BSafe Case Study 13 — Symptoms Blamed on the Weather, Not the Cargo

A Hold That Was Never Confirmed Gas-Tight

After loading 2,750 tonnes of bulk corn in France, fumigation technicians placed aluminium phosphide in the hold to release phosphine gas during the voyage — verbally confirming with the master that the hold was suitable, with no independent inspection of its gas-tight integrity. The chief officer alone received training on the gas detection equipment provided; not all crew attended his briefing to the rest.

Heavy Weather, Closed Ventilation, and a Misread Set of Symptoms

A day into the voyage, in deteriorating weather, a wave flooded the galley through the ventilation trunking. The crew stopped the ventilation system and shut the accommodation's flaps — without considering what that would do to the accommodation's air pressure relative to a space carrying a fumigated cargo next door. Losing positive pressure in the accommodation let the fumigant find its way in.

By early afternoon, several crew had headaches, fatigue, and severe nausea — attributed to seasickness, lunch, or engine exhaust. Most stayed in their cabins or went to get fresh air. It wasn't until around 1800, when the master realised at least three crew were genuinely unwell, that fumigant poisoning was even considered. He tested the atmosphere and confirmed phosphine gas in the accommodation. A rescue helicopter's first attempt failed due to weather and a technical issue; a second, later helicopter arrived with a medical team. By then, the AB/Cook — who had gone back to his cabin unnoticed sometime before 1900 — was found dead.

What the Investigation Found

• The company's SMS contained no guidance on carrying fumigated cargo or confirming a ship's suitability for in-transit fumigation before accepting the charter.
• No risk assessment for fumigated cargo existed, and no contingency plan had been developed for fumigant ingress into the accommodation.
• The hydraulic room door between the cargo hold and accommodation was misaligned and could not be made gas-tight, even fully dogged down — a physical gap that had never been identified through maintenance.
• Only the chief officer was trained by the fumigation company; his own briefing to the rest of the crew didn't adequately convey the operation's risk or poisoning symptoms, and at least two crew missed it entirely.
• Stopping accommodation ventilation and closing the flaps, done for an unrelated reason (flooding), removed the positive pressure that had been keeping the fumigant out.
• Periodic atmosphere monitoring wasn't conducted at the required frequency, and the fumigant's garlic-odour additive wasn't a sufficient warning on its own.