2011X60 Dangers of entering enclosed spaces

02 Nov 2011 MARS

Dangers of entering enclosed spaces
Various Locations

Report No. 9xxxx


The dangers of entering enclosed spaces have beenwritten about time and time again. In spite of this, these type of incidentsstill happen all too often, just a few weeks ago a case occurred off theEast Coast of England and was reported in the National Press. Here are extractsfrom reports of a casualty investigation by The Isle of Man Department ofTransport which shows how some innocent looking cargoes can be lethal, asecond incident investigated on behalf of the Deputy Commissioner of MaritimeAffairs, Republic of Vanuatu and an article reproduced from the ChevronSafety Bulletin.
This unfortunate incident occurred on a tween deck dry cargo vessel whichwas fitted with several deep tanks designed for the carriage of vegetableoil cargoes inter-island in the Pacific and on the return voyage to Europe.The ship had loaded palm oil on the previous voyage in several deep tanks.There are access trunks from the main deck at each side between #1 and #2hatches to lobbies at tween deck level. In each lobby there is a boltedmanhole cover at the top of the appropriate deep tank. The deep tanks areprotectively coated and are fitted with stainless steel heating coils tomaintain the oil temperature during the voyage and to raise the cargo oiltemperature prior to discharge.

After discharging the Palm Oil in Hull, the tanks were ballasted withsea water for the passage to the South Pacific. No cleaning was done afterthe discharge of the palm oil and the ballast was loaded directly on topof the remaining palm oil residue. Some 10 to 12 days into the voyage fromEurope to Panama, the Deck Maintenance Hand (DMH) was taking his routinetank soundings when he noticed a bad smell emanating from the sounding pipesfor #2 and #3 deep tanks. This was not unusual and regarded as a normalfeature of the carriage of ballast water in these tanks, nevertheless, hereported the fact to the Chief Officer who was new to the vessel. FollowingCompany requirements, the ballast water was changed after passing throughthe Panama Canal. Palm oil is a category D substance within the meaningof MARPOL 73/78 and the ship carries an IPP certificate for the carriageof noxious liquids in bulk. The ship carries an approved procedure manualfor ventilation and washing of the tanks. Several of the tanks were cleanedby the crew during the passage under the Chief Officer's direction and usingthe approved procedure.

De-ballasting commenced during the afternoon of 2nd October. During theevening watch the same day the two engineer Cadets were sent forward bythe 2EO when the ballast pump lost suction to check on the water levelsin #2 and 3 tanks. The Cadets first checked #2 tank by going down the accesstrunk to tween deck level and opening a steel screw-down inspection portin the manhole lid. Having established that the ballast seemed to be out,they re-emerged and opened the door of the access trunk to #3 tank and thepump room. Here they found a foul smell of such strength that they declinedto enter and reported back to the 2EO. On the assumption that all the ballastwater was out, both tanks were re-ballasted with clean sea water. Afterre-ballasting, the Deck Maintenance Hand reported that the smell from theair pipes of both tanks did not improve.

A Fleet Circular from the Company drew attention to the possible dangersof hydrogen sulphide gas evolving from decomposing palm oil in ballast waterand requested Masters to ensure that ballast water is changed at sea andthat under no circumstances is access to the tanks or pump rooms to be alloweduntil entry procedures have been followed and a permit to work issued. Theissue had reportedly been discussed on board at a recent Safety Meetingbut had not been minuted.

At 0530 on 21 October the CO asked the 2EO to pump the ballast out ofthe tanks and at about 0630 the DMH, with the assistance of another seaman,was asked to remove the lids of #2 and 3 tanks. At about 0700, the BangladeshiDeck Serang reported to the bridge to discuss the work for that day. At0840 the CO reported to the 2EO that the ballasting was well under way andthat he expected the tanks to be empty by early afternoon. At this pointthe Serang appeared and discussed getting things ready for tank cleaning.The 2EO was left under the distinct impression that tank cleaning wouldnot commence until afternoon. The Serang then went forward with 5 men tothe tank access trunks. They rigged a hose and prepared a cargo cluster.The Deck Serang and a Seaman III went down the access trunk at the starboardside leading to the tween deck lobby where the manhole access to #3 deeptank had been opened earlier and the Serang entered the tank. After a veryshort time, the Seaman III at the manhole shouted up "Serang fall down",he then entered the tank and the other Seamen heard him shout "SerangSerang" from inside the tank, then nothing more was heard. At 0850the 3O heard shouting on the deck. At approximately the same time the DMHwas alerted by crew members running down the deck shouting "Two menfall down in tank". On receiving the message, the CO directed thata self contained breathing apparatus (SCBA) set be brought and went forwardand entered the access trunk. He was wearing a boiler suit but no SCBA andhad not stopped to put boots on, he did not come out again. The DMH enteredthe trunk but due to the strong smell of gas did not look in the tank. TheDMH returned to the open deck and a few moments later the Master arrivedclosely followed by a Seaman bringing an SCBA.

The Master donned a breathing apparatus and descended to tween deck level.He found the hose and cargo cluster which had been rigged earlier. He sawthe CO slumped on a stringer plate below the manhole but could not see theothers. He considered that he was unable to assist on his own and returnedto the deck. The CEO and 2EO arrived on the scene, donned SCBA sets, foundthe CO and put an oxygen set on him which had been obtained by the Purser.As the CEO lifted the CO to a more upright position he noticed another manhanging upside down from the stringer plate with one leg caught in the ladder(later identified as the Serang). A Neil Robertson stretcher was loweredbut put aside by the two engineers as being ineffective in the circumstances.Shortly after this an SCBA alarm sounded. As they were uncertain which sethad sounded an alarm it was decided the two Officers should return to thedeck and by the time they reached the deck both alarms were sounding. Sparebottles had been organised by the Master and the CEO accompanied by the2O then entered whilst the 2EO went to organise recharging the empty bottles.The CEO took a line that was already attached through a turning block inthe top of the access and attached it to the CO. Then, with the assistanceof the 2O standing by the manhole an attempt was made to haul the CO out.This line was intended for lowering tools down and was not strong enough,it broke and the CO and CEO fell back down on to the stringer plate. TheCEO re-secured the oxygen mask on the CO and then had to retire as the BAlow level alarm sounded.

Air bottles were again changed and the CEO and 2EO returned to the tank.They then secured a BA lifeline around the CO and he was eventually hauledto the deck at approximately 1000. Resuscitation and cardiac massage wereattempted by the Master and Purser but was abandoned when it became apparentthat there was no sign of life. As there was no chance of the Serang orthe Seaman being alive it was decided that further risk to personnel wasunwarranted and that de-ballasting should continue with a view to recoveringthe other bodies when the tank was empty.

CHEVRON SAFETY NOTICE
Accidents continue to occur involving personnelentering or working in enclosed spaces. Tragically, many of the accidentshave involved loss of life. Recently, within days of each other, accidentshave been reported in which a number of lives have been needlessly lost.The cause in all cases was entry into an enclosed space which turned outto contain an unsafe atmosphere. In one case at least, additional liveswere lost when other personnel outside the space went to the rescue andwere overcome themselves.

The incidents reported were not on board shipscarrying obviously hazardous cargoes. Furthermore, incidents have occurredin spaces other than cargo tanks or hold spaces. Ballast tanks, void spacesand engine compartments have all featured in casualty reports. Time andtime again circumstances have shown that when well established and provenprecautions have not been observed, accidents result. The majority of thefatalities in enclosed spaces could have been prevented by simple supervisionand by following agreed procedures. Ignoring the need for such proceduresputs lives at risk.

Rapid rescue of personnel who have already collapsedor are clearly in distress represents particular risks. It is a naturaland understandable reaction to go to the aid of a shipmate in difficulties,but far too many additional and unnecessary deaths have occurred from theimpulsive and ill prepared rescue attempts. There is considerable information,guidance, recommendations, codes, etc., dealing with the subject of entryinto enclosed spaces. Many ICS and other industry guides detail the safetyprecautions necessary - it is essential they should be observed.


The Vanuatu report concerns the death of a shoreside worker who was preparingto fumigate a vessel which had been carrying a cargo of New Zealand Pinewood logs with the bark attached. The logs had been stored in the holdsas well as on deck and the hold ventilators had been blocked off to allowfor the deck stowage. The holds had not been opened for 4 weeks. Pursuantto quarantine regulations, it is normal procedure in Far Eastern ports tofumigate log cargoes within the holds prior to discharge. During this process,the crew are required to evacuate the vessel. Whilst the crew were assembledwaiting to leave the vessel, the Bosun reported that two shore workers werelying on the main deck close to a hatchway. The ship's personnel were underorders not to go on the deck so had to wait until the arrival of the medicalauthorities who subsequently removed the two workers to hospital. It waslater reported that one of the workers had died and the other was in a seriouscondition. It was concluded the cause was the depletion of oxygen in theholds caused by the timber and not a result of the fumigation process asfumigation lines were still being set up and the seals on the fumigationbottles were all intact.

The Chevron report reads "Accidents reported during past years haveregularly included the loss of lives resulting from personnel being overcome,either by toxic fumes or lack of oxygen, in enclosed spaces aboard ship.The need for procedures has long been recognised, and many safety guidelinesand recommendations have always endeavoured to ensure that seafarers arereminded of the potential hazards and the need for precautions. In additionto the guidance issued by the shipping industry, other organisations, notablythe ILO and IMO, have also published recommendations on the subject. Infact, a correspondence group established by IMO is currently working onproducing further guidelines aimed at alerting all those concerned to theneed for sound procedures and constant vigilance when entering enclosedspaces. The need to repeat warnings about the dangers of enclosed spaceentry is backed up by recent reports in the press. With this in mind, thefollowing notice was produced to convey a brief and simple message to thoseconcerned with ship operations, including, and most importantly, seafarers".