Lack of training on safe cargo work and working in enclosed spaces, combined with a tragic oversight by the ship’s crew, lead to three deaths, according to a report from they Maritime Accident Investigation Branch (MAIB).
Three stevedores died because they entered a space that was so depleted of oxygen that it could not sustain human life.
A stevedore entered an access space in the wrong cargo hold and collapsed. The ship’s crew, who were well-trained in emergency response to incidents in enclosed spaces, rushed to collect rescue equipment. However, in their haste, they did not take into account the fact that on-shore workers were on-board the vessel and the crew did not guard the entrance to the enclosed space. Two other stevedores then attempted to rescue their workmate in the absence of the crew. They too were overcome and later died.
Background to the deaths
Stevedores were working aboard the 92,732 gross tonnage bulker, on 27 June 2022 at about 13:00 local time at the Bunyu Island anchorage, near the major Indonesian island of Kalimantan. They were loading coal from barges using a floating crane into hold No. 7 and were using a bulldozer in that hold to level the coal so as to minimise the free surface effect and to maximise coal loading space.
Loading stopped owing to heavy rain and and all hatches were closed. Before the work was paused, the bulldozer was being operated by one of the stevedores. After work was called off that operator left the ship.
The rain stopped, work resumed, and a second, separate, bulldozer operator wanted to access the bulldozer so as to resume levelling work. That operator mistakenly entered into the access space of hold No. 8 while looking for the bulldozer. However, that space did not have sufficient oxygen and he collapsed.
Crew and stevedore reaction led to more deaths
An assistant foreman began to check progress on cargo working about five minutes later and continued to carry out checks. By approximately 16 minutes later, he was looking for the second bull dozer operator. After about 25 minutes later, the assistant foreman found the second bulldozer operator lying unconscious on the deck of hold No. 8. He immediately raised the alert by radio and verbally by calling for help. The second officer attend the scene and shouted to the bulldozer operator in the hold, who did not respond. Giving instructions to the assistant foreman that no-one else was to enter the space, the second officer and other crewmembers left the scene to further raise the alarm and to gather rescue equipment, including breathing apparatus.
About three minutes later, six stevedores had gathered on the scene and two of them climbed down the ladder into the access space of No. 8 hold to carry out a rescue, but they quickly collapsed.
The crew returned approximately one minute later to discover three casualties. A crewmember ordered the hatch covers to be opened and also carried out a gas test: methane levels were at 38%, oxygen levels had fallen to 0.9%, carbon dioxide had risen to 2,147 parts per million and hydrogen sulphide had risen to 3,100 parts per million. By way of comparison, the access space in the open adjoining hold N0.7 had no methane, no carbon dioxide, and no hydrogen sulphide. It also had normal levels of oxygen.
Approximately 11 minutes later, at 13:41, the crew – now wearing breathing apparatus – entered the access space and recovered the stevedores. Resuscitation was attempted and oxygen was provided however, none of the casualties regained consciousness. They were taken ashore where they were later declared dead.
Coal cargoes present a known risk of causing death by asphyxiation
Coal cargoes are a known risk for causing of death by asphyxiation (death caused by a lack of access to oxygen) as coal naturally and inevitably depletes oxygen from the atmosphere by a series of complicated chemical processes (coal oxidation at low temperatures). Hydrogen sulphide can be given off by some coal seams and is a known safety risk. It is a heavier-than-air gas (so it tends to accumulate in closed spaces) and it is a highly toxic gas that is neuro-toxic, causes cell-death, stops oxygen processes, and stops the cellular production of the chemical adenosine triphosphate which is the molecule that basically provides energy for the human body at the cellular level. It is notable that, in humans, hydrogen sulphide can induce knockdown i.e. immediate unconsciousness. “Individuals who have undergone or experienced knockdown have been described as falling “as if letting the strings loose on a marionette [a puppet]“. Coal oxidation also produces carbon dioxide which displaces the oxygen in the air. Some coals can also emit the compound gas, methane, which also displaces oxygen although it’s not toxic itself. The reduction of oxygen in an enclosed space alongside the build-up of deadly asphyxiants therefore poses a major safety risk.
Accident investigation conclusions
- The three stevedores died after entering a cargo hold access space that had been closed for two days and which had an atmosphere that had been in direct contact with coal.
- Noxious gases were present in the hold in high levels; testing earlier that day had proved that the coal had already depleted the air quality. The hold was oxygen deficient, noxious, and presented a severe risk to life.
- Upon entry into the cargo access space, all three stevedores were immediately incapacitated by breathing in noxious air which shut down their brains and / or lungs and led to their deaths.
- It appears that procedures onboard the ship for atmosphere testing before cargo hold entry were not routinely followed; an opportunity to identify the hazardous atmosphere was missed. The first person to die, the second bulldozer operator, was observed to be making several entries into cargo hold access areas and void spaces without following appropriate procedures.
- Stevedores working on board the vessel were not wearing appropriate protective equipment and were observed to be working in a way that was generally unsafe.
- There was an assumption that the stevedores were being monitored; this assumption was incorrect.
- The Ship-Shore Safety Checklist did not specify who was responsible for supervising the stevedore’s activities and consequently no one was; the stevedores were engaging in unsafe acts and were not challenged. The actual number of stevedores aboard at any one time was unknown which made it difficult to account for all personnel when there was an emergency. There was ineffective supervision of the safety of stevedores and their safety was not managed.
- Although it was theoretically possible to prevent unauthorised physical access to cargo and void spaces, at the time of the accident there was no physical means to prevent access (hatches and enclosed spaces were not locked), and access control relied on adherence to procedural instructions.
- There were no legible warning labels as some of the warning labels at the booby hatches had become damaged, and therefore unreadable. Stencilled warnings on the booby hatches were in English but the stevedores had little knowledge of this language.
- The ship safety management system required permits to work for persons entering into enclosed spaces; it appears that a deviation from this procedure had become normal over time. From the movements of the stevedores (visible on a recording), it is indicative that appropriate permissions were not being sought.
- After the second bulldozer operator had been discovered collapsed into Hold No.8, the cargo access space was left unguarded, which enabled two other persons to attempt a rescue which proved fatal.
- The foreman, and the bulldozer operators, had not received any training on cargo operators, enclosed spaces, or general shipboard safety. The three casualties were experienced in shipboard working.
- The absence of hazard awareness, safety training, personal protective equipment, and risk assessments meant the stevedores were ill-equipped to either work safely on board Berge Mawson or respond appropriately to an emergency situation.
Actions and recommendations:
The shipping company has reviewed its procedures and has fitted physical barriers on all of its bulkers so as to prevent unauthorised entry to cargo hold spaces.
Reommendation(s)
- to the UK Maritime and Coastguard Agency to review the guidance provided in the Code of Safe Working Practices for Merchant Seafarers on the inclusion of third parties such as stevedores during enclosed space drill scenarios
- to terminal and port authorities to ensure adequate training of stevedores
- have been made to the industry bodies Intercargo, InterManager, and RightShip, to compile and issue a minimum safety standard for stevedores engaging in cargo operations on ships
Read the full accident investigation
