Report published into fatal accident on Berge Mawson

Occurred at Bunyu Island Anchorage, Indonesia in June 2022

An accident investigation report has concluded that three dockworkers from an Isle of Man registered bulk carrier died after one mistakenly descended into the wrong cargo hold and his two colleagues attempted to rescue him.

The incident took place aboard the Berge Mawson in June 2022 at Bunyu Island Anchorage, Indonesia.

The three casualties were Indonesian nationals who were regularly assigned to work on vessels loading at Bunyu Island as stevedores (dockworkers).

At around 1:45pm on 27 June 2022 three unconscious stevedores were recovered from a cargo hold access space.

Despite 'prompt medical attention by ship and port staff', the three men died.

Berge Mawson was loading a bulk cargo of coal from barges using a floating crane.

The coal in cargo hold No.7 was being levelled by a bulldozer, when loading was paused, and all hatches were closed due to heavy rain.

Once the rain had stopped, a stevedore made several attempts to gain access to the bulldozer.

Unsupervised, the stevedore mistakenly descended into cargo hold No.8's access space where he collapsed.

As Berge Mawson’s crew were collecting rescue equipment, two stevedores also collapsed into cargo hold No.8's access space as they attempted to rescue their stricken colleague.

Postmortem examinations on the men were not conducted, and the cause of death was not confirmed.

However, the atmospheric readings of the cargo hold No.8 forward access space taken after the casualties were found showed a deficiency of oxygen and a high level of hydrogen sulfide.

The report concludes that it is highly likely that the noxious air breathed by the three stevedores caused them to be incapacitated upon entry into the cargo access space, and the resulting shutdown of their brain and/or lungs led to their deaths.

TRAINING

At the time of the accident, stevedores supplied by PT Bintang Kartika Segara (BKS), PT Tara Jaya Samudera (TJS) and PT Tanjung Mas were working on board Berge Mawson.

Neither BKS, TJS nor PT Tanjung Mas provided safety or cargo operations training for employees who were appointed to on board duties.

As such, none of the casualties involved in the accident had completed enclosed space awareness training.

Indeed, none of the casualties had completed the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers 1978, as amended (STCW) certification, the syllabus for which included personal survival techniques, firefighting and personal safety.

This certification had been completed by the wider crew of the Berge Mawson.

CASUALTIES

Bulldozer operator two was 49-year-old Fredi Simon.

He was the first to descend into the hatch and was employed by PT Tanjung Mas.

A qualified bulldozer operator, he held no formal qualifications for working on board a ship and could not read or speak English.

The foreman was 28-year-old Muhammad Sajuddin, who held a diploma in trade and port ship management.

He had joined BKS as an assistant foreman in October 2020 and was promoted to foreman a year later.

He was reported to have a passable standard of English.

Bulldozer operator three was 38-year-old Marten Seko.

He was also employed by PT Tanjung Mas as a qualified bulldozer operator but held no formal qualifications for working on board a ship and could not read or speak English.

INVESTIGATION

As a result of the three very serious marine casualties, an investigation was conducted by the Marine Accident Investigation Branch (MAIB) on behalf of the Isle of Man Ship Registry.

It concluded that:

• The stevedores died because they entered an enclosed space that had a noxious atmosphere that could not sustain life.
• Atmosphere testing of cargo spaces was not routinely carried out before stevedores entered the compartments.
• The stevedores were not adequately supervised on board Berge Mawson.
• Access ways to cargo spaces were not locked closed when not in use.
• The stevedores were unable to understand safety labels and warnings and cargo space identification.
• The agreed Ship-Shore Safety Checklist had limited validity after the commencement of cargo operations.
• The terminal had not trained the stevedores in line with international guidelines on safe cargo work on board bulk carriers.
• An industry-led initiative that requires bulk terminals to implement safety training and management systems could improve stevedore safety on board vessels

As a result of the investigation, Berge Mawson's management company, Berge Bulk Maritime Pte. Ltd, has 'reviewed its procedures for entry into cargo hold spaces, undertaken to fit physical barriers to prevent unauthorised cargo hold access on all its bulk carriers and revised its Ship-Shore Safety Checklist'.

Additionally, a recommendation has been made to the Maritime and Coastguard Agency to review the guidance provided in the Code of Safe Working Practices for Merchant Seafarers on the inclusion of third parties such as stevedores during enclosed space drill scenarios.

You can find the Marine Accident Investigation Branch report in full HERE.