RMI investigation: Cadet’s death in enclosed space associated with failure to identify hazard


Casualties | 17/02/20

A Deck Cadet lost his life in an enclosed space onboard the RMI-registered bulk carrier LA DONNA I, in August 2018. The Republic of the Marshall Islands issued its investigation report on the accident, identifying lack of familiarity with procedures as contributing factor to the fatality.

The incident

The Republic of the Marshall Islands-registered bulk carrier LA DONNA I, managed by FML Ship Management Ltd., arrived in the Port of Paradip, India on 12 August 2018 to discharge a cargo of 61,557 metric tons (MT) of coal.

At approximately 17301 on 14 August 2018, during cargo discharge operations, the Deck Cadet was reported to have been incapacitated due to oxygen deficient conditions in the enclosed Australian ladder trunk of Cargo Hold No. 6.

In response to the incident, the Chief Officer (C/O) entered the space to assist the Deck Cadet and subsequently lost consciousness.

The Deck Cadet and C/O were rescued from Cargo Hold No. 6 by the ship’s crew.

The C/O regained consciousness and recovered, however, the Deck Cadet did not survive.

Probable causes

The RMI marine safety investigation concluded that the causal factors that contributed to the Deck Cadet’s loss of life include:

  • asphyxiation due to insufficient oxygen levels within the space where he was working;
  • the C/O’s failure to properly identify the Australian ladder trunk as an enclosed space when he entered, and subsequently directed the Deck Cadet to enter, the cargo holds;
  • the failure of the C/O to identify the potential hazards despite the warning statement present on each access hatch cover;
  • the failure of the Deck Cadet to follow the OS’s advice that a self-contained breathing apparatus (SCBA) should be used when entering the enclosed trunk;
  • the failure of the Deck Cadet to identify the potential hazards despite the warning statement present on each access hatch cover; and
  • the C/O’s failure to follow and enforce enclosed space entry and rescue procedures.

Additional causal factors which likely contributed to the Deck Cadet’s loss of life include:

  • lack of familiarity with ship design characteristics in relation to design of the enclosed Australian ladders within the cargo holds;
  • inadequate onboard implementation of pre-task risk identification, assessment, and control procedures;
  • inadequate supervision of trainee crew members during high-risk or non-routine work assignments;
  • ineffective communication amongst crew members related to the transfer of duties and responsibilities;
  • delays in effecting a properly organized rescue of the Deck Cadet due to the C/O attempting a rescue alone and without raising the general alarm; and
  • ineffective onboard implementation of “Stop the Work” policy when crew members observed unsafe actions or conditions

Actions taken

In response to this very serious marine casualty, the Company has taken the following preventive actions:

  1. All managed ships having similar enclosed Australian ladder designs were identified, and ship-specific entry plans developed.
  2. Within 24 hours, a safety alert was sent to all managed ships which detailed the findings and lessons learned from the incident. In addition, all ships carrying coal were reminded of the requirement to keep access hatches for loaded cargo holds locked.
  3. The Classification Society was requested to review the Australian ladder design and recommend modifications to increase ventilation of the enclosed areas.
  4. For ships fitted with enclosed type Australian ladders, an overview of the design will be added to initial crew member orientation.
  5. Safety training was conducted for all crew members regarding the precautions to be taken when entering the enclosed Australian ladders for the cargo holds.
  6. All superintendents will be provided with the findings and lessons learned for their awareness and for use as a training aid on board their ships.

Additionally, the Administrator has taken the following action:

  1. Issued Marine Safety Advisory (MSA) 23-18 on 30 August 2018 reporting preliminary findings based on the Administrator’s marine safety investigation of the enclosed space entry incident that occurred on board LA DONNA I and ones that occurred on board other Republic of the Marshall Islands-registered ships. The MSA also included recommendations for ship managers and Masters regarding enclosed space entry and enclosed space rescue procedures.


The following recommendations by RMI are based on the above conclusions and in consideration of the actions taken:

  1. It is recommended that the Company review its “Stop the Work” policy and take positive steps to encourage appropriate use of this policy onboard managed ships via additional crew training, crew seminars, and other appropriate measures. It is further recommended that this incident be used as a practical case study in such training.
  2. Due to the similarity of this incident with other recent incidents occurring on Republic of the Marshall Islands-registered ships, the previous safety recommendation for the Administrator related to enclosed space entry training is reaffirmed.

Leave a Reply

SSCP   CAS-002   9L0-066   350-050   642-999   220-801   74-678   642-732   400-051   ICGB   c2010-652   70-413   101-400   220-902   350-080   210-260   70-246   1Z0-144   3002   AWS-SYSOPS   70-347   PEGACPBA71V1   220-901   70-534   LX0-104   070-461   HP0-S42   1Z0-061   000-105   70-486   70-177   N10-006   500-260   640-692   70-980   CISM   VCP550   70-532   200-101   000-080   PR000041   2V0-621   70-411   352-001   70-480   70-461   ICBB   000-089   70-410   350-029   1Z0-060   2V0-620   210-065   70-463   70-483   CRISC   MB6-703   1z0-808   220-802   ITILFND   1Z0-804   LX0-103   MB2-704   210-060   101   200-310   640-911   200-120   EX300   300-209   1Z0-803   350-001   400-201   9L0-012   70-488   JN0-102   640-916   70-270   100-101   MB5-705   JK0-022   350-060   300-320   1z0-434   350-018   400-101   350-030   000-106   ADM-201   300-135   300-208   EX200   PMP   NSE4   1Z0-051   c2010-657   C_TFIN52_66   300-115   70-417   9A0-385   70-243   300-075   70-487   NS0-157   MB2-707   70-533   CAP   OG0-093   M70-101   300-070   102-400   JN0-360   SY0-401   000-017   300-206   CCA-500   70-412   2V0-621D   70-178   810-403   70-462   OG0-091   1V0-601   200-355   000-104   700-501   70-346   CISSP   300-101   1Y0-201   200-125  , 200-125  , 100-105  , 100-105  , CISM   NS0-157   350-018  , NS0-157   ICBB  , N10-006 test  , 350-050   70-534   70-178   220-802   102-400   000-106   70-411  , 400-101   100-101  , NS0-157   1Z0-803   200-125  , 210-060   400-201   350-050   C_TFIN52_66  , JN0-102  , 200-355   JN0-360   70-411   350-018  , 70-412   350-030   640-916   000-105   100-105  , 70-270  , 70-462   300-070  , 300-070   642-999   101-400   PR000041   200-101  , 350-030   300-070  , 70-270  , 400-051   200-120   70-178   9L0-012   70-487   LX0-103   100-105  ,