Master – All Vessels

Dear Captains,

We are extremely saddened to report an unfortunate incident onboard a Bulk Carrier,

wherein a deck cadet lost his life after entering into a cargo hold, partially filled with the
cargo of coal.

WHAT WENT WRONG (from preliminary reporting) ?

1. Vessel was in port, discharging bulk coal. Cadet, along with the ordinary seaman
was assigned the task of taking photographs of the booby hatch entrances and
general condition of the Australian ladder.
2. The Australian ladders on this vessel is “fully enclosed type” i.e. the ladder is
fully encased by steel structure in order to avoid cargo finding its way into the
ladder area. Please see the attached photograph showing the ladder
arrangement.
3. The openings are only on top and in the bottom. However, the bottom opening
of the Australian ladder was already blocked by the coal cargo.
4. As a result of above, the Enclosed space containing Australian ladder probably
had accumulation of toxic gases like METHANE, Carbon Mono-oxide and lack of
oxygen in this space. Even hold ventilation at sea would not have resulted in
proper air-circulation of this enclosed space.
5. The Hatch-covers were open for cargo discharging and this would have given a
false sense of safety to the crew.
6. At around 6 PM, when rest of the crew were knocked-off for the day, Cadet
opened the No.6 Cargo hold booby hatch entrance and entered alone into the
space. No other crew was standing-by or monitoring this activity.
7. In a short while, Chief Officer started calling Cadet on Walkie-Talkie and asked
Bosun to look for him. Bosun while looking for the Cadet, reported that
apparently Cadet has fallen on the ladder of No.6 cargo hold.
8. Chief officer rushed to the hold and instinctively entered into the space to save
the Cadet. However, he too became unconscious on the ladder.
9. Crew immediately mustered with SCBA sets and took both of them out on Deck,
first-aid given and taken to Hospital. While C/officer recovered, unfortunately,
Cadet lost his life.

LESSONS LEARNT:
 1. Company procedures, Health & Safety Manual section 9 and Cargo operation
manual (Non-Tanks) section 2.1.3 states that Loaded / Partially Cargo holds are
to be treated as “Enclosed Spaces” and all precautions / checklists and permit
requirements shall be strictly complied with.
2. Every entry into Enclosed spaces must be supervised and lone person must not
be allowed to enter any such space.
3. Company’s Cargo Operations Manual (Non-Tank) section 2.1.8 requires that prior
to their arrival in to discharge port, Master must ensure that cargo hold
entrances are locked and keys are retained by the Chief Officer. Cargo hold
entrances shall be opened only after checking cargo hold atmosphere for safe
man-entry and receiving C/officers permission.
4. Bulk cargoes like Coal, Copper concentrates etc will cause oxygen depletion and
presence of toxic gases. The presence of these gases cannot be ruled out in
certain pockets, even after cargo hold ventilation. Hence, personnel entering into
the loaded cargo holds must carry personal gas meters, even if the atmosphere
is checked and considered safe for entry.
5. On Bulkers carrying hazardous cargoes, crew may get a false sense of safety if
cargo hatch-covers are open and they may not realize the risk of asphyxiation /
exposure to Toxic gases.
6. All Booby hatch entrances shall be marked with warning sign “Danger”
and “Lack of Oxygen”.

Company has a ZERO tolerance approach towards non-compliance with Enclosed Space
entry procedures. Any activity requiring Enclosed space entry must be discussed during
daily TOOL-BOX talk and required precautions must be taken.

Please carry out a SAFETY STAND-DOWN and discuss this high-level safety alert with all
staff onboard. We would like to receive a duly signed copy (signed by all staff onboard)
of this message to confirm understanding and strict compliance with Company
procedures in this regard.

Kind regards,
FML, QMS
(As agents)

SAFE CREW, SAFE SHIPS, CLEAN SEAS