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Case Study: Pacific Endeavor Fatal Accident

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Pacific Endeavor Fatal Accident

Viewpoint: On 19 June 2010, the ship arrived discharging port “Zhenjiang Port” China to discharge cargo “Coal” (36,861 metric tons) in bulk which had been loaded in Samarinda, Muara Jawa Anchorage, Indonesia. At 0705, on 21 June 2010, when the ship crew were inspecting cargo holds after the completion of cargo discharging at Zhenjiang Port, the Third Officer reported to the Chief Officer that water leaked from the transverse bulkhead lower stool space between cargo hold No.3 and No.4. The water was seeping from the welding joint that attached the bulkhead ladder onto the lower stool slope plating of No.3 cargo hold aft bulkhead. Therefore, the Chief Officer and the Bosun went down to the No.3 cargo hold to inspect the area. To further …show more content…

The Bosun proceeded to enter the enclosed space alone without following the company’s Safety Management System and the approval by the Master. The Bosun entered the void space and lost his conscious there. He was sent to hospital for rescue. However, he was certified dead by the hospital on the same date. On that day, when the Vessel completed her discharging of coal cargo at Zhenjiang, China, the Bosun on board was suffocated inside the void space at the aft transverse bulkhead lower stool of cargo hold No.3.
The investigation into the accident revealed that the enclosed lower stool space was not properly ventilated before entry. The Bosun was likely overcome by high concentration of carbon monoxide and oxygen depletion inside the space that was lethal to him. The investigation had also revealed that the procedures stipulated in shipboard Safety Management Manual (SMM) had not been followed on the entry of enclosed spaces or confined dangerous

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