Read the report below and then answer the question.
Executive Summary
Test Your Understanding
What were the key factors that contributed to the unsafe atmosphere in the cargo hold access space?
The investigation revealed that the atmosphere in the closed and unventilated cargo holds, where coal was being loaded, had become oxygen-depleted and likely contained other noxious gases such as carbon monoxide.
The cargo access spaces themselves lacked ventilation other than opening the booby hatches.
Procedures for atmosphere testing before entering these spaces were not routinely followed, and no tests were conducted prior to the stevedores' entry on the day of the accident.
The cargo access spaces themselves lacked ventilation other than opening the booby hatches.
Procedures for atmosphere testing before entering these spaces were not routinely followed, and no tests were conducted prior to the stevedores' entry on the day of the accident.
How did the lack of adherence to safety procedures on board the Berge Mawson contribute to the accident?
The deceased stevedores had not received basic safety training, including enclosed space awareness or general shipboard safety, nor had they completed the STCW Basic Safety Training course.
They were also not provided with appropriate Personal Protective Equipment (PPE) by their employers.
This lack of training and equipment meant they were likely unaware of the dangers of entering enclosed spaces with potentially hazardous atmospheres and were ill-equipped to protect themselves.
They were also not provided with appropriate Personal Protective Equipment (PPE) by their employers.
This lack of training and equipment meant they were likely unaware of the dangers of entering enclosed spaces with potentially hazardous atmospheres and were ill-equipped to protect themselves.
How did the interaction between the ship's crew and the port stevedores contribute to the accident?
There appeared to be a lack of clear understanding and enforcement of responsibilities between the ship's crew and the port supervisors regarding the safety of the stevedores.
The crew may have assumed the port was solely responsible for monitoring the stevedores, and unsafe practices may have become normalized.
The gangway log was not consistently maintained, making it difficult to track who was on board. While the crew was aware of the stevedores' presence and their intention to enter the cargo hold, their subsequent unsupervised actions went unchallenged.
The crew may have assumed the port was solely responsible for monitoring the stevedores, and unsafe practices may have become normalized.
The gangway log was not consistently maintained, making it difficult to track who was on board. While the crew was aware of the stevedores' presence and their intention to enter the cargo hold, their subsequent unsupervised actions went unchallenged.
What shortcomings were identified regarding industry regulations and guidance concerning enclosed spaces and bulk cargo operations?
While regulations like the IMSBC Code and the BLU Code address the hazards of bulk cargoes and enclosed spaces, the investigation found that guidance specifically addressing the safety of third parties like stevedores during cargo operations lacked detail, particularly concerning safe enclosed space entry and cargo trimming.
The focus of these documents seemed to be more on preventing damage to vessels than on the detailed safety of personnel, especially shoreside workers.
The focus of these documents seemed to be more on preventing damage to vessels than on the detailed safety of personnel, especially shoreside workers.
What actions have been taken and what recommendations have been made to prevent similar accidents in the future?
Following the accident, Berge Bulk has updated its SMS procedures, including adding physical barriers to booby hatches, revising training to include lessons learned, enhancing procedures for signage and entry point identification, amending checklists to include atmosphere testing, and revising the Ship-Shore Safety Checklist.
Recommendations have been made to the Maritime and Coastguard Agency to review guidance on including third parties in enclosed space drills, to the port authorities and stevedore companies to provide adequate training and PPE to stevedores, to Berge Bulk to ensure clear guidance for safe operations, and to industry organizations like Intercargo and Inter Manager to develop a minimum safety standard for stevedores working on their members' vessels.
Recommendations have been made to the Maritime and Coastguard Agency to review guidance on including third parties in enclosed space drills, to the port authorities and stevedore companies to provide adequate training and PPE to stevedores, to Berge Bulk to ensure clear guidance for safe operations, and to industry organizations like Intercargo and Inter Manager to develop a minimum safety standard for stevedores working on their members' vessels.
According to Berge Bulk's Safety Management System (SMS), when should atmospheric testing be conducted before entering an enclosed space?
According to Document 07.04.05 of Berge Bulk’s SMS (Permit to work systems), prior to entry into a confined space, atmospheric testing shall be conducted with ventilation stopped for the duration of the test.
Testing should be conducted at a minimum of three levels, including the lowest point of the space.
If the enclosed space is entered 30 minutes after the permit is issued, the gas of the space should be checked again and recorded in the permit before entry is permitted by the Responsible Office
Testing should be conducted at a minimum of three levels, including the lowest point of the space.
If the enclosed space is entered 30 minutes after the permit is issued, the gas of the space should be checked again and recorded in the permit before entry is permitted by the Responsible Office
What specific gases does Berge Bulk's SMS mention for routine testing in spaces adjacent to cargo spaces when carrying coal?
Berge Bulk's SMS states that routine testing for methane, oxygen, and carbon monoxide levels shall also be performed in all working spaces, storerooms, passageways, tunnels, and other spaces adjacent to cargo spaces when carrying coal cargoes.
Considering the accident on the vessel Suntis, what important consideration regarding the location of oxygen testing in enclosed spaces is highlighted?
The accident on the Suntis highlighted that atmospheric conditions can vary significantly within different levels of an enclosed space.
While the oxygen content at the access hatch was normal (20.9%), it reduced to 10% just below the main deck level and to between 5% and 6% at the bottom of the ladder.
This demonstrates that a single oxygen reading at one location may not accurately represent the atmosphere throughout the entire enclosed space, and testing at multiple levels, including the lowest point, is crucial as emphasized in Berge Bulk's SMS
While the oxygen content at the access hatch was normal (20.9%), it reduced to 10% just below the main deck level and to between 5% and 6% at the bottom of the ladder.
This demonstrates that a single oxygen reading at one location may not accurately represent the atmosphere throughout the entire enclosed space, and testing at multiple levels, including the lowest point, is crucial as emphasized in Berge Bulk's SMS
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