All Sectors

Three in the Hold: What the Deaths on Berge Mawson Tell Every Chief Officer About Stevedores, Coal Cargo, and the PTW System

🕑 5 min read words Safety • Incident

Vessel: Berge Mawson, bulk carrier
Date & location: 27 June 2022, Bunyu Island anchorage, Indonesia
Outcome: Three stevedores died in a cargo hold access space — oxygen 0.9%, CO 2,147ppm, H2S 3,100ppm. Two died attempting to rescue the first
Human factors: Normalisation · Situational Awareness · Supervision Gap
Source: MAIB Report 5/2025

9 decision nodes4 outcome paths — controlled / uncontrolled entry~7 min read + Knowledge Checker

Bunyu Island, 27 June 2022

Coal loading to cargo hold No.8 on Berge Mawson had finished on 25 June. The hold had been closed for approximately 48 hours — a normal part of the operation. At 0830 on 27 June, a routine atmosphere test of hold No.8 logged an oxygen reading of 5.8%. Normal air is 20.9%; the safe entry threshold is 19.5%. The reading was already life-threatening. It was logged. No further action was taken. The hold remained accessible.

At around 1230, bulldozer operator Fredi Simon, 49, asked crew to open hold No.7 to retrieve his bulldozer. He then moved to the adjacent booby hatch on hold No.8. Its label was damaged and unreadable, and Simon had little English — he could not read the stencilled warning: Insufficient oxygen — entry with C/O permission only. He opened the hatch and entered. He was overcome immediately and fell, wedged at the foot of the access ladder.

The Rescue That Became Two More Deaths

Foreman Muhammad Sajuddin, 28, found Simon and entered to pull him out. Bulldozer operator Marten Seko, 38, followed. Both were overcome within minutes. When rescuers arrived with testing equipment 40 minutes after discovery, the atmosphere read oxygen 0.9%, CO 2,147ppm, H2S 3,100ppm, methane 36% LEL. None of the three had received enclosed space training or PPE.

Recommended Actions

Revise COSWP to require enclosed space rescue drills to include the possible presence of shoreside staff and third parties (MAIB 2025/101)
Provide stevedores with training and PPE for bulk carrier cargo work, per IMSBC Code, BLU Code and BLU Manual requirements (2025/102)
Maintain clear guidance on cargo operation duties for ship and shore personnel, with robust control of access (2025/103)
Develop a minimum operational safety standard for stevedores across member vessels — Ship-Shore Safety Checklist, hold entry procedure, PPE (2025/104–105)

Human Element Analysis

Normalisation

Eight days of cargo operations without incident had eroded the permit-to-work system into disuse. No PTW was issued for any stevedore hold entry during the entire loading operation — not because the system was absent from the SMS, but because it had quietly stopped being used.

Situational Awareness

The 0830 reading of 5.8% oxygen was a clear signal the hold was lethal. It was logged and then ignored. The booby hatch that killed three men was left unlocked, indistinguishable from the adjacent, safe hold, with a warning label too damaged to read and written in a language none of the men understood.

Supervision Gap

MAIB found that because the respective roles of ship's crew and the shore foreman had never been clarified, each side assumed the other was monitoring the stevedores. Neither was. The gangway log was not consistently used — the actual number of stevedores on board at any time was unknown.

How This Pattern Repeats

Industry	Incident	The parallel
Nuclear	Tokaimura criticality accident, 1999	Workers with no formal training in the specific hazard performed a task outside written procedure because it had been done informally that way before — the same drift from a written system into an unwritten, riskier routine.
Rail	Purley rail crash, 1989	A signal passed at danger by a driver working outside the formally briefed system exposed a supervision gap between separate parties assuming the other was managing risk.
Offshore	Piper Alpha, 1988	A permit-to-work handover failure — each shift assuming the other had control of a hazard — is the same structural failure MAIB found between Berge Mawson's crew and shore foreman.

See How You'd Handle It

The scenario opens at 0830, with the atmosphere test result for hold No.8 already on your clipboard. What you do with that number is the first decision point.

What Every Chief Officer Should Take From This

An atmosphere test result that shows a lethal reading must trigger an immediate action, not just a logbook entry
Booby hatches not in active use should be physically padlocked, not just dogged
Hazard labels must be legible and should not rely on English alone
When a person is found unconscious in an enclosed space, the first response is to guard the entrance, not to follow them in

Test Your Knowledge

Think you've got this covered? Put it to the test in Crew Connect's free Knowledge Checker — try a quick safety round and see how you score. Or try the full branching Decision Simulator scenario built from this investigation — work through the real decision points and see which ending you reach.