Improper entry into an enclosed space with fatal outcome

Causes:

• Exposure to dangerous atmosphere causing suffocation or poisoning – The AB entered the cargo hold without a SCBA set when the oxygen level inside was approximately 10-12%
• Lack of awareness of cargo hazards – The AB entered the cargo hold without realizing the risk of oxygen deficient atmosphere inside
• Lack of risk assessment – The booby hatch maintenance job was considered to be straightforward. Hence a risk assessment was neither carried out nor hazards involved discussed with personnel carrying out the job
• Failure to follow procedures / instructions – The emergency team did not undertake the rescue operation as per the muster list. Unassigned personnel entered the cargo hold to rescue the AB wearing an EEBD. This could not be done in the first attempt resulting in loss of valuable time
• Inadequate communication / information – There was no sign at the cargo hold entrance to warn the crew to treat the cargo hold as an enclosed space

Lessons learnt:

• Before carrying out any task, conduct a risk assessment and discuss the possible hazards with all personnel involved
• Place posters warning about the dangers associated when working in or near an enclosed space
• Carry out briefing / training to raise safety awareness of all crew regarding entering an oxygen deficient area without SCBA set even for a short period
• Take steps to improve relationship among crew, especially between officers and ratings
• Conduct realistic emergency drills for rescue from enclosed spaces