Report on investigation of an occupational accident on board the Solstraum, LDEB3, en route to Rotterdam 4 February 2011
Marine report 2012/07 eng
The Accident Investigation Board (AIBN) has carried out a safety investigation in connection with an occupational accident on board the chemical tanker Solstraum 4 February 2011. The pumpman died when he entered one of the cargo tanks, during tank cleaning operation while the ship was in transit to Rotterdam, before the cleaning and ventilating process had been finished. The actual cargo tanks had been inerted with nitrogen (N2) in connection with the transport of ethylene dichloride (1.2 dichloroethane), and the tanks were discharged in Wilhelmshaven earlier the same day.
At the time of the accident, the oxygen content of the atmosphere at the bottom of the tank
was probably less than 7 %, and the AIBN assumes that the pumpman died as a result of oxygen deprivation.
The investigation has revealed underlying safety problems related to lack of compliance with the procedures in the safety management system. This does not only concern the deceased pumpman who entered the cargo tank without following the procedures for entering enclosed spaces. On the voyage in
question, the procedures for holding a pre-arrival conference, the procedures for holding a tank cleaning meeting and the procedures for logging nitrogen inerting were not complied with.
After the accident, the shipping company has decided to arrange a S & QMS (Safety & Quality Management System) refresher course for all the shipping company's employees, to establish a programme to improve the HSE culture (Health, Safety & Environment culture), to put leadership and
cultural differences on the agenda, to introduce labelling/sealing of inerted cargo tanks, and to prohibit filter masks and physically remove the masks from all the company's vessels.
Based on follow up of the shipping company the AIBN's finds no need to
propose safety recommendations in this report.
Facts
| Location | On route from Wilhelmshaven til Rotterdam |
| Occurrence date | 04.02.2011 |
| Accident category | Personal injury |
| Area | International Waters |
| IMO number | 8913708 |
| Name of vessel | Solstraum |
| Accident type | Fatal Accident, Enclosed space entry, Occupational accident |
| Vessel type | Tanker |
| Register | The Norwegian Ship Register |