G A R D N E W S ISSUE 1 7 9 August/ October 2 0 0 5

A fatal tanker accident

The problems of gas and lack of air on board tankers are a part of the job and
there is no shortage of procedures and warnings. Still, accidents do happen. The
following accident, which took place in 2004, led to the death of the vessels
master.

The incident
An LPG/ethylene tanker insured with Gard
was being prepared for dry-docking
following a discharge of ethylene. In order
to arrive at the yard with breathable air in
the cargo tanks, purging and gas-freeing
operations were carried out. Due to
technical problems there were several stops
of the vessels oil-fired inert gas generator,
and the final inerting was done by wet inert
gas, bypassing the dryer and the compressor.
The inert gas was partly of poor quality and
observed at times to be quite blackish. Once
the inerting process was completed,
ventilation of all tanks was started.
When the oxygen content of cargo tank
No. 3 was measured to 21 per cent, the
master and chief officer entered the tank for
a five-minute inspection, wearing ELSA sets
for safety. Around the sump of the pump
suction some water from the wet inert gas
was found, and to remove this, three crew
members with a portable pump entered the
tank. Once the pump was rigged, one AB
remained in the tank to monitor the
pumping. After about 20 minutes, he began
to feel dizzy and started to climb the ladder
when he passed out. The last thing he
remembered was hooking his foot behind a
ladder step to avoid falling down.
The two other crew members were higher
up in the tank when the AB collapsed, and
climbing out they notified the master of
the accident. One can not know for sure,
but the master, who had just been inside
the tank, may have felt over-confident, or
perhaps responsible for the AB being in the
tank on his orders. Anyhow, he immediately
entered the tank and did not take time to
don any breathing apparatus. Struggling to
rescue the AB, the master managed to put a
rope around him before getting into trouble
himself and falling to the bottom of the tank,
unconscious. After 20 minutes crew

Crew member with air bottle. A number of bottles were used during the rescue attempt.

The AB had to be removed

from the ladder first, and a
chain block had to be rigged
on deck to hoist the master.
members managed to rescue the AB, who
regained consciousness once brought to
open air on deck. Later he was brought to a
hospital and recovered quickly.
The master was worse off a heavy man
lying in the bottom of the tank. The AB had
to be removed from the ladder first, and a
chain block had to be rigged on deck to
hoist the master. It took 40 minutes to get

him out. It also took considerable time to

get him ashore by a launch, while supporting
him on the vessels portable oxygen supply,
until it eventually ran out. The master was
pronounced dead upon arrival ashore, and a
post mortem examination concluded that
he died of a heart attack.

Lessons learned
The member in question had always focused
on safety on board and had up to this incident
not had any fatal accident on his vessels.
Good procedures were in place, experienced
personnel and adequate gas monitoring and
safety equipment were on board. Following
the accident a thorough investigation was

is highly toxic because it replaces oxygen in

the bloodstream.

2
To get the master out of the tank a chain block was rigged above the tank entrance. A chain
block is powerful but slow and it might have been faster to use a simple pulley block with
rope and a few crew members to pull.

Before entering the tank, the oxygen level

was tested, but no test for hydrocarbons or
CO was carried out, although testing for toxic
gases was called for in the Tank Entry Permit
Procedure. Tanker personnel may only think
about toxic gases from cargoes in this
context, but especially after the problems
of the inert gas generator, the possibility of
CO being present in the tank should have
been verified. The member has now
underlined the need to check for CO in the
revised entry permit form. Furthermore, the
paperwork was not fully completed before
entering the tank, and the exact level of
oxygen was not recorded. When the AB
collapsed, the masters rescue attempt was

carried out, as well as a review of the safety

procedures for tank entry. The case has since
been used as an example in the training of
personnel and other loss prevention
schemes. Gard commends the member for
these initiatives, because once tragic
accidents have happened, they can be used
to prevent others.
On the balance of probability, and judging by
his symptoms, it was concluded that the ABs
collapse inside the tank was due to carbon
monoxide (CO) poisoning. CO is a colourless
and odourless gas, produced by the
incomplete combustion of fuel. In a
combustion-based inert gas space there is
probably always some amount of CO. The gas

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heroic, but he should not have entered the tank

without the available breathing apparatus. It
is easy to say that with hindsight and from a
shore-based office, but being the captain of
the ship he should not have undertaken the
rescue task at all, and should have stayed in
command.

Ventilation of cargo tank No. 3 through the entrance opening.

Following the accident, the member has also

amended the Entry Permit to include a
requirement for all personnel to use ELSA
sets for entry into enclosed spaces, and to
carry gas monitors. As medical assistance and
transportation ashore was difficult to obtain,
the member also debated whether a PANPAN
or a MAYDAY signal should have been sent
out to speed up shore assistance, a decision
that would have been easier had the master
not been the one to be evacuated.