A Grand-Daughter’s Grief

February 5, 2008


The Viking Islay

Mary-Laura O’Brien, granddaughter of Bob O’Brien, on of the three casualties of the Viking Islay incident has responded to the Chain Locker Assassin post:

“My grandad was one of the three men that was killed in the Viking Islay accident. I say “accident” lightly as i cannot comprehend the fact that such a small matter of having a alarm in place could have prevented this from happening, shipping companies (Vroon offshore in particular) have alot to answer for if they cannot even manage to obide within simple health and Safety laws. No one should die of something so preventable. It makes me sick just thinking about it. I hope that some good may come of this tragity in highlighting the need for far tighter and stricter health and Safety laws.”

Bob O’Brien,59, from Leven in Fife, was a coxswain aboard the 53 metre emergency response and rescue vessel Viking Islay supporting the Ensco 92 drilling rig on BP’s Amethyst Field in the Southern North Sea when the accident occurred.

Along with two others, Finlay MacFadyen, 46, from Aberdeen and boatman Robert Ebertowski, 40, from Gydnia, Poland, he entered the vessel’s anchor locker on the tween deck to secure anchor chain, leading to deaths of all three.

anchor locker Viking Islay
Three men entered the anchor locker
The Maritime Accident Investigation Branch is currently investigating the incident.
While we cannot comment until the final report is released, the fact is, as Ms. O’Brien says, No one should die of something so preventable.

Confined Space Casualties – Worse Than Expected

February 4, 2008

Early results of a study by the Maritime Accident Investigators International Forum, MAIIF, of accidents in confined spaces aboard ships suggest that the problem may be far bigger than anticipated. Despite decades of regulation and training, it’s a problem that continued to take the lives of seafarers at an alarming, and under-reported rate.

Still incomplete, the MAIIF figures report 44 deaths and 66 injuries in 63 incidents on ships of 15 Flag States since 1993. The data was supplied by the UK’s MAIB and similar organisations in Vanuatu, Latvia, Cyprus, Marshall Islands and Germany. Figures for Hong Kong have yet to be included and more information has been promised by Sweden and South Africa and Finland.

In an email to MAIIF members, Don Sheetz of the Vanuatu administration, who has been tasked with gathering information for the report, says: “The information obtained so far is very troubling as the problem we originally identified may be even larger than anticipated.”

The study began following last October’s MAIIF meet in Beijing and an impassioned speech by Sweden’s Captain Sven Andersen to 60 maritime investigators from 28 maritime adminmistrations anbd presentations by investigators on a variety of incidents.

A review of incidents already show that a confined space “may be any space, of any size, containing cargo, oil, water, petroleum, or nothing at all. A confined space may even be, as in the case of the fatality on the Monika a cabin where a crewmember died,” says Sheetz.

A new approach may be needed in defining a confined space. Says Sheetz: “It is apparent that the issue of confined space entry is not a single dimensional issue about entering a space which could be defined as a potential risk, but a multi-dimensional one where any space could, by virtue of its cargo, lack of oxygen, use of toxic chemicals, gaseous atmosphere, inerting, etc., cause death or injury, either shortly after the person enters or even several hours later. And the space could be a tiny lazarette, a battery room, a diesel engine cylinder, a boiler, a paint locker, an access way, a cargo hold, a cargo tank, a pump room, a chain locker, a fore peak or after peak tank, void spaces, fish meal processing rooms, the carpenter’s shop, etc. It could be small enough to permit access only to a person’s head or it could be 100,000 cubic meters or more in size.”

Bob Couttie, administrator of Maritime Accident Casebook, a maritime safety internet site at
www.maritimeaccident.org, which operates a confidential reporting system for seafarers, says: “Confined spaces often don’t have visible hazards so there’s a lot of complacency. Very saddening are those cases in which would-be rescuers come to grief trying to save a fellow seafarer. What we have to look at is how to establish and maintain seafarer competency in the workplace. Until the industry addresses the competency issue we’ll go on seeing this kind of incident.”


Do you have experience of a confined space incident, an actual or close call incident, whether officially reported or not? Sharing that information through the Maritime Accident Casebook confidential report system might help save the lives of other seafarers. Your identity will remain confidential. The address is confidential@maritimeaccident.org.

Grinding teeth, staying alive in Enclosed Spaces

December 11, 2007

Whenever one talks to maritime accident investigators about deaths in enclosed spaces one can hear the distinct sound of teeth grinding with furious frustration at a situation that should a rarity but which seems impervious to solution.

After The Case Of The Electric Assassin went online a leading accident investigator sent this comment:

“Your Zebu Express 1-1-1- trichloroethane case where the 2 guys were
overcome in the bowthruster room reminds me that we had exactly the same
case on the Cold Express back in 1994. 2 guys died while using Drew
electric parts cleaner — 1-1-1 trichloroethane: they were overcome in
the bowthruster room while cleaning up after a leak. The rescue attempts
were like a Keystone cops movie with people not knowing what they were
doing, SCBA bottles running out of air, etc.”

The Ice Express report is almost a photocopy of the Zebu Express incident and you can download the Ice Express report here .

There appear to be several other cases, which we’re checking out, that are remarkable in their similarity – two seafarers go into the bowthruster compartment, use a non-flammable solvent, take a break, return to work, and die, followed by rescue attempts characterised by incompetence and equipment failure.

1) Regard all solvents as deadly, especially chlorinate hydrocarbons.

2) Read the precautions on the label and follow them.

3) Read the MSDS, anything you don’t understand, ask about.

4) Know the symptoms of over-exposure, such as fatigue, dizziness, breathing difficulty, unsteadiness and evacuate the space if you feel them.

5) Watch for evidence of such symptoms in those you are working with and evacuate the space if they appear.

6) If possible, open doors and hatches to the space 24 hours before work starts.

7) Use whatever equipment is available to thoroughly ventilate the space, not only putting fresh air into it but removing contaminated air from it.

8) Always have someone on safety watch beside the point of entry with a means of communication – even if it’s a whistle – to call for help.

9) Always have SCBA and rescue equipment beside the point of entry ready for use.

10) Check that SCBA air bottles are full and the equipment working. Don’t wait, check it now.

11) If you don’t know how to use SCBA, find out and practice now.

12) If you haven’t practiced rescue from an enclosed space, do it now.

13) Read your ship’s SMS regarding enclosed space entry and emergency procedures. Do it now.

14) Strictly follow enclosed space entry procedures. Refresh your memory in the ship’s library, now.

15) When you tick off the boxes on an enclosed space entry checklist, make sure everything you’re ticking off is there or has been done.

16) Before entering an enclosed space, do a risk assessment, identify the hazards and make sure you either removed the hazard or can respond appropriately if it happens.

17) Check the air before entering and regularly while work is going on.

In EVERY case of enclose space entry deaths four or more of the above have not been followed.

Enclose Space Entry – Complacency Cannot Be Allowed To Grow

December 7, 2007

Commenting on the recent meeting of the Maritime Accident Investigators International Forum in Beijing, Stephen Meyer, Chief Inspector of Marine Accidents for the UK’s MAIB writes in the latest Safety Digest, released this month,

“Please read these cases and then consider, if accident investigators from around the world all see these same issues time and again in accidents, how confident are you that you/your ship/your company are getting them right?

The other key concern we all shared was the apparent growth in the number of accidents involving entry into enclosed/confined spaces. Although there are no examples in this Safety Digest, MAIB is currently dealing with three such cases, two of them fatal, and many other countries at MAIIF reported similar. Please look again at your systems and re-brief your crews on the importance of correct ventilation and entry procedures. This is a critical area, where complacency cannot be allowed to grow.”

Enclosed space entry accidents are a hot button for MAC. They’re covered specifically in two episodes (The Case Of The Silent Assassin and the Case Of The Electric Assassin – due for broadcast 7th December) as well as the related Case Of The Lethal Lampshade – all available on the podcasts page.

Sadly, such cases often involve multiple casualties: the seafarer who was first effected followed by the would-be rescuer/s.

Of the incidents we’ve looked at to date one theme seems to be consistent: ship’s officers who think they’re smarter than the people who wrote the enclosed space safe entry procedures and set poor safety standards that they pass on those those under their command. Poor monitoring of safety procedures by the ship’s management and an almost total lack of competency assessment compound the problem.

Be pro-active. Always assume an enclosed space is dangerous, because it is, know the rules about safe entry and stick to them.

Enclosed Space – Two Lucky People – The MAIB PE For Panguric II

November 20, 2007

Panurgic II

Category Merchant
Vessel name Panurgic II
Manager: Privately owned
Type: Hopper/Dredger
Built: 1950
Construction: Steel
Length overall: 34.74m
Gross tonnage: 139.9
Date & Time 14 October 2007, 1420 (UTC+1)
Location of incident: Flixborough Wharf, River Trent
Incident Type: Accident to person
Persons onboard: 3 crew
Injuries/fatalities: 2 crew injured
Damage/pollution: Vessel holed prior to accident – no pollution


On 14 October 2007 the hopper/dredger Panurgic II was dredging at Flixborough Wharf on the River Trent, when water was observed entering her accommodation space.

The skipper started the bilge pump for that space and manoeuvred the vessel onto a mud bank at the end of the berth to ensure she was safe. The crew then placed a portable, petrol driven, pump into the accommodation space, which was located below the main deck of the vessel.

With both pumps coping with the ingress of water, the skipper manoeuvred the vessel off the mud bank and positioned her alongside the wharf. He then left the vessel to purchase repair materials from a nearby store. Two crew members remained on board to oversee the continuing pumping operation.

While the skipper was ashore, the vessel took the bottom and trimmed by the head as the tide ebbed. This resulted in water flowing forward from the accommodation space into an adjacent confined space.

At this point the pumps in the accommodation space lost suction and the two crew members decided to move the portable, petrol driven, pump into the adjacent confined space. They attempted to gain suction with the pump positioned on deck, but this proved unsuccessful, so they lowered the pump into the space and then entered the compartment to place the suction hose in the water. This proved successful and with the pump working well both men left the space.

Some time later the pump lost suction and one of the crew members went into the space to investigate. His colleague then joined him in the space and together they managed to regain suction on the pump.

However, the first crewman to enter the space then reported feeling dizzy and was making for the ladder when he collapsed and lost consciousness. The second man then stopped the pump and left the space to get a rope to pull his colleague out.

Fortunately, the skipper and another man returned to the vessel at this time and were able to quickly extract the unconscious crew member from the space. They applied first aid and summoned an ambulance. The crew member regained consciousness as the ambulance arrived.

Both crew members were taken to hospital. They were found to be suffering the effects of carbon monoxide poisoning and spent some time in hospital before recovering fully.

A hole in the vessel’s bottom was eventually located and plugged. The vessel then proceeded to dry dock for permanent repairs.

Action taken:

The Chief Inspector of Marine Accidents has written to the owner of Panurgic II commending him on the actions he took to ensure the vessel’s safety after the hull was breached and in giving prompt first aid to the injured crewman. The Chief Inspector also stressed the importance of undertaking risk assessments for on board operations to help in ensuring that they are conducted in a safe manner, referring to the operational guidance contained in the Code of Safe Working Practices for Merchant Seamen.

The owner has scrapped the petrol driven pump and replaced it with a diesel pump capable of obtaining suction from the deck.

New Episode: The Case Of The Lethal Lampshade

November 9, 2007

Episode 10 of Maritime Accident Casebook is now online:

Three men lay more than a hundred yards from the thick torn metal that once covered the top forward ballast tank, they were dead.

In the gathering darkness, in the roughening seas around the ship, the bodies of four other men were being carried away on the current, three of them never to be found.

Inside the gray powder-coated ballast tank, burned and injured one man lived. He would not survive his injuries. The last sound he heard, if he heard it, before the massive explosion may have been the quiet pop of a light-bulb breaking…

It wasn’t the Silent Assassin that killed the eight men aboard
the Nego Kim, it was a deadly lampshade.

Lethal Lampshade

Go to the Podcast Page, Click Here

Headwind Of “Huh?” And Death In Spaces

November 8, 2007

The Viking Islay incident has sharpened up concern about the continuing number of fatalities in enclosed spaces aboard ships. The Maritime Accident Investigators International Forum, MAIIF, has got the bit between its teeth for a submission to the IMO. Talking to maritime investigators regularly what comes through is a sense of frustration at being called upon to investigate the same sort of incidents, with the same type of fatalities, time and time again. Their job, after all, is to find out the lessons to be learned from such incidents and disseminate those lessons throughout the industry, but not enough people seem to be listening.

What is especially tragic is that all too often seafarers die trying to save others who have got into trouble in enclosed spaces, often officers whose responsibilities include supervision and enforcement of safe entry procedures.

So what on earth is going on?

At the heart of this problem is competency, or competency assurance, a concept that seems to be having a hard time against a headwind of “huh?” from the industry. Competence is the ability to carry out a task safely to a given standard.

Successfully completing a course in, say, enclosed space entry, on board, on shore, online or on a computer doesn’t assure the seafarer’s competency in the workplace. It certainly doesn’t provide any assurance that a seafarer will remain competent in six months or a year’s time. People forget, they acquire bad habits, both of which feature in The Case Of The Silent Assassin. Sometimes they haven’t been adequately trained or simply don’t understand what an enclosed space actually is or where the danger comes from.

If there is to be a solution to the continuing unnecessary deaths of seafarers it must be holistic. It has to start with onboard assessment of seafarer competency to identify the training needs that will keep them alive.

It’s a fairly commonsense approach but one which the industry has yet to accept but until it does seafarers will go on dying in the numbers they do now.