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Report on investigation of marine accident mv Star Java - IMO no 9310513 occupational accident in Squamish 18. august 2008

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Description

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.