Report on occupational accident on board the factory trawler Nordstar on 10 June 2018
Sjøfart rapport 2020/02 eng
On 10 June 2018, a crew member died on board the factory trawler Nordstar in connection with preparations for cleaning a silage tank. The investigation has shown that methane gas as well as toxic hydrogen sulphide gas had probably formed as a result of a decomposition process in the silage tank. The investiation has shown that the risk of gas being formed during the production and storage of silage had not been identified as a hazard in the shipping company's safety management system. The investigation has also shown that knowledge of the hazards associated with the formation of gas when fish waste/silage decomposes was not transferred in an effective manner from the other parties in the project to the shipping company, and nor were they identified by the shipping company or the supervisory authority (the Norwegian Maritime Authority) during the operating phase of the project.
It is likely that the fisherman was quickly exposed to immediately lethal levels of gas as he climbed down to the bottom of the tank. It was a demanding job to get the fisherman up from the tank.
The hazards associated with gas formation were not mentioned in the shipping company's risk assessments, checklists or work procedures. Tanks with contents that represented a potential gas hazard were not sufficiently labelled, and equipment for detecting hazardous gas was lacking. This contributed to a situation where personnel carrying out work on storage tanks and those responsible for approving such work were unaware of the potential risks to which they were exposed. The crew lalso acked sufficient emergency preparedness training and training in how to rescue people from a tank.
The shipping company has implemented several measures since the accident.
The shipping company's expectations that other parties would assist by providing detailed information about the hazards associated with silage production and work in tanks was not in agreement with the parties’ own understanding of their role in the project. This resulted in risks associated with the production and storage of silage not being identified or taken into consideration in the plant's operation.
Nor did the NMA's audit detect that the operational hazards associated with silage production and storage were not mentioned in neither the shipping company's nor in the vessel’s safety management system.
The investigation of the accident on board the Nordstar on 10 June 2018 has not identified new areas in which the Accident Investigation Board Norway deems it necessary to propose safety recommendations for the purpose of improving safety at sea.
Fakta
| Sted | International waters south of Iceland |
| Hendelsesdato | 10.06.2018 |
| Ulykkeskategori | Personskade |
| Område | Internasjonalt farvann |
| IMO-nummer | 6920111 |
| Fartøyets navn | Nordstar |
| Type hendelse | Dødsulykke, Entring av lukket rom, Fall om bord, Person-/arbeidsulykke |
| Type fartøy | 6 - Fiske-/ fangstfartøy |
| Register | NIS |