Fatal Fall of Shore Worker in Cargo Tank – Investigation Report

At 2258 on 19 February 2010, a German shore worker was fatally injured on board the oil/chemical tanker Bro Arthur. Bro Arthur had part-discharged at Rotterdam before arriving in Hamburg to offload her remaining crude palm oil cargo. A team of three cargo “sweepers” had been arranged under the operational direction of a supercargo (person who has wide experience in cargo operations, and normally acts on behalf of the charterer). While exiting No 2 cargo tank on completion of the “sweeping” operation, one of the “sweepers” fell to the bottom of the tank.

Bro Arthur arrived at Hamburg’s Cargill Terminal at 0600 on 19 February 2010 for full discharge of her remaining cargo before proceeding to Portugal for a planned dry docking.

The chief officer completed the Ship/Shore Safety Checklist with the terminal staff who issued him a radio for emergency communication purposes with the terminal. At 1005 cargo operations started with the discharge of stearin from No 2 cargo tank followed, at 1045, by the CPO in No 1 cargo tank. At the time that discharge started, the cargo temperatures were recorded as 68.7ºC and 55.8ºC respectively. At 1300 the chief officer carried out a cargo tank “sweeping” risk assessment, which identified risks same with the ones identified in Rotterdam for the a similar operation. After the risk reduction measures were applied the risks were considered acceptable. No consideration was given to the use of a safety harness or fall arrestor during the entry or egress from the tank. The master and chief officer made regular visits to the Cargo Control Room (CCR) to check on the cargo discharge operations. At 1400 the master’s replacement arrived on board and, from that point on, the master concentrated on his handover procedures.

At 1540 “Sweepers” 1 and 2 arrived on board. The chief officer directed them to a spare cabin until they were required; other than that the “sweepers” were provided with no other instructions by the crew. A short time later the supercargo (person who has wide experience in cargo operations, and normally acts on behalf of the charterer) met with the “sweepers” and gave a toolbox talk covering the “sweeping“ requirement. He advised that, due to interruptions in the cargo discharge, they would not be required for some time. The “sweepers’” level of English was poor but the supercargo was confident they understood what was required of them. Notably, the supercargo noticed a strong smell of alcohol coming from the “sweepers”, although he was unsure whether it was from one or both of them. The chief officer also noticed the odd demeanour of the “sweepers” and suspected this might have been due to alcohol. Although concerned, the supercargo decided to wait and reassess their condition at the time they were required for “sweeping” operations.

During the afternoon the “sweepers” regularly visited the mess room. They declined food but drank copious amounts of coffee. Both the chief cook and messman commented that the “sweepers” smelt strongly of alcohol and their behaviour was strange, because they were loud, running around the mess room and engaged in “play fighting” However, neither the chief cook nor messman brought this to the attention of the chief officer.

At 1600 the water-driven forced ventilation fan was started to purge No 1 cargo tank. At the same time the chief officer instructed the duty AB to rig the tank lighting, which consisted of a single pneumatically powered light, and to position a range of tank emergency safety equipment adjacent to the No 1 cargo tank hatch.

Left -Water-driven forced ventilation fan
Right – Tank emergency safety equipment

At about 1740 the ventilation fan was stopped and at 1750 the chief officer tested the 17.35m deep tank’s atmosphere using an oxygen (O2) meter with a 20 m extension hose. He also tested the atmosphere for CO, hydrocarbons and hydrogen sulphide using a PGM connected to a 10 m extension hose. The reading for O2 was 21% and for CO and hydrocarbons it was 0%.

“Sweepers” 1 and 2 were called at 1800 to “sweep” No 1 cargo tank. As they entered the tank the supercargo noted that “Sweeper” 2 needed assistance from “Sweeper” 1 to descend the ladders. However, once at the bottom of the Tank “sweeping“ was completed efficiently and the supercargo declared himself  satisfied at 1835. The “sweepers” then left the tank and returned to their spare cabin to await the instruction to “sweep” No 2 cargo tank.

At 2058 “Sweeper” 3 arrived on board and was directed to the mess room to meet up with the other “sweepers”. He noted the strange behaviour of “Sweeper” 2 and in particular his eye reactions. He believed that he might have been under the influence of drugs, although he did not mention this to anyone else.

No 2 cargo tank’s forced ventilation was started at 2115. At the same time, the tank emergency safety equipment was moved adjacent to No 2 cargo tank hatch, and the tank lighting was rigged. At about 2150 the ventilation fan was stopped, and at 2205 the chief officer checked the tank atmosphere using the same equipment as for No 1 cargo tank, and obtained the same results.

At about 2220 the ventilation fan was restarted and the three “sweepers” met with the chief officer and supercargo adjacent to No 2 cargo tank hatch. Both noticed that the alcohol they had previously smelt had disappeared. As an AB lowered the “sweeping” squeegees to the bottom of the 17.34m deep tank, it was noted that surfaces of the hatch coaming and ladders were covered with a slippery coating of hard, white, waxy, solidified stearin.

The chief officer told the group that the tank was safe to enter. They did not have their own safety checklist, and readily accepted the chief officer’s opinion. To give added reassurance the chief officer gave “Sweeper” 1 a ship’s Personal Gas Monitor (PGM) to provide warning of any change in the tank’s atmosphere.

As the three “sweepers” descended the first vertical ladder, the supercargo followed and remained on the top resting platform to act as communications link with the chief officer who was at the hatch coaming on the main deck. As the “sweepers” descended the three angled ladders to the bottom of the tank the supercargo once again noted that “Sweeper” 1 was assisting “Sweeper” 2, but this did not cause him sufficient concern to abort the operation.

From his prominent position, and because of the lighting levels, the supercargo was able to easily monitor the cargo being “swept” into the pump suction well. At 2255 the supercargo called to the “sweepers” that he was satisfied, and indicated they should leave the tank. The supercargo saw the “sweepers” heading towards the first angled ladder as he exited the tank.

Cargo tank pump suction well

The “sweepers” carried their own squeegees up the ladders, and as “Sweeper” 3 reached the top resting platform he left his squeegee on the platform. Before going up the final vertical ladder he turned and noted that “Sweeper” 2 was just starting up the final angled ladder towards the top resting platform, followed by “Sweeper” 1.

As “Sweeper” 3 arrived on the main deck he moved forward of the cargo hatch. A few seconds later, he and the supercargo heard at least one heavy thump. This was immediately followed by “Sweeper” 1 emerging from the hatch coaming shouting that “Sweeper” 2 “had fallen and is dead”. The chief officer immediately contacted the Cargo Control Room (CCR) instructing the duty officer to alert the terminal staff on the emergency radio.

The supercargo descended onto the tank’s top resting platform and could see “Sweeper” 2 lying motionless on the tank top. He then decided to leave the tank to allow the ship’s emergency party to deal with the situation.

By 2305 the master was informed of the accident and he went directly to the CCR to assume a command and control role. At the same time, the chief officer went to the bottom of No 2 cargo tank to see if he could render assistance to “Sweeper” 2. He found the casualty lying on his back, and it was clear from the amount of blood surrounding the casualty’s head that he had suffered severe trauma. The chief officer was unable to locate a pulse, but decided to stay with the casualty as the second officer entered the tank to provide additional support.
Some time between about 2305 and 2315 “Sweepers” 1 and 3 left the ship unobserved by any of the crew, without recovering their belongings from their cabin.

At 2315 the local Fire and Rescue Service (FRS), police, ambulance and paramedic teams arrived on board. They entered the tank and informed the chief officer that the casualty was deceased. The chief officer offered the use of the ship’s casualty recovery equipment, but the FRS declined, preferring instead to use their own light, easily portable, equipment. By 0020 on 20 February the master had informed BTFR, the charterer and A.P. Møller-Maersk A/S of the accident.

The postmortem toxicology report identified that the casualty (“Sweeper No. 2”) was under the influence of a variety of prescription and illegal drugs which would have caused severe impairment. All the evidence suggests that he fell from the vertical ladder as he lost his hand grip on the slippery surface. He had not been provided with a safety harness or fall arrestor. The casualty (“sweeper No. 2”) had been sub-contracted by a German cargo tank cleaning company.

The MAIB investigation found that Bro Arthur’s safety management lacked direction in a number of organisational and equipment areas. Among others there were issues relating to:

  • Superficial risk assessments: The chief officer carried out a risk assessment for the sweeping operation. He did not identify the need to wear a safety harness or fall arrestor. The “sweeping” risk assessments for both Rotterdam and Hamburg were superficial in that they only identified three risks.
  • Inaccurate atmosphere testing routines: The O2 content of the atmospheres in No 1 and No 2 cargo tanks was measured using the correct meter connected to a 20m extension hose which reached to the bottom of the tanks. This was not the case when the atmosphere was tested for the presence of other gases including CO because the hose used was only 10m long and so the atmosphere was only tested to less than halfway down the tank, and not at the bottom, where the work was to take place.
  • Weak control of contractors: The “sweepers’” level of English was poor but the supercargo (person who has wide experience in cargo operations, and normally acts on behalf of the charterer) was confident they understood what was required of them. Both the supercargo and the Chief Officer noticed a strong smell of alcohol coming from the “sweepers”.  The supercargo although he had noticed that “Sweeper No. 2” needed assistance from “Sweeper No. 1” to decent the cargo hold did nothing to prevent “Sweeper No.2” from working in the Cargo hold and did not requested “Sweeper No. 2” to be substituted.
  • An unwillingness to confront individuals when their condition compromised safety: None of the officers or crew gave a dedicated safety briefing to the contractors engaged with “sweeping” the cargo holds, and had no other conversation with them regarding instructions.
  • Non-compliance with mandatory safety drill: The casualty rescue drill from an enclosed space was not specified as a separate drill in the schedule
  • Unsuitable casualty recovery equipment: With the exception of general comments in the ship’s SMS and COSWP, that rescue equipment should be available during entry into a dangerous space, there was very little guidance on the requirements for casualty recovery equipment.

The MAIB investigation having identified the abovementioned safety issues as directly contributing to the accident issued the following recommendations:

  • Additional guidance should be provided on the management of contractors and sub-contractors with emphasis on the master’s and other officers’ and crew members’ related health and safety responsibilities.
  • Need for the provision of lightweight, portable casualty recovery equipment suitable for recovery from deep cargo tanks. The crew should be fully trained in its use.:
  • Effective risk assessments should be carried out and identify control measures that are adhered to.
  • Equipment specific guidance on atmosphere testing equipmen.

Source: MAIB

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