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BSafe Case Study 5 — A Rescue Attempt That Became a Second, Then a Third, Emergency

🕑 5 min read words Safety • Incident

Vessel: Bulk carrier, log cargo, Port Marsden, New Zealand
Date & location: Cargo hold No. 5, during pre-fumigation inspection
Outcome: Double fatality — the chief officer and an able seaman died of asphyxia; a first engineer was hospitalised after his own rescue attempt
Human factors: Uncoordinated Rescue Response · Stop Work Authority Not Exercised · Equipment Misuse Under Pressure
Source: Britannia P&I Club, BSafe Incident Case Study No. 5, drawn from Transport Accident Investigation Commission (TAIC), New Zealand, Report 10-201

1 real case studyTAIC Report 10-201~5 min read

A Routine Check Before Fumigation

The ship had loaded logs at several New Zealand ports and taken on more at Port Marsden. Fumigation officials came aboard to inspect ahead of the passage to China and reported two things to the master: several hatches had excess water needing removal, and the rubber seal on hold No.5's aft access door needed replacing. The master discussed this with the chief officer, who went on deck, asked the bosun to follow him to hold No.5, opened the access hatch, and started down the ladder.

He fell onto the logs below after only a few steps. The bosun immediately raised the alarm and went for a rescue rope. What followed was not one emergency response — it was a cascade of separate, increasingly desperate rescue attempts, each one adding a new person to the risk.

Every Attempt Added Another Casualty

The second officer fetched breathing apparatus and oxygen. An AB ran to alert the third officer, then tried to follow toward the incident himself — and disappeared from view. When the bosun returned, he found that same AB already climbing down into the hold, with another crew member about to follow him in. The bosun stopped the second crew member, but heard the AB fall. Looking down, he saw him lying on top of the chief officer.

The third officer arrived, put on a BA set, tied a rescue rope around himself, and went in — he managed to attach the rope to the chief officer and got him hauled onto deck, but was too exhausted to attempt the AB's rescue himself. The first engineer then took the second BA set down, but the equipment's bulk meant he couldn't manoeuvre past a protruding log. He came back out, switched to an emergency escape breathing device (EEBD) — equipment designed only for escaping a hazardous atmosphere, not entering one — and went back in anyway. He reached the AB, briefly removed his own EEBD mask to try to revive him, reattached it, and got the rope secured. As he neared the top of the ladder his EEBD ran low on air and he had to be hauled out, himself now suffering from asphyxia.

Ambulance staff arrived and tried to resuscitate the chief officer and the AB. Both were pronounced dead at the scene. The first engineer was airlifted to hospital.

What TAIC's Investigation Found

Oxygen levels three metres down the ladder tested as low as 3% after the incident — organic decomposition of the logs, a well-documented hazard in this trade, had depleted the hold's atmosphere.
The ship's SMS referenced the cargo's dangers and enclosed-space entry procedures — these were not followed.
No evidence of enclosed-space drills or training in the previous three months could be found.
Why an experienced chief officer ignored the bosun's warning and entered anyway could not be established.
An effective Stop Work Authority programme would have supported the bosun in the moment it mattered most.
The onboard rescue response was not well coordinated or practised — given how fast the atmosphere incapacitated people, any effective rescue needed to be immediate and pre-planned, not improvised in real time.
EEBDs are not entry equipment. Using one to enter an oxygen-deficient space, as the first engineer did, put him at serious and unnecessary additional risk.

Recommended Actions

Drawn from TAIC's own findings, not invented:

Cargo known to deplete oxygen through decomposition — logs among them — requires the same enclosed-space precautions as any other hazardous atmosphere, treated as standing SMS policy, not situational judgement.
An effective Stop Work Authority culture has to function in the moment a junior crew member is watching a senior officer about to do something unsafe — not just exist on paper.
Rescue response needs to be planned and drilled before it's needed, not assembled from whoever happens to be nearby — an uncoordinated response can turn one casualty into several.
EEBDs are escape-only equipment. Entering a hazardous atmosphere requires self-contained breathing apparatus, full stop — no exception for an emergency.
Enclosed-space drills need to happen on a real, checkable schedule — three months with no evidence of one is itself a finding worth acting on before an incident, not after.

Human Element Analysis

Uncoordinated rescue response

Four separate people attempted rescue, largely independently, with no single person directing who did what. That's how a one-casualty incident becomes a double fatality with a third hospitalisation — good intentions and real courage, but no plan behind them.

Stop work authority not exercised

The bosun warned the chief officer and was ignored. He then had standing to stop the AB entering too, and did — but only after the chief officer was already down. The gap in this case isn't the absence of anyone willing to speak up; it's the absence of a system that makes speaking up actually stop the job.

Equipment misuse under pressure

The first engineer knew the risk of an oxygen-deficient space, tried the correct equipment, found it unwieldy, and substituted escape gear rather than stop and reconsider. Under real time pressure with two colleagues down, having the right equipment on hand matters as much as knowing the rule.

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