Enclosed Space Entry fatalities: Do marine investigations encourage a blame culture?

According to a survey conducted in 2018 by InterManager to which some 5,000 seafarers responded, a number of issues related to continuing deaths in enclosed spaces were raised:

·??????Procedures often seem difficult to understand, confusing, and do not take account of the resources, equipment and time available aboard the vessel.

·??????Design and equipment added to the problems by creating hazards.

·??????Commercial/time pressure is a significant factor and was described as ‘verging on abuse’.

·??????Investigations of fatalities point to failures in the victims and in particular their failure to follow procedures.

Procedures on enclosed space entry are built around the IMO Resolution A.1050(27) Revised recommendations for entering enclosed spaces aboard ships. ??

However, statistics compiled by InterManager for the period between 2000 and 2022 show that the Resolution has not been effective. On the contrary, the number of fatalities increased since 2011, when the Resolution was last updated.

Numerous issues with the Resolution have been identified and InterManager was successful in its proposal to the Sub-Committee on Implementation of IMO Instruments to amend it.

As a member of the Human Element Industry Group, InterManager also works on proposals to change vessel design pertaining to enclosed spaces and industry practices to reduce excessive time pressure that affects safety.

The saddest part of the survey though is “… a widespread belief that a blame culture is deeply rooted within the shipping industry. Respondents felt that the majority of accident investigations stop at finding the ‘guilty party’ and very rarely go further to discover why the accident occurred or the reasons for the actions of those killed or injured”.

Another set of interviews of both incident/casualty investigators and seafarers conducted within the Safemode project resulted in the same conclusions: “In particular the phrase ‘blame the ship’ came up independently numerous times. In this respect it was notable that investigations rarely consider more distant and onshore contributory factors to accidents, reinforcing the notion that the ultimate culpability lies with the ship and its master”.

Recognizing that there are different casualty/accident investigations, where those for action in civil or criminal proceedings look for the immediate cause of an accident and apportion blame, at least safety investigations conducted by Flag states with a view to improving safety at sea should investigate differently, delve deeper and search for circumstances or parties who may have contributed or even caused an incident to occur.

The Casualty Investigation Code states clearly that “Marine safety investigations should … be seen as a means of identifying not only immediate causal factors but also failures that may be present in the whole chain of responsibility”.

?And yet, the chain with all its links seems to always remain on board the ship as there is a consistency in blaming seafarers for complacency, lack of knowledge, disregard for procedures, acting on emotion, and letting commercial pressures get the best of them (it is implied that they somehow shouldn’t).

It is well known that it takes Flag states years to issue their investigation reports, if ever. It has also been noted by the IMO that there are serious gaps in the quality of reporting for those that are submitted.

However, Flag states rejected a proposal for mandatory new rules that could improve casualty reports by requiring investigators to understand the root causes of serious accidents. Flag states argued that the existing frameworks for investigations were adequate.

Be it as it may, let us examine one safety investigation report on a fairly recent enclosed space incident that stands out in that there was no explicit blame on the victim, nor were ‘not followed procedures’ listed.

The incident occurred in 2020, on the Stavanger Bliss, an oil tanker where the Captain lost his life inside a cargo tank containing inert gas. The Flag state report was issued two years later in 2022.

A brief description of the incident

Following unloading, Charterers complained that there was too much cargo remaining on board (ROB) resulting in a claim of about USD230k.

The Captain was concerned about the claim and decided to enter a cargo tank containing inert gas to (supposedly) check the cargo quantity, although a joint survey of cargo ROB was planned for the next port of call.

The Captain went inside the tank alone, wearing a self-contained breathing apparatus. Although he reported exiting the tank after some twenty minutes, an emergency was declared and fifteen minutes later the rescue party found the Captain lying on a platform; no pulse or breathing could be detected.

The Captain died and the post-mortem report showed that the cause of death was a heart attack. It could not be determined with any certainty that the cause of the heart attack was carbon monoxide poisoning.

The Flag state report analysis and conclusions

The investigation report focused on two possible immediate causes of the incident:

-?????????the management company’s handling of ROB claims

-?????????the vessel’s safety management system (how it could have prevented the entry of a tank with an unsafe atmosphere).

There were no issues found with either one so safety recommendations had not even been issued. Instead, “the shipping company planned/implemented several measures to prevent similar accidents”.

Admittedly, it was recognized that the Captain was faced with extraordinary challenges caused by the Covid-19 pandemic which may have affected his decision-making.

It was also recognized that the Captain was concerned about too much cargo remaining on board as claimed by Charterers, and wanted “to gain an overview of the situation in the tank”.

Delving deeper

A number of questions can be raised with that report. To begin with, one of the safety recommendations by the management company was “improving the system for follow-up, guidance, and motivation of captains and chief engineers following unsatisfactory performances”.

What was the system of performance evaluation before the incident?

Is it possible that the Captain went inside the tank to check ROB because he was not only concerned but tormented by the possibility that he made a mistake causing the alleged cargo shortage? A mistake that would affect his performance evaluation?

Was the ROB issue followed up? What went wrong?

Since the cause of the heart attack had not been determined, why was carbon monoxide poisoning even suspected?

Is it because just one breath of inert gas (nitrogen) would have caused asphyxiation, but not a heart attack, and the only gas that can cause a heart attack is carbon monoxide?

Is it possible that the Captain simply had a heart attack, with or without an underlying heart condition? ?

Was an expert medical opinion sought?

The list of questions is not exhaustive, and the reader of the report is left to wonder…

When an investigation focuses on the immediate cause, as it mostly does, the sense of blame for wrongdoing, whether explicit or implicit, cannot be avoided.

The conclusions of this particular case, despite the best efforts not to blame the victim, give a sense of implied blame: the man did the incomprehensible, acted against all the rules and procedures, and died. Nothing else to say.

To add insult to injury, the management company implemented a measure of “further developing a progressive sanction system ranging from formal warnings to dismissal if a person does not comply with the company’s guidelines”.

Certainly inducing more fear is not helpful in preventing similar incidents.

So yes, there is a blame culture, even when hidden within the ‘lessons learned’ principle.

While there is an ever-increasing number of rules and procedures which sometimes require robotic behaviour on the part of seafarers, followed or not, they still keep failing in preventing accidents.

Therefore, one must look elsewhere to find fault. A thorough investigation would certainly at least occasionally point towards commercial pressures, design issues, fear of being inadequate, or eagerness to please. This would drag other links of the chain of responsibility into play, and shed some light on their detrimental effect.

Such thoroughness should apply even to those investigations that seek to ‘serve justice’.

There is no justice in persistently blaming seafarers alone.

InterManager: InterManager urges crew to help identify enclosed space solutions (November 2018)

Safety4sea (Capt. Kuba Szymanski): Does enclosed space entry need more regulation? (September, 2019)

InterManager: InterManager survey reveals widespread concern at enclosed space deaths (May, 2019)

Norwegian Safety Investigation Authority: Work accident on board ‘Stavanger Bliss’ off Yeosu in South Korea on 5 November 2020

InterManager: Industry group reveals initial results from research into maritime deaths in enclosed spaces (December, 2021)

Lloyd’s list: Flag states reject proposal to improve casualty reports (August, 2022)

Safemode: Towards a Safety Learning Culture for the Shipping Industry