Another Life Lost in Enclosed Space Operation

by | Jun 20, 2016 | News

Enclosed space rescue operations training

With SWZ Maritime's June issue coming up, including a selection of Mars Report No. 283, you can already read the full report here on SWZonline.

Gyro out of Step: Mars 201623

Edited from official Canadian TSB report M14C106

A bulk carrier was approaching a lock entrance in daytime and with good visibility. Two persons were in the wheelhouse: the master was at the con and a helmsman was at the wheel. The master had previously instructed the Officer of the Watch (OOW) to go on deck in preparation for the lock transit. As they approached the lock outer piers, at a speed of about nine knots, the master called the engine room (ER) and requested the bow thruster. Once the power to the bow thruster was transferred to the bridge, it ran for approximately one minute without being used, at which point its circuit breaker tripped.

The circuit breaker was reset and closed by ER staff and the bow thruster restarted; the voltage in the electric distribution system dropped and the No.3 generator main circuit breaker tripped. However, the No.1 generator continued powering the main switchboard. The main engine continued to operate and the lights remained on throughout the vessel.

The drop in voltage set off a number of power failure alarms on the bridge, including both gyrocompasses. The radars defaulted to standby mode and two of the three rudder angle indicators on the bridge were disabled. The master put the engine astern and initiated a starboard turn to abort entry to the lock canal entrance.

For five minutes, while engine room staff repeatedly undertook the blackout procedure, the power failure alarms on the bridge sounded three more times following their initial activation. The bridge team did not know why the alarms were repeatedly activating. The second officer arrived on the bridge and began silencing and resetting the alarms, as per the master’s orders. Meanwhile, the master took measures to increase the vessel’s rate of turn to starboard. He was monitoring the vessel’s turn on the Electronic Chart Precise Integrated Navigation System (ECPINS), but without confirming through visual navigation. He then ordered the helmsman to steer 180 degrees gyro (°G) so that the vessel would proceed on a southerly course, away from land.

A few minutes later, the master looked at the ECPINS slave monitor and noticed that the vessel’s course made good was easterly, but that the vessel-shaped marker that indicates the heading was pointing southerly. He requested the magnetic heading from the helmsman, who reported it to be 111° magnetic (M). The master looked outside and saw that the shoreline was on the vessel’s port side, instead of on its stern. He immediately ordered the helm hard to starboard to correct the vessel’s course and increased the propeller pitch to get more power ahead. The vessel began turning to starboard but, moments later, the hull touched bottom and the vessel ran aground 1.5nm southeast of the lock outer piers (number 7 in diagram).

The official report found, among other things:

  • A number of power failure alarms on the bridge created a situation that resembled a blackout and was interpreted as such.
  • Engineers responded to the developing situation by applying the vessel’s blackout procedure twice, which caused additional power interruptions to the bridge; however, the engineers were unaware that these actions were having this effect.
  • The power interruptions on the bridge, combined with the vessel’s turn to starboard, caused the gyrocompass to become misaligned.
  • Following the power interruptions the master was (unknowingly) using inaccurate data from the ECPINS. Additionally, he was not using all available bridge resources to monitor the vessel’s progress for nearly 15 minutes before the grounding.

Lessons Learned

  • Electronic charts are a wonderful navigation tool that give real-time situational awareness. But these instruments can also be a trap that is easy to fall into. Use all means at your disposal, especially visual means if possible, to confirm that what you are seeing on the screen is in fact reality.
  • The gyro compass is one of your best friends. Always check on its accuracy, especially after a blackout or electrical interruption.

Grinding Disc Cuts Deep: Mars 201624

The vessel was en route to a European port. Deck maintenance was in progress, including repairs to a stand located at the cargo hold hatch covers. During the cutting of a steel bar using a portable grinder, the cutting disc suddenly broke into pieces. Part of the cutting disc (or possibly the steel bar) hit a nearby crew member near his right knee area. The wound was about 5cm long and 2cm deep and pieces of loose bone (or cartilage) were observed in the wound.

First aid was given immediately and medical advice was requested via radio. Treatment of victim was advised and it was decided to evacuate the victim by helicopter to a shore hospital for further treatment.

Some of the findings of the company report were as follows:

  • A grinding disc had been used instead of a cutting disc.
  • The grinder did not appear to have its protective cover attached.
  • Grinding wheels are subject to deterioration if stored in damp or humid conditions. The effects are a reduction in bond strength caused by the ingress of moisture; this affects the balance and causes surface growth, which reduces the bursting speed.
  • Grinding and cutting discs should be discarded after three years storage as physical deterioration during this period may render the disc unsatisfactory.

Lessons Learned

  • Always use the right tool for the task. In this case, a grinding disc was being used for cutting.
  • Never detach or render ineffective safety devices such as protective covers – they are there to protect you.
  • Grinding and cutting discs, among other power tools, operate at very high speeds. Make sure the various parts and consumables are in topnotch condition and of reliable quality.

Hot and Bothered Coal: Mars 201625

Edited from UK P&I Club checklist ‘How To Monitor Coal Cargoes From Indonesia’

Self-heating incidents involving coal cargoes loaded at Indonesian ports have become more frequent in recent years. The problem appears to be related principally to the nature of the coals, and it may be exacerbated by the way they are handled before and during loading. Recommendations for the safe carriage of coal are contained in Appendix 1 of the IMSBC Code (the Code), which became mandatory worldwide on 1 January 2011.

The extensive lessons learned and best practices from recent experience are set out below.



Enclosed Space Fatality: Mars 201626

Edited from official Isle of Man casualty investigation report CA118

While discharging an oil cargo from a tanker, an oil sampler (similar to that shown in the photograph) was lost to the bottom of tank 3P. It was decided that once the discharge was finished and crude oil washing completed, the sampler would be retrieved before loading the next cargo into 3P to avoid any potential damage to the ship’s equipment from the sample bucket or tape. Once empty, the tank was ventilated.

Over several days the tank atmosphere of tank 3P was measured using an explosimeter and sample hose. Although oxygen was near normal levels, HC was at 57% of LEL on day one of ventilation and 38% of LEL on day two. After discussion,it was agreed that entry into 3P tank would start the next morning (day three) if the gas levels were ‘less’.

The next morning, the tank atmosphere of 3P tank was found to be 20.6% oxygen, with HC at 26% of LEL. Tank entry equipment was prepared and placed near the tank access hatch; breathing apparatus (BA) sets, emergency escape breathing devices (EEBDs), stretcher and heaving lines. The master was shown the risk assessment and work permit for enclosed space entry and although the HC LEL was indicated at 26% he stated that the oxygen content was good. It was decided that two crew should go in, each wearing an EEBD.

Two crew members entered the cargo oil tank via the tank access hatch each with an EEBD worn over the shoulder, a torch and a personal gas meter. Several other crew members and the master were in attendance at the tank access hatch. The lead crew member proceeded down to the first platform and checked the atmosphere across the platform with his gas meter. The second crew member then proceeded down the stairs to meet him. This was repeated for the remaining platforms until they reached the tank bottom almost 20 metres below the main deck.

The lead crew member then reported feeling dizzy and heard his personal gas meter alarming. The second crew member reached the tank bottom and instantly felt the effects of the gas inhalation; he also heard his personal gas meter alarming. The lead crew member shouted and gestured to the second to wear his EEBD and leave the tank. The lead crew member immediately proceeded to exit the tank.

The second attempted to don his EEBD and activate it but collapsed soon afterward. Meanwhile, on deck, the master entered the tank with an EEBD worn over his shoulder. Although another crew member warned the master not to enter the tank the master nonetheless proceeded into the tank. Two crew members on deck donned the BA sets already available at the entrance.

The lead crew member exited the tank and had passed the master heading down to retrieve the second crew member, now collapsed on the tank bottom. Upon arrival at the tank bottom the master also collapsed. Within 10 minutes, three crew members descended into the tank with BA gear in order to evacuate the two victims. The master, secured in a Neil Robertson stretcher, was raised to the main deck by all available crew pulling the gantline to the main deck through the tank access hatch. The second victim was subsequently retrieved in the same manner.

Oxygen was administered to the victims; one victim did recover, but the master did not and was later pronounced dead.

Some of the findings of the official report were:

  • Normally, inert gas is introduced into the tank to drive out the hydrocarbon content (purging) to below a level out of the flammable range before replacing the inert gas with fresh air (gas freeing – ie HC to be at 2% or less). It is not known why this procedure was not carried out in this instance.
  • With a HC level of 26% LEL the atmosphere was too rich to allow an explosive condition, but was also too high to support a tank entry without BA gear.
  • The rescue tripod was not made ready at the tank access hatch. Consequently, the casualties were raised from the tank bottom with all available crew on the main deck heaving on the gantline, which was rubbing against the lip of that tank access hatch during heaving. This gave the potential for excessive and accelerated wear. Had the line parted the victim may have fallen and suffered significant additional injury.
  • The responsible person at the tank access hatch was not aware of the tank atmosphere and only advised that ‘Everything is completed and is OK’. Neither did he sight the enclosed space entry permit. Had he known the tank atmosphere measurements he could have been in a position to stop tank entry proceeding.

Lessons Learned

  • An emergency escape breathing device (EEBD) should be used only for escape from a compartment that has a hazardous atmosphere and should not be used for fighting fires, entering oxygen-deficient voids or tanks, or worn by fire-fighters.
  • Always follow procedures, as not doing so could have deadly consequences.
  • Never shrink from politely questioning a colleague or even a superior about a work practice if you think it is unsafe.

Acknowledgement

Through the kind intermediary of The Nautical Institute we gratefully acknowledge sponsorship provided by:
American Bureau of Shipping, AR Brink & Associates, Britannia P&I Club, Cargill, Class NK, DNV, Gard, IHS Fairplay Safety at Sea International, International Institute of Marine Surveying, Lairdside Maritime Centre, London Offshore Consultants, MOL Tankship Management (Europe) Ltd, Noble Denton, North of England P&I Club, Sail Training International, Shipowners Club, The Marine Society and Sea Cadets, The Swedish Club, UK Hydrographic Office, West of England P&I Club

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Picture: Enclosed space rescue operations training.