BRAZILIAN NAVY DIRECTORATE OF PORTS AND COASTS

Transcription

Brazilian Navy - Directorate of Ports and Coasts
Marine Safety Superintendence
Department of Inquiries and Investigations of Navigation Accidents
Accident with people in the vessel ”UBC TOKYO”
Marine Safety Investigation Report
\
BRAZILIAN NAVY
DIRECTORATE OF PORTS AND COASTS
ACCIDENT WITH PEOPLE IN CONFINED SPACE OF THE
M/V “UBC TOKYO”
JUNE 28, 2014
MARINE SAFETY INVESTIGATION REPORT
The ship UBC TOKYO at the Praia Mole Terminal, Port of Tubarão, on the day of the
accident.
Reference :
Accident Investigation Code of the International Maritime Organization (IMO) MSCMEPC.3 / Circ.2, of 13 June 2008 / Resolution MSC.255 (84)
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INDEX
LIST OF ABBREVIATIONS ............................................... ...................... 2
I INTRODUCTION ................................................ .....................................3
II SYNOPSIS ................................................ ...............................................3
III GENERAL INFORMATION ............................................... ..................4
IV DATA ACCIDENT SITE ........................................................................6
V HUMAN FACTORS AND CREW ...........................................................7
VI SEQUENCE OF EVENTS ......................................................................8
VII PROCEDURES AFTER ACCIDENT ...................................................8
VIII CONSEQUENCES OF ACCIDENT ....................................................9
IX EXPERT EXAMINATION ……………………………………………..9
X ANALYSIS OF DATA COLLECTED AND CAUSAL FACTORS .......13
XI LESSONS LEARNED AND XI PRELIMINARY CONCLUSIONS ....14
XII SAFETY RECOMMENDATIONS .......................................................15
XIII LIST OF ANNEXES ............................................................................16
2
LIST OF ABBREVIATIONS
CPES - the Port Authority of the Holy Spirit.
DPEM - Damage Compulsory Insurance for Personal Injury Caused by Boats or on its
Load.
IMO - the International Maritime Organization
ISAIM - Security Investigation of Marine Casualties and Incidents
ISM Code - International Safety Management Code
MSC - Maritime Safety Committee of the International Maritime Organization.
NR 33 - Regulatory Standard No. 33 - Health and Safety at Work in Spaces Confined.
SQMS - Health, Environment, Safety and Quality.
STCW 78 - International Convention on Education Standards, Certification and Watch Keeping
for Seafarers, 1978.
VHF - Very High Frequency (very high frequency of 30 MHz to 300 MHz).
2
I – INTRODUCTION
For the purpose of accomplishing the collection and the analysis of evidences, the
identification of the causal factors and the elaboration of the recommendations of safety that are
necessary, in order to avoid that in the future occur similar maritime accidents and/or incidents,
the Port Captaincy of Espírito Santo( CPES ) carried out the present Safety Investigation of
Maritime Accidents and Incidents (ISAIM) in compliance with that laid down in the Code of
Investigation of Maritime Accidents, of the International Maritime Organization (IMO), adopted
by Resolution MSC.255(84).
This Final Report is a technical document that reflects the result obtained by the CPCE in
relation to the circumstances that contributed or may have contributed to unleash the occurrence
and does not resort to any procedures of proof for verification of civil or criminal responsibility.
Furthermore, it should be emphasized the importance of protecting the person responsible
for the supplying of information related to the occurrence of the accident, for the use of
information included in this report for ends other than the prevention of future similar accidents
may lead to erroneous interpretations and conclusions.
II – SYNOPSIS
In the period when it was in the discharge of the coal, when the merchant ship UBC
TOKYO, was docked at the Praia Mole Terminal, a crew member died and two others suffered
physical damage, in the accesses to the cargo hold #5. The vessel in question is a ten years
freighter used in international shipping, flying the flag of Cyprus. Its special features are detailed
below. There was no damage to the vessel.
Chronology:
The docking of the ship in Praia Mole occurred in June 27, 2014, around noon
day,
and
at
13.20
began
the
unloading
of
the
hold
#5.
At
4:00
a.m.
this basement was empty and clean. The accident occurred at about 5:20 a.m. in the duct
Australian ladder (1) for access to the basement. By decision of the Captain, the operation of
discharge of other basements was paralyzed for usual procedures related with the accident
investigation. The CPES took note of the fact on the afternoon of the 28th, through a call from
the Maritime Agency representing the Owner of the ship, in Victoria.
(1) This name is derived from Australian legislation (Marine Order No. 32) that prescribes the requirements for operations of
loading and unloading of ships, including access to cargo spaces and cargo holds. Basically, this Standard establishes the design
and construction requirements of the stairs.
3
III - GENERAL INFORMATION
a) vessel specifications - UBC TOKYO (photo 1):
Photo#1 - ship moored in Praia Mole, on the day of the accident
Type of vessel: multipurpose dry cargo freighter and containers.
Place of Construction: Saiki Industries Co. Ltd, Saiki, Oita, Japan.
Keel beat Date: December 17, 2004
Date of delivery: 05 October 2005.
Hull material: steel.
Length: 182.59m.
Length between perpendiculars: 174.60m
Breath: 28.60m.
Molded depth :15,06m.
Gross Tonnage: 24,140.
Draft loaded: 10.87m
Loaded displacement (summer): 46, 903 tones.
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Deadweight: 37, 865 tones.
Lightweight: 9,038 tones.
Maximum height (keel to mast): 47.50m
Capacity: 48,818.53 m³ in six cargo holds.
Cranes: 3 (3x36 tons) - Mitsubishi.
Propulsion: by diesel engine.
Details of the diesel engine: Akasaka - Mitsubishi 6UEC52LS.
Fuel used: Marine Diesel Oil (MDO).
Port of Registry: Limassol / Cyprus.
International call sign: CADT2.
No. IMO: 9300752.
Classification society: Germanischer Lloyd.
Owner: Speedwave Shipping Company Limited.
Company: Athena Marine Co.
b) Vessel Certificates
- Issued by the Classification Society:
Date of issue
validity
Construction Safety
16/11/2010
31/10/2015
Equipment Safety
03/12/2013
31/10/2015
Security Radio
16/11/2010
31/10/2015
International Oil Pollution Prevention Certificate 16/11/2010
31/10/2015
International Edge Free
16/11/2010
31/10/2015
Document of Compliance - ISM Code
12.09.2013
24.02.2018
Security Management
12/09/2013
04/03/2016
International Protection Certificate for Ships
12/09/2013
04/03/2016
International Air Pollution Prevention Certificate 16/11/2010
10/31/2015
Class Certificate
20/12/2010
31/10/2015
International Sewage Pollution Prevention
16/11/2010
10/31/2015
Document of Compliance with Special requirements for ships carrying of Dangerous Goods,
Issued by Flag State::
16/11/2010
10/31/2015
Date of issue
validity
Minimum Safe Manning
19/02/2012
Indeterminate
International Tonnage
18/08/2005
Indeterminate
Registration
02/19/2014
Indeterminate
P & I insurance: North Insurance Management Limited, valid until 20 February 2015.
c) Travel details
The last port of the ship was the Terminal San Jose, Venezuela, where he received the
load of coal coke type of oil coal in bulk. From there, set sail bound for Praia Mole on 1 June
2014. He arrived at Praia Mole anchorage area on the 14th and docked on the 27th. Between the
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departure of St. Joseph and the mooring in Praia Mole were 26 days. There were no reports of
incidents during this trip.
d) Condition of the ship during the investigation
The vessel had all the equipment and the systems for their class and showed no evidence
of structural shortcoming.
V - ACCIDENT SITE DATA
The Coal Terminal of the Port of Praia Mole (Photo n ° 2 and 3) is located in the state of
Espírito Santo, Vitória, north side of the Bay of the Holy Spirit, Shark Point, the geographical
position coordinates are Latitude: 20 ° 17 '52' South and Longitude 040 ° 14 '12 "West.
Photo # 2 - Google Earth image of the accident site
Photo # 3 - image taken from Electronic Navigation System UBC TOKYO,
shows the ship position in relation to the Praia Mole pier on the day of the accident.
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The environmental conditions on the day of the accident were as follows:
Sea conditions: calm.
Current: negligible along the mooring pier.
Tide: flood.
Wind: Northwest, with 3 knots.
Visibility: 15 nautical miles.
Weather:good.
Temperature:21ºCelsius.
V - HUMAN FACTORS AND CREWMEMBERS
a) Personal list and safety crew.
Were shipped 22 members of the crew, as the Crew List. The Captain, Polish, 54, was
aboard for four months and three days; the rest were Filipines, having thus the minimum
crew requirement established by the flag State, and requirements under the Convention
STCW / 78.
b) Crew members involved in the accident.- Second Deck Officer CRISTOPHER
MONTERO SITJAR, 40, was aboard for two months and nine days;
- Able Seaman JAN L. KING MACALALAD, 25, was aboard for nine months and
seventeen days; and
- Ordinary Seaman EVAN MICHAEL T. BAUSO, 27, was aboard for two months and nine
days.
All had certified STCW / 78 issued by the Maritime Authority of the Philippines and
experience for the performance of their duties, as informed by the Captain.
The health condition of the crew before the accident was good, according to information
obtained on board. Specifically on the Second Deck Officer, the Medical Certificate
document for Service at Sea attests that he was fit for service on board. On the eve of the
accident, according to the Captain, he was humorous as usual, rested and in good health.
c) Periods of work and rest.
The board records testified that they were completed the minimum periods of rest, as
established by the Convention STCW / 78. Note that the thirteen days of the vessel at anchor
before docking in Praia Mole, provided good conditions for the rest of everyone on board.
d) Accommodations on board .
The accommodations were adequate for the crew, conforming to the standards of comfort,
cleanness, temperature, lighting and noise common to ships of that type.
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e) Alcohol, drugs and medicines.
No evidence has been obtained from the use of alcohol, drugs and or drug without medical
prescription by the crew.
f) Safety Management:
The vessel had the current Safety Management system, evidenced by the existence of the
Safety Management Manual and the hiring and crew familiarization process. The onboard
Manual in Chapter 6 shows procedures for confined space entry, adapted from recommendations
contained in IMO Resolutions A.864 and A.1050(27). The Company provided a copy of the
document “Acknowledgement & Familiarization with the HSEQ”, the Attendance List in
training (“Entering Into Enclosed Space”) and the Familiarization List as evidences that the
victims knew those instructions. English was the working language.
VI - SEQUENCE OF EVENTS
On the day of the accident, unloading coal was made by stevedores, using the harbor cranes,
while the service crew performed the ballast maneuvers necessary to balance the ship. The
Second Deck Officer CRISTOPHER (fatal victim) was coordinating ongoing operations; A.B.
MACALALAD probed the ballast tanks and the Ordinary Seaman BAUSO controlled the access
to the gangway. Meanwhile, the Chief Mate, in his cabin, was monitoring their communications
made through transceivers VHF and all wore on normally. When cleaning the hold # 5 was
completed by stevedores, the Second Deck Officer decided to check the structural integrity of
the compartment. In given time, the A.B.MACALALAD decided to seek the Second Deck
Officer because it did not answer the calls made by radio and headed toward the hold # 5 where
he saw opened the hatch giving access to the Australian staircase. When entering the
compartment he saw the Second Deck Officer fallen and faint downstairs. So, he tried to
communicate with the Chief Mate by radio, but failed and collapsed. The Chief Mate, noting that
the officer and the A.B. MACALALAD not communicated nor responded to their calls,
instructed the Sailor BAUSO to check what was happening. This Sailor, when reached the
compartment, came across the A.B. MACALALAD fallen in the first go, after the first flight of
stairs, and decided to help him. Entering he began to feel dizzy, but he could seek help from the
Chief Mate before fainting. When the Chief Mate went to the scene and found the situation,
returned to the accommodations and triggered the general alarm to wake the crew. Soon a rescue
team was formed, while asked for help to the port.
VII - PROCEDURES AFTER ACCIDENT
The rescue team, consisting of three crew members, led by the Boatswain, employing
artificial respiration and gas meters equipment, managed to retrieve the victims compartment.
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First was rescued Sailor BAUSO (still conscious), after the AB MACALALAD (unconscious)
and finally the Second Deck Officer (unconscious and not breathing). Meanwhile, the doctor's
port support was present with two ambulances and paramedics and then he took the unconscious
victims to hospital care in Victoria.
VIII - CONSEQUENCES OF THE ACCIDENT- Personal Injury:
It caused the death of the Second Deck Officer as the Death Certificate issued by the
Registry SARLO - Civil Registry and Notary, whose the cause of death was identified as acute
myocardial infarction (the details of this conclusion are in the autopsy report, RG No. 1340/2014
and the Office No.590 / SESP / PC / SPTC / DML / GAB, the State Secretariat of Public
Security of the State of Espírito Santo). The sailors suffered a temporary damage (loss of
consciousness for lack of oxygen). However, the health of both was restored in the same day.
- Environmental damage:
There was no environmental damage.
- Damage to property:
There was no property damage.
IX - EXPERT EXAMINATIONS
Investigation on board was started on the afternoon of the accident, moments after CPES be
informed. Initially we obtained the reports of the Captain, the Chief Mate and Sailor BAUSO
(recovered and on board). Also was checked the ship's documents and made a preliminary
examination of the accident scene. This work was interrupted due to the compartment has not yet
been ventilated and because of the prevailing unsafe conditions, aggravated by the
precariousness of lighting (it was night). The next morning (Sunday) was made the
reconstruction of the accident.
Before describing the reconstitution carried to term, it is important to outline the local
configuration (illustration 1 and photo No. 7) to conclude that it is a confined space.
The Australian housing ladder connects the main deck (access through a hatchway) to the
basement floor. In the basement floor level there is a steel door with cleats but permeable to air,
as stated by the Captain. Usually the hatchway and the door is kept closed, to guarantee the
tightness and to prevent the load from the basement invade the space of the ladder. This
arrangement only allows natural ventilation space when the hatchway and the door are open.
Thus justified the warning posted on hatchway on the potential danger of entering the
compartment without ventilation. The Photo#7 shows this feature.
9
watertight door on the floor
in the hold#5, normally held closed
Illustration No. 1 arrangement of the Australian ladder and ends.
One must also consider the nature of the cargo. The coal that Safety Data Sheet records the
gases it produces may aggravate pre-existing lung conditions and in the case of inhalation, the
victim should be removed to fresh air. And, in case of respiratory arrest, should be
administered artificial respiration, keeping the patient at rest and heated until the arrival of
medical help.
In the 26 days when coal was in the basement gases produced contaminated the atmosphere
of the space of the ladder. This was verified by the team of Praia Mole firefighters to make
atmospheric measurement in the compartment when measured oxygen concentration at 9.5%.
This was given to 6h20min obtained soon after the victims were rescued, confirming that the
site had not been ventilated before the entry of the victims.
The following pictures show the details of the door adjacent to the basement floor # 5. If this
door had been opened, with the hatch to the deck, the location of accident would have been
natural ventilation (photos #4, #5 and #6).
10
Photo # 4 - access from the main deck
Photo # 5 - door closed
Photo # 6 – door open
The characteristics of a confined space, as Resolution A.864 and Resolution A.1050(27) of
IMO, thus defines similarly to:
Confined Space is any area or environment not designed for continuous human occupation,
which has limited means of entry and exit, the existing ventilation is insufficient to remove
contaminants or where there could be a deficiency or enrichment of oxygen.
These standards also clarifies the concept of oxygen deficiency as "atmosphere containing
less than 20.9% oxygen by volume at normal atmospheric pressure and the percentage must be
properly monitored and controlled. Therefore, it is justified the warning posted on hatchway to
pay attention to the potential risk, as shown in the following image.
Photo# 7- warning posted on hatchway on the potential danger of entering the enclosure without
ventilation.
11
It is also important to mention the requirements of Resolution A.864 (20) and Resolution
A.1050 (27) of the IMO, which shows recommendations for entry into confined spaces on ships.
In establishing the need for risk assessment allowed to enter, general precautions, atmospheric
testing, precautions during the remained of people within confined spaces, etc. Those
resolutions states that accidents of this nature occur, among other reasons, by the lack of
victims precautions and forcefully encourages the adoption of safety procedures.
Photo #8 - position of the duct of the Australian ladder. The arrows indicate which were found
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The reconstruction showed how the victims were found by rescue team and the difficulty to
remove. This and the following pictures show the positions victims inside the compartment
(illustration #2).
Sailor BAUSO fell near the chamber opening
Sailor MACALALAD, a flight of
AB MACALALAD fell down a flight of stairs from the hatchway
Deck Officer CRISTOPHER fell down a flight of stairs from the hatchway
the hatch
llustration #. 2 - simulation of the positions of victims within the Australian ladder compartment.
X - ANALYSIS AND CAUSAL FACTORS
In the present case, there was even evidence that safety procedures (Safety Management
Manual, and IMO Resolutions A.864 and A.1050(27)) were followed. Certainly, Sailors, each
one, come on site to provide assistance, but no reason was found to justify the entry of the
Second Deck Officer. And this issue has become more relevant when it was observed that there
was a safe alternative, which was the ladder (in the basement, attached to the bulkhead forward)
used by stevedores for cleaning, photo # 9.
13
Photo #9 - internal stairway to the hold # 5 used by stevedores
Asked about this, the Captain replied that he had not determined the Second Deck Officer
to inspect the hold #5 in that turn and similarly responded the Chief Mate, although agreed that
the inspection was within his obligations. Therefore, when it is proved that the victims did not
use personal protective equipment suitable for confined space entry (only had boots, helmets and
overalls), and that they had not permission to enter the compartment, which was characterized
that the personal involved not complied with the ship's Safety Management System.
XI - LESSONS LEARNED AND PRELIMINARY CONCLUSIONS
a. the atmosphere within a confined space can become lethal as the tragic circumstances
elucidated in this report;
b. is mandatory never get into the confined space if safer alternatives are available. And if the
confined space entry is unavoidable, robust security procedures should be put in place which
should include arrangements for emergencies and permission to entry the compartment, usually
referred to onboard Safety Management System;
c. even a small reduction in the air we breathe in a compartment can kill quickly with little or no
14
warning;
d. single persons should not attempt to rescue a victim in confined space without such permission
and without accompaniment;
e. within a confined space, if the person perceive changes in their well-being, or suspected of
serious
and
imminent
risk,
shall
abandon
immediately
the
location;
f. the confined space entry, even after security procedures completed, should be monitored;
g. each crew member shall cooperate with the Company in compliance with safety standards and
should properly use the safety equipment provided by the Company pertaining to each task;
h. the tasks to be performed by service personnel at night should be planned and clearly
designated in writing; and
i. in the light of what was found, it is concluded that the accident was due to the entry of the
victims in the confined space of the Australian ladder, at odds with the safety requirements laid
down in the ship's Safety Management Manual as well as those set out in International
Convention for the Safety of Life at Sea (SOLAS) Consolidated Edition 2014, Resolution A.864
and Resolution A.1050 (27) of IMO.
XII - SAFETY RECOMMENDATIONS.
a. the Company shall ensure the training of the crew to go into confined spaces, through specific
courses with certification;
b. the Company shall establish an annual program of training for staff about confined space
entry;
c. the Company must indicate formally responsible for compliance with the training program on
confined space entry;
d. the Company must establish controls to ensure that the entry of people in confined spaces is
made only as there is a risk analysis and the corresponding permission to work;
e. the Company shall make available suitable equipment for emergency in a confined space; and
f. on board there should be warnings posted in easy viewing sites on the dangers in confined
spaces, as well as summary safety instructions.
g. is mandatory never get into the confined space if safer alternatives are available. And if the
confined space entry is unavoidable, robust security procedures should be put in place which
should include arrangements for emergencies and permission to entry the compartment, usually
referred to onboard Safety Management System;
h. within a confined space, if the person perceive changes in their well-being, or suspected of
serious and imminent risk, shall immediately abandon the location; and
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i. the confined space entry, even after security procedures were completed, should be monitored
at all times.
XIII - LIST OF ANNEXES
ANNEX A – Ship`s Particulars
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BRAZILIAN NAVY DIRECTORATE OF PORTS AND COASTS

Transcription

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