Japan investigation Report: Bulk Carrier EVER FELICITY fatality in cargo hold

(www.MaritimeCyprus.com) While the bulk carrier EVER FELICITY was engaged in cargo handling operations berthed at the North Wharf of Hibarino in Ishinomaki Port, Ishinomaki City, Miyagi Prefecture, at around 07:35 on May 20, 2024, two stevedores lost consciousness and collapsed inside a cargo hold. Both of the Stevedores were transported to a hospital; one was later pronounced dead, and the other sustained injuries.

Probable Causes

This accident is more likely to have occurred during the loading of palm kernel shells (PKS) at the North Wharf of Hibarino in Ishinomaki Port. Two stevedores entered No.1 CH without a prior working environment measurement. As a result, they inhaled air with an oxygen concentration lower and a carbon dioxide concentration higher than those of standard atmospheric conditions, lost consciousness, and collapsed onto the PKS.

The failure to conduct a working environment measurement in No.1 CH prior to entry is more likely to have resulted from the fact that the Sempoku Branch of Nippon Express Co., Ltd. did not prepare a safe work procedure manual—including a risk assessment covering the working environment inside the cargo hold—nor did it implement the legally mandated safety management measures for stevedores engaged in cargo hold operations.

The absence of a safe work procedure manual for the PKS loading operation is more likely to have resulted from the following factors:

1. The Sempoku Branch of Nippon Express Co., Ltd. representative judged that, due to the
   vessel entered the port in a light (empty) condition and there was no perceived hazard inside the cargo hold, the work could be conducted simply by reversing the unloading procedure. Accordingly, he determined that the loading operation did not constitute work involving the adoption of new work methods or procedures as stipulate under the Nippon Express Occupational Safety and Health Management System.
2. Within the Sempoku Branch of Nippon Express Co., Ltd., did not conduct to direct
   instructions or comments were issued indicating that a new risk assessment work procedure manual should be prepared, in response to the judgment made by the representative as described in (1) above. It is probable that the implement of the loading operation could be safely conducted using conventional methods according to experience and procedures related to the loading of bulk cargo, and subsequently the stevedores were instructed to perform the operation in accordance with the planning sheet.
3. The representative and stevedores at the Sempoku Branch of Nippon Express Co., Ltd failed to recognize that the working environment might change as the loading of PKS progressed within cargo hold, and they were not aware that the operation fell under the requirements of the Japanese regulations, which mandate the measurement of the working environment in such situations.

For more details, Preventive Actions and other measures, click below to download the full investigation report from the Japan Transport Safety Board:

Source: Japan Transport Safety Board

For more maritime investigation reports, click HERE.