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Master dies during enclosed space rescue

enclosed space
Image hereabove is used for illustration purposes only

Enclosed-space incidents continue to exact a heavy toll on seafarers, often because simple safety precautions are overlooked. A new Mars Report, issued by the Nautical Institute, refers to an enclosed space fatality on board an oil tanker in which an oil sampler had to be recovered from an empty tank.

The atmosphere was found to be 20.6% oxygen, with hydrocarbon at 26% LEL. The Master approved the risk assessment and work plan for two crew members to enter the space with emergency escape breathing devices. When they reached the tank bottom, the men felt dizzy; one exited but the other collapsed. Despite being warned not to, the Master entered the tank and was overcome. Although both men were brought out by crew wearing breathing apparatus, the Master could not be revived.

The Incident

While discharging an oil cargo from a tanker, an oil sampler 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 felt dizzy and 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.

Source: Mars Reports/ Nautical Institute


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  1. Capt. Sundeep S Shivangi


    Enclosed spaces are silent killers. It’s a fact which has been more than emphasised time and again. It’s really unimaginable how a Master of a ship can take such risks with HC being so high. And that too in today’s era where the dangers and the consequences are well known.

    • Afolabi Busayo

      Also the procedure was wrong as the master should not go in with out a BA SRT and also the crew was not suppose to use EEBD to enter a tank, its only used for escape

      Fully agree with you, Please do not forget deaths in enclosed spaces are not a risk on tankers, but also drybuld ships, when carrying oxygen eating cargoes of cellousa, such as wood chips or wood pellets. Many have died or become injured on ships carrying these cargoes.
      Everybody should cafefully follow the safety rules and use the proper safety equipment required. On tankers and on drycargo ships.
      Wire down the gas meter first!

    • When teaching STCW course I stress this all the time. Stick to the plan, there was BA at the ready so use it and do not be tempted to use a EEBD for any other use than exiting. Sad for the Masters family but a lesson for the classroom.

  2. Ewen Sutherland

    I cannot believe in these situations if they have BA equipment available why it was not used for the sake of recharging cylinders and cleaning surely in this day safety is paramount

  3. Capt. Shawkat Iqbal

    The incident highlights the incomprehension of the crew members and surprisingly of the master of hazards involved with enclosed spaces, espicially when HC level was so high.
    EEBD should not have been worn for such operations and master should have follow procedures. This is total disregard for safety; time and time again we have seen that such practices have costed very dearly.
    This raises a serious question on the training, experience and competence of the master !

    How many lives have to be lost before we learn?

  4. Henning Heinemann

    WTF? They had SCBA breathing devices on hand, why weren’t the first two guys wearing them? This was death by stupidity.

  5. Cap/ O. RODRIGUEZ

    If the circunstance said that you need to enter the the cargo tank to avoid a further isquemia, you never consider do it using an EEBD, you have yo use a BA of long time period

  6. May the Master’s soul rest and wish solace to his family and crew. That said, BA sets are to be used for such work (EEBDs are meant only for escape). That should be in the SMS documents.

    Secondly, just as in the case of hot work, the home office should approve the risk permit. In this case, it was a three day build up and there was sufficient time for the full involvement of the home office staff. My take is that even if it was a case of a three day preparation (but an on the spot assessment to enter the tank), the home office staff must be made aware of the decision on the risk permit and must be party to it.

  7. Captain felt a huge obligation of responsibility and made a choice that killed him. Going in without oxygen was a mistake other ways to die include going in with a half full bottle of oxygen.

  8. Why wasn’t the gas detector lowered on a rope to get the reading first? Surely that is procedure.

  9. Alexander Hyslop

    The tank at 26% HC was unsafe for entry under any circumstances. If entry was necessary to save a life
    or the vessel full BA should have been worn, safety lines used and lifting device set up to pull the men out
    if they showed any sign of being in trouble.
    I sailed for 44 years on tankers from junior engineer to chief engineer, worked in tanks many times but
    never entered a tank with a reading above 2% HC.

  10. cusrow minocher

    My condolences to those who suffered loss of life.
    basics were missing or ignored.
    Mistake 1: System failure that allowed entry. How did the enclosed space entry permit conditions allow entry with 26%LEL? Against ISGOTT clearly requiring: Oxygen 21% LEL <1% and Toxic Gases NIL. System failure?
    Mistake 2: ELSAs are not for entry but for escape! EEBDs are only for use in escape in smoke filled atmospheres in accommodations.
    Mistake 3: Having a BA set ready yet not donning it or utilising it! WHY? WHY? Even after reprot of gas and one man collapsing? This kind of mistake was made in case of Neptune Crux 20 years ago which lost 5 persons in similiar conditions!!!
    Mistake 4: The loss of a sample would do no great harm staying inside the tank. Risking life to retrieve it was never worth it. Risk assessment was obviously wrongly done or done for paperwork only!
    Mistake 5: Not knowing or not accepting the fact HCs are to be found and will displace Oxygen in the bottom 2 metres of the tank.
    Mistake 6: Master should have ordered complete emergency evacuation the moment first alarm went off.

    I have and do not deny having done a thing like this, {now I say I was young and stupid then} entering a COT knowing there was 7% LEL. It was done under great commercial pressure and recklessness at the time. Would I do it again? NEVER knowing the dizzying conditions even at 7% LEL.

    But these things have never stopped and will keep happening again and again simply because of company work cultures that put pressure on ships staff. The staff was under pressure to close out the operation after 3 days of venting.

  11. May crew member’s soul rest in peace. This accident could be avoided if they use scba sets or best approch reduce hydrocarbons and toxic gas of life is most important.

  12. capt. roonama

    Dear all good day
    Many of the comments you’ve used, were useful and valuable, but judgment with this tiny information is not fair.

  13. Ole Pedersen

    It is almost incomprehensible to once again experience a situation of a Master failing to understand, that his position of command oblige him to be in overall control and not showing a single ” I will fixed it if no one else apparently are unable to”. His obligation in this particular situation is to have a cool mind and resolute and constructive attitude to evaluated what remedy is the best, most logically and given under the present situation, the best chance of success without further loss of life. That being either with further action by the crew or by shore assistance.

  14. The confined space issues are well noted – but how could they do this if properly trained?

    Read the full report; it’s interesting that the Master had no alternate who knew the password for company e-mail. (see page 12)

  15. Quite enough has been said highlighting the failures that led to the death of the unfortunate master. One other point comes to mind – Besides HC LEL limits, a simple thing that was emphasized in our tanker safety courses – if the Oxygen level is below 20.9%, then there’s something else in there, and that something could kill you. Remember that, and it will help keep you alive.

  16. Capt. Nilesh Kalyanpur

    May the departed soul rest in peace and heartfelt condolences to the family. Cant imagine the kind of pressure the master would have been undergoing in order to approve and undertaking the responsibility for this dangerous operation.
    1. The damage / loss caused by the sampler at the bottom would have been very minimal as compared to what it is now.
    2. I must confess that I have been party to such sort of unsafe tank entry acts and have authorized several such stupid acts. These types of dare devilry was prevalent 20-25 years ago. I am sure that many of colleagues will agree with me. With hindsight I can say that we all were safe due to sheer luck. Possibly with time and age, we all learnt how to deal with such kind of pressures and situations and stopped these activities. Thanks to the ISM Code and general awareness in the maritime industry, I believed that these kind of practices would have stopped long long ago.. Cant imagine it still prevails.
    3. The tank with LEL >1% should not have been entered (even with operational BA set). An entry with an operational BA set should be in every case of tank entry and when LEL less that 1%.

  17. Capt. Salil Srivastava

    It was appalling to read such accidents.. When the basics are ignored, tragic deaths are bound to happen. The enclosed space permit system check list were not followed to the letters and spirits.
    Why was it decided to enter in the enclosed space with such high HC?
    Why EEBD when it was known still to have high HC?
    EEBD is meant for escape not entry.
    Why was SCBA not used even though it was ready at hand?

    Depite the emphasis on following the permit systems and check lists over many years, such accidents brings our efforts back to zero.

  18. Capt. G. Suquinagua

    Lamentable loss of human life. However further of the facts like The EEBD are to leave, not to enter, and try to understand what passed through his head at that moment the captain. Is important to Know:
    The facilities have had this oil tanker
    How removed hydrocarbon gases, and achieved as appropriate oxygen concentration.
    Used they the inert gas plant for supply inert gas properly and purge the hydrocarbon gases in cargo tank from the volumetric concentration to lower them as close to 1% by volume of safe way. Monitored they the atmosphere with an HC detector (volumetric scale) and appropriate Oximeter for inert atmospheres to verify the quality of the inert gas used, for this first step in the exchanging of the atmosphere ???????
    Then subsequently using the same blowers of the plant, supplied they air properly to the cargo tank to lower the concentration of hydrocarbon gases to below 1% of LEL, while increased oxygen up to 21%, and eliminates toxic gases, especially H2S and Benzene. Monitored the atmosphere with an HC detector (scale of LEL), oximeter, and toxic gas detection equipment or colorimeters, for this second step of the exchanging of the atmosphere ???????
    As we noted above to prepare a cargo tank to enter, so it is simply to remove something that should not be inside, such as a sampler, mainly and primarily involves spending TIME and ENERGY RESOURCES onboard, which should raise awareness Masters, Shipowners, Operators and Charterers and be involved as well.

  19. Capt Joselito Amahan

    Obviously the Risk Assessment and Management procedure for Hazard Identification werent properly quantified , the Master wasnt realistic and considering the consequences in doing so,being shown that the tank atmosphere HC 26% and oxygen 20,6 were the risk so High ( intolerable/unacceptable level ), master should lower then to acceptable level ( ALARP ) or As Low As Reasonably Practicable…awaiting until the LEL reading less than 1 % and oxygen to 20,9 %…. He should think that Master sole duty and responsibilty is to ensure proper implementation of ( SMS ) safety onboard ,,,, were crew’s life is “PRICELESS”…


    terrible mistakes assumed
    1 is not allowable to go into with 26% LEL and Oxigen less than 20.9%
    2 Many times the commercial terms superseded the safety of life terms which is not correct
    3 The Master of the vessel never have to go into as the rescue person he must be coordinating

    We as crew memebers have to advice the compañy about the high risk on this entrance

  21. Capt. Jorge Ruiz

    Desperation and self confidence is a dangerous mixture. Safety considerations must be always before any action taken, and that can be accomplished only by a solid safety training.

    Several improper actions and safety measures caused two men dead. This is something that never had to happen in a well trained crew with a correct situational awareness.

    My deepest condolences to their families and colleagues.

  22. Capt. Mian Qayyum

    Sorry to hear about loss of Human Lives. But do you believe that reports prepared and sent by ship are true and accurate?????????

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