Enclosed space fatality

Incident description

On a loaded bulk carrier, a bulkhead stool void space was due for periodical internal inspection. The chief officer instructed the bosun to open the main deck lid to the vertical access trunk and  place a small ventilation fan over the opening. In the meantime, he completed a permit to work in his office. About 20 minutes later, he joined the bosun at the void space access. The C/O instructed the bosun to remove the fan and stand by the opening while he entered to carry out the inspection. It was agreed that the C/O would maintain communication via walkie-talkie and use his personal gas meter to  check the atmosphere at each ladder platform before descending down to the next level.. After the C/O had reached the bottom of the ladder, he did not report, and when he failed to respond to the bosun's calls, the bridge watch keeper was alerted. The bosun then entered the access trunk to render assistance to the C/O, but upon reaching the bottom of the ladder, he became dizzy and collapsed. Other crew members  performed a rescue using self-contained breathing apparatus. Although the bosun regained consciousness, the C/O lost his life.

Analysis

The void space had not been opened for about 6 months and was not fitted with any natural ventilation. In these conditions, the oxygen content of the atmosphere became depleted over time due to the effects of corrosion. The ventilator fan had minimal effect on the atmosphere in the lower part of the space in the short time it was used. The fan was too small and should have been fitted with flexible ducting. Additionally, the preparations for entry into this enclosed space were not in accordance with the vessel's Safety Management System and IMO recommendations. A risk assessment was not carried out, and the Permit to Work was not properly completed at the site of the task. Furthermore, the C/O placed too much reliance on his personal gas meter instead of checking the atmosphere at all levels remotely. Although well intentioned, when the bosun entered the space, he not only placed his own life in danger but critically hindered the chances of successfully rescuing the C/O.

Lessons Learnt

• Strictly follow documented shipboard procedures for enclosed space entry
• Be alert to the ways in which all enclosed spaces on board your ship can become dangerous
• If in any doubt, speak up and stop the job until all safety concerns have been eradicated
• Resist the instinct to rush in any help a casualty. Always raise the alarm and perform a team rescue, in accordance with drilled procedures
• Remember, enclosed spaces are dangerous until proven otherwise!