Ja då har vi ju lastat lite farligt gods enligt IMDG code. Det är stålspån och rester från svarvning och borrning. Ser ganska ofarligt ut men kan faktiskt självantända. Fick temperaturschema från lastningen och vi skall försöka ha koll på den under hela resan. Blir svårt att komma åt lasten när vi går ute på öppet hav och man kan ju inte skicka ner någon i lastrummet heller eftersom den förbrukar syret när den reagerar med luft. Så det enda vi kan försöka göra är att stänga igen lufttillförseln och se till att lasten inte blir våt. Vi har dessutom fått en deklaration att det inte är radioaktivt. Det måste kontrolleras angående allt järnskrot som skeppas.
FERROUS METAL BORINGS, SHAVINGS, TURNINGS or CUTTINGS UN 2793
in a form liable to self-heating
Metal drillings usually wet or contaminated with such materials as unsaturated cutting oil, oily rags and other combustible material.
This schedule should not apply to consignments of materials which are accompanied by a
declaration submitted prior to loading by the shipper and stating that they have no self-heating properties when transported in bulk.
- ANGLE OF REPOSE: Not applicable
- BULK DENSITY (kg/m3): Various
- STOWAGE FACTOR (m3/t): Various
- SIZE:Diameter: Not applicable
- CLASS: 4.2
- GROUP: B
- HAZARD: These materials are liable to self-heat and ignite spontaneously, particularly when in a finely divided form, wet or contaminated with such materials, as unsaturated cutting oil, oily rags and other combustible matter. Excessive amounts of cast iron borings or organic materials may encourage heating. Self-heating or inadequate ventilation may cause dangerous depletion of oxygen in cargo spaces.
- STOWAGE & SEGREGATION: “Separated from” foodstuffs.
- HOLD CLEANLINESS: Clean and dry as relevant to the hazards of the cargo.
- WEATHER PRECAUTIONS: This cargo shall be kept as dry as practicable. This cargo shall not be handled during precipitation. During handling of this cargo all non-working hatches of the cargo spaces into which this cargo is loaded or to be loaded shall be closed.
- LOADING: During loading the material shall be compacted in the cargo space as frequently as practicable with a bulldozer or other means. The bilge of each cargo space in which the cargo is loaded shall be kept as dry as practicable. After loading the cargo shall be trimmed to eliminate peaks and compacted. Wooden wet battens and dunnage shall be removed from the cargo space before the cargo is loaded.
- PRECAUTIONS: The temperature of this cargo shall be measured prior to and during loading. The temperature of the cargo in the stockyard shall be measured at points between 200 mm and 350 mm from the surface of the cargo pile. This cargo shall only be accepted for loading when the temperature of the cargo prior to loading does not exceed 55°C. If the temperature of the cargo in any cargo space exceeds 90°C during loading, loading shall be suspended and shall not be recommenced until the temperature of the cargo in all cargo spaces has fallen below 85°C. The ship shall not depart unless the temperature of the cargo in all cargo spaces is below 65°C and has shown a steady or downward trend in temperature for at least eight hours.
- VENTILATION: The cargo spaces carrying this cargo shall not be ventilated during voyage.
- CARRIAGE: The surface temperature of the cargo shall be monitored and recorded daily during the voyage. Temperature readings shall be taken in such a way as not to require entry into the cargo space or, alternatively if entry is required for this purpose, at least two sets of self-contained breathing apparatus, additional to those required by SOLAS regulation II-2/10.10 should be provided.
- DISCHARGE: Entry into the cargo spaces containing this cargo shall only be permitted for trained personnel wearing self-contained breathing apparatus when the main hatches are open and after adequate ventilation is conducted or for personnel using appropriate breathing apparatus.
- CLEAN-UP: Prior to washing out the residues of this cargo, any oil spillages shall be cleaned from the tank tops and the bilge wells of the cargo spaces for this cargo.
- SPECIAL EMERGENCY EQUIPMENT TO BE CARRIED: Self-contained breathing apparatus
- EMERGENCY PROCEDURES: Nil
- EMERGENCY ACTION IN THE EVENT OF FIRE: Whilst at sea, any rise in surface temperature of the material indicates a self-heating reaction problem. If the temperature should rise to 80oC a potential fire situation is developing and the ship should make for the nearest suitable port. Batten down. Water should not be used at sea. Early application of an inert gas to a smouldering situation may be effective.
- MEDICAL FIRST AID: Refer to the Medical First Aid Guide (MFAG), as amended.
Här nedan följer utdrag ur en olycka som hänt med denna lasten.
Iron in the Fire
A general cargo vessel was scheduled to load ferrous cuttings which included cast iron filings. The cargo was designated as UN 2793 – Ferrous Metal Borings, Shavings, Turnings or Cuttings, and was delivered directly from the engineering works to the dockside. On delivery, it was noticed that the cargo also contained cutting oil and other combustible materials including plastic bottles and rags.
The waste disposal contractor carried out the temperature checks as required in the Code of Safe Practice for Solid Bulk Cargo 2004, and although it was confirmed that the temperature was below the maximum 55°C required, this was not formally recorded. At 2200 cargo loading was suspended until the following morning but, despite it starting to rain, none of the hatch covers were put in place.
At about 0235, the duty AB detected a small fire in the open hold. He alerted the crew, who attempted to extinguish the fire. However, this was unsuccessful. At 0308 the local fire and rescue service attended the vessel and began to douse the cargo with water (Figure 1). The ship’s master and harbour authorities advised against using large amounts of water because of potential stability concerns. At about 0330 the fire was declared to be under control, and three out of the five fire tenders providing assistance were released.
At 0530 the cargo loading crane driver arrived, and an hour later he started to remove the smoking cargo to the dockside, where it was cooled down once more. The temperature of the hold cargo was constantly monitored; it reached a maximum of 93°C (Figure 2). The cargo and hold water removal, and cargo re-load took a further 60 hours.
The cargo was liable to self-heat and ignite spontaneously because it contained fine shavings contaminated with cutting oil, cast iron borings and organic flammable materials.
The self-ignition risk was increased because the simple precaution of closing the hold hatches had not been taken. The Code of Safe Practice for Solid Bulk Cargo 2004 specifically highlights that cargo loading should not be undertaken in wet conditions, and that hatch covers should be closed when the hold is not being worked.
The master relied on the waste management contractor to ensure that the cargo was safe to load. In this case, the temperature was reported to be compliant with the regulations, but it was not recorded. In addition, no attempt was made to remove the organic matter, which significantly increased the risk of self-ignition.
To prevent the risk of self-ignition, the following precautions should be taken as laid out in the Code of Safe Practice for Solid Bulk Cargo 2004:
1. The temperature of UN 2793 cargoes should be recorded by the waste management contractor. Prior to loading, the temperature taken from between 200-350mm into the pile should not exceed 55°C.
2. If the cargo temperature exceeds 90°C during loading, operations should be stopped until the temperature has fallen below 85°C.
3. A vessel should not depart unless the temperature is below 65°C and has shown a steady downward trend for at least 8 hours.
4. Cargo loading should be suspended during wet conditions, and the hold hatches should be closed when the holds are not being worked.
Ytterligare en olycka där man inte varit noga med att kontrollera syrenivån i lastrummet.
Report on the investigation of the accident on board
28th April 2009
S1.1 On the 28th April 2009, the Gibraltar registered general cargo ship,
Vigoroso was on a voyage from St Petersburg to Barcelona with a cargo of
ferrous scrap when it was discovered that the Second Engineer had collapsed
at the bottom of the aft hold access ladder. He was recovered from the hold
by crew members. The ship diverted towards the Swedish port of Karlskrona
and the Second Engineer was transferred by helicopter from the ship to
hospital. The Second Engineer did not regain consciousness and died on 25th
December 2010 in hospital. This publication of this report has been delayed
pending the outcome of the medical treatment of the Second Engineer.
S1.2 Following the helicopter transfer, the ship proceeded to Brunsbuttel to
await the arrival of a replacement second engineer before continuing on
passage to Barcelona.
S1.3 Between 24th and 26th April, the Vigoroso had loaded a cargo of
“Secondary ferrous metals (metal) scrap) – Steel swarf”, IMDG Code 4.2,
ferrous metal turnings, at St Petersburg, Russia, for discharge in Barcelona,
S1.4 The ship arrived in Barcelona on 7th May and the cargo was discharged
without incident. However, “smoke” was observed emanating from the cargo
when the hatch covers were opened.
S1.5 Gibraltar Maritime Administration was informed of the incident by the
ship’s operators on 7th May and an investigation started in accordance with
IMO guidelines for accident investigations.
S1.4 Factors contributing to the accident included:
S1.4.1 Reduction of oxygen levels in the hold due to the nature
of the cargo.
S1.4.2 Failure to observe the correct procedures for the entry
into an enclosed space.
S1.4.3 Lack of proper temperature monitoring equipment
S1.4.4 Appropriate recommendations have been made which can be found in
Section 4 of this report.
SECTION 1 – FACTUAL INFORMATION
1.1 PARTICULARS OF MV VIGOROSO & ACCIDENT
1.1.1 Vessel Details
Name: : Vigoroso
IMO Number : 9191943 .
Registered owner. : Shipcom Bereederungs GmbH & Co
Betreibs KG MS ‘Scaldis’
Gartenstr 2, Haren, Germany
Operator : ShipCom Bereederungs GmbH
Rheinallee 14, Duisburg, Germany
Charterer : Österströms
Hotellgatan 5, SE-601 02 Norrköping,
Crew Managers : Marlow Navigation Co Ltd
13 Alexandrias St, CY-3720 Limassol
Port of registry : Gibraltar
Flag : British
Type : Multi Purpose Dry Cargo
Built : 2007
Classification society : Germanischer Lloyd
Construction : Steel
Gross Tonnage : 4,244
Engine power : 4505.76 bhp, 3360 kW
1.1.2 Accident details
Injuries to personnel : Asphyxiation of Second Engineer
Damage to ship : Nil
Pollution : Nil.
Location of Accident : 50° 06’.9 N 016° 38’.7 W
(South east of the Swedish island of Oland in the
Date and Time : Approx 1140 (UTC + 2) on 28th April 2009
1.2.1 The Vigoroso, launched in 2002, was a single hold general cargo ship
with her main superstructure, accommodation and bridge situated aft.
1.2.2 At the time of the accident, the hold contained a cargo of “steel
turnings” which had been loaded in St. Petersburg.
1.2.3 The Vigoroso held valid Document of Compliance for the Carriage of
Dangerous Goods and Document of Compliance for the Carriage of
Solid Bulk Cargoes.
1.2.4 The Vigoroso mainly traded in the Baltic / North Europe area carrying
timber products. Previous cargoes had included sawn timber, logs,
wood chips and occasionally steel products. The cargo carried
immediately prior to the accident had been asphalt granules.
1.2.5 The official working language of the ship was English and the ISM
documentation was in English.
1.2.6 The company operating the ship was experienced in the management
and operation of small general cargo ships. The company had a valid
Document of Compliance for the operation of this type of ship, issued
by the Det Norske Veritas on behalf of the Government of Antigua &
Barbuda and a valid ISM Code Document of Compliance (Letter of
Acceptance) issued by the Government of Gibraltar.
1.2.7 The ship had a valid Safety Management Certificate issued by the
Gibraltar Maritime Administration and had been subject to an external
ISM audit and Flag State inspection in May 2007. During the month
prior to the accident, the ship had been inspected in Germany under
the Paris MOU for port state inspections. No deficiencies were
identified during that port state inspection. During the previous two
years, four further inspections had been completed during which no
major deficiencies had been identified. A number of minor deficiencies
related to accident prevention and safety operations had been raised.
1.3 NARRATIVE (ALL TIMES SHIP’S TIME)
1.3.1 The Master was first informed of the nature of the cargo ( steel
turnings, IMO 4.2) to be loaded in St Petersburg approximately six
weeks prior to arrival. This was confirmed by email from the charterers
in which the cargo was described as “min 5200 mts of steel turnings,
1.3.2 The Master was familiar with this type of cargo and consulted the BC
Code and the ship’s Document of Compliance for the Carriage of Solid
1.3.3 On 24th March the Master brought to the attention of the charterers that
the ship did not have on board temperature sensors for measuring the
temperature of the cargo as required by the DoC and BC Code.
1.3.4 The ship departed Sillamäe, Estonia on 21st April, having discharged a
cargo of asphalt granules. On the same day, the operators instructed
the Master to advise them if the proposed steel cargo was oily and
brought to the Master’s attention, pages 126 and 127 of the BC Code
which refer to Ferrous Metal Borings, Shavings, Turnings or Cuttings,
1.3.5 The ship berthed in St Petersburg at 0350 ST on 24th April and
commenced loading that afternoon. The Master was unable to obtain
any temperature sensors at St Petersburg through the agent or
charterer. The Second Engineer offered to fabricate two sensors
during his free time, using temperature measuring devices from the
ship’s incinerator, which was not in use. He completed this and
installed the sensors, one forward and one aft, with remote readouts in
the aft cargo office and in the fo’c’sle workshop
1.3.6 A domestic thermometer had been obtained from a chandler in St
Petersburg to enable measure cargo surface temperatures before and
1.3.7 The Master was provided with a Certificate of Cargo Characteristics at
Time of Loading and a Declaration of the Transportation
Characteristics and Conditions for the Safe Shipment of Bulk Cargo
issued by the Russian Maritime Register of Shipping.
1.3.8 Loading was completed on 26th April. The cargo was levelled and
compacted. In compliance with the requirements of the DoC for CSBC,
the cargo had been loaded such that there was a 3 metre space
between the cargo and the aft hold bulkhead and clear of the forward
gasoil fuel tanks. Thus the forward and aft access ladders to the hold
were clear of cargo. On completion of loading, hatches were closed,
ventilation fans isolated and hold access hatches secured. The Chief
Officer tested the atmosphere in the hold and recalls that the oxygen
level was low. The actual value was not recorded.
1.3.9 Notices regarding enclosed entry were displayed adjacent to each hold
access hatch and in the accommodation.
1.3.10 Temperatures of the cargo were recorded, commencing 26th April at
0800, 1200, 1600 & 2000 hours by one of the seamen in a note book.
The temperature record shows that no temperature was recorded from
the aft sensor at 0800 ST, 27th April. Temperatures were not recorded
in the logbook.
1.3.11 There were no records of testing the atmosphere in the hold.
Page 1 0 of 25
1.3.12 On 27th April the Master informed the operators that the Second
Engineer had made and installed electronic devices, fore and aft, to
enable cargo temperature to be monitored and requested confirmation
of payment of a bonus to be made to the Second Engineer for
completing this work.
1.3.13 On the morning of the 28th April, at about 1100, the Chief Engineer, on
his way to the engine room control room, recalled seeing the Second
Engineer in the cargo office having a coffee break. At this time the
bosun was working on the bridge deck, one seaman was painting
hatch covers and the Master was on watch on the bridge.
1.3.14 At about 1140 ST, the bosun passed the aft hold access on his way to
the deck store and noticed the access lid was open. He collected a
torch, looked into the hold and saw the Second Engineer collapsed at
the foot of the hold ladder. He immediately contacted the Master on
the bridge and called the deck crew to assist. The Master called the
Chief Officer to prepare SCBA equipment and the Second Officer to go
to the bridge.
1.3.15 One seaman entered the hold wearing SCBA with a rescue line and
the Second Engineer was hauled up onto the deck. He was not
breathing and no pulse could be detected. The Chief Officer and
seamen immediately commenced CPR. The Master arrived on deck
having collected the oxygen resuscitation equipment from the ship’s
hospital. At about 1205 ST the Second Engineer started to breath
spontaneously and oxygen was administered. The seaman / cook
brought a stretcher from the hospital and the Second Engineer was
transferred into the shelter of the accommodation
1.3.16 After relieving the Master on the bridge, the Second Officer prepared a
medical information card for transmission. When the Master returned
to the bridge, they altered course towards the nearest port. The ship
was approximately 20 n.miles from Karlskrona so they were able to
contact Karlskrona pilots by VHF who directed them to VHF Channel
16 and 81 to the Swedish Rescue Service. Contact with the rescue
service was established at 1250 ST. At 1320 ST the rescue boat
Bjornchister was in attendance. At 1405 ST a Swedish rescue
helicopter lifted off the Second Engineer and transferred him to
1.3.17 Following the helicopter evacuation, the Master consulted the
operators and crewing agent and the Vigoroso proceeded to Kiel
Canal, approximately 170 n.miles away. The ship anchored on arrival
at Brunsbuttel to await the arrival of a replacement Second Engineer
and a representative of the crew management company before
continuing on passage to Barcelona.
1.3.18 The cargo was discharged at Barcelona without incident but the cargo
was observed to start emitting “smoke” shortly after the hatch covers
were opened and continued to “smoke” throughout the discharge
operation. On completion of discharge, both temperature sensors were
recovered. The sensor situated aft was found to be damaged.
1.3.19 A report dated 5th May from Blekinge Hospital, Karlscrona stated that
CT scans had revealed that the Second Engineer had no apparent
bleeding, infarction or increased intracranial pressure but following
further tests, the assessment was that he had been exposed to carbon
dioxide causing severe anoxic brain damage.and epileptiformic
1.3.20 On 25 December 2010 it was confirmed by the crew managers that the
Second Engineer had died while still in hospital in a coma
1.4.1 The Vigoroso had a complement of officers and crew in compliance
with the requirements of the ship’s Safe Manning Document. The
ship’s Master was Ukrainian, and officers and crew were Russian,
Ukrainian and Bulgarian.
1.4.2 All of the crew were employed by crewing agency Marlow Navigation
who were contracted by the operators to supply officers and crew to
comply with the Safe Manning Document.
1.4.3 The official working language of the ship was English, but Russian was
more commonly in general use.
1.4.4 The crew on board Vigoroso consisted of the Master, Chief Officer,
Second Officer, Chief Engineer, Second Engineer, three seamen and a
seaman/cook. The Master, officers and crew were experienced
seafarers and were holders of appropriate certificates of competency.
1.4.5 The Master had served at sea for more than eighteen years, had
qualified as Master – STCW II/2 in April 2003 and had served as Master
for five years. He had completed specialised training in the carriage of
dangerous & hazardous substances in compliance with STCW Section
1.4.6 The Second Engineer was 41 years old with a valid medical certificate
for service at sea. During his service on board the Vigoroso he had
received treatment for an ear infection and had been observed by the
Second Officer to apparently use an inhaler. An inhaler was not found
in the Second Engineer’s cabin or on his person following the accident.
Small quantities of salicylic acid tablets (aspirin), diclofenac gel
(analgesic) and otrivin (nasal decongestant) were found in his cabin.
According to the Chief Engineer, neither ear problem nor use of an
inhaler appeared to affect his ability to carry out his duties.
1.4.7 The ship had a UMS notation and the Chief Engineer and Second
Engineer normally worked on a day-work system between the hours of
0800 and 1800. The engineers alternated “on call“ responsibility for
answering any engine room alarms during the period 1800 to 0800.
1.4.8 The Chief Engineer reported that he and the Second Engineer had
obtained sufficient rest prior to their periods of duty. This was
supported by Records of Hours of Rest on board. These records
indicate that the Second Engineer had been working for three hours
prior to the accident and had been off duty for fourteen hours before
prior to that.
1.5.1 The cargo loaded was steel turnings. These are the by-product of, and
are produced by, the machining, turning, milling and drilling of steel.
1.5.2 The cargo was described by the charterer in their voyage instructions
to the Master as steel turnings IMO 4.2.
1.5.3 The Russian Maritime Register of Shipping issued cargo
documentation to the ship, describing the cargo as Secondary ferrous
metals (metal scrap) – Steel swarf IMO Code Class 4.2 having the
• Steel swarf No.1 – a finely divided material,
• Steel swarf No. 2 – a finely divided material which does not contain
• balls of spiral-like steel swarf and
• A spiral – swarf, to be used for processing purposes
1.5.4 The Bulk Cargo Shipping Name (BCSN) for steel turnings is Ferrous
Metal, Borings, Shavings, Turnings or Cuttings UN 2793 in a form
liable to self heating.
1.5.5 Steel turnings are liable to self-heat and ignite spontaneously,
particularly when in a finely divided form, wet, or contaminated with
cutting oil, oily rags or other combustible material. This process
reduces the oxygen content within the space containing such cargo.
1.5.6 Steel turnings are also subject to simple oxidisation (rusting) which will
also reduce the oxygen content of enclosed spaces in which the
turnings are stored. Oxidisation is accelerated if the turnings are
1.5.7 The cargo was stored ashore in the open and was observed by the
Master and Chief Officer to be damp and rusty.
1.5.8 Prior to loading the cargo, the hold was swept clear of previous cargo
residue and was dry
1.5.9 Monitoring of the temperature of this cargo is required by the BC Code.
The charterer and operators had failed to provide a suitable
temperature sensor system to enable remote monitoring despite being
made aware, in ample time by the Master, the required equipment was
not on board. The Master was unable to purchase the necessary
equipment at the load port. The Second Engineer offered to make up a
sensor system using materials on board and was paid a bonus for this.
If he had not done so, the ship would have been delayed loading.
1.5.10 The cables from the sensor to the read-out displays were passed
through the hold access hatches. These hatches could therefore not
be fully screwed down tight without damaging the cables.
1.6.1 Ferrous Metal Turnings are an IMDG Code Class 4.2 material:
Substances liable to spontaneous combustion
1.6.2 Both IMDG Code and the BC Code entries for Ferrous metal boring,
shavings turnings or cuttings in a form liable to self heating (UN No.
2739) note the self heating properties of these cargoes, particularly
when carried in a finely divided form, wet or contaminated with cutting
oil or combustible material.
1.6.3 The Codes state that:
Self heating or inadequate ventilation may cause a dangerous
depletion of oxygen in the stowage spaces and that swarf should be
protected from moisture prior to and after loading.
1.6.4 The BC Code also states that:
After loading, the cargo should be trimmed to eliminate peaks and
compacted. The cargo should not be ventilated.
1.6.5 The BC Code Recommendations for entering enclosed spaces aboard
The atmosphere in any enclosed space may be deficient in oxygen and
/ or contain flammable and / or toxic gases or vapours. Such an unsafe
atmosphere could also subsequently occur in a space previously found
to be safe.
No person should open or enter an enclosed space unless authorised
by the master or nominated responsible person and unless the
appropriate procedures laid down for the particular ship have been
Entry into enclosed spaces should be planned and the use of an entry
permit system, which may include the use of a checklist, is
1.6.6 Copies of the IMDG and BC Codes were held on board the Vigoroso.
1.7.1 In accordance with the BC Code, a cargo of steel turnings should be
assigned a Bulk Cargo Shipping Name (BCSN) and a United Nations
(UN) number prior to shipping, confirmed in writing and supported by
appropriate shipping documents prior to loading.
The charterer informed the Master by email that the cargo to load at St
Petersburg would be steel turnings, IMO 4.2.
The ship operators were aware of the possible hazards of this cargo
and brought to the attention of the Master, by email, the relevant
pages in the BC Code regarding the cargo, including the BCSN & UN
number and highlighting the hazards and precautions during loading,
carriage and discharge. They also instructed the Master to inform
them if the cargo was oily.
The Russian Maritime Register of Shipping issued a Certificate of
Cargo Characteristics at the Time of Loading and a Declaration of the
Transportation Characteristics and Conditions for the Safe Shipment of
Bulk Cargo. These documents provide details of the cargo owner and
shipper, a description of the cargo and the safety requirements and
measures to be taken to ensure safe cargo handling.
1.7.4 Classification Society.
The ship had been issued with a Document of Compliance for the
Carriage of Solid Bulk Cargoes by Germanischer Lloyd on behalf of the
Gibraltar Government. Attached to this DoC was a Supplement listing
the cargoes categorised in Group B of the BC Code that the Vigoroso
could carry. The list included the UN No., IMO Class and footnotes
relevant to each cargo
1.7.5 The Supplement included Ferrous Metal Borings, Shavings, Turnings
or Cuttings, in a form liable to self heating, UN No. 2793, IMO Class
4.2. The relevant footnote (28) stated:
Suitable instruments for measuring the surface temperature of the
cargo are to be provided. In case of portable temperature sensors the
arrangement shall enable the measurement of temperature without
entering the hold.
1.7.6 Germanischer Lloyd has also issued, on behalf of the Government of
Gibraltar, a Document of Compliance for the Carriage of Dangerous
Goods. Attached to this DoC was Schedule 1(a) which permits the
carriage of IMO Class 4.2 cargo in packaged or bulk form. For bulk
cargo Class 4.2, a minimum 3 metre separation from the engine room
bulkhead is stipulated. Special arrangements / requirements are listed
in Schedule 2 of the DoC.
1.8 HOLD ATMOSPHERE
1.8.1 The ship was equipped with portable gas detecting equipment (RKI
Instruments Model GX-2001) capable of monitoring lower explosive
limit (LEL), oxygen (O2) and carbon monoxide (CO). The equipment
appeared to be functioning correctly but no recent calibration certificate
1.8.2 No record of testing of the hold atmosphere was available.
1.8.3 On completion of loading the hatches were secured. As is the normal
safe practise for this type of cargo, the hold was not ventilated during
1.8.4 Hospital reports on the Second Engineer’s condition indicated that he
had not suffered from any injury that would have caused bleeding,
brain infarction or inter-cranial pressure and did not suggest that
carbon monoxide poisoning was a factor. Similarly, the reports did not
indicate the presence of alcohol or drugs.
1.8.5 The hospital staff’s diagnosis was anoxic brain damage due to
exposure to carbon dioxide. This could also be described as exposure
to an atmosphere deficient in oxygen. The reference to CO2 may have
been influenced by the ship’s medical report which stated “Has
presumably lost consciousness because of disadvantage of oxygen at
hold. Poisoning CO2 “.
1.8.6 Oxygen (O2)
The Chief Officer recalled testing the hold for atmosphere on
completion of loading and found oxygen levels to be low but did not
record the level.
1.8.7 The cargo was observed to “smoke” when the hatch covers were
removed at the discharge port and the sample of hold sweepings
showed evidence of rusting. It may be deduced from this that
oxidisation had occurred after loading which would have significantly
reduced the level of oxygen in the hold.
1.8.8 The normal ambient level of oxygen is about 30% by volume.
Exposure to an atmosphere containing less than 18% by volume of O2
is a significant risk. Levels below 11% by volume may result in fainting
within a few minutes of exposure. Levels below 6% by volume result in
fainting almost immediately with a high risk of brain damage.
(ref: University of Oxford Policy Statement S/403 – Health & Safety)
1.8.9 Carbon Dioxide (CO2)
In moderate to high concentrations, CO2 is a respiration stimulant and
acts as an asphyxiant.
1.8.10 The ship’s fixed fire fighting systems include compressed carbon
dioxide. There was no indication of any release of CO2 into the hold.
1.8.11 Carbon Monoxide (CO)
CO is extremely flammable and forms an explosive mixture with air
with explosive limits between 12.5 – 74 % by volume. Raised levels of
CO are common in this type of cargo. However, there are no records
of CO levels during loading, carriage or discharge. Raised levels of
CO cause increased carboxyhemoglobin levels in the blood which may
result in toxic anoxia. Medical reports available do not indicate any
symptoms associated with carbon monoxide poisoning.
1.9 ENCLOSED SPACE ENTRY
1.9.1 Procedures for enclosed space entry were included in the ship’s safety
management system (SMS). These procedures include Form 09 –
Permit to Work and Checklist CL 05 – Checklist for Work Permits –
Entry into enclosed or confined spaces.
1.9.2 Further information regarding entry into enclosed spaces is contained
in The Code of Safe Working Practises for Merchant Seamen, a copy
of which was on board the ship.
1.9.3 Specific instructions regarding entry into spaces containing cargo
carried by the Vigoroso were contained in the cargo documentation
provided by the Russian Maritime Register of Shipping and in the BC
1.9.4 Signage regarding entry into the hold was displayed adjacent to the
hold access hatches, fore and aft. Further notices were displayed on
bulkheads in the accommodation.
1.9.5 The hold access hatches could not be dogged down completely
because of the temperature sensor cables. The access hatches were
not marked with tape, tie-wraps or anything similar to make them more
conspicuous and so alert the crew to the danger or to make it more
difficult to open them.
1.9.6 The Master discussed the nature of the cargo and associated dangers
with the crew and posted signs in the messrooms prohibiting entry into
the hold without his permission.
1.9.7 The Second Engineer joined the ship on 13th March 2009. On that day
he completed the SMS Checklist CL 11 – Familiarisation Check List.
The remarks section of this checklist includes the statement,
”Furthermore he is instructed not to enter enclosed spaces, to weld, to
work aloft and to work in un-manned machinery spaces without
SECTION 2 – ANALYSIS
2.1.1 The purpose of the analysis is to determine the contributory causes and
circumstances of the accident as a basis for making recommendations to
prevent similar accidents occurring in the future.
2.2 THE ACCIDENT
2.2.1 The cargo of ferrous metal turnings had been stored ashore outside
and was loaded damp, resulting in conditions for self heating /
oxidization of the cargo causing in depletion of oxygen within the cargo
2.2.2 It is not possible to state with certainty why the Second Engineer
decided to enter the hold without taking the normal precautions and
without consulting any other member of the crew. However, it may be
surmised that, while in the cargo office, he noted that the aft
temperature sensor was not working properly, and, having received a
bonus for constructing the sensor, felt a personal responsibility to
2.2.3 The evidence suggests that he the entered the hold and, very shortly
afterwards, collapsed due to the oxygen depleted atmosphere
Fatigue is not considered to have been a contributory factor to this accident.
The ship was UMS and the Chief and Second Engineer worked a day work
system which enabled them benefit from regular periods of unbroken rest.
Immediately prior to the accident the Second Engineer had been at work for
about three hours before which records indicate that he had been resting for
more than 14 hours.
2.4 SAFETY MANAGEMENT
2.4.1 The ship had an ISM Safety Management System manual which
included procedures for a permit to work system for entry into enclosed
2.4.2 The last recorded issue of a work permit for enclosed space entry was
dated 10 November 2007 for work in the fore peak tank.
2.4.3 The Master was aware of the dangers associated with the cargo and
discussed these dangers with the crew informally.
2.4.4 The SMS required the Master to conduct safety committee meetings on
a monthly basis (refer SMS 6.9) and report the results to the Company.
Such a meeting was held on 30th March 2009 and would have been an
ideal opportunity to communicate to the crew the precautions
necessary while carrying the cargo in a more formal way. The meeting
report shows that the following safety matters were raised:
• ISM Code- interpretation
• Shipboard operations
• Safety work on board
• Designated Person ashore and on board
The meeting was concluded after 30 minutes.
2.4.5 An internal ISM audit was conducted by the Company on 20th October
2008 at which time the auditor identified a need for an improvement in
crew knowledge of the SMS, particularly with regard to maintenance
and record keeping, including enclosed space entry, and regular
inspections and audits
2.5 ON BOARD RESPONSE
2.6.1 The ship’s crew’s response to the accident was rapid, recovering the
Second Engineer within minutes of the alarm being raised. Their
subsequent actions – applying CPR, administering oxygen, obtained
advice and assistance were prompt and well organized
2.6.2 The seaman that discovered the Second Engineer in the hold was
sufficiently aware of the dangers related to the cargo to raise the alarm
rather than enter the cargo hold alone or without the appropriate
2.6.3 The actions of the crew after the alarm was raised indicated that they
were aware of the nature and danger posed by the cargo.
2.6.4 A safety committee meeting was held on 29th April 2009. The main
topics covered were:
• IMDG Code
• Work in enclosed spaces, individual protection
• Safety work on board
• Opening and closing hatch covers
• Accident report 28.04.2009 – Incident with 2nd Engineer
• Action of crew for the rescue of injured person
2.6.5 The meeting minutes also recorded a drill, “Injured person/ stretcher”
had been completed on 13th April 2009.
2.7 COMPANY RESPONSE
2.7.1 Following the accident the Company arranged the attendance of a
representative of the crew managers to attend on board at Brunsbuttel
to conduct a preliminary investigation and to provide the Master and
crew with support should they need it.
2.7.2 The Company issued:
• Standing Order No. 04 – Subject: Entering cargo hold
• Standing Order No. 05 – Subject: Cargo Information
• A4 Poster “Enclosed Spaces can kill” with instructions to display the
poster in the messroom
2.7.3 The Company circulated an email to the Master of each of their ships
reminding them of the need to follow the BC Code, SOLAS Dangerous
Cargo, IMDG Code and the Company ISM procedure regarding
“Enclosed spaces with checklist and works permit.”
2.7.4 The email to the Masters also included a link to the UK MAIB website
with a request that Masters print a copy of the MAIB report of the Sava
Lake case which relates to the death of crew members on a ship
carrying a similar cargo to that of the Vigoroso.
2.7.5 The Gibraltar Merchant Shipping (Accident Reporting & Investigations
Regulations) 2006, require, in the event of accident or serious injury, a
report be sent to the Maritime Administrator as soon as practical
following the accident and by the quickest means available.
2.7.6 The Company did not advise Flag State until 9 days after the incident.
Consequently the formal investigation into the incident was significantly
SECTION 3 – CONCLUSIONS
3.1 SAFETY ISSUES
3.1.1 The following are safety issues identified by the investigation. They are
not listed in any order of priority:
18.104.22.168 Use of cargo monitoring equipment not specifically designed for
purpose. [1.3.3, 1.3.5, 1.3.6, 1.3.11, 1.5.9, 1.7.5, 2.2.2]
22.214.171.124 Easy access to potentially hazardous spaces [1.5.10, 1.9.5]
126.96.36.199 Lack of appreciation of the hazards associated with certain cargoes.
[2.2.2, 2.4.4, 2.4.5]
188.8.131.52 Delayed reporting of a serious accident to the Flag State. [2.7.6]
Page 2 5 of 25
SECTION 4 – RECOMMENDATIONS
Safety recommendations shall in no case create a presumption of blame or
4.1 The Owners / Operators of Vigoroso are recommended to:
4.1.1 Review their Safety Management System to:
184.108.40.206 Identify all dangerous and potentially hazardous spaces on board
their vessels. [ 1.9.5 ]
220.127.116.11 Identify means to prevent access to potentially hazardous spaces
[ 1.4.5 ]
18.104.22.168 Ensure appropriate procedures and equipment are in place for the
monitoring and recording of the temperature and atmosphere in
cargo spaces as appropriate. [ 1.3.6, 1.3.8, 1.3.10, 1.3.11, 1.5.9,
1.7.5, 17.6, 1.8.2, 1.8.6 ]
22.214.171.124 Ensure that the responsibility for the provision of specialised
equipment required for the carriage of potentially hazardous
cargoes is clearly defined. [ 1.3.3, 1.3.5, 1.3.6, 1.5.9 ]
126.96.36.199 Ensure that the appropriate authorities are informed of serious
accidents and incidents without unnecessary delay. [ 2.7.6 ]
4.1 The Crewing Management Company are recommended to:
4.1.1 Review the safety training requirements for crew joining multi-purpose
general cargo ships. [ 2.4.5 ]
4.1.2 Review the information provided to crew prior to joining a ship to
identify ISM and safety related topics specific to the ship. [ 2.4.5 ]