Lack of Training Implicated in Enclosed Space Deaths

The UK Marine Accident Investigation Branch (MAIB) has issued its report on the deaths of three stevedores in a cargo hold access space on board the bulk carrier Berge Mawson.

On the morning of 27 June 2022, three unconscious stevedores were found in a cargo hold access space on the Isle of Man registered bulk carrier Berge Mawson at Bunyu Island Anchorage, Indonesia. Despite prompt medical attention all three men died.

Berge Mawson was loading coal from barges using a floating crane. During a pause in loading due to heavy rain, all hatches were closed. After the rain stopped, a stevedore attempted to access a bulldozer in cargo hold No.7 but mistakenly entered the access space of cargo hold No.8 and was overcome. Two other stevedores collapsed while attempting to rescue him as crew collected rescue equipment.

The key safety issues identified were:

• The three stevedores died because the access space had an oxygen depleted atmosphere that could not sustain human life.

• Access hatches into cargo spaces were not locked when not in use.

• The stevedores had not been trained on safe cargo work on board bulk carriers or on the dangers of enclosed spaces.

A recommendation has been made to the Maritime and Coastguard Agency to review and revise the Code of Safe Working Practices for Merchant Seafarers to ensure that emergency drill scenarios for enclosed space rescues include the possible presence of shoreside staff or third parties.

Recommendations have also been made to Bunyu Port Organizing Unit, PT Bintang Kartika Segara and PT Tanjung Mas to follow the guidelines set out in the IMSBC Code, BLU Code and BLU Manual to provide stevedores with training and PPE to enable them to work safely on board bulk carriers.

A recommendation has been made to Berge Bulk Maritime Pte. Ltd maintain clear and precise guidance for masters and ships’ crews on cargo operations and ensure that specific duties for shore personnel are considered and the control of access is robustly applied.

Recommendations have been made to Intercargo, InterManager and RightShip to develop a minimum operational safety standard for stevedores conducting cargo operations on board their members’ vessels to include and encourage their members to introduce the minimum operational safety standard for stevedores.

Andrew Moll OBE, Chief Inspector of Marine Accidents said: “Cargo operations on board bulk carriers require stevedores and other shore workers to carry out tasks on board, often working separately from the crew. In this accident, it is evident that the stevedores did not have sufficient understanding of the hazards posed by coal cargoes nor, more worryingly, had they received training about the dangers associated with entering enclosed spaces.

“Although Berge Mawson’s crew were well-trained in their emergency response to enclosed space accidents, their drill scenarios did not involve shore workers who could be on board at the time. In the crew’s rush to collect rescue equipment they left the entry point to an enclosed space containing a noxious atmosphere unguarded, and this oversight tragically led to the second and third stevedores dying in a well-intentioned but misguided attempt to rescue their colleague.

“Despite international and industry guidance on the training stevedores should receive before working on bulk carriers, InterManager data shows that, of the 257 enclosed space fatalities reported between 1999 and 2023, 67 (26%) were stevedores or shore workers. To help prevent further loss of life it is essential that bulk carrier and terminal operating procedures, practices and training equip shore workers to operate safely on board the vessels they attend.”