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

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

1. Revise COSWP to require enclosed space rescue drills to include the possible presence of shoreside staff and third parties (MAIB 2025/101)
2. Provide stevedores with training and PPE for bulk carrier cargo work, per IMSBC Code, BLU Code and BLU Manual requirements (2025/102)
3. Maintain clear guidance on cargo operation duties for ship and shore personnel, with robust control of access (2025/103)
4. 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