202616 Pin holes create pathway to fatal reckoning

As edited from MAIB (UK) report published 23 January 2015

A bulk carrier loaded feed wheat into the vessel’s two holds. Once loading was complete, a specialised fumigation contractor applied aluminium phosphide pellets, loose, into the cargo. The fumigation process was intended to continue during the voyage to the discharge port as the tablets decomposed and gave off phosphine gas.

Before departing the ship, the fumigator-incharge provided a brief to the chief officer, as well as leaving some gas detection equipment.

The voyage was uneventful, but the weather deteriorated and the ship encountered force 7-8 wind on the port bow. During the same day a crew member noticed a smell in the corridor outside his cabin but attributed this to some vomit he found in the laundry sink.

The following morning, another crewman was found deceased in his cabin, lying on the floor next to his day bed. The cabin was sealed and the agent in the arrival port was contacted.

The fumigator appointed to meet the vessel in the arrival port found a very high concentration of phosphine gas in the deceased crewman’s cabin and in the hospital next door. Both these spaces were adjacent to the aft bulkhead of the hold. The cabin deck also overlapped into the hold by half a metre.

No obvious leakage path for the fumigant gas was located, even after smoke testing the hold and stripping back the bulkhead linings. However, following de-scaling of the area, some pin holes were discovered in the underside of the cabin deck that overhung the cargo hold. All indications are that the crewman died of phosphine poisoning from phosphine gas migration from the hold through the pin holes and into his cabin.

Lesson learned

• Phosphine gas is extremely effective for its intended purpose. It is also potentially fatal to humans at very low concentrations.
• There is no antidote to phosphine poisoning. Treatment consists solely of supportive respiratory and cardiovascular care. Prevention is critically important for crew safety. (Ref. Marinepublic.com)
• Vessels with common bulkheads between cargo holds and crew accommodation require extra scrutiny, as these configurations have been involved in multiple fatalities.
• Safe in-transit fumigation requires proper crew training, including gas detection equipment operation, safety procedures, and emergency response protocols. At least two crew members, including one officer, must demonstrate competency with all safety equipment.

As edited from MAIB (UK) report published 23 January 2015