Tajae Harripersad (62803 | Health & Safety

ERRV Viking Islay

II |

ANALYSIS OF THE CASUAL FACTORS CONFINED SPACES (2225

WORDS)

Table of Contents
Introduction..........................................................................................................................2
Discussion............................................................................................................................4
Conclusion...........................................................................................................................8
References............................................................................................................................9

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Introduction
Confined spaces represent one of the most hazardous shipboard environments for the
unwary seafarer. It has been projected that working in a confined space is 150 times more
dangerous than working elsewhere. Almost every case often involves injury and multiple
deaths. A US-based recuse team, Roco Rescue, gathered some alarming statistics on
fatalities as a result of confined spaces; During a 5-year period (2005-2009), there were a
total of 481 fatalities. This averages to about 96.2 fatalities per year (or 1.85 fatalities per
week). This equates to 1 fatality about every 4 days, keeping in mind that this data only
covers incidents with at least one fatality or death, so these numbers dont include all of
those incidents that resulted in serious injuries or illnesses.
These fatalities occurred in 28 states across the United States with just about every age
group other than the very young and the very old equally represented. Over 61% (or 298)
of these incidents occurred during construction, repairing or cleaning activities. For 203
of the fatalities, the victim worked in the construction industry regularly; however, 17%
(or 83) of the victims were in management positions. Over 61% of confined space entry
fatalities occurred during construction, repairing or cleaning activities (Francelle Theriot,
2010).
One of the most surprising statistics had to do with the causes of these fatalities.
Generally, you would assume that the most common cause of confined space emergencies
would be atmospheric hazards. However, during this particular period, that was not the
case. The largest cause by a significant measure was Physical Hazards. This broad term
encompasses a lot of territory including, struck by, caught in, collapses, and falls.
Physical hazards accounted for 294 or 61% of the fatalities. Atmospheric hazards
(including fires) accounted for 160 or 33% of the incidents (Francelle Theriot, 2010).
Prior to introducing its standards on confined spaces, OSHA reviewed industry incidents
and statistics to determine what was needed to develop standards. What the agency found
when studying confined space fatalities was that (Scott Safety, 2010):
89% of fatalities occurred with jobs authorized by supervisors.

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 80% of fatalities happened in locations that had been previously entered by the same
person who later died.
In 40% of fatal atmospheric accidents, the hazard was not present at the time of initial
entry.
35% of those who died were supervisors.
Only 7% of locations had warning signs indicating that they were confined spaces.
These figures are very disturbing. Scott safety, however, found that sixty-five percent
(65%) of confined space fatalities are due to atmospheric hazards. The remaining thirtyfive percent (35%) are due to factors such as electrical shock or electrocution, being
caught in or crushed by machinery, engulfment, falls inside the confined space, and
ingress or egress accidents.
According to the Code of Safe Working Practices for Merchant Seamen 2010 (COSWP
2010), a Dangerous Space is defined as: Any enclosed or confined space in which it is
foreseeable that the atmosphere may at some stage contain toxic or flammable gases or
vapours, or be deficient in oxygen, to the extent that it may endanger the life or health of
any person entering that space. The atmosphere of any enclosed or confined space is
potentially dangerous. The space may be deficient in oxygen and/or contain flammable or
toxic fumes, gases or vapours. Where possible, alternative means of working which avoid
entering the space should be found.
On 29 23rd September 2007, three seamen on board the ERRV Viking Islay lost their
lives as a consequence of entering an enclosed space. The ERRV Viking Islay was
working in the North Sea conducting rig support operations when two of the vessels
seamen entered an enclosed space with the intention of securing a rattling anchor chain
within the chain locker. One of the seamen entered the chain locker and collapsed. It was
likely that the other seaman, realizing that help was immediately required, raised the
alarm with the duty watchkeeping rating on the bridge before he too, entered the chain
locker in an effort to help his companion. He also collapsed. Below we would discussion,

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why this situation happened, the parties involved and what should have been done to
prevent it from repeating.

Discussion
Individual Involved

Mr. MacFayden 8/12

seaman

Actions/Errors/Mistakes

Type of Error

Slip
Lapse
Slip
Mistake

Being left in charge, no

permit to work was
issued/no risk assessment
conducted/did not inform
Master
Shouted for help instead
of alarming Master/did
not sound general the
alarm
Removed breathing
apparatus to enter into
space
Use of EEBD is
forbidden in oxygen
deficient tanks, yet it was
still

Mr. Ebertowski day

worker

Mr. OBrien day worker

Took no equipment/
safety related document
before entering
Did not test atmosphere
Saw the collapse of
college and entered
without PPE
Did not test atmosphere

Mistake (rulebased)
Mistake (rulebased)

Slips
Mistake

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Master

Chief Mate

The Company - Vroon

Internal Vessel Auditors

Did not consult with mate

on entry into enclosed
space procedure
Made no request of
conducting Risk
Assessment
Did not follow SMS.
Entry into closed spaces
are only to be conducted
while in port

Turned a blind eye to

several issues onboard

Slip
Slip
Mistake

Slip

Ordered 12/4 seaman to

enter into chain, with no
risk assessment being
done

Supply of inappropriate
atmospheric testing
equipment
Errors included in Risk
Assessment Document
No safety coaches
Drills were not properly
conducted

Mistake
Mistake
Slip

Mistake

Table 1: Showing the Individuals involved in the incident with the errors made by
each person.
Now there are several factors, particularly human factors, which came into play which
resulted in the incident, which could have been avoided if simple procedures were put in
place and properly followed. Its very easy just to point the finger and put blame on
someone but in this situation, and in fact any other situation, there is no one person to
blame, rather the incident was a result of many errors. We would discuss a collection of
issues/errors that were present in this case, both ship-side and shore-based, and examine
exactly where this system has failed those three individuals who lost their lives. A series
of issues will be discussed below pursuant to this case.

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COSWP 2010, lays out the necessary precaution to be taken when working in enclosed
spaces. The steps are as follows;
1.
1.
2.
3.
4.
5.
6.

A competent person should make an assessment of the space and a

responsible officer to take charge of the operation should be appointed
The potential hazards should be identified
The space should be prepared and secured for entry
The atmosphere of the space should be tested
A permit-to-work system should be used
Procedures before and during the entry should be instituted

On the Viking Islay, none of these steps were carried out, according to the report. No
competent person made an assessment of space, no risk assessment conducted, no testing
of atmosphere and no permit to work issued. That day, there was some discussion
between 8/12 seaman and the master about entering the chain locker to resolve the
knocking sound, however that was as far as that conversation got between them. Even
though the companys policy states that entry into enclosed spaces are to be conducted
only when in port. The master was not informed prior to entry of the day worker into the
enclosed space. Mr. MacFayden, being left in charge, ordered both workers to carry out
the task which required one person to enter into the chain locker. Unaware of the fact that
this was indeed an enclosed space, therefore a dangerous space, no necessary
documentation was presented. This is where we see the lack of training coming into play.
It was even mentioned in the MIAB report that most staff where not aware that the chain
locker was categorized as an enclosed space. This is no surprise if safety drills were being
conducted in an open area and not an equivalent enclosed space, more specifically, the
laundry room. A true appreciation of the drill would not be fulfilled and it is not realistic.
Mr. MacFayden also failed to inform the Master that such work was being initiated. This
reflects lack of following procedures which can then be tied back to lack of proper
training.
The initial cause of the deaths, according to MIAB report was due to the oxygen-deficient
atmosphere. An acceptable range of oxygen can range from, 19.5% - 23.5%. However, it
was estimated that the oxygen concentration at the time was at a very low concentration
(around 4.45) which resulted in the instantaneous collapse of the workers. Considering
the vessel was 22 years of age, it is without doubt it is susceptible to a high rate of

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corrosion and more frequent maintenance is necessary. As a result of the atmosphere not
being tested, Mr. OBrien, Mr. Ebertowski and Mr. MacFayden were unaware of the
potential toxic gases that existed. There were also no ventilation fans present at the time.
If proper training were to be implemented, it would be instilled in workers what is the
right thing to do, correct procedures to follow. Also Mr. MacFayden, in an attempt to
rescue his colleges who had no type of breathing apparatuses with them upon entry, lost
his life as well. Mr. MacFadyen, upon entering the confined space, removed his breathing
apparatus and the Emergency Escape Breathing Device (EEBD) was used. This was a big
mistake as EEBDs are, just as the name suggests, to be only used for escape purposes
only and not in oxygen deficient areas. We see these issues related to training coming
together in just short space in time within this incident. Once there is proper training on
the use of equipment, appropriate drills conducted and proper risk assessment procedures,
there will be a reduction in these occurrences.
On the shore-based side, there was a major fail in the companys Safety Management
System. This is where we witness the root-causes of this particular incident. Most of the
companys policy was adopted from the previous owners, Blue Islay. This was the
companys first mistake, in my opinion. What the company should have done, was to
revise all policies that were left from previous administration. Simple as updating the
necessary signage indicating that a particular area was an enclosed space and placing it
somewhere that is visible to all staff and ensuring that the policy was coherent with the
overall duties of the company. After the incident, Viking Islay was detained by surveyors
from the local Maritime and Coastguard Agency due to major non conformities with the
Safety Management System. This is where the Designated Person and even internal
auditors have failed to do what they are ought to do. Had they been operating in the line
of their duty, these non-conformities would have been highlighted at an early stage and
the necessary changes made. The company even went as far as to hire safety coaches that
would go onboard ships, however, it was discovered that they never visited.
As mentioned before, it was not in the policy to enter into an enclosed space out at sea.
What about is there is an urgent situation onboard vessel? In my view, the company
should have enforced entry into confined spaces in port areas only unless there is an

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emergency. If such a cases unfolds, on-shore staff should be contacted immediately and
both parties will treat with the situation from that point. Additionally, there were no
equipment onboard capable of testing the atmosphere as the company only provided a
personal alarm unit which also had a limited shelf life. To replace this, the company
provided a single gas monitor not even capable of detecting oxygen levels. Improper
equipment, improper training, this was simple a disaster waiting to happen.
These were the building blocks to the catastrophe. Its unfortunate that we see these
situations unfolding again and again. In a similar case that occurred before the Viking
Islay, the Silent Assassin, two persons died as a result of not following proper safety
procedures, comparable to this case. The official report issued in 1999 said: Every time
there is a fatal accident involving entry into an enclosed space and personnel being
overcome in a non-life supporting atmosphere the question is asked as to how does this
keep happening?. Training and familiarization should ensure that all crew members are
aware of the dangers in entering a space without first checking the atmosphere.
Unfortunately, it would appear that education is still needed to get the message through .
These words are very relevant now as they were then and reflects deep meaning,
especially in cases today.

Conclusion
It is very saddening that an ERRV/stand-by vessel whose purpose is that of a safety cover
and emergency response command and control center, could tackle an emergency
onboard their own. In this particular case, there are major underlying causes that were
highlighted within the discussion; Failure of Safety Management System (SMS) inclusive
of risk management and permit to work, Training/Drills and no relationship between
ship-side and shore-side. Once we have a properly functioning SMS together with the
relevant training, a strong bond will be developed between ship and shore-based
members, coming together to minimize whatever potential hazard that they may face.
Human error was unmistakable in this case, both in the planning stage, in terms of

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company policy and execution, in relation to carrying out the task. As a result, three (3)
men died in the process.

References
Francelle Theriot, L. (2016). Confined Space Fatalities A closer look at the numbers.
[online] Rocorescue.com. Available at: http://www.rocorescue.com/roco-rescueblog/confined-space-fatalities-a-closer-look-at-the-numbers#.VsFSOfIrLWI
[Accessed 14 Feb. 2016].
Marine Accident Casebook, (2014). [podcast] The Case of the Silent Assassin. Available
at:

http://maritimeaccident.org/about/free-podcasts/the-case-of-the-silent-assassin/

[Accessed 28 Feb. 2016].

MCA, (2010). Code of Safe Working Practices for Merchant Seamen. United Kingdom:
MCA.
MIAB, (2008). ERRV Viking Islay. United Kingdom.

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Scott Safety, (2010). Confined Space Safety. 1st ed. [e-book] Available at:
http://scottsafety.com [Accessed 18 Feb. 2016].

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