise".
Therefore it cannot be ascertained whether "actual physical training takes place on board or whether it is purely a simulation-type drill". The report also observed the absence of a "training dummy" for use during drill exercises.
In addition, the report found no evidence of specific shipboard procedures on the carriage of timber related products, or the dangers of oxygen depletion, "The existing safety management system and shipboard operational procedures do not take into account the carriage of timber related cargoes and the dangers posed by oxygen depletion."
The dangers of oxygen depletion are outlined in a table in the report, which shows the physical effects dependent upon percentage of oxygen. At 4-6%, an individual would fall into a coma in 40 seconds, and meet their death in three minutes. As part of the investigation a measure of the oxygen levels in the incident-related cargo hold access and stairway were taken using a portable oxygen meter. The report found, "One such reading indicated an oxygen level of 4.5%. The lowest observed reading was noted to be 3.5% of oxygen."
While six laminated warning and information notices on enclosed space entry were found "in the accommodation" of the ship, no notices were posted at the point of entry to the cargo hold access where the accidents occurred - either on the outside or inside of the access lid.
The behaviour of the crew responding to the incident was found to be a cause for "serious concern".
"Despite" training and rescue drills, that two of the ship's officers "persisted on entering a space totally unprepared for the consequences of their actions", shows, said the report, that the "message about the dangers associated of entering such spaces has apparently still not permeated the human psyche".
However, the rescue operation by the more junior crew members was praised in the report as "quickly and effectively executed".
The IMSR states that it is satisfied Carisbrooke Shipping "have taken the appropriate steps … to amend and issue new procedures to avoid a reoccurrence of this incident" as per the report's recommendations.
Among the recommendations, Carisbrooke Shipping should review its SMS to ensure that procedures for entering enclosed spaces are included as key shipboard operations, and also review its SMS cargo operations procedures to include hazardous and/or oxygen depleting cargoes.
Recommendations to the IMSR include the re-issue of Merchant Shipping Notice No.23 Entry to enclosed spaces and the dangers posed by oxygen depletion from timber cargoes, and circulation of the current report to all Isle of Man-registered ships.
In a statement sent to IHS Maritime, Carisbrooke Shipping said it "welcomes and accepts the findings" of the IMSR casualty investigation.
The company said that the second officer injured during the accident "is at home with his family and is making steady progress in his recovery". Carisbrooke chief executive officer Robert Wester said the company "remained deeply shocked by this incident and the loss of our two valued colleagues".
The company confirmed its implementation of "all" the recommendations cited in the report including reviewing its SMS and conducting risk assessments of all enclosed spaces on its vessels.
Commenting on the report, safety expert and chairman of safety product company Salvare Worldwide, Captain Michael Lloyd, told IHS Maritime that enclosed space equipment "is still a rare commodity".
"Think what a difference a resuscitator or meaningful exercises with a proper dummy may have meant. Or a proper enclosed space management system that would prevent anyone from entering without reference to this, and would provide the data required both for entry and rescue," he said.
Around 50% of enclosed space deaths on ships are multiple tragedies. Lloyd said that while tanker and chemical carriers have made progress in stamping out the problem, the "general cargo and bulk sectors still bury their collective head in the sand and cling to the industry's motto, 'if it's not required by SOLAS, don't do it'".
He said that the latest IMO recommendation calling for all ships to audit their spaces and list them "has been totally ignored by almost all shipping companies".
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