The Republic of the Marshall Islands (RMI) Maritime Administrator has issued an investigation report into an incident where a Chief Officer collapsed and died inside a cargo tank after entering an inadequately gas-freed space.
The incident
On the morning of 25 August 2025, the C/O on board a Republic of the Marshall Islands-registered oil/chemical tanker was entering Nos. 1–3 P/S CTs to inspect them after they had been washed and gas freed following the carriage of benzene as cargo.
Deck ratings then entered the cargo tanks to rinse them with de-ionized water after they had been inspected by the C/O. The C/O had reportedly tested the atmosphere inside these cargo tanks earlier that morning and had determined they were safe for entry. Neither the C/O nor the other crewmembers were wearing a personal gas detector while entering the cargo tanks.
Approximately five minutes after the C/O entered the ship’s No. 3 P CT, crewmembers who were on deck heard a noise and, after looking through the tank dome, saw the C/O lying on the tank top inside of the cargo tank.
They immediately called for help and then began bringing rescue equipment to the tank dome. After arriving at the tank dome, the ship’s Master put on a BA set and entered the cargo tank to assist the C/O, who was unconscious and breathing weakly.
The Master took the mask of his BA set off and held it over the C/O’s face. The Master then alternated between holding the mask on the C/O’s face and using it himself until he exited the cargo tank when two other crewmembers arrived on scene with a rescue harness. After putting on another BA set, the Master reentered the cargo tank carrying an EEBD that he put on the C/O. The C/O was then hoisted out of the cargo tank.
Once the C/O was on deck, crewmembers started to administer CPR after determining that he did not have a pulse and was not breathing. There were no visible injuries consistent with a fall from height. Despite all efforts to revive the C/O, it was subsequently determined that he was deceased.
The marine safety investigation conducted by the Republic of the Marshall Islands Maritime Administrator determined that the gas freeing operation that had been conducted on 24–25 August 2025 was not effective, the atmosphere inside the cargo tanks had not been properly tested, and the C/O was not wearing a personal gas detector as required by company procedures.
The Administrator’s marine safety investigation also identified evidence of an ineffective safety culture both at the management level and on board the ship. Some examples include ineffective management oversight by shore management and by the ship’s Master, and the Master having acted contrary to his overall responsibility for ensuring the safety of the ship and all crewmembers by entering No. 3 P CT to assist the C/O.
Other examples include that enclosed space rescue drills were likely conducted as pre-scripted exercises rather than conducted to ensure that crewmembers were prepared to respond to an actual emergency and that the crewmembers’ records of work and rest hours were not accurately maintained.
Conclusions
Causal factors that contributed to this very serious marine casualty included:
(a) the gas freeing operation that was conducted on board the ship on 24–25 August 2025 was not effective;
(b) the atmosphere in Nos. 1–3 P/S CTs was not tested on the morning of 25 August 2025 as required by company procedures;
(c) the C/O was not wearing a personal gas detector when he entered No. 3 P CT;
(d) ineffective management and oversight by the Master of the cargo tank cleaning and gas freeing operations that were conducted on 24–25 August 2025 and of the enclosed space entry on 25 August 2025; and
(e) an ineffective safety culture both within the company and on board the ship.
Additional causal factors that may have contributed to this very serious marine casualty included:
(a) the deck ratings on board the ship may not have had adequate awareness to recognize the existence of an unsafe act or condition prior to the C/O entering No. 3 P CT or the confidence to exercise stop-work authority.
Actions or events that reduced the adverse consequences of this very serious marine casualty included the:
(a) fact that none of the crewmembers who were working on deck entered No. 3 P CT to assist the C/O, but instead immediately called for help and then gathered and brought rescue equipment to the No. 3 P CT tank dome; and
(b) crewmembers who entered No. 3 P CT to put a rescue harness on the C/O did not remove their BA set masks to assist the C/O while they were inside the cargo tank.
Additional issues that were identified but that did not contribute to this very serious marine casualty included:
(a) onboard enclosed space rescue drills were likely conducted as pre-scripted exercises rather than conducted to ensure that crewmembers were prepared to respond to an actual emergency;
(b) the procedure for cleaning the ship’s cargo tanks on 24–25 August 2025 was not in accordance with the company’s established procedures;
(c) the guidance in the company’s procedures for using a toxic gas detector sample pump with an extension hose was not consistent with the manufacturer’s instructions; and
(d) a dedicated Lookout was likely not on duty during hours of darkness or when the existing conditions might not have been appropriate for the OOW to serve as the ship’s only Lookout while the ship was underway in the Persian Gulf and transiting the Strait of Hormuz on 24–25 August 2025.
Lessons learned
- The atmosphere inside an enclosed space must be properly tested to determine if it is safe for entry.
- Gas detection equipment must be used in accordance with the manufacturer’s instructions.
- Enclosed spaces should never be entered for any reason without completely implementing established shipboard procedures.
- A positive safety culture both on shore and on board a ship is essential and requires that both shore-based and sea-based staff place safety above all else.
- Enclosed space rescue drills should be conducted as if it was an actual emergency, not as pre-scripted exercises.
- Deviations from established procedures increase the risk of accidents.
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