Date of occurrence	:	July 2019
Type of Vessel	:	Chemical/Oil Products Tanker, GT 24222
Location	:	Vessel in port – during cargo operation

What happened

A tanker, berthed alongside an oil terminal, completed discharging its Crude Palm Oil cargo using its cargo pump.

The Bosun and two Able-Bodied (AB) Seamen were then tasked to squeegee the cargo in the No. 4 Port Tank (4PT).

While working in the cargo tank, the Bosun felt dizzy and had difficulty breathing. Assisted by the two ABs, he managed to walk up to the 1st platform of the cargo tank. Feeling extremely weak, the Bosun was unable to proceed further and he was then hoisted to the main deck.

The Bosun appeared to have lost consciousness and the terminal was notified to provide medical assistance.

While waiting for the paramedics to arrive, the tanker’s officers rendered first aid by administering oxygen to the Bosun.

The paramedic boarded the tanker and the Bosun was ascertained to have no heartbeat. The Automated External Defibrillator (AED) was applied to him, followed by Cardiopulmonary Resuscitation (CPR).

A short while later, the Bosun regained consciousness. He was then transferred in an ambulance to the hospital for further treatment and assessment.

Findings

To prevent crude palm oil cargo from solidifying, and for ease of discharge, the cargo is heated by passing steam through the pipes (heating coils), raising the temperature inside the tank to about 55ºC.

The Bosun had been working inside the cargo tank for over 1 hour when he felt dizzy and had difficulty breathing. This led to his subsequent fainting/loss of consciousness. He had suffered the ill effects of the heat and odour from the crude palm oil cargo inside the tank.

The tanker’s Risk Assessment Form (TSM Form 089) identifies the hazard of overexposure to tank conditions and permitted each crew to remain inside the cargo tank for a maximum of 30 minutes.

The person in-charge of the tank stripping/squeegeeing operation had failed to ensure that crew working inside the cargo tank are to be relieved after 30 minutes – not complying with safety control measures.

Causal Factor

Poor Operation:

The person in-charge of the operation had failed to comply with the vessel’s SMS procedure for working inside the cargo tank – where the crew would be subjected to overexposure to the tank’s hot, humid and foul-smelling conditions. Had the crew involved in the squeegeeing operation been relieved every 30 minutes, the incident could have been averted.

Root causes

1. 1. Lack of risk assessment
   The crew involved had failed to fully assess the hazardous working condition and precautionary measures to mitigate the hazards.
2. 2. Inadequate briefing/supervision
   The person in-charge had failed to brief the crew about the situation/tank condition. He also did not monitor the tank temperature and the progress of the tank cleaning operation.

Lessons Learnt

• The crew involved in working inside tanks should be familiar with the requirements/recommendations of the guide ‘Entry into Enclosed Space’ and be aware of the risks/hazards involved.
• The crew should be encouraged to intervene/use the STOP card when coming across unsafe acts/conditions.

Recommendation

• Ship owners, managers and masters should ensure that the crew complies with procedures stated in the Safety Management System when tasks are performed onboard.
• Marine Superintendent shall carry out real-time cargo audits, to observe loading/discharging/tank stripping/tank cleaning operations.