Of their newest BSAFE case examine, Britannia P&I Membership reviewed a benzene vapour fatality aboard, following an unauthorised cargo tank entry.
On 20 January 2024, whereas a ship was underway after discharging benzene, a crew member entered a cargo tank earlier than enclosed-space entry procedures had been authorised and earlier than confirming the ambiance was protected. he was later discovered collapsed on the backside of the tank and, regardless of rescue efforts, didn’t survive. The investigation report concluded with the presumption that residual benzene vapours and oxygen-deficient ambiance throughout the tank had been the first elements resulting in his fast incapacitation and subsequent fatality.
Background of ship and voyage particulars
An 8,270 gt oil/chemical tanker had discharged benzene on its earlier voyage and was continuing in ballast in direction of Korea to load its subsequent nominated cargo. The ship had accomplished discharge at Jiangyin, China and departed for Yeosu, Korea. The deliberate sequence between voyages included a full cycle of fuel liberating and cleansing of cargo tanks in preparation for the subsequent chemical cargo.
The ultimate a part of the cleansing course of required bodily tank entry to conduct guide wiping or “mopping”, of any residual wash water. As is normal, tank entry required an enclosed house entry allow to be issued by the grasp. This firm’s coverage was to mark the hatch cowl of the house to point out {that a} allow had been issued, and it was now protected for entry.
A few of the cargo tanks had beforehand carried benzene. Though the tanks had been rinsed and ventilated for fuel liberating, residue benzene vapours remained a critical hazard. Benzene is extremely unstable and poisonous; in a confined or poorly ventilated setting, inhalation can quickly trigger dizziness, incapacitation, collapse, respiratory failure or deadly publicity.
The ship had a multinational crew, with personnel from Korea, Indonesia, and Myanmar.
What occurred
On the morning of the incident, the ship was a number of hours into the passage. Preparations had been underway for the “mopping” stage of tank cleansing. This stage usually happens solely after fuel liberating has progressed sufficiently and the tank ambiance has been fuel examined and verified protected.
At round 1010 hrs the chief officer (C/O) instructed 4 deck scores (bosun, in a position seaman, and two peculiar seamen) to deliver mops and rags to the principle deck in preparation for mopping operations which had been deliberate to happen contained in the washed cargo tanks. At this level, the “enclosed house entry allow” course of had not but been initiated, and no affirmation had been made that the tank ambiance was protected. It’s understood that the C/O had famous a robust scent of cargo residue from throughout the cargo tanks at deck degree, and had subsequently felt it pointless to check the ambiance because it was clearly nonetheless unsafe.
Shortly afterwards, one of many peculiar seamen (OS) seems to have acted forward of the authorised sequence. They entered the cargo tank by way of an open hatch, earlier than the ambiance had been examined and confirmed protected. It was later found that they weren’t carrying a conveyable multi-gas detector and was as an alternative sporting a filter-type masks, presumably as “safety”. The filter-type masks worn provided no safety in an oxygen-deficient house and couldn’t shield towards residual benzene or different poisonous vapours that may nonetheless linger contained in the tank.
Round 1035 hrs, the bosun, who was strolling throughout the deck, seemed down into cargo tank 10 Port. Seeing the OS mendacity collapsed on the tank backside, the bosun instantly raised the alarm. The bridge knowledgeable the grasp, and shipboard emergency response commenced.
The C/O and second officer donned Self Contained Respiration Equipment (SCBA) and entered the tank to recuperate the OS. They fitted the OS with an Emergency Escape Respiration System (EEBD) however he remained unresponsive. The OS was introduced as much as deck degree on a stretcher and CPR was initiated, with medical help sought from the shore rescue authorities. Regardless of extended resuscitation efforts, the OS didn’t regain consciousness and was later declared deceased upon hand-over ashore.
The following post-mortem recognized traumatic harm per a fall onto a tough floor, together with cervical spinal fracture – that means the ambiance incapacitated the OS earlier than that they had reached the underside. Benzene was detected within the OS’s cardiovascular system. Based mostly on this, and the truth that the tank backside was solely accessible by ladder, it was decided that the OS had entered the tank of their very own volition, inhaled residual benzene vapours, collapsed contained in the tank and fell, sustaining deadly harm. The tank ambiance had not been examined and confirmed protected previous to entry, and the filter-type masks worn by the OS was not appropriate or authorised for cover towards benzene vapours or oxygen-deficient atmospheres.
This occasion developed quickly and at a degree the place the tank had not but been formally cleared for entry. Till an enclosed house allow is issued, a cargo tank should be handled as hazardous, no matter whether or not the hatch is open, a fan is operating, or the tank has been not too long ago washed.
The aim of the allow course of is to verify, by way of measured knowledge and recorded fuel testing, that it’s protected to proceed. Tanks could look innocent from above but can nonetheless harbour atmospheres that may shortly incapacitate or kill with out warning. Due to this fact, visible look from the deck degree can’t be relied upon; the ambiance inside a tank can stay harmful even when it appears inactive or benign.
Britannia commentary on the incident
Organisational controls – Enclosed house allow
On this case, a elementary management barrier was bypassed: tank entry commenced earlier than the enclosed house entry allow system had been formally initiated. your entire protecting structure and different layers (fuel measurement, authorisation, ppe verification, standby watch, steady communication, scba presence, rescue readiness) solely turns into lively and accountable as soon as the enclosed house entry allow has been opened. There was no intent to avoid process; reasonably, there seems to have been an assumption that circumstances had been already appropriate to proceed.
Nevertheless, assumption isn’t a management measure. procedural self-discipline and proper sequencing stay essential safeguards. the os didn’t await the formal authorisation sequence, and the c/o had not but transitioned the operation from “getting ready gear on deck” to “protected to enter”. Between these two phases lies the only most consequential barrier in enclosed house security. The os had been onboard for roughly eight months – lengthy sufficient to be acquainted with the ship’s routines, format and operations. nonetheless, prolonged familiarity can generally introduce a cognitive “normalisation” danger, the place hazards seem much less threatening over time as a result of they’re encountered continuously.
Additionally, the c/o had recognized that the odour remained sturdy and had already determined that entry was not but protected however didn’t report this to the grasp, nor did he halt the ahead momentum of preparations, doubtlessly additional creating ambiguity round “readiness standing”. As an extra layer of safety, bodily boundaries or momentary guards over hatches could also be thought-about to forestall untimely entry to areas that haven’t but been declared protected for entry. This straightforward measure reinforces the procedural standing of the house, reduces ambiguity, and gives a right away bodily reminder that the tank stays “closed”, and reduces the chance of somebody stepping right into a tank “simply to examine” or to organize gear earlier than controls are totally in place.
Fuel testing self-discipline – By gear, not by nostril
Within the hours main as much as the incident, a “sturdy” odour was reported. Reliance on scent is essentially unreliable; the human nostril desensitises shortly to sure smells, and plenty of harmful vapours are both odourless or solely detectable by scent at concentrations already above hazardous limits. Atmospheric acceptance standards are quantitative and instrument-based for a motive. “Smells sturdy” or “smells acceptable” should not exams. Tank atmospheres can’t be safely assessed by instinct, visible checks, open hatches, or air flow alone.
Even not too long ago washed tanks should still comprise vapour pockets or oxygen-deficient zones. Entry circumstances should subsequently be verified utilizing calibrated devices, with readings recorded and in contrast towards outlined tolerances, earlier than anybody enters the house. Additionally, reagent tubes or type-specific fuel detectors needs to be used the place relevant. It can be crucial that exams are performed for the particular hazards current – on this case, benzene – in order that the evaluation displays the precise danger reasonably than a basic hydrocarbon take a look at. Deciding on the appropriate detection methodology is a part of making certain ambiance testing is significant, not merely procedural.
Pre limitations
Filter-type masks, no matter branding, should not acceptable respiratory safety for cargo tank entry. They can’t provide oxygen, nor can they reliably shield towards unknown or combined poisonous vapours which may be current in an enclosed house. On many tankers, there can generally be a cultural tendency to deal with filter masks as an “additional layer” of safety. In observe, this creates danger as a result of the person could consider they’re protected when they don’t seem to be. For enclosed house entry into cargo tanks, respiratory safety should be SCBA, or equal authorised respiration equipment as specified within the ship’s SMS. Nevertheless, PPE can’t exchange or compensate for, the formal enclosed house entry course of.
Emergency response & rescue readiness
It’s constructive that no crew member tried a right away rescue with out respiratory safety — a standard reason for secondary casualties throughout enclosed-space incidents. The C/O and a pair of/O accurately donned SCBAs earlier than getting into the house which demonstrated adherence to coaching and an understanding of the dangers concerned. Nevertheless, the OS was fitted with an EEBD, which is designed for self-escape reasonably than rescuing an unconscious casualty. This displays a standard misunderstanding on many ships and highlights the necessity for periodic refresher drills on the right sequence and collection of rescue gear throughout enclosed-space and different emergencies. Shore notification additionally seems to have been initiated promptly as soon as the casualty was introduced on deck, and the ship subsequently deviated to port upon the coast guard’s instruction.
Readability of SMS & multilingual understanding
The official investigation really helpful that the corporate present translated variations of the SMS and P&A Handbook so that every one crewmembers – particularly these for whom English isn’t a primary language – can totally perceive the necessities. For prime-risk duties comparable to enclosed house entry, clear and easy-to-understand language is an important security management measure. If procedures are misunderstood or solely partly understood, this could weaken compliance, notably throughout handovers or when work deviates from the standard routine. Offering key SMS sections in languages acquainted to the crew helps cut back the danger of errors and helps safer operations on board.
Security culture- Supervision and command
Casual “go-ahead” assumptions typically develop in repeat duties. Nevertheless, enclosed house standing solely adjustments when the C/O and Grasp authorise it. Fatigue, routine familiarity, or the will to “put together work early” can push seafarers throughout a boundary they rationally know shouldn’t be crossed. Crucially, private expertise doesn’t take the place of procedural self-discipline and will by no means be used as justification to bypass it. Supervisors should actively handle the essential transition between getting ready gear on deck and authorising entry from the second a activity strikes from preparation to execution.
That is the place security tradition is seen in actual time: within the choice on when it turns into formally protected to enter. Particularly in a high-risk setting, proactive supervision shouldn’t be seen negatively as micro-management however reasonably recognised and embraced as an vital layer of safety. It’s the mechanism that retains essential authorisation boundaries intact and safeguards the crew. A robust security tradition ought to empower each particular person to talk up confidently every time there are considerations about their very own security or that of others.
Reflective studying materials
The questions under will show you how to to assessment the incident case examine both individually or in small teams. If doable, focus on your conclusions with others, as that is an efficient mind-set concerning the points in additional depth. Please use the data offered within the case examine along with your personal experiences and ideas, to replicate on the incident and the way the problems recognized would possibly relate to your personal scenario.
What do you consider was the instant reason for the incident?
What different elements do you suppose contributed to the incident?
What do you consider had been the boundaries that ought to have prevented the incident from occurring?
Why do you suppose these boundaries may not have been efficient on this event?
How typically do you personally validate that fuel take a look at outcomes are recorded earlier than entry is permitted?
Was the excellence clear between “getting ready gear on deck” and “getting into a tank to start work”?
What would you might have executed in a different way as c/o while you first smelled the sturdy odour throughout fuel liberating?
How does your ship reinforce that “allow to work” isn’t a paper kind — however a security barrier?
Are you acquainted with your organization’s sms procedures for enclosed house entry?
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Supply: Britannia P&I
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