Marshall Islands investigation report: Enclosed Space Entry Fatalities on M/V Blue Cecil

the C/E were talking. The Bosun reported smelling a strong odor after the booby hatch was opened.

The Bosun and deck ratings resumed work on deck after the coffee break. From where they were on deck, they were not able to see where the C/E, ETO, and Fitter had been working on the electrical junction box before the coffee break.

The 2/E did not see the C/E, ETO, or Fitter and did not look for them when he went out on deck to check on the work being done on the electrical junction box after the coffee break was over. While in the Changing Room at the end of the workday, the Bosun determined that no one had recently seen the C/E, ETO, or fitter.

The Bosun went out on deck with a flashlight and after not seeing the C/E, ETO, or Fitter on deck, he entered Cargo Hold No. 1 without telling the OOW or wearing an SCBA. While on the vertical ladder leading from the main deck to the upper platform, the Bosun saw light reflect from what he presumed were reflective patches on the missing crewmembers’ coveralls as he scanned with his flashlight.

He went back on deck, raised the alarm, and then started removing the cleats for the cargo hold hatch cover so that it could be opened. A rescue was conducted per the ship’s enclosed space entry rescue plan and the C/E, ETO, and Fitter were removed from Cargo Hold No. 1 without further incident. All three were  unresponsive when removed from the cargo hold. They did not respond to CPR and were subsequently determined to be deceased.

The Republic of the Marshall Islands Maritime Administrator’s marine safety investigation determined that the C/E, ETO, and Fitter had entered Cargo Hold No.1 to recover the welding cable and other tools without complying with the Company’s enclosed space entry procedures despite the Bosun’s prior warning to the C/E that it was dangerous and required permission from the Master.

Safety findings and lessons learned:

1. Entering a loaded cargo hold without authorization and without following established shipboard enclosed space entry and rescue procedures is extremely hazardous and should not be attempted.
2. Physical boundaries are critical for preventing unauthorized access into an enclosed space.
3. Enclosed space rescue procedures must be properly practiced and drills conducted as if they were a real emergency.
4. Stop-work authority can prevent marine casualties. For stop-work authority to be effective, crewmembers must not only be aware that they have this authority, but they must also have confidence that the authority is non-negotiable and can be exercised without fear of repercussion. They must also be as familiar with how to issue and respond to a stop-work action or instruction as they are with their other shipboard duties.

Conclusions:

1. Causal factors that contributed to this very serious marine casualty include:

1. 1. a welding cable and other tools being left in Cargo Hold. No. 1 on 30 November 2023 after repairs to the No. 1 P TST were completed; and
   2. the C/E’s decision to enter Cargo Hold No. 1 without complying with the Company’s enclosed space entry procedures to recover the welding cable and other tools despite the warning from the Bosun that it was not safe.

b. Additional causal factors that may have contributed to this very serious marine casualty include:

1. 1. ineffective onboard implementation of the Company’s Stop-Work Process.

c. Additional issues that were identified but that did not contribute to this very serious marine casualty include:

1. 1. the Bosun entering Cargo Hold No. 1 by himself without complying with the Company’s enclosed space entry procedures, such as informing the OOW or wearing an SCBA.

Preventive Actions:

In response to this very serious marine casualty, the Company has taken the following Preventive Actions:

1. On board all Company-managed ships, it is required that:

1. 1. all cargo hold bobby hatches be locked and that the keys be held by the ship’s C/O;
   2. notices be placed in strategic locations after loading cargo indicating the cargo carried and the dangers associated with the cargo;
   3. the Company’s Stop-Work Process be enforced by all officers and crew; and
   4. additional training be conducted regarding enclosed space entry and rescue.

2. A review was conducted of the Company’s safety culture and implementation of industry best practices.

3. An internal audit was conducted on the implementation of the Company’s enclosed space entry procedures on board all Company-managed ships;

4. The lessons learned were shared with all ships in the Company-managed fleet.

5. The pre-joining briefing for crewmembers working on board Company-managed ships was revised to include the lessons learned from this very serious marine casualty.

The Administrator has taken the following Preventive Actions:

1. MSA No. 03-24 was issued reminding ship managers of the need for continued vigilance regarding enclosed space entry and rescue training. MSA No. 03-24 included a number of recommendations based on a review of enclosed space entry incidents that had occurred on board Republic of the Marshall Islands-registered ships between 2020–2023.

For more details, click below to download the full Marshall Islands investigation report:

Source: Marshall Islands Flag Administration

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