202618 Crew poisoning from fumigant with two fatalities

As edited from State Marine Accident Investigation Commission (Poland) report WIM 14/15

The crew and stevedores had completed loading a cargo of shea nuts on a general cargo vessel. Before departure, two persons arrived on board to distribute fumigating agent (a phosphine emitting agent). The fumigators explained that the fumigating agent would begin to work after around 15 minutes from its distribution in the cargo hold. With their face masks on, they began to lay out the bags with fumigant and sprinkle them with liquid. The bags were placed on the surface of the cargo.

During the distribution of the fumigant, the crew smelled an unidentified sharp odour. The crew were advised to avoid inhaling the substance when closing the hatches. The crew then completed the closing of hold covers and prepared the ship for sea. When the hatches were closed and the hooks tightened, the odour was not present anymore. The chief officer did not receive any information or warning leaflets about the effects of the fumigant from the fumigators.

The day after departure, from about midnight, the crew began experiencing stomach pains and vomiting, with an accompanying feeling of cold and generalised weakness. Later that day, the condition of individual crew members began to deteriorate and symptoms started to worsen. The Master, who exhibited similar symptoms, consulted other officers and notified the shipowner, and then a physician from a coast radio station.

The Master suspected food poisoning and the attending radio physician suggested going to the nearest port. A local physician arrived by motorboat and prescribed various medicines which were distributed according to his recommendations.

The next night, the condition of the crew deteriorated further. The chief officer, who would normally stand the 4/8 watch, called the OOW at around 3am and asked him to remain on watch past 4am since he felt very bad. Sometime after 4am, a crew member went to the chief officer’s cabin and found him lifeless. Resuscitation was started and emergency medical assistance was requested. During the resuscitation of the chief officer, the condition of the third officer also deteriorated. He had breathing problems and was given oxygen. Resuscitation began, but he was declared deceased after 40 minutes.

The rest of the crew (15) were disembarked to undertake testing, and were diagnosed with phosphine gas poisoning.

The investigation explained, among other things, the effects of exposure to an atmosphere containing phosphine, depending on its concentration:

• 0.3 ppm – exposure for up to 8 hours a day;
• 1.0 ppm – exposure for less than 15 minutes without any effects;
• 5.0 ppm – exposure for up to 1 hour without lifethreatening effects;
• 100 – 190 ppm – exposure for 30–60 minutes results in serious consequences for health;
• 290 – 430 ppm – exposure for 30–60 minutes causes a threat to life;
• 400 – 600 ppm – exposure for 30–60 minutes causes death.

The investigation found, among other things, that leaks in the ventilation trunk of the air conditioning system allowed poisonous gas from the fumigated cargo hold to get to the A/C control room and on to the crew living quarters. This was a major contributing factor to the crew poisoning.

The chief officer had carried the same cargo of shea nuts on his previous voyage, but the cargo was not fumigated. On the ill-fated voyage, he did not expect fumigation and did not know how to proceed.

Lessons learned

• Specialised fumigators are required to leave instructions and procedures for crew to follow. If they have not done so, do not proceed to sea.
• If you are unfamiliar with fumigation procedures and are required to carry such cargo, call a stop work until all the information is available.
• If you are transporting fumigated cargo and there is general sickness on board amongst the crew, assume the worst – that it is fumigant poisoning.
• A vessel carrying fumigated cargo should carry fumigant gas-detection equipment, instructions on disposal of residual fumigant material, at least four sets of adequate respiratory protective equipment and a copy of the latest version of the Medical First Aid Guide for Use in Accidents Involving Dangerous Goods, as well as appropriate medicines and medical equipment.
• If fumigation is ongoing, perform gas concentration safety checks in such spaces as accommodation, engine-room, navigation bridge and frequently visited working areas. The checks should be performed at least at eight-hour intervals, and the readings should be recorded in the ship’s logbook. In some cases eight hours is probably too long an interval.

As edited from State Marine Accident Investigation Commission (Poland) report WIM 14/15