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JICOSH Home > Case Studies > Case No.46
Case No.46

Anoxia fatality during hatch-opening work following lumber fumigation in a ship's cargo hold

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[Discription of Incident]

This accident occurred during work to discharge fumigation gas by opening the ship's hatch after fumigation of lumber.

On the day of the accident at 11:15 a.m., the concentration of gas in a ship's hold where fumigation had been conducted on the previous day was measured in the presence of a health official. As the effect of fumigation was confirmed as a result of this measurement, two workers and three security personnel started work to open the hatche of each hold under the supervision of the operations chief, who was the victim.

Under the instruction of the victim, two workers went towards the bow and opened the hatches of holds No.1 through No.4 successively.

The victim went to the starboard with three seamen, and instructed them to open and close the hatches while the victim supervised their work.

Upon the completion of work to open the hatch of the last hold (No. 4 hold), two workers went back to the bridge after directing the three seamen who had returned (who were conducting the work together with the victim) to a safe place. 

Although they did not see the victim at this time, they thought that he was making a final conformation of the opening work.

However, as time passed and the victim still did not show up, they started looking around the ship for him at 11:50 a.m., but could not find him. They then went to the office as they thought the victim may have gone to the office to report on the completion of fumigation work, but could not find him there.

This raised the concern of those present - including the general manager of the branch - who returned to the ship and went out in several parties to search for the victim. They found a hatch open on the deck. When they looked into the hold from this hatch, they saw the victim lying on his back wearing a gas mask.

[Causes supposed]

1.       Although a ship's hold poses special dangers of anoxia, no measurements of oxygen concentrations were conducted before entry.

2.       No ventilation was conducted.

3.       The type of self-contained, compressed-air breathing apparatus that is effective in anoxia-prone sites was not used.

4.       While the workers were familiar with fumigation work as well as the work to open hatches after cargo fumigation, they should have established work procedures after examining the details of the ship's structure prior to such work, as a ship's structure differ from each other. However, such procedures had not been established.

5.       While fumigation work is extremely dangerous, any special education had not been sufficiently provided.

[Type of business] Other
[Caused by] Abnormal environment, etc
[Type of accident] Contact with harmful substances
[Number of victims] One fatality