Safety Alert: Confined Space Fatality on board bulk carrier in port

Incident Date: 20 May 2024

Location: Ishinomaki Port, Japan

Vessel: EVER FELICITY (Bulk Carrier, IMO 9379856)

Cargo: Palm Kernel Shells (PKS)

Casualties: 1 stevedore Fatality and 1 stevedore Injured

Summary

Two stevedores collapsed inside cargo hold No.1 of the vessel during loading operations. One died and the other was injured.

The vessel berthed in a light (empty) condition, and was scheduled to load 10,000 MT of PKS from open piles at the wharf into cargo holds 1 and 2. Loading took place from 15 to 18 May, except May 17 when the operation was suspended due to bad weather. Hatch covers were closed on the evening of May 18 with hold No. 1 partially loaded.  There was no work on May 19 – a designated non-working day.  At around 07:05 on May 20, as instructed by the stevedoring office, crew members opened the hatch covers of No.1 and 2 holds to resume loading.

The two casualties appear to have been rendered unconscious quickly on entry into No. 1 hold; an attempt by the crane operator to contact one of them by radio approximately 5 minutes later received no response. The crane operator then looked into the hold and saw both stevedores laying on the cargo. Emergency services were called and rescue teams on scene within approximately 12 and 20 minutes respectively of the original entry into the hold. One of the casualties regained sufficient consciousness to get back to the vicinity of entry point and then in a dazed condition, sat down. A rescuer in self-contained breathing apparatus was able to assist the casualty out of the hold via the entry point vertical ladder. The remaining, unconscious, casualty was evacuated by basket stretcher lifted by the fore-side crane. Both casualties were transported to hospital. Sadly, the unconscious casualty did not recover.

Both stevedores were experienced port workers, each with not less than 14 years on port cargo handling operations.

Key Findings

Atmospheric Hazard:

the cargo hold had low oxygen and high carbon dioxide levels, likely caused by fermentation of PKS.

No Prior Testing:

entry was made without atmospheric checks, thereby missing a critical opportunity to manage confined space risk.

Safety Oversight:

the Japan Transport Safety Board concluded that the cargo handling company did not prepare a safe work procedure manual or a risk assessment covering the working environment inside the cargo hold, nor did it implement the legally mandated safety management measures for stevedores engaged in cargo hold operations.

Contributing Factors

Assumption of Safety:

the cargo handling company representative judged that, because the vessel entered port empty, there was no perceived hazard inside the cargo hold and the work could be conducted simply by reversing the unloading procedure. They concluded that the loading operation did not constitute work requiring any new work methods or procedures specified in their own Occupational Safety and Health Management System.

Routine Operation:

potentially because the work was judged routine there was no new risk assessment or work procedure prepared. It was probably thought that loading operations could be safely conducted using conventional methods according to experience and procedures related to the loading of bulk cargo, and the stevedores were instructed to perform the operation in accordance with the planning sheet.

Risk Awareness:

The representative and stevedores did not recognise that the working environment might change as the loading of PKS progressed within cargo hold, and they were not aware that the operation fell under regulations which mandate measurement of the working environment in such situations. There was insufficient understanding of the risks associated with PKS cargo and confined space hazards.

Recommendations

The following main recommendations were in the JTSB report:

• Mandatory Atmospheric Testing: before entry into cargo holds, especially with organic cargoes
• Enhanced Training: for stevedores and supervisors on confined space risks
• Compliance Enforcement: strict adherence to safety laws and internal procedures
• Cargo Risk Profiling: Develop guidelines for handling high-risk cargoes like PKS

For further detail see JTSB report below.