BSafe Case Study 21 — Thirteen Days Between a Headache and a Death

Fifteen Minutes Near a Vent

The chief officer assigned the fitter to repair work in cargo hold No.5, with the deck cadet assisting. Both noticed a strong smell of fumes from a nearby heavy fuel oil tank vent before starting. The job took 15 to 20 minutes; the cadet spent it passing equipment into the hold while standing near the vent, and came out afterward saying he felt uncomfortable.

The next day he told the chief officer he had a headache, which he put down to the fumes. He was advised to rest. The master was informed. Over the following days his condition worsened — reduced appetite, diarrhoea. The company arranged medical advice by phone: the guidance was a ‘light diet.’

A Decision Deferred, Then Deferred Again

Nine days after the exposure, with the cadet now also experiencing dizziness and vomiting, the master contacted the crewing manager to discuss signing him off in Mauritius — four days away by the ship's ETA. A plan was made for a second officer to accompany the sign-off and for onshore medical care to be arranged on arrival. Encouragement to eat and further remote medical advice continued in the meantime. His condition kept deteriorating.

Thirteen days after the original exposure, another cadet checking on him every two hours found him unresponsive. CPR was started. He did not recover.

What Went Wrong, in Sequence

• A genuine exposure — strong fumes, acknowledged by the crew before the job even started — was followed up with rest advice, not a formal assessment of what had actually been inhaled or its likely effects.
• Worsening symptoms over several days (headache, then reduced appetite and diarrhoea, then dizziness and vomiting) were each treated as the current problem to manage, rather than read together as a single, deteriorating trend.
• The decision to get the cadet ashore was made, but tied to the ship's own ETA in Mauritius rather than to how quickly his condition was actually declining — four more days elapsed between that decision and arrival.
• Remote medical advice was sought and followed, but the case shows how easily ‘rest’ and ‘light diet’ can become the default answer when the person giving remote advice has less real-time information than the officers actually watching the patient decline.