Marshall Islands Accident investigation report: Enclosed Space Entry Fatality on AVRA

(www.MaritimeCyprus.com) On 25 July 2025, the Republic of the Marshall Islands-registered bulk carrier AVRA, managed by A.M. Nomikos Transworld Maritime Agencies S.A. (the “Company”), was berthed at MB5, Daesan Port, Republic of Korea.

The ship was discharging the bulk cargo of wood pellets when the Bosun was found collapsed inside the CH No. 4 aft access hatch space. At 1033,2 the crew rescued the Bosun and brought him out onto the main deck, where medical first aid and CPR were immediately commenced.

At 1120, the shore emergency team arrived and transported the Bosun to the local hospital. However, at 1216, the ship received information from the local agent that the Bosun was deceased.

The Republic of the Marshall Islands Maritime Administrator’s marine safety investigation determined that the Bosun had entered the CH No. 4 aft access hatch space to gain access to the CH No. 5 forward inspection platform to sweep off cargo residues on the platform without complying with the Company’s enclosed space entry procedures.

CONCLUSIONS

The following Conclusions are based on the above Factual Information and Analysis and shall in no way create a presumption of blame or apportion liability.

A. Causal factors that contributed to this very serious marine casualty included:

1. the Bosun’s decision to enter the CH No. 4 aft access hatch space, an adjacent connected space to CH No. 4;
   and
2. lack of oversight by the C/O of the Bosun’s movement and work activities during cargo operations in port due
   to the Bosun’s perceived level of experience.

B. Additional causal factors that may have contributed to this very serious marine casualty included:

1. there were no requirements for the reporting of personnel entry into enclosed spaces where the spaces were
   identified as low risk (Appendix I – MLC Crew Manual); and
2. poor and/or lack of warning signs or physical barriers to prevent unauthorized entry into the cargo holds access
   hatch spaces.

The following lessons learned were identified.

• Entering a space that is part of a fully loaded cargo hold without authorization and without following established shipboard enclosed space entry procedures is extremely hazardous and should not be attempted.
• Physical barriers and warning signs are critical for preventing unauthorized access into an enclosed space.
• Compliance with established safety procedures is paramount and should always be prioritized to ensure personal
  safety.

For more details, click below to download the full Marshall Islands investigation report:

Source: Marshall Islands Flag Administration

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