**Executive Summary**
This Casualty Circular, issued by the Directorate General of Shipping, Mumbai on November 17, 2023, reports on a tragic incident on February 10, 2017, involving the loss of lives of crew members who entered an enclosed ballast tank. The circular outlines the incident, its causal factors, actions taken, and lessons learned. It stresses the importance of enclosed space entry procedures and proper maintenance of vessels and cargo holds.
**Key Points / Main Content**
* **Incident Summary:**
* On February 10, 2017, crew members on an Inland Vessel engaged in lighterage operations entered the 3(S) wing ballast tank to address a water pumping issue.
* After initial crew members went unresponsive, further attempts to check on them resulted in more crew members collapsing inside the tank.
* Four crew members died due to toxic gas exposure; the Master initially survived but later passed away in the hospital.
* **Investigation Findings:**
* High concentrations of CO (19 PPM), H2S (32 PPM), and PH3 (22 PPM) were detected in the tank, indicating the presence of 'Phosphine'.
* Residues of fumigant from grain cargo transfer from mother vessels to the barge were identified as the source of the toxic gas.
* Pitting in the hold, inadequately repaired, allowed cargo and fumigant to leak into the 3(S) tank.
* **Causal Factors:**
* Entry into the tank without following safety procedures.
* Water and grain cargo entered the tank due to holes in the shell plating and cargo hold.
* Toxic gas formed from the accumulation of grain cargo soaked in water and fumigant residues, creating lethal phosphine gas.
* The mother vessel's fumigation practices did not adequately ventilate or gas-free the holds.
* **Actions Taken:**
* MRCC and Port control were notified.
* Entry was made with breathing apparatus to rescue personnel.
* The bodies of three crew members were removed from the tank.
* **Lessons Learned:**
* Enclosed space entry procedures must be strictly followed with required checks and precautions.
* Barges must be maintained in good condition to prevent leakages from the hull or cargo holds.
* Inland vessel crews require adequate training to handle perceived job risks.
* Merchant vessels handling grain cargo should comply with recommendations for safe pesticide use in cargo holds.
**Impact Analysis**
**Stakeholder: Inland Vessel Crews**
* **Impact:** Increased awareness of the hazards associated with entering enclosed spaces, particularly ballast tanks, and the importance of strict adherence to safety protocols.
* **Action Required:** Undergo comprehensive training to handle perceived risks and adhere to enclosed space entry procedures.
**Stakeholder: Barge Owners/Operators**
* **Impact:** Must ensure proper maintenance of barges to prevent leakages and potential accumulation of hazardous materials in enclosed spaces.
* **Action Required:** Implement rigorous maintenance schedules and procedures to maintain the integrity of hulls and cargo holds.
**Stakeholder: Merchant Vessels Handling Grain Cargo**
* **Impact:** Required to follow recommendations regarding the safe use of pesticides in cargo holds to prevent the transfer of toxic fumigant residues.
* **Action Required:** Comply with guidelines for safe pesticide use, including proper ventilation and gas-freeing procedures.
**Stakeholder: Port Authorities and MRCC**
* **Impact:** To maintain awareness of response protocols.
* **Action Required:** Review and update emergency response procedures for incidents involving enclosed spaces.
Key Entities Referenced
Directorate General of Shipping, Mumbai: Issuer of the casualty circular and primary regulatory body overseeing shipping activities.
Casualty Circular - 02 of 2017: The specific circular detailing an incident involving loss of life in an enclosed space (ballast tank) and subsequent findings.
Mumbai: Location of the incident (Mumbai port lighterage area) and the Directorate General of Shipping.
Ministry of Ports, Shipping and Waterways: The ministry which the Directorate General of Shipping is a part of.
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MINISTRY OF PORTS, SHIPPING AND WATERWAYS
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DIRECTORATE GENERAL OF SHIPPING, MUMBAI
Date:l7,.ll .2023
F. No.25-1 90 1 1 /6/2020-NT-DGS
Casualtv Circular - 02 of 2017
Su .: Los of liv s of crew members after en closed s ace s ta
Summary of Incident:
The subject vessel was an Inland Vessel, which was engaged in lighterage operations
with mother vessels for bringing cargo from Mumbai port lighterage area to the docks' On
lO.O2.2OlT,itwaslighteringcargoofwheatfromaSingaporeflaggedvessel'duringtheloading
of the barge, some of the cr"w *e-be.. were trying to pump out water from No' 3(S) wing tank
,rrirg a portubl. pump. There was some issue in pumping out of the water' hence to check the
."u,o,, fo, same, around 2145 hrs one of the crew member went inside the ballast tank, upon not
gettinganyresponsefromthecrewmemberwhowentinsidetheballasttank.twomorecrew
members went inside, however there was no response from them either, thereafter the barge
masterwentdowntheballasttanktocheckthestatushimself,howeverhefaintedatthebottom
of the vertical ladder. Thereafter, another crew member went down' but sensing something
wrong he immediately came out and was rescued by other crew'
Thereafter, the Port and MRCC was informed' and entry was made using breathing
apparatus, the crew members were found dead inside the tank' and the Master was found
unconscious,andwasrescuedfromthetank.TheMasterandothercrewwhocameoutofthe
tank,wereshiftedtohospitalimmediately,howevertheMasterdidnotsurvive.Thebargewas
then brought to dock and rernaining three bodies were recovered from the tank'
Duringinvestigation,itwasobservedthatthetankshadhighconcentrationofCo(19
PPM),H2S6zrrr',9andPH3(22PPM).Thisindicatedpresenceofextremelytoxicgas
,nnorfnin",aiso in the 3(s) tank, it may be noted that Phosphine is the most widely used
fumigant on board ships carrying grain cargoes. Hence, giving clear indication that the residues
of fuirigant got transferred utonJriitt tt grain cargo from the mother vessels to the barge, since
the barge was engaged in lighterage o" f grain cargoes for a period of three to four months
preceding the casualty. l'urthlr, due to piuing in the hold' which were inadequately repaired'
someofthecargoalongwiththefumigantleakedinthe3(S)tank,whichleadtolossoflivesof
ctew members who went inside the tank'
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gth Floor, BETA Building, l-Think Techno Campus, Kanjur Village Road, Kanjurmarg (E), Mumbai400042
rdHrr"t No., +g1-22-2575 2o4ot1lzg ftffi/F"r.' +g1-22-2575 2)2gt35 {-tfl/emait: dgship.dgs@nic.in aE(f{aruvebsite: www.dgshipping.govinCausal Factors:
1. Entry was made in the tank without following any safety procedures.
2. Water entered into the tank / space due to holes in the shell plating.
3. Cargo i.e grain entered the tank space due to holes in the cargo hold.
4. Toxic gas was present due to accumulation of grain cargo in the tank / space which
remained soaked in water for considerable period, and also due to residues of fumigant
which entered into tank and these factors resulted in extremely lethal phosphine gas in the
tank.
5. The mother vessel was fumigated using Aluminum Phosphate tablets but holds were not
ventilated or gas freed as per procedures.
Action Taken:
1. MRCC and Port control was intimated regarding the incident.
2. Entry was done using breathing appamtus to rescue the personnel, one found unconscious
was evacuated and hansferred to hospital.
3.
Bodies of three crew members were removed from the tank.
Lessons Learnt:
1. Enclosed space entry procedures are to be followed at all times, and no entry into
enclosed space should be made without required checks and precautions.
2. Barges in operation should be maintained in good condition without any leakages from
hull or cargo holds.
3. The inland vessel crew should be trained adequately to be able to handle all perceived
risks of the job.
4. Merchant vessels loading or discharging grain cargo's should comply with
recommendations on the safe use ofpesticide in cargo holds.
(Capt. V Singh Manhas)
Dy. Nautical Adviser cum Sr. DDG (Tech.)
To,
All stakeholders through DGS website.