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

🕑 5 min read words Safety • Incident

Vessel: Small general cargo ship, 3,000 DWT, carrying bulk corn
Date & location: English Channel, in transit from France to the UK
Outcome: One fatality (AB/Cook), three crew evacuated by helicopter with serious phosphine gas poisoning
Human factors: Symptoms Misattributed · No Fumigation-Specific SMS Guidance · Incomplete Crew Briefing
Source: Britannia P&I Club, BSafe Incident Case Study No. 13, drawn from an investigation by the Bahamas Maritime Authority

1 real case studyBahamas Maritime Authority~5 min read

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.

Recommended Actions

Direct from the investigation's findings:

Any charter involving in-transit fumigation needs SMS guidance covering ship suitability, gas-tight integrity verification, and a contingency plan for fumigant ingress — before the charter is accepted, not worked out after cargo is already loaded.
Gas-tight integrity of a hold adjacent to accommodation needs physical verification (smoke testing, pressure checks), not verbal confirmation between master and fumigator.
Every crew member needs the safety briefing on a fumigation operation, not just the officer nominated to hold the gas detection equipment — symptoms unrecognised are symptoms untreated.
Any change to accommodation ventilation, for any reason, needs to be checked against its effect on gas-tight integrity when a fumigated cargo is aboard — not treated as an isolated response to whatever triggered it.
Unexplained crew illness affecting multiple people at once, during a fumigated-cargo voyage, should trigger an atmosphere test early — not be worked through a list of more comfortable explanations first.

Human Element Analysis

Symptoms misattributed

Every individual explanation offered — seasickness, food, exhaust — was plausible on its own. None of them were checked against the one possibility that actually mattered, until hours had passed and it was too late for one crew member.

A gap in the SMS, not just the crew's judgement

No procedure existed to tell the crew what fumigation actually required of them, or what to do if it went wrong. The individual decisions that followed were made without the structure that should have shaped them.

Incomplete briefing

Training the chief officer alone assumed that knowledge would reliably reach everyone else. It didn't — at least two crew members never received the briefing that might have told them what their own symptoms meant.

Test Your Knowledge

Think you've got this covered? Put it to the test in Crew Connect's free Knowledge Checker — try a quick cargo/chemical safety round and see how you score.