Report on the investigation of

work undertaken in a dangerous enclosed/confined space

and the consequent attempted rescue on board

ERRV Viking Islay

resulting in the loss of three lives

at the Amethyst gas field, 25 miles off the East Yorkshire coast, UK

23 September 2007

Marine Accident Investigation Branch

Carlton House
Carlton Place
Southampton
United Kingdom
SO15 2DZ

Report No 12/2008
July 2008
 Extract from

The United Kingdom Merchant Shipping

(Accident Reporting and Investigation)

Regulations 2005 – Regulation 5:

“The sole objective of the investigation of an accident under the Merchant Shipping
(Accident Reporting and Investigation) Regulations 2005 shall be the prevention of
future accidents through the ascertainment of its causes and circumstances. It shall
not be the purpose of an investigation to determine liability nor, except so far as is
necessary to achieve its objective, to apportion blame.”

NOTE

This report is not written with litigation in mind and, pursuant to Regulation 13(9) of
the Merchant Shipping (Accident Reporting and Investigation) Regulations 2005,
shall be inadmissible in any judicial proceedings whose purpose, or one of whose
purposes is to attribute or apportion liability or blame.

Further printed copies can be obtained via our postal address, or alternatively by:
Email: [email protected]
Tel: 023 8039 5500
Fax: 023 8023 2459
All reports can also be found on our website:
www.maib.gov.uk
CONTENTS
Page
GLOSSARY OF ABBREVIATIONS AND ACRONYMS

SYNOPSIS 1

Section 1 - FACTUAL INFORMATION 2

1.1 Particulars of Viking Islay and accident 2
1.2 Narrative 3
1.2.1 Events preceding the accident 3
1.2.2 The initial accident 7
1.2.3 The consequent fatal rescue attempt 8
1.2.4 Subsequent rescue efforts 9
1.3 Viking Islay at Immingham 10
1.4 Specialist analysis and opinion 10
1.4.1 Atmosphere analysis by Health and Safety Executive specialists 10
1.4.2 HSE opinion 11
1.4.3 Medium term O2 depletion 12
1.4.4 The physiological effects of reduced oxygen 12
1.5 Investigations at Immingham 13
1.6 Actions by the Maritime and Coastguard Agency 16
1.6.1 Detention of Viking Islay 16
1.6.2 General inspections of other Vroon ships 16
1.6.3 Safety Management Certificate DOC audit 16
1.7 The ERRV or “standby vessel” business and Viking Islay 16
1.7.1 The ERRV business 16
1.7.2 ERRV Viking Islay – ship certification 16
1.7.3 Entering the chain locker and securing the anchor chain 17
1.8 Vroon Offshore Services Ltd - The managers and operators 17
1.9 Manning 17
1.10 Personnel 18
1.10.1 The master 18
1.10.2 The chief mate 18
1.10.3 The day work seamen - the first two victims 18
1.10.4 The 8/12 seaman - the third victim 18
1.11 Viking Islay’s safety equipment 18
1.11.1 Atmosphere testing equipment 18
1.11.2 Other equipment 19
1.12 Emergency Escape Breathing Devices 15
1.12.1 Requirement to provide Emergency Escape Breathing Devices 19
1.12.2 EEBDs provided on board Viking Islay – Sabre ELSA type 19
1.12.3 Limitations of constant flow EEBDs 21
1.12.4 Requirement to provide training for EEBDs 21
1.12.5 EEBD training on board Viking Islay 21
1.13 The Vroon Offshore Safety Management System 22
1.13.1 The Safety Management System (SMS) 22
1.13.2 Risk Assessment for tank/space entry 22
1.13.3 Toolbox-talk Risk Identification Card (TRIC) 23
1.13.4 Permit-to-Work system 23
1.13.5 Internal vessel audit 23
1.13.6 Safety coaches 23
1.14 Entry into Dangerous Spaces Regulations 24
1.14.1 The Merchant Shipping (Entry into Dangerous Spaces)
Regulations 1988 24
1.14.2 Duties under the Entry into Dangerous Spaces
(EDS) Regulations 24
1.14.3 Drills 24
1.14.4 Atmosphere testing equipment required 24
1.15 Code Of Safe Working Practices for Merchant Seamen (COSWP) 25
1.15.1 Background and Legislation 25
1.15.2 Vroon induction programme 25
1.16 Dangers of enclosed/confined spaces - other advice and guidance 25
1.16.1 Marine Guidance Note 309 25
1.16.2 Further guidance on dangerous enclosed/confined spaces 26
1.17 Similar accidents 26
1.17.1 MAIB statistics 26
1.17.2 Marine Accident Investigators’ International Forum (MAIIF) 26

Section 2 - ANALYSIS 27
2.1 Aim 27
2.2 Fatigue 27
2.3 Manning & personnel 27
2.3.1 Manning levels 27
2.3.2 Crew nationalities and languages spoken on board Viking Islay 27
2.4 The hazard 27
2.5 The initial accident 28
2.6 The consequent rescue attempt 28
2.6.1 Training, drills and rescue procedures 28
2.6.2 Command and control 29
2.6.3 EEBD limitations 29
2.7 Subsequent rescue efforts 30
2.7.1 The master 30
2.7.2 The ENSCO 92 rescue team 30
2.8 Company policy on dangerous enclosed/confined spaces 30
2.8.1 Operational requirement for entry to dangerous spaces 30
2.8.2 Shipboard equipment 31
2.8.3 Actions following the accident 31
2.9 Hazard perception and risk acceptance 31
2.9.1 The chain locker 31
2.9.2 Approval of the task 32
2.9.3 The would-be rescuers 32
2.10 The ship - shore disconnect 33
2.11 Similar accidents 33
Section 3 - CONCLUSIONS 35
3.1 Safety issues directly contributing to the accident which
have resulted in recommendations 35
3.2 Safety issues identified during the investigation which have not
resulted in recommendations but have been addressed 35

Section 4 - action taken 36

4.1 Vroon Offshore Services 36
4.2 The Maritime and Coastguard Agency 37
4.3 Marine Accident Investigation Branch 37

Section 5 - recommendations 38
GLOSSARY OF ABBREVIATIONS AND ACRONYMS
AB - Able Bodied Seaman, an experienced and qualified member of
the deck crew

AMA - Advanced Medical Aider, an advanced first-aid qualification

particular to the offshore industry

BA - Breathing Apparatus

CO - Carbon Monoxide

CO2 - Carbon Dioxide

CoC - Certificate of Competency

COSWP - Code of Safe Working Practices for Merchant Seamen

CPP - Controllable Pitch Propeller

CPR - Cardiopulmonary resuscitation

DOC - ISM - Document of Compliance

DDPA - Deputy Designated Person Ashore

DPA - Designated Person Ashore

EDS - The Merchant Shipping (Entry to Dangerous Space) Regulations 1988

EEBD - Emergency Escape Breathing Device (Sabre ELSA on Viking Islay)

ELSA - Emergency Life Support Apparatus (a type of EEBD, a short

duration BA, to be used for escape purposes only)

ENSCO 92 - A jack-up type drilling rig, operated by the ENSCO Company

ERRV - Emergency Response Rescue Vessel (A “standby vessel”)

FCP - Forward Control Point

FRC - Fast Rescue Craft

GMT - Greenwich Mean Time

GRT - Gross Registered Tons

H2S - Hydrogen Sulphide (an extremely hazardous, toxic gas)

HSE - Health and Safety Executive

IACS - International Association of Classification Societies

IMO - International Maritime Organization

ISM Code - International Management Code for the Safe Operation of Ships

Knots - Speed in nautical miles per hour

kW - Kilowatt

LR - Lloyd’s Register of Shipping classification society

MAIIF - Marine Accident Investigators’ International Forum

MCA - Maritime and Coastguard Agency

(The UK Flag State administration)

MGN - Marine Guidance Note

MIN - Marine Information Note

O2 - Oxygen

OOW - Officer of the Watch

PFEER - Prevention of Fire and Explosion and Emergency

Response

ppm - parts per million

PTW - Permit to Work

RA - Risk Assessment

SEC - Cargo ship Safety Equipment Certificate

SMC - ISM - Safety Management Certificate

SMS - Safety Management System

SOLAS - The International Convention for the Safety of Life at Sea

1974 (as amended)

STCW - The International Convention on the Standards of

Training, Certification and Watchkeeping for Seafarers
1978 (as amended)

STW - IMO Committee on Standards of Training for Watchkeeping

T - Tonnes

TRIC - Toolbox-talk Risk Identification Card

UK - United Kingdom

UKOOA - UK Offshore Operators Association

VHF - Very High Frequency Radio

Vroon - Vroon Offshore Services Ltd

Times: All times used in this report are GMT unless otherwise stated
Viking Islay
SYNOPSIS
On 29 September 2007, three seamen on board the ERRV Viking
Islay lost their lives as a consequence of entering an enclosed space.
The ERRV Viking Islay was working in the North Sea conducting rig
support operations when two of the vessel’s seamen went forward
with the intention of securing a rattling anchor chain within the chain
locker. One of the seamen entered the chain locker and collapsed.
It is probable that the other seaman, realising that help was urgently
required, raised the alarm with the duty watchkeeping rating on the
bridge before he, too, entered the chain locker in an attempt to help
his companion. He also collapsed.

During the consequent rescue efforts, the first rescuer found he was unable to enter the chain
locker wearing a BA, and he therefore donned an EEBD. He entered the space, but at some
point the hood of the EEBD was removed, or became dislodged and this rating also collapsed.

All three seamen died as a result of an oxygen deficient atmosphere within the chain locker.

The MAIB’s investigation has concluded:

• The oxygen deficient atmosphere within the chain locker was caused by natural on-going
corrosion of the steel structure and anchor chain within the space.
• The crew of Viking Islay failed to recognise the chain locker was a potentially dangerous
enclosed/confined space, or the likelihood that the atmosphere within the space could
become oxygen deficient over time. Consequently, well established permit to work
measures were not considered before the space was entered.
• Training and subsequent drills in the use of EEBDs had not been sufficient to ensure the
limitations of the equipment were recognised in an emergency.
• The ship manager’s company policy on entry into enclosed spaces was not clear and did
not take into account scenarios that could require crews to enter confined spaces while
at sea. A further consequence of this was that gas monitoring equipment supplied to the
vessel was unsuitable for ensuring safe entry into enclosed spaces.
• The audit regime employed by the ship’s managers to ensure compliance with its SMS
failed to detect deficiencies in training, equipment and safety culture on board Viking Islay.

The ship manager has taken action to address many of the safety issues identified during the
investigation. However, recommendations have been made to Vroon Offshore Ltd and the
Maritime and Coastguard Agency on the promulgation of additional information to highlight
limitations on the use of EEBDs and improvements in the training given to mariners in the use
of this type of equipment.

1
Section 1 - FACTUAL INFORMATION
1.1 Particulars of Viking Islay and accident

Vessel details
Registered owner : Viking North Sea Ltd, Aberdeen, UK
Manager(s) : Vroon Offshore Services Ltd, Aberdeen
Port of registry : Aberdeen
Flag : UK
Type : Emergency Response Rescue Vessel, Class B
(up to 300 survivors)
Built : 1985, Spain
Classification society : Lloyd’s Register of Shipping, +100A1 Offshore
Supply/Standby Vessel
Construction : Steel
Length overall : 53m
Gross tonnage : 928
Engine type and power : Two MAK Diesel engines, 2921kW total
Other relevant info : Twin screw CPP, one tunnel thruster at bow

Accident details
Time and date : 1100 GMT 23 September 2007
Environmental Swell 1.5m, sea 0.5m, 3/8th cloud cover,
conditions visibility good

Location of incident : 53 42.22N 001 08.9E

While standing-by rig ENSCO 92, at the
Amethyst gas field, 25 miles off the East
Yorkshire coast, Southern North Sea, UK

Persons on board : Twelve

Injuries/fatalities : Three fatalities. No other injuries
Damage : None

2
1.2 Narrative
1.2.1 Events preceding the accident
On Friday 21 September 2007 the Emergency Response and Rescue Vessel (ERRV)
Viking Islay arrived at Immingham pilot station, following a duty period of about 28 days
offshore. The ship had not anchored during the trip as anchoring was forbidden at the
offshore location.

As was normal in preparation for arrival, Viking Islay’s starboard anchor had been
walked out a short distance; it was not dropped clear of the hawse pipe, but just moved
enough to confirm that it was free and clear to be run out in case of any emergency.
Possible impediments to the anchor chain running free included the expanded foam,
that was routinely used to seal the top of the spurling pipe1 on the foredeck, and light
rope lashings used to secure the anchor chain within the chain locker (Figure 1).

Figure 1

For’d store access hatch

Expanded foam used to seal spurling

pipes - no other chain locker vents

Port Starboard

The foam was used to prevent water entering the chain locker via the spurling pipe.
Light lashings were sometimes applied inside the chain locker by the crew, in order to
prevent the hanging part of the anchor chain from moving in rough weather (Figure
2). Such movement could cause the chain to bang noisily against the spurling pipe, or
other steelwork.

1 Spurling pipe: The tube running from below the anchor windlass on the foredeck, through the foc’sle store
down to the chain locker, so enclosing the anchor chain

3
 Figure 2

Chain locker - showing rope lashings used to

stop anchor chain rattling

The port anchor was not walked out and the port spurling pipe remained sealed with
expanded foam.

The ship was alongside at 0950. The purpose of the visit was to take on bunkers and
stores, undertake some minor repairs and, as was normal routine, conduct a full crew
change. Both the off-going and on-coming masters were regulars on Viking Islay, as
were the majority of the crew. Many crew members had been on this ship for several
years, and all were experienced in the ERRV business. Those crew members who were
new to Viking Islay received their safety induction as per company instructions.

The chain locker was not entered during the port visit.

At 1150 on Saturday 22 September 2007, Viking Islay sailed for the rig ENSCO 92. The
pilot was dropped at 1420; the starboard spurling pipe was resealed using an aerosol of
expanding foam (of the type commonly used ashore in building works). At 1625, Viking
Islay arrived on station, the relief vessel was released and Viking Islay began its 28-day
standby routine. The weather conditions at that time were logged as swell 1.5m, sea
0.5m, 3/8th cloud cover, visibility good.

4
 Figure 3

8/12 Seaman’s cabin

Chain
locker

Mess room

Side and plan views of Viking Islay

Due to the motion of the ship during the night, the starboard anchor chain began
to bang against something within the chain locker, probably the spurling pipe. This
disturbed the 8/12 seaman2, Mr MacFadyen, whose cabin shared a common bulkhead
with the chain locker. It is possible that others were aware of the noise, as the mess
room also abutted the same bulkhead (Figures 3 and 4).

No routine maintenance work was planned for Sunday 23 September. However, the
crew expected operational and emergency drills to be conducted during the afternoon.

2 8/12 seaman: The crew member assigned the 8 to 12 watch (both am and pm) on a ship with a standard
three watch system.

5
6
Chain locker

Store

Store

Cabin & mess room

Figure 4

Viking Islay - bow profile and plan

1.2.2 The initial accident
It is likely that the noise made by the anchor chain during the night was discussed
between Mr MacFadyen and the two day workers3, Mr Ebertowski and Mr O’Brien, over
breakfast, before they started work at 0800.

At 0800, the master and Mr MacFadyen took over the bridge watch. At about 0900,
Mr MacFadyen told the master that the two day workers wanted to go into the chain
locker to tie off the anchor chain and so stop it banging. The master agreed that this
work could be done, but later in the morning as a helicopter movement to the rig was
expected shortly.

Just before 1000, Viking Islay stood by for the helicopter movement. Sometime after
the helicopter departed, the master went to his cabin to use the lavatory, leaving Mr
MacFadyen in charge of the watch and alone in the wheelhouse. At about 1055, the
two day workers, carrying a portable VHF radio, went forward to enter the chain locker.
They took no other equipment with them, and no safety related documentation (such as
a risk assessment or a permit to work) was completed.

The day workers went forward and opened the hatch down to the foc’sle store from
the foredeck. This store area was used to store mooring ropes and other general
deck gear. As a regularly used working area, the store was well lit and was naturally
ventilated.

The two day workers went to the aft part of the foc’sle store and lifted the loose
duckboards, beneath which were three access manholes. The forward hatch served
the fore peak water ballast tank, and the after two gave access to the port and
starboard sides of the anchor chain locker. Although there were two manholes, the
internal dividing bulkhead which separated the two anchor chains only extended to
about half the height of the chain locker, and the upper parts of the spaces were
common. The manholes serving the chain locker were smaller than that serving the
ballast tank, and were square in shape rather than the more conventional oval found at
the ballast tank access. The heavy steel manhole covers were secured with eighteen
24mm nuts and bolted down onto a rubber gasket, so forming a watertight seal (Figure
5).

The day workers removed only the starboard cover to access the compartment, and
no portable lighting or ventilation fans were rigged. The atmosphere within the chain
locker was not tested.

As all three people directly involved in the initial accident died, it has been necessary
for MAIB to construct the most likely scenario from the evidence available. It was likely
that:
Mr Ebertowski entered the chain locker to tie off the chain; this was a one man
job. Mr O’Brien, the leading hand4, stood by at the entrance, keeping in radio
contact with Mr MacFadyen in the wheelhouse. As Mr Ebertowski descended
into the chain locker, he collapsed. Mr O’Brien saw this, and called the bridge
by VHF to alert Mr MacFadyen to the problem.

Mr O’Brien then entered the chain locker in an attempt to rescue Mr Ebertowski,

but he too was overcome and collapsed at the bottom of the chain locker, partly
on top of his colleague.

3 Day workers: seamen who do not keep routine watches, but carry out routine work during the day.
4 Leading hand: The senior day work seaman, nominated by the master as “in charge” of the other day
worker.
7
 Figure 5

Foc’sle store - showing access hatches to chainlocker

1.2.3 The consequent fatal rescue attempt

On hearing the VHF call from the leading hand, Mr MacFadyen left the wheelhouse and
ran down through the accommodation; he was clearly agitated and raised the alarm by
shouting for help. His calls were heard by several others, including the mate and second
mate, and these two ran forward with Mr MacFadyen and entered the foc’sle store.
Looking down through the open chain locker access, they were able to see two bodies
at the bottom of the dark space. They returned to the accommodation and, assisted by
the cook, gathered together rescue equipment including breathing apparatus (BA) and a
short duration emergency escape breathing device (EEBD). The intention was that the
EEBD could be fitted to a casualty as a form of emergency first-aid.

The master returned to the wheelhouse and, at 1107, sounded the general alarm. This
roused the remaining crew members, who gathered at the designated muster point aft
of the accommodation, before making their way to the foredeck. The master informed
ENSCO 92 of the emergency by VHF radio, and the rig began its own preparations to
assist Viking Islay.

At 1110, the rescue party returned to the foc’sle; Mr MacFadyen quickly donned BA and
entered the store, assisted by the cook, carrying an EEBD. The 12/45 seaman donned
the ship’s second BA and stood by at the foc’sle hatch, together with the chief mate. The
second mate was called to the wheelhouse to assist the master.

5 12/4 seaman: The crew member assigned the 12 to 4 watch (both am and pm) on a ship with a standard
three watch system

8
 Inside the foc’sle store, Mr MacFadyen attempted to enter the chain locker. Being
a large man, he was unable to descend through the hatch while wearing BA, so he
removed it. He asked the cook to give him the EEBD; the cook opened the EEBD case
and the air supply started automatically. Mr MacFadyen donned the EEBD by pulling
the hood over his head, and immediately began to enter the chain locker. The chief
mate ordered the 4/86 seaman to don the BA discarded by Mr MacFadyen and to stand
by in the store, together with the 12/4 seaman.

The cook crossed the compartment to collect torches, and when he returned to the
hatch a few seconds later he saw Mr MacFadyen in difficulties, at the bottom of the
ladder. His EEBD hood was partly off, pushed high up on his head and, as the cook
looked down, he saw Mr MacFadyen collapse.

1.2.4 Subsequent rescue efforts

The chief mate then directed the 12/4 seaman to enter the chain locker using BA.
Before doing so, the 12/4 seaman looked in and saw the three men at the bottom of
the space. Mr MacFadyen was collapsed on one side of the locker. The EEBD hood
remained pushed high up on his head and the 12/4 seaman could hear the air still
discharging. However, the EEBD bottle was not on Mr MacFadyen’s body, but was
lying on the other side of the locker with the air supply hose stretched tautly. With the
help of the cook, the 12/4 seaman, an agile and slim man, was able to enter the chain
locker without removing his BA. He took a line with him to recover Mr MacFadyen.

Mr MacFadyen’s EEBD air supply was exhausted by the time the 12/4 seaman reached
the fallen men. He checked Mr MacFadyen for a pulse and signs of breathing; none
was found. He then tied a rope under Mr MacFadyen’s arms and climbed out of
the locker. Together with the 4/8 seaman, and with great difficulty, they hauled Mr
MacFadyen out of the chain locker into the foc’sle store. The 4/8 seaman also checked
the victim, but found no signs of life. It was now about 1122.

The 12/4 seaman’s BA low air alarm sounded, so both men left the store. Once on
deck they fitted fresh BA cylinders. The 12/4 seaman was by now exhausted, so the
chief mate ordered the third engineer to don that BA set.

Realising the scale of the problem facing his crew, the master contacted HM
Coastguard, seeking help and additional supplies of air. Other ships that were close-by
immediately offered assistance.

Meanwhile, the rig had mobilised a team of four men ready to transfer to assist the
crew of Viking Islay. This group consisted of a three man “extraction team” (specialists
trained in the use of BA and techniques for rescue from dangerous enclosed/confined
spaces) and a medic.

The 4/8 seaman, now accompanied by the third engineer, re-entered the foc’sle store,
wearing BA, and together they recovered Mr MacFadyen to the upper deck where other
crew members began Cardiopulmonary Resuscitation (CPR). It was now 1125. The
rig medic gave medical advice to Viking Islay by VHF radio.

At 1133, the third engineer entered the chain locker, with the 4/8 seaman standing by at
the entrance. Both were wearing BA.
6 4/8 seaman: The crew member assigned the 4 to 8 watch (both am and pm) on a ship with a standard
three watch system

9
 At 1140, the master manoeuvred Viking Islay closer to the rig to allow the rig’s rescue
team to transfer to Viking Islay using a personnel basket attached to the rig’s crane.
This transfer was completed at 1151, and the rig team went immediately to the foredeck
where the rig medic took charge of the resuscitation efforts.

Over the next 40 minutes the rig team, working together with Viking Islay’s crew,
recovered Mr O’Brien and Mr Ebertowski from the chain locker. In order to access
the chain locker, the extraction team had to remove their BA cylinders; however
they managed to keep their face masks in place, and therefore breathed good air
throughout. During this time a rescue helicopter arrived and landed another medic on
board, and resuscitation efforts continued on Mr MacFadyen, but without success.

The reason for the dangerous atmosphere within the chain locker could not be
determined, and it was decided that the space should be sealed. The third engineer
started to replace the manhole cover. As he was doing this, his BA’s low air supply
alarm sounded so he left the task part completed and went up on deck. The used
EEBD was abandoned in the foc’sle store.

At 1247, the rescue helicopter, with three victims on board, left the scene for the Hull
Royal Infirmary.

By 1340, all the rig’s personnel had been transferred back to ENSCO 92, and Viking
Islay was then released from standby duty. The vessel berthed in Immingham at 2000
on Sunday 23 September 2007.

1.3  Viking Islay at Immingham

When Viking Islay arrived at Immingham, the foc’sle store hatch was dogged down,
and since the accident had been opened only to retrieve the mooring ropes. The chain
locker had remained closed since the accident.

Both compartments were treated as dangerous enclosed/confined spaces; safety cover

for the attending analysts was provided by the Humberside Fire and Rescue Service.

On 24 September, samples of the atmospheres of both the foc’sle store and the
chain locker were obtained, using an extension tube connected to a direct reading
atmosphere testing meter. Care was taken to minimise any mixing of the atmospheres
of the foc’sle and the chain locker.

Results of testing the atmosphere of the chain locker were as follows: Oxygen (O2)
15.9% by volume, Nil Carbon Monoxide (CO), Nil Hydrogen Sulphide (H2S) and Nil
flammables. The chain locker cover was immediately closed and the foc’sle store
secured, so as to preserve evidence.

1.4 Specialist analysis and opinion

1.4.1 Atmosphere analysis by Health and Safety Executive specialists
On 26 September, specialist inspectors from the Health and Safety Executive (HSE)
attended Viking Islay to take air quality measurements, and obtained air samples from
the chain locker.

10
 Samples were taken from three different depths within the chain locker, on both the port
and starboard sides. Their findings are summarised below:

• Atmosphere measurements (samples taken)

O2: 15 - 19%; Nitrogen (N): 78 - 82%; Argon: 1 - 1.1%; Carbon Dioxide (CO2):
0.07 - 0.14 ppm; CO: 0 - 4 ppm, H2S: 0 ppm.

• The reduced concentration of O2 was consistent with that obtained by a direct

reading instrument on-site.

• The slightly increased levels of CO2 might be due to microbial action on organic
materials in the chain locker. However, these concentrations are within acceptable
limits.

• The analysis of the samples also indicated very low concentrations of volatile
organic compounds, within acceptable limits.

1.4.2 HSE opinion

There were no significant amounts of toxic gases in the chain locker, and the internal
steel surfaces (including the anchor chains) were heavily rusted.

The increased concentration of Argon (compared to the air reference value of 0.97%)
indicated depletion of O2, rather than another gas displacing or diluting air within the
chain locker.

Iron and steel when exposed to moist air will react with O2 in the air to form iron oxide
(rusting). Rusting requires both O2 and water and is accelerated in the presence of
salt. The corrosion of the steel within the chain locker caused the O2 to be consumed
in the process of rust formation, and this resulted in an O2 deficient atmosphere.

The atmospheric measurements reported were taken 3 days after the accident. In the
interim, the space had been opened, and rescuers wearing BA had been working in the
space. As a consequence, the air quality measurements taken were not representative
of the atmosphere in the chain locker at the time of the accident.

The chain locker was tightly sealed with, effectively, no natural ventilation being present
prior to the entry by the three crewmen. It is difficult to estimate the concentration of
O2 at the time of the accident, but based on the speed of effect and available data from
other incidents it is likely that O2 concentrations in the chain locker at the time of the
accident were below 10%.

In the opinion of the specialist HSE inspector, the depleted O2 concentration in the
chain locker was the primary reason for the collapse and subsequent death of the three
crewmen.

11
1.4.3 Medium term O2 depletion
In order to assess whether the O2 depletion found in the chain locker could have been
caused by corrosion, and to provide an estimate of the O2 levels possible at the time of
the accident, an expert was consulted7.

Expert analysis concluded that corrosion within the sealed chain locker (since the
locker had last been certified gas-free) could have led to a loss of O2 resulting in an
atmosphere that was unable to support human life; levels as low as 4.4 % (by volume)
were estimated to have been possible.

The full report is at Annex A.

1.4.4 The physiological effects of reduced oxygen

In a normal ambient atmosphere the expected O2 level would be around 20.9%, by
volume.

In general, O2 deficiency leads to a loss of mental alertness and a distortion of judgment

and performance. This happens within a relatively short time, without the person’s
knowledge and without prior warning.

The following table8 indicates the effects of O2 deficient atmospheres on humans.

These values are approximate and can vary. Note that exposure to an atmosphere
containing less than 18% by volume of O2 poses a significant risk.

Asphyxia – Effect of O2 Concentration

O2 Effects and Symptoms
(volume %)
18-21 No discernible symptoms can be detected by the individual.

11-18 Reduction of physical and intellectual performance without

the sufferer being aware.

8-11 Possibility of fainting within a few minutes without prior warning.

Risk of death below 11 vol%.
6-8 Fainting occurs after a short time. Resuscitation possible if carried
out immediately.

0-6 Fainting almost immediate. Brain damage may occur,

even if rescued.

Table 1

7 Opinion provided by the Research Institute for Industry at the University of Southampton.

8 Reference source - University of Oxford http://www.admin.ox.ac.uk/safety/s403.shtml

12
1.5 Investigations at Immingham
Once the atmosphere samples had been taken, the foc’sle store was force ventilated
(using portable fans obtained from ashore) and then certified by the attending analyst
as safe for entry.

On entering the foc’sle store an empty EEBD was found, and a notice was seen posted
up on the after bulkhead of the compartment, near to the manholes (Figure 6). The
notice appeared to have been made onboard during the period 2002 – 2005. The
ship’s crew did not know when the notice had been posted.
Figure 6

Sign attached to aft bulkhead of foc’sle store

A reminder of the correct size of spanner needed to open the manhole covers was
seen, handwritten in marker pen, near the openings (Figure 7).

Being aware of the most probable cause of the accident, both chain locker manhole
covers were removed, the foam broken out of both spurling pipes and the space was
force ventilated. The analyst re-tested the space and certified it safe to enter; the
manhole openings were noted to be particularly small (Figure 8).

The inside of the chain locker was inspected, measured and photographed. The
main part of the chain was found piled in the middle of the space in a fairly solid lump,
probably indicating that it had not moved for an extended period of time. No significant
foreign objects were found, other than small amounts of textile material, probably rags
used to plug the spurling pipes prior to applying expanded foam. Some salt water was
present in the bilges at the bottom of the chain locker, below the false floor (Figure 9).

13
 Figure 7

Position of
sign (Figure 6)

Hand-written reminder of spanner

needed to open chain locker hatch

Foc’sle store looking aft

Figure 8

Foc’sle store - showing cramped access to chain locker

14
 Figure 9

Chain locker - showing anchor chain

Both anchors were walked back to their bitter ends to clear the chain from the locker
and the water residues removed. Once the atmosphere within the empty locker
had again been verified as safe for entry, a full condition survey of the space was
conducted. This revealed the locker to be structurally sound but with a minor level
of corrosion to the steel surfaces overall. No significant quantities of mud or organic
material were found. The bilge suction was blocked, and reportedly had not been
functioning for some time; the chain locker bilge line was subsequently found to be
disconnected from the bilge system within the bow thruster room.

15
1.6 Actions by the Maritime and Coastguard Agency
1.6.1 Detention of Viking Islay
Viking Islay was boarded by surveyors from the local Maritime and Coastguard Agency
(MCA) Marine Office who detained the vessel on 25 September, following discovery of
the following major non conformities with the owner’s International Management Code
for the Safe Operation of Ships (ISM Code) Safety Management System (SMS):

• The Permit to Work system (PTW) was not being followed

• The oxygen/gas testing equipment was inappropriate for the task

Viking Islay was released from detention by the MCA on 21 October 2007.

1.6.2 General inspections of other Vroon ships

A representative sample of ten Vroon ships was targeted for general inspection. At
the time of writing, this action was not complete, however some evidence was found of
anchor chains on other vessels having been tied off as they had been on Viking Islay.

1.6.3 Safety Management Certificate DOC audit

The MCA carried out the scheduled second annual verification audit of the Vroon
Document of Compliance (DOC) in November 2007. It was then agreed that an
additional verification audit would be programmed for spring 2008, after the general
inspection programme of other Vroon vessels had been completed.

1.7 The ERRV or “standby vessel” business and Viking Islay

1.7.1 The ERRV business
The requirement for ERRV vessels arises from the Prevention of Fire and Explosion
and Emergency Response (PFEER) Regulations (1995) which requires the duty holder
to ensure a good prospect of recovery to a “Place of Safety” for all manned offshore
installations.

ERRVs provide:
• Safety cover for helicopter movements, over the side (of the rig or platform) working
and platform abandonment
• Guard ship duties (to protect both surface and sub sea installations from damage)
• An emergency response centre/frontline command and control centre, to be used in
the event of an offshore disaster.

1.7.2 ERRV Viking Islay – ship certification

Certification for the ship to be operated as a conventional vessel was issued by the
MCA and Lloyd’s Register (LR). The Cargo Ship Safety Equipment Certificate (SEC)
was issued by the MCA.

The certificate of Survey of Vessel Standing by Offshore Installations, required to

allow a vessel to operate as an ERRV, and issued under the terms of a UK Offshore
Operators Association (UKOOA) approved code of practice, was issued in January
2003, to expire in January 2008. The survey was undertaken by the MCA Aberdeen
Marine Office.

16
 All certification was valid, and there were no relevant conditions of class at the time of
the accident.

The ISM certificates, both the DOC for the owners Vroon and the Safety Management
Certificate (SMC) for Viking Islay, were issued by the MCA. There were no
observations or non-conformities relevant to this accident at the time of the last audit.

The Minimum Safe Manning Document was issued by the MCA. This required a crew
of six to operate in the near coastal area9; but due to ERRV operational requirements
Viking Islay had a crew of 12 at the time of the accident.

1.7.3 Entering the chain locker and securing the anchor chain
The last fully documented entry to the chain locker was in June 2006, to allow
steelwork repairs to be undertaken by shore contractors. The Vroon SMS was correctly
used at that time.

No evidence was found of the Vroon SMS system being used by the crew when
entering the chain locker to secure the chains. However there was evidence that this
task had been done before, probably on many occasions. There was also evidence
that this practice had occurred on other Vroon ships.

1.8 Vroon Offshore Services Ltd - The managers and operators

Although a relatively new company, Vroon has a long pedigree in the North Sea
standby business. BUE North Sea and Viking Standby Services merged in 2002, and
this company traded as BUE Viking from 2002 to 2005. BUE Viking became Viking
Offshore Services in 2005, which in turn became Vroon in May 2007.

As part of the Vroon expansion and investment strategy, both the DPA and DDPA were
recruited from the offshore industry, instead of the ERRV industry. The DPA was a
graduate engineer with Merchant Navy and offshore project management experience.
The DDPA, who was a graduate safety professional, was also the Quality, Health,
Safety and Environment Manager.

1.9 Manning
Many of the men on board Viking Islay had served with Vroon, or its previous
incarnations, for many years and were regulars on this ship. Most of them had
extensive experience serving on board stand by vessels.

The whole crew worked a 28 days on board, 28 days on leave routine. Watchkeepers
worked conventional 4 hours on, 8 hours off watches while at sea, and the deck
department was enhanced by two day workers.

Viking Islay was manned by a mixture of British and Polish nationals (both officers and
crew). English was the nominated language for all operations within the Vroon fleet.

9 Within 150 miles from a safe haven in the UK.

17
1.10 Personnel
1.10.1 The master
The master was a British national aged 64. Originally serving on board fishing vessels,
he had achieved his Fishing “Skipper Full” certificate of competency (CoC) in 1974, and
had served as skipper/master on board both fishing and various offshore vessels for
many years. He had served with Vroon since 2002.

In 2000, he was required to convert his fishing vessel CoC, due to the changes
introduced by the International Convention on Standards of Training, Certification and
Watchkeeping for Seafarers 1978 (STCW) (as amended). As a part of this conversion
process, he had completed an ERRV command and control course. At the time of the
accident, the master held STCW II/2 Master CoC which was limited to use on Standby,
Seismic Survey and Oceanographic Research Vessels only.

1.10.2 The chief mate

The chief mate was a British national aged 55. He originally went to sea on board
fishing vessels in 1975, and had served with Vroon since 1997. In 2001, he had been
required to convert his original fishing vessel “Second Hand Full and Special” CoC
to an STCW II/2 Chief Mate; limited to Standby, Seismic Survey and Oceanographic
Research Vessels only. He had completed an ERRV Command and Control course.

1.10.3 The day work seamen - the first two victims

• Mr Robert Ebertowski
Mr Ebertowski, a Polish national aged 40, held a Seaman Grade 1 AB qualification.
He had, through a Polish crewing agency, worked on board various foreign ships,
including several trips as an engineer on LPG carriers before joining the ERRV
industry. He had worked for Vroon since March 2005 and had been on contract
service with Vroon since 2007.

• Mr Robert O’Brien
Mr O’Brien, a British national aged 59, held a Seaman Grade 1 AB qualification. He
was also the ship’s nominated Advanced Medical Aid responder (AMA). Seafaring
was his second career, having previously served many years in the UK armed
forces as an army medic. He had worked for Vroon for 7 years.

1.10.4 The 8/12 seaman - the third victim

Mr Finlay MacFadyen, a British national aged 46, held a Seaman Grade 1 AB
qualification. He had previously served many years as a motorman/oiler in the British
Merchant Navy. He had worked in the ERRV industry for several years and for Vroon
for almost 2 years.

1.11  Viking Islay’s safety equipment

1.11.1 Atmosphere testing equipment

Prior to this accident, Viking Islay had been equipped with a Crowcon EIKON personal
O2 alarm. It was not possible to use this instrument to measure the oxygen levels in a
space before first entry. It was designed as a personal alarm unit to provide individual

18
 users with a warning should the oxygen level within an enclosed space reduce to a
hazardous level. The Crowcon EIKON held on board Viking Islay had a limited shelf life
and had become time expired. Accordingly, in February 2007, ship's staff had ordered
a replacement as described below:

EKON H2S gas monitor: make Crowcon [sic].

As a consequence, Vroon supplied the ship with a disposable single gas monitor for the
protection of personnel against toxic H2S hazard10 as a replacement.

The crew of Viking Islay were unaware that the original O2 “meter” was in fact a
personal gas alarm and not an atmosphere testing device, and that the replacement
personal gas alarm supplied by Vroon detected H2S and not O2 levels.

1.11.2 Other equipment

Viking Islay had no portable vent fans or portable lighting at the time of the accident.

Viking Islay was provided with a dedicated air compressor in order to re-fill BA cylinders
on board. This allowed more realistic drills to be undertaken, as the crew were able to
become practised in the use of BA, yet retain the ship’s emergency response capability
at all times.

1.12 Emergency Escape Breathing Devices

1.12.1 Requirement to provide Emergency Escape Breathing Devices
Viking Islay carried five Sabre Emergency Life Support Apparatus (ELSA), in
accordance with statutory requirements11 to carry EEBDs. These devices provide
personnel with breathing protection against a hazardous atmosphere, while escaping
to a place of safety. IMO MSC Circular 849 specifically forbids the use of EEBDs for
entering oxygen deficient voids or tanks.12

1.12.2 EEBDs provided on board Viking Islay – Sabre ELSA type

The Sabre ELSA is a self-contained, open circuit, compressed air, constant flow EEBD.
It comprises a compressed air cylinder with a combined reducer/cylinder valve, attached
to a close fitting escape hood by a breathing hose. The whole unit is contained within
a stowage bag ready for immediate use. The high-visibility bag is clearly marked
ESCAPE USE ONLY (Figures 10 and 11).

10 Hydrogen Sulphide [H2S], an extremely hazardous, toxic gas. It is a colourless, flammable gas that can
be identified, in relatively low concentrations, by a characteristic rotten egg odour. The gas occurs naturally
as a product of decaying sulphur-containing organic matter, particularly under low oxygen conditions. Many
petroleum industry jobsites are potential locations of this gas.
11 SOLAS 74 Chapter II-2, Part D, Reg 13, paragraph 3.4. Promulgated by IMO MSC/Circ.849 of June
1998, this amended regulation required EEBD to be carried on board most vessels. This SOLAS amend-
ment was given effect within UK regulations by SI 2003 No.2951, the Merchant Shipping (Fire Protection)
Regulations (Amendment) Regulations 2003.
12 Paragraph 2 of the Annex to MSC/Circ.849 of June 1998 states: An EEBD is a supplied-air device only
used for escape from a compartment that has a hazardous atmosphere…EEBD’s are not to be used for
fighting fires, entering oxygen deficient voids or tanks, or worn by fire fighters. This is repeated in Annex 1 of
MGN 215 (M+F), dated March 2002.

19
 Figure 10

Close fitting hood

Breathing air hose

Contents gauge Compressed air cylinder

and control valve inside stowage bag
Sabre ELSA type EEBD
Figure 11

Sabre ELSA type EEBD

20
 The 10 minute duration of the ELSA is achieved by means of a reducer/cylinder valve
which restricts the flow of air from the cylinder to the mask, so that once activated a
steady flow of air is provided to the wearer13. It is not a demand valve system.

The ELSA user instructions state:

In general, constant flow escape breathing apparatus is NOT suitable for use
where:
• There are unknown hazards,

• There are no planned escape routes,

• Escape routes that require physical exertion, e.g. ladders, tunnels

and hatches.

No evidence was found that there was any technical fault with the ELSA used in the
fatal rescue attempt.

1.12.3 Limitations of constant flow EEBDs

One significant disadvantage of the constant air flow arrangement is that it is possible
for a wearer undertaking particularly strenuous activity to require a greater flow of air
than the EEBD can supply. This might result in the hood collapsing in on the wearer’s
face, producing an unpleasant suffocating sensation.

It is not widely known that the limitations of the air supply provided by the ELSA (or
other similar constant flow type EEBDs) could be exacerbated by a wearer with a high
air demand; for example a person with a particularly large tidal volume14, or one whose
ventilation was increased due to exertion and/or stress.

It is also possible that an inadequate air supply could be due to hood volume rather
than gas flow rate. If the wearer’s tidal volume exceeds that which is available within
the EEBD hood (due to the difference between the volume of the hood and that of the
wearer’s head), the hood could tend to collapse in upon the wearer’s face.

1.12.4 Requirement to provide training for EEBDs

The requirement to provide training for EEBDs carried on board ships is given in both
SOLAS and UK legislation15. However the content of the training and its degree of
realism is not prescribed.

1.12.5 EEBD training on board Viking Islay

EEBDs were provided for all vessels in the Vroon fleet about 5 years ago, and a
training regime was instigated. Vroon records confirm that the majority of the crew
on board Viking Islay at the time of the accident (including the victim who entered the
chain locker wearing EEBD), had received training in June 2006. The training focused

13 Manufacturers quote 38 litres per minute.

14 The tidal volume of the lungs is the quantity (volume) of air inhaled and exhaled with each normal breath.
15 SOLAS Chapter II-2, Regulation 15, paragraph 2.2.2: Training in the use of the EEBDs shall be con-
sidered as part of onboard training. Also in UK legislation: SI 2003 No.2951. The Merchant Shipping (Fire
Protection) Regulations (Amendment) 2003. Training in the use of EEBDs shall be included in the onboard
training of each crew member as soon as possible…after he first joins the ship.

21
 on the EEBD as a means of supporting an individual in escaping from a smoke-filled
environment, and stressed that the units were to be used for escape purposes only.
The limited duration was highlighted, but no mention was made of the potential for an
inadequate air flow under certain circumstances and the ship’s personnel were not
given the opportunity to use the equipment in circumstances where this limitation would
become apparent.

The ship did not have the capability to recharge any EEBDs used on board. Additional
sets were specifically provided for training purposes only, and supplied to the ship when
a shore-based trainer attended.

A fleet-wide programme of enhanced refresher training was underway, but had not been
completed on board Viking Islay at the time of the accident.

1.13 The Vroon Offshore Safety Management System

1.13.1 The Safety Management System (SMS)
Much of the Vroon SMS was inherited from BUE Viking, and a review process was
on-going.

Office staff stated that the intent of the SMS with respect to entering dangerous
enclosed/confined spaces for the purposes of routine work was that they should only be
undertaken when in port, and with the support and guidance of shore-based specialists.
This was the reason why individual ships were not provided with the equipment
necessary to effect safe entry. However, no documentary evidence was available to
support Vroon’s intended policy of restricted entry only, other than the risk assessment
that had been written on board.

Viking Islay was supplied with the documentation required by the Vroon SMS to effect
safe entry into an enclosed/confined space. Prior to entering the chain locker the SMS
required the following to be completed:
1. Risk Assessment
2. Toolbox-talk Risk Identification Card (TRIC)
3. Permit To Work (PTW)

1.13.2 Risk Assessment for tank/space entry

The SMS risk assessment for tank/space entry carried on board Viking Islay did not
make the company policy regarding enclosed/confined spaces completely clear, and
individual ships were authorised to amend their own risk assessments. Page 1 (taken
from the SMS) gives details of the control measure required, while page 2 (produced on
board) states:
Tanks must not be entered until chemist has ensured space is gas free, and
oxygen level sufficient.

(Annex B)

22
 Viking Islay’s risk assessment for tank/space entry had several errors, including a
mismatch between the risk assessment and the equipment actually available on
board. For example, the control measures mention ventilating the space, but not
testing the atmosphere. The document was marked BUE Viking Ltd 2003. The SMS
risk assessment did not tally with the enclosed/confined space rescue checklist, which
specifically required that the atmosphere be tested (Annex C).

1.13.3 Toolbox-talk Risk Identification Card (TRIC)

TRIC was an “offshore” work system, adopted as an additional safety measure by
Vroon and other offshore operators, which aimed to make the generic risk assessment
appropriate for a particular job, on a particular day. The process formalised the
‘toolbox-talk’ by identifying hazards not covered by the risk assessment, along with
any control measures required, and recorded them on the TRIC. A card was required
to be completed for any non-routine task or when there had been any change to the
planned work scope. It was Vroon’s intention that as a final safeguard, the master’s
signature on the TRIC was required before work commenced. However, the format of
the TRIC, and the associated instructions within the Vroon SMS, did not make this step
completely clear.

In an attempt to make the system effective, Vroon had provided its fleet with guidance
on how many TRICs it expected to be completed monthly. On board Viking Islay, this
had been interpreted as a “target”, resulting in the cards being completed for arguably
non hazardous operations such as transferring food from the ship’s store rooms to the
galley. However, a TRIC was not completed for the entry into the chain locker.

Another sign that completion of the TRIC was treated as an administrative function
rather than an important safety tool was that the master was signing them on a routine
basis, instead of signing the cards as they were compiled and before the relevant task
was undertaken.

1.13.4 Permit to Work system

A valid risk assessment must be in place before a PTW can be granted. The Vroon
SMS stated that the master or responsible officer had the overall responsibility for
ensuring that PTW forms were completed before any work was carried out.

The responsible officer issuing the permit had to complete all sections, and then sign
the certificate of checks. In order to comply with the terms of the PTW, the responsible
officer would have to visit the work site.

1.13.5 Internal vessel audit

Staff from the Vroon Heath, Safety and Environment department carried out an internal
audit of Viking Islay on 1 March 2007. Safe working practices and the PTW system
were reported as satisfactory, as was the ship’s emergency preparedness.

1.13.6 Safety coaches

Vroon employed two safety coaches who were ex-seafarers, specifically to go to sea
on board their ships in order to evaluate onboard practices and identify improvements
where applicable. The coaches had managed to spend significant periods of time on
board the majority of the Vroon fleet. Vroon records show no coaching visits to Viking
Islay prior to the accident.

23
1.14 Entry into Dangerous Spaces Regulations
1.14.1 The Merchant Shipping (Entry into Dangerous Spaces) Regulations 1988
The Regulations16 apply to United Kingdom (UK) ships and other nations’ ships while
they are in a UK port. Within the Regulations, “dangerous space” means:
Any enclosed or confined space in which it is foreseeable that the atmosphere
may at some stage contain toxic or flammable gases or vapours, or be deficient
in oxygen, to the extent that it may endanger the life or health of any person
entering that space.

The Regulations require that the entrances to unattended dangerous spaces are
secured against entry; that procedures for entry into dangerous spaces are laid down
and observed; that drills are periodically carried out; and that equipment for testing
dangerous spaces is carried where entry into a dangerous space might be necessary.

1.14.2 Duties under the Entry into Dangerous Spaces (EDS) Regulations
• The employer shall ensure that procedures for ensuring safe entry and working in
dangerous spaces are clearly laid down; and
• The master shall ensure that such procedures are observed on board the ship

• No person shall enter or remain in a dangerous space (except in accordance with

safe procedures)

• In fulfilling their duties under these regulations, the employer, master and any other
person shall take full account of the principles and guidance contained in the Code
of Safe Practice for Merchant Seamen (COSWP) (see 1.15).

1.14.3 Drills
The EDS regulations require the master to ensure that drills simulating the rescue of a
crew member from a dangerous space are held at intervals not exceeding 2 months,
and that a record of such drills is entered in the official logbook. This applies to tankers
of 500 Gross Registered Tons (GRT) and over, and to any other ship of 1000 GRT and
over. As Viking Islay was 928 GRT this regulation did not apply; however the Vroon
SMS incorporated a requirement to conduct this type of drill, and they were regularly
undertaken on board Viking Islay.

The scenario provided as an example in the Vroon SMS emergency response manual,
describes an incident during which one of the crew becomes unconscious when working
in a confined space. A standby man outside the space raises the alarm and then enters
the space and also falls unconscious. The drill seeks to provide practice in confined
space rescue, use of BA and first-aid. For reasons of safety during drills, Viking Islay
used the ship’s laundry as the confined space, having interpreted ‘confined’ to mean
‘awkward’ or ‘restricted’, rather than ‘dangerous’.

1.14.4 Atmosphere testing equipment required

The EDS regulations require the employer to ensure that each ship, where entry into
a dangerous space may be necessary, shall carry or otherwise have available an
oxygen meter and such other testing device as is appropriate to the hazard likely to be

16 SI 1988/1638. See : http://www.mcga.gov.uk/c4mca/mcga-mld-page.htm?textobjid=D397CBD0CAB6BD81

24
 encountered in any dangerous space on board. The regulations also require that the
master ensures that the oxygen meter, and any other testing device provided on board,
are maintained in good working order and, where applicable, regularly serviced and
calibrated according to the manufacturers’ recommendations.

1.15 Code Of Safe Working Practices for Merchant Seamen

(COSWP)
1.15.1 Background and Legislation
The COSWP is published by the MCA, and is mandatory for UK ships17. Regulations
place a duty on the ships’ operators to ensure that sufficient copies of the COSWP
are carried on every ship to which the regulations apply, based on the number of
workers on the ship. Printed copies of the current code were available in Viking Islay’s
wheelhouse and mess room.

The chapters particularly relevant to this accident include:

• Chapter 6: Means of access and safe movement
• Chapter 10: Emergency procedures
• Chapter 16: Permit to work systems
• Chapter 17: Entering enclosed or confined spaces

The full text of the relevant sections of the COSWP is not included in this report, but
can be viewed on the MCA website.

1.15.2 Vroon induction programme

An induction programme that Vroon provided to all new sea staff highlights the
importance of the COSWP, and focuses specifically on risk assessment and the
company’s PTW system.

1.16 Dangers of enclosed/confined spaces - other advice and

guidance
1.16.1 Marine Guidance Note 309
Although primarily aimed at the fishing industry, Marine Guidance Note18 (MGN) 309
(F) gives advice that might be useful to other small ships, particularly those with limited
crew numbers. It highlights that all spaces receiving little or no ventilation should
be treated as potentially dangerous, and that one common cause of low O2 levels is
corrosion or rusting.

17 The Merchant Shipping (Code of Safe Working Practices for Merchant Seamen) Regulations 1998, S.I
1998/1838. See: http://www.mcga.gov.uk/c4mca/mcga-mld-page.htm?textobjid=DBB616EB3DACD5BC
18 MGN 309 (F) See: http://www.mcga.gov.uk/c4mca/mcga-mld-page.
htm?textobjid=6BAA95EDEA5ACC7D

25
1.16.2 Further guidance on dangerous enclosed/confined spaces
While the MCA’s COSWP should be considered as the definitive information source on
this topic for UK seafarers, much other information is available, e.g.
• International Maritime Organization (IMO) publication, Assembly Resolution A.864
(20) Recommendations for Entering Enclosed Spaces Aboard Ships. This document
includes an example of an enclosed space entry permit.
• Many flag states have relayed this information to ship-owners, for one example see
footnote19.
• The International Association of Classification Societies (IACS) provides guidance
for ship surveyors20.
• Various Protection and Indemnity clubs have issued advice and guidance to their
members and ships’ crews.
• The HSE provides guidance for shore-based industries21.

1.17 Similar accidents

1.17.1 MAIB statistics
IMO Assembly Resolution A.864(20): Recommendations for Entering Enclosed Spaces
Aboard Ships was adopted in 1997 following widespread industry concern over the
number of fatalities that had occurred resulting from ship’s personnel entering spaces
in which the atmosphere was oxygen depleted, toxic or flammable. MAIB records show
that 15 deaths and 31 reportable injuries, as a result of accidents in circumstances
similar to the Viking Islay accident, have occurred on UK registered vessels, or in UK
waters, during the period since IMO Assembly Resolution A.864(20) was adopted.

MAIB is currently investigating two other accidents in which three men died under
broadly similar circumstances.

1.17.2 Marine Accident Investigators’ International Forum (MAIIF)

Concerned at the continued loss of life due to improper confined space entry
procedures, MAIIF tasked the Department of Maritime Affairs, Vanuatu, with the
collection and dissemination of material relating to confined space entry, in anticipation
of a paper on the subject being submitted to the IMO.

At the time of drafting this investigation report, Vanuatu had collated data from six
administrations which listed 63 separate confined space incidents, resulting in 44
deaths and 63 injuries on board vessels of 15 different flag states, during the period
1993 to the current date. The data also identified that deaths due to lack of oxygen
or toxic atmosphere were occurring in spaces other than those routinely identified as
dangerous compartments.

19 This example also warns against the incorrect use of EEBDs for rescue purposes:
http://vanuatuships.com/content/view/150/2/
20See: http://www.iacs.org.uk/document/public/Publications/Guidelines and recommendations/PDF/
REC_72_pdf212.pdf
21 See: http://www.hse.gov.uk/confinedspace/
26
Section 2 - ANALYSIS
2.1 Aim
The purpose of the analysis is to determine the contributory causes and circumstances
of the accident as a basis for making recommendations to prevent similar accidents
occurring in the future.

2.2 Fatigue
The effect of fatigue on the master and crew of Viking Islay was assessed. The crew
were fresh from 28 days leave; the two day workers had had a full night’s rest. Mr
MacFadyen had been off-watch for his full 8 hours, albeit to some (not fully known)
extent disturbed by the noise made by the anchor chain. However, if his rest had been
severely disturbed, he would have been able to temporarily move from his cabin to a
quieter location to sleep (e.g. the ship’s hospital or survivor accommodation); there was
no evidence to suggest that he had done this. Also, other members of the crew did not
report significant sleep disturbance caused by the noise from the chain locker, indeed
some were not aware of the noise at all. Therefore fatigue was considered not to be a
contributory factor to this accident.

2.3 Manning & personnel

2.3.1 Manning levels
Viking Islay was manned well in excess of the vessel’s minimum safe manning
document. A lack of manpower on board Viking Islay was not a contributory factor to
this accident.

2.3.2 Crew nationalities and languages spoken on board Viking Islay

All of those interviewed had satisfactory spoken English skills; there is no evidence to
suggest that language difficulties played any part in this accident.

2.4 The hazard

Air quality measurements showed that at the time of the accident the atmosphere in the
chain locker was O2 deficient, and that no other gaseous hazards existed. Subsequent
expert analysis has shown that this deficiency was due to depletion, rather than
displacement or dilution of the O2, and that the O2 levels could have been sufficiently
low – around 4.4% - so as to cause instantaneous collapse of any person breathing
such an atmosphere. This supports the recollections of the witness who saw Mr
MacFadyen collapse in this way. It is therefore very likely that the first two victims were
similarly overcome.

The chain locker had no natural ventilation other than via the spurling pipes, and it
was practice on board Viking Islay for these to be sealed with expanding foam once
the vessel was clear of harbour and had secured her anchors for sea. Over the
18 months since the compartment had last been gas-freed and proven for normal
atmosphere, the rusting of the inner surfaces of the compartment and the chain would
have been steadily depleting the O2 in the air. Rusting is invariably found within chain
lockers, given the intermittent presence of damp conditions and exposed steel. The
breaking free of the anchor chain to enter and leave harbour, sometimes followed

27
 by a crew member entering the space to re-secure the chain, would have freshened
the atmosphere a little, but certainly not enough to restore O2 percentages to normal
atmospheric levels.

The deterioration in O2 levels would have been slow and progressive. That crew
members had been able to successfully enter the chain locker over that 18 month
period can be accounted for in three ways. Firstly, a crew member only needed to
descend part way down the ladder to tie off the anchor chains, and would therefore
have been near to the entrance opening and so in the freshest air. Secondly, on
previous visits to the chain locker, members of the crew might well have experienced
some of the effects of the lack of O2 but not recognised the symptoms (table 1,
page 12). Thirdly, it is likely that the chain locker was last visited to tie off the chains
sometime before the summer. There was therefore an extended period during which O2
was being depleted and no-one was opening up the compartment.

2.5 The initial accident

It was likely that Mr Ebertowski, being a younger fitter man and the junior rating of the
two, entered the chain locker to tie off the chain. This was a one man job, and the
restricted space available within the chain locker meant it was unlikely that two men
would have entered in the first instance.

The leading hand, Mr O’Brien, would have stood by at the entrance, maintaining radio
contact with the wheelhouse. It was possible that the atmosphere was such that Mr
Ebertowski was overcome immediately he entered the space. It is also possible that
he dropped something that caused him to go right down to the bottom of the chain
locker, and caused his collapse there. With Mr Ebertowski lying at the bottom of the
chain locker, it would then have been necessary for anyone attempting to rescue him to
descend into that area.

Witnesses’ descriptions of the way Mr MacFadyen raised the alarm as he ran down
through the accommodation, indicate that he probably was already aware of the first
victim, and possibly had been told by Mr O’Brien that he was entering the chain locker
to try to rescue Mr Ebertowski.

2.6 The consequent rescue attempt

Mr MacFadyen’s ill fated rescue attempt began well, but ended tragically. This was due
to several reasons.

2.6.1 Training, drills and rescue procedures

The training regime for dangerous enclosed/confined space rescue on board Viking
Islay did not prepare the crew for an accident of this nature. The crew had been drilled
in the rescue of a person from a confined space, specifically the ship’s laundry. While a
useful drill in itself, it did not prepare them for a dangerous space rescue, especially one
with a noxious atmosphere.

More appropriate drills could have included the particular difficulties of recovering an
unconscious casualty from a very confined compartment, and negotiating an unusually
narrow access hatch. The crew would thus have been given opportunities to learn
effective rescue techniques, and to practice using the equipment necessary for those

28
 techniques. Such drills might also have identified that the size of the access was a
problem when wearing BA, and allowed that problem to be resolved. It is noteworthy
that the extraction team that boarded the vessel from ENSCO 92 were better able to
cope with the unusually small entrance as they had drilled for such an eventuality.

2.6.2 Command and control

The forward control point (FCP) for the rescue was, in effect, the foredeck. Given the
limited working area inside the foc’sle store, and its proximity to the chain locker which
contained, at that time, an unidentified hazard, this was not unreasonable. However,
the hatch opening from the foc’sle store to the chain locker was the most significant
physical obstacle the rescue party had to negotiate, and the officer in-charge of the
FCP, the mate, had not identified this because he could not clearly see Mr MacFadyen
struggling to get through it.

Had the mate realised the difficulty Mr MacFadyen would have negotiating the
entrance, wearing a breathing apparatus, he could have detailed a smaller man for
the task, or arranged for his breathing apparatus to be passed through the hatch
separately. Certainly, he would have been able to stop Mr MacFadyen attempting to
enter the chain locker, wearing an EEBD.

Many of the benefits to be gained from more effective training have been covered
above. However, such training would also have allowed command and control by the
person in-charge of the FCP to be rehearsed and, where appropriate, enhanced.

2.6.3 EEBD limitations

Mr MacFadyen had received EEBD training in the previous year, and was likely to have
been well aware of the time-limited air supply provided by the EEBD. In a desperate
attempt to rescue his shipmates, he probably took a chance with the EEBD, thinking
that 10 minutes would be sufficient time in which to help them.

However, he was unlikely to have been aware that the rate at which air was supplied to
the face mask was restricted, unlike the demand system on a breathing apparatus, and
that it was possible to ‘over breathe’ an EEBD while conducting strenuous activity.

In electing to wear an EEBD rather than a BA, Mr MacFadyen took two chances with
his life. The first, that the 10 minute EEBD would last long enough to enable him to
help the victims and then to retreat before his air supply ran out. The second, that
the EEBD would be able to provide him with an air supply adequate for the task he
faced. For good reason, the use of an EEBD for rescues, or for otherwise entering a
dangerous atmosphere, is forbidden.

While it is possible that the facemask became dislodged, the more likely explanation for
Mr MacFadyen’s collapse inside the chain locker was that, experiencing the suffocating
effect of the restricted air supply as he climbed down into the chain locker, he removed
the EEBD face mask to take a deep breath. In doing so, he breathed in the noxious
atmosphere of the chain locker and collapsed instantaneously.

Had Mr MacFadyen been able to rehearse an escape wearing an EEBD prior to this
accident, he might have been more alert to its limitations. Then, once it was clear he
could not enter the chain locker in breathing apparatus, he might have notified the
officer in-charge of the FCP and sought an alternative plan.

29
 The EEBD training provided by Vroon satisfied statutory requirements. However, those
requirements were not effective in revealing the true limitations of this type of equipment
as they did not require realistic drills in their use.

As part of its fleet-wide programme of refresher training Vroon should include an

opportunity for all crew members to experience wearing an EEBD, ideally under
conditions of some physical stress.

To further enhance this training, the syllabus should include adequate instruction on
both the time and air flow rate limitations of these devices and consideration should
be given to providing its fleet with the capability to recharge EEBDs on board ship, so
continuation training on EEBDs can be conducted during the 28 day periods on location
offshore.

2.7 Subsequent rescue efforts

2.7.1 The master
The master quickly realised the scale of the problem facing his ship, and correctly made
an early call for external assistance. When this was forthcoming from ENSCO 92, he
used his skills and experience to good effect in promptly manoeuvring Viking Islay close
enough to the rig for the rescue party to transfer on board quickly and safely.

2.7.2 The ENSCO 92 rescue team

By the time the ENSCO 92 team were available to help, they were undertaking a
recovery operation rather than a rescue.

The extraction team from the rig were able to enter the chain locker using very similar
equipment to that which was available to the ship’s crew. This indicates that ENSCO
92’s training and drills were more effective than those undertaken on board Viking Islay.

2.8 Company policy on dangerous enclosed/confined spaces

2.8.1 Operational requirement for entry to dangerous spaces
It was Vroon’s policy that dangerous spaces should only be entered in port (with
appropriate specialists in attendance). Accordingly, the company did not provide the
specialist equipment required for members of the crew to safely enter such spaces
when their vessels were at sea.

Although the reason why the crew on Viking Islay had elected to enter the chain locker
could not be considered an urgent task, there will be occasions when entry into the
space at sea is necessary. These could include, for example, inspection for damage, to
free a bight in the anchor chain, to unblock the bilge strainer, and to release the bitter
end. Evidence was found on other Vroon vessels that entry into the chain locker was
considered necessary on occasions.

While the Vroon policy restricting confined space entry to port was clear to shore-based
staff, it did not take account of scenarios that could require crews to enter confined
spaces while at sea. Neither did the policy provide guidance on which spaces were to
be considered confined/dangerous, and under what conditions. In these respects, the
policy was unrealistic and provided the crew with insufficient practical guidance for the
conduct of day-to-day operations.

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2.8.2 Shipboard equipment
The result of the company’s policy on entering dangerous enclosed/confined spaces
was that Vroon did not supply Viking Islay with the equipment required to make a safe
entry to a dangerous enclosed/confined space. The ship was provided with a single
personal H2S alarm, but ship’s staff had no means of testing an enclosed/confined
compartment’s atmosphere before entering it; neither did the ship carry the equipment
to force ventilate any compartment before entry if it proved necessary.

2.8.3 Actions following the accident

Following the accident, Vroon issued a safety alert re-affirming the company’s policy of
using shore based support for planned work in dangerous enclosed/confined spaces.
The document also stated that a master should only consider initiating a dangerous
enclosed/confined space entry at sea as a last resort, and only after he has exhausted
all other solutions. Therefore, it should be necessary to contemplate entering
dangerous enclosed/confined spaces only in extreme circumstances, and only once
a risk assessment, TRIC and PTW had been completed. If the ship did not have the
capability to do the job safely, then the job should not take place.

However, as a result of the MCA’s inspection and subsequent detention of Viking Islay,
Vroon has equipped her with the equipment necessary to effect safe entry to dangerous
enclosed/confined spaces.

2.9 Hazard perception and risk acceptance

2.9.1 The chain locker
A simple inspection, taking only a few minutes, would have shown that Viking Islay’s
chain locker was effectively a tank, made completely air tight by the application of
expanding foam to seal the spurling pipes. Even without the expanding foam it was,
without doubt, a potentially dangerous enclosed/confined space, and with the foam in
place its airtight integrity was assured. Therefore, as written, the Vroon SMS process
for entering a dangerous space should have been followed, and the chain locker only
entered in port with specialists in attendance.

Evidence suggests that on Viking Islay entry into the chain locker had, over time
been undertaken to tie off the noisy anchor chain on many occasions. Nothing has
been found to indicate that either Mr Ebertowski or Mr O’Brien deliberately ignored
the potential hazards of the chain locker, or that they agreed to take a calculated risk
in conducting this task. Instead, it is perhaps because this task had evolved into a
familiar process that they did not recognise the potential risk Mr Ebertowski was taking
when he entered the chain locker. It is clear that the locally produced sign, posted on
the aft bulkhead (Figure 6) had been of limited effect in informing the crew’s perception
of the compartment and its hazards.

Other crew members on Viking Islay were found to have mixed perceptions of
the hazard posed by the chain locker, and of the risks faced when entering that
compartment. Some were clear that the chain locker was a dangerous space; while
some other crew members, including the master, were not aware that the chain locker
was a dangerous enclosed/confined space. Some crew members had done similar
tasks in similar spaces (both on Viking Islay and other ships) and admitted that they

31
 would have continued to do so had it not been for this accident. More than one crew
member expressed shock and surprise that three men could die simply by entering a
chain locker.

Viking Islay and other Vroon vessels did not maintain a register of spaces to which
crew members could refer if in any doubt about appropriate precautions to be taken for
operations in, or entry to any given space. Had they done so, any ambiguity about the
status of the space or activity would have been removed, and appropriate actions could
then have been followed.

2.9.2 Approval of the task

The master, who had not visited the chain locker, did not consider that it was an
enclosed/dangerous space. Perhaps for this reason, he did not consult with the mate,
who would normally be in-charge of deck department activities, before approving the
task. This notwithstanding, entry to the chain locker was not a frequent occurrence,
and it would therefore have been appropriate to have required the seamen to complete
the TRIC procedure before commencing the task. Properly completed, the TRIC
would likely have alerted the master to some of the potential hazards, and he might
then have given the issue more consideration before granting permission to proceed.
Unfortunately, the TRIC procedure on board had become a retrospective administrative
process instead of a proactive safety mechanism, so it is unsurprising that it was not
completed as part of the task approval procedure.

2.9.3 The would-be rescuers

The situation for the would-be rescuers was quite different, and doubtless the
adrenaline-fuelled instinct to help fallen shipmates was overwhelming. The
phenomenon of multiple deaths during accidents involving dangerous confined spaces
is well known; the COSWP specifically cautions seafarers against such rescue attempts.

In Mr O’Brien’s case, his problem was immediate; his colleague had fallen/collapsed at
the bottom of the chain locker. He raised the alarm, and immediately entered the space
to render assistance. Whether he had any suspicions about the hazard he faced is not
known. Either way, his attempt to rescue his colleague was instinctive but, tragically, ill-
fated.

Mr MacFadyen was faced with a different problem. He had probably received a warning
on the VHF radio of the first casualty, had himself raised the alarm on board, and
was the first on scene. There he saw two apparently unconscious casualties whose
condition was unknown. Having tried to enter the space wearing a BA, and finding it
impossible, Mr MacFadyen donned an ELSA, a piece of equipment inappropriate for the
task, and entered the space. It cost him his life.

Drills and training on board ships have two important purposes. Firstly, they provide an
opportunity to test and prove procedures and equipment in realistic settings. Secondly,
and most importantly, they practice the crews in sets of procedures that they can fall
back on during emergency situations, when there is great urgency, and often noise and
confusion. Without this bedrock of training, Mr MacFadyen was ill-prepared for his part
in the rescue, and he resorted to instinct.

32
2.10 The ship - shore disconnect
It was evident that key working practices impacting on the safety of Viking Islay and
her crew were at variance with specific requirements laid down in the Vroon SMS.
However, the company’s own internal audit system had not detected the disconnect
between Vroon’s performance expectations, as detailed in its SMS, and the actual work
practices being observed by members of Viking Islay’s crew.

The difficulty for Vroon, which has been experienced by many other companies, was
ensuring that its policies and procedures were being carried out effectively at sea.
The particular hazards associated with confined space entry were addressed during
dedicated crew training sessions held before oncoming crews embarked their vessels.
However, in the case of the crew members who lost their lives on Viking Islay, this
training was ineffective.

Vroon had also tried to verify and improve the effectiveness of its SMS by employing
safety coaches, who carried out monitoring and training, both in port and at sea.
However, Viking Islay had not been visited as a part of this programme at the time of
the accident. Subsequently, having identified that this was partly due to the trading
patterns of its fleet, Vroon has employed additional coaches in order to accelerate the
training programme.

2.11 Similar accidents

Arguably, there can be few aspects of personal safety on board ships that have
received more attention than the importance of following the correct procedures before
entering an enclosed space. Very sadly, accidents such as that which occurred on
board Viking Islay, continue to happen.

The lessons below have deliberately been copied from an MAIB Safety Digest article
following a similar fatal accident in 200222. They remain as valid now as they did then.
Tragically, if learnt, they would have prevented this accident too.

1. Anyone who has been at sea for some time in merchant ships will be all too
familiar with stories of people who have entered enclosed spaces without taking
the necessary precautions, and died as the result. The lessons from such
incidents have been hammered home time and time again and still it happens.
Although it is impossible to know exactly what victims are thinking before they
make an entry, it is feasible to assume they think the space is sufficiently safe to
warrant entry. After all, it looks all right, so what could possibly go wrong?

2. Some spaces are evidently dangerous, and there are very sound rules in
place to prevent accidents. Consult the IMDG code to know the properties and
characteristics of dangerous bulk cargoes before entering a space where such
cargo is being, or has been carried. Follow the excellent advice in the Code of
Safe Working Practices for Merchant Seamen, which documents the procedures
for entering enclosed spaces. The main points are: the space must always
be tested before and during each entry, personnel should be standing by with
safety equipment at the entrance, and the space should be well ventilated.

22 See MAIB Safety Digest 1/2002 http://www.maib.gov.uk/cms_resources/Safety%20Digest%201_2002.pdf

33
 3. Other spaces are not necessarily quite so obvious. They include void
spaces not normally entered, compartments that might have been flooded, or
areas separated from dangerous cargo by a portable bulkhead. If in doubt,
assume the space is potentially dangerous and take the necessary precautions.
Remember 3.5% of oxygen looks exactly the same as the 18% which is the
minimum required for human beings to breathe safely. Anything below that can
lead to loss of life.

4. Never ever carry out an entry alone. A well-formulated plan should always be
followed. A short-cut could prove fatal.

5. And one final point. If you see someone lying motionless at the bottom of a
ladder in an enclosed space, don’t rush in to carry out a rescue without taking all
the appropriate precautions. Failure to do so will only result in more fatalities.

34
Section 3 - CONCLUSIONS
3.1 Safety issues directly contributing to the accident which
have resulted in recommendations
1. EEBD training provided by Vroon was not sufficiently realistic to give the crew a
complete understanding of the limitations of the constant flow type EEBDs provided
on board Viking Islay. (2.6)

2. Statutory requirements for EEBD training were not sufficiently robust to ensure
that the full extent of the limitations of this type of equipment were revealed, and
required no realistic drills in their use. (2.6)

3.2 Safety issues identified during the investigation which have

not resulted in recommendations but have been addressed
1.  Viking Islay was not provided with the equipment necessary to test the atmosphere
of the chain locker. (2.4, 2.8)

2. Some crew members on board Viking Islay were not aware that the chain locker
was a dangerous enclosed/confined space, or that the O2 level within the chain
locker could be dangerously depleted by corrosion, to the point that the atmosphere
could become lethal. (2.5, 2.8, 2.9)

3. The training regime for dangerous enclosed/confined space rescue on board Viking
Islay did not adequately prepare the crew for an accident of this nature. (2.6)

4. Command and control at the FCP was not fully effective, and best use was not
made of the human and equipment resources available on board. (2.6)

5. Normal checks and routines that should have prevented this accident were not
applied. (2.9)

6. Vroon office staff were clear that the company policy was that confined space entry
should not occur unless specialist advice and support was available. However, the
policy did not take account of scenarios that could require crews to enter confined
spaces while at sea. Neither did the documentation provide guidance on which
spaces were to be considered confined/dangerous, and under what conditions. In
these respects, the policy was unrealistic and provided the crew with insufficient
practical guidance for the conduct of day-to-day operations. (2.8)

7. The Vroon SMS was not being correctly implemented with respect to dangerous
spaces on board Viking Islay, and audits and inspections had not detected this.
(2.9, 2.10)

8. Vroon shore-based management were not aware of the working practices that had
developed on their ship. (2.10)

35
Section 4 - action taken
4.1 Vroon Offshore Services
Vroon Offshore Services has:
• Provided Viking Islay, and other ships in the Vroon fleet, with portable atmosphere
testing equipment. Key onboard personnel have been trained in its use. Personal
gas monitors have also been supplied to the Vroon fleet, to be worn by personnel
entering a space once it has been tested and certified safe to enter.

• Issued a series of internal safety alerts that address the issues raised by this
accident:

• Safety Alert 15/07: Details the immediate safety lessons from this accident and
identified the need to reinforce Vroon safety systems and processes including
hazard recognition, risk assessment and the PTW system. This document
unequivocally states that once the TRIC has been completed, and before the
job starts, the card should be reviewed and signed off by the master. It required
whole crew briefs on all Vroon vessels. The brief emphasised Vroon policy
regarding dangerous enclosed/confined space entry requirements, reminding
crews that the COSWP is integral to the Vroon SMS. This safety alert also gave
detailed definitions of enclosed or confined spaces.

• Safety Alert 16/07: Provided additional clarification in response to questions

from the fleet about SA15/07. It reinforced Vroon confined/enclosed space entry
requirements and repeated the definitions of dangerous spaces that were given
in the previous alert.

• Safety Alert 18/07: Gave details of the Vroon fleet-wide compartment

assessment programme, together with a questionnaire designed to assist
masters in completing the assessment of compartments on Vroon ships. If
doubt existed as to whether any given space was, or had the potential to
become dangerous, the questionnaire was to be completed and submitted to
Vroon headquarters for assessment. The intention was to compile a register of
dangerous spaces for each vessel in the Vroon fleet. Such spaces will be clearly
marked as dangerous, and reference to the register will identify appropriate
precautions to be taken.

• Commissioned an independent third party consultancy company to undertake an

audit of the Vroon SMS, its fleet and, where necessary, revisit risk assessments.

• Undertaken to recruit additional staff to reinforce the Vroon safety management

team: two training/development masters (to sail on board Vroon ships), a marine
manager shipboard standards and an additional Quality Safety Health and
Environment advisor.

• Begun the testing and evaluation of portable vent fans and lighting equipment.
Vroon will then decide which is the most suitable, in terms of portability and
electrical safety.

36
4.2 The Maritime and Coastguard Agency
The Maritime and Coastguard Agency has:
• Conducted an ISM SMC additional verification audit on Viking Islay, and found two
major non-conformities. However, because a full review of the PTW system was
ongoing, and as the second crew (the crew on board at the time of this accident)
had not been audited, the non-conformities were downgraded from major to minor,
rather than closed out.

• Witnessed tank entry and rescue, fire, and abandon ship drills on board Viking
Islay, and found them to be satisfactory.

• Commenced a series of general inspections on a number of other ships in the

Vroon fleet.

• Scheduled an ISM DOC audit of Vroon during spring 2008.

• Issued an Operational Advice Note to ensure that MCA surveyors remind ships’
crews, particularly those in the short-sea sector, about safe procedures concerning
entry to dangerous enclosed/confined spaces. When carrying out surveys,
inspections or ISM audits, surveyors have been requested to include checks:

• That the content of the SMS is appropriate and is being applied

• That confined space rescue drills have been correctly carried out

• That the master is fully aware of his particular responsibilities regarding confined
spaces on board his ship

• To ensure that testing equipment is fit for purpose, is calibrated and in-date, and
that the crew have been trained in its use

• That those persons responsible for issuing permits to work for entry into
enclosed spaces are aware of section 17 of the COSWP.

4.3 Marine Accident Investigation Branch

The MAIB has:
• Issued a Safety Flyer, giving a summary of the findings of this investigation to the
marine, offshore and fishing industries via representative organisations in order to
heighten owners’, operators’ and seafarers’ awareness over the dangers of entry
into enclosed/confined spaces.

37
Section 5 - recommendations
Vroon Offshore Services Ltd is recommended to:
2008/135 Review its training regime for the use of EEBDs on board all vessels in its fleet.
Such training should include practical “hands-on” experience of both equipment
capabilities and limitations, and should be undertaken in a safe, yet realistic
environment. In order to achieve this recommendation within reasonable
timescales, it may be necessary to arrange additional equipment and training
to allow the safe re-charging and re-packing of any EEBD used for training
purposes while the vessel is at sea.

The Maritime and Coastguard Agency is recommended to:

2008/136 Review the guidance currently available to seafarers regarding the limitations
of constant flow type EEBDs, and publish any such additional guidance on the
subject as the MCA deems necessary.

2008/137 Consider changes to regulation and guidance regarding the nature and extent of
training and drills in the use of EEBDs on board ships. It is recommended that
awareness of the correct use of EEBDs is firmly reinforced by practical “hands-
on” experience of actual equipment capabilities and limitations, to be undertaken
in a safe, yet realistic environment. The use of “dummy” EEBDs for training
purposes should be discouraged.

Marine Accident Investigation Branch

July 2008

Safety recommendations shall in no case create a presumption of blame or liability

38