Confidential Human Factors
Incident Reporting Programme
The Charity
Aviation
Maritime
M2292
Initial Report
A shipyard has been fined after a welder suffered carbon monoxide (CO) poisoning while working in a confined space on a ship in drydock. The welder continued cutting metal for 40 minutes, unaware that his gas monitor had been sounding an alarm.
According to the incident report, the alarm went off just two minutes after the worker began arc gouging, a welding process that uses a carbon electrode, power, and compressed air to cut metal. This alarm should have prompted an immediate evacuation, but the welder didn’t hear it and kept working until he started feeling sick and left the space on his own.
The report also revealed that the welder should have been wearing a full-face respirator with its own air supply. However, the respirator was broken, so he used a half-face respirator, which did not protect him from CO.
Additionally, the person assigned to monitor the welder had not been properly trained and was not at the entrance of the confined space for at least 40 minutes. When the welder finally exited, another worker noticed his condition and raised the alarm. Paramedics took the welder to the hospital, and he made a full recovery.
CHIRP Comment
This report highlights several serious safety violations that could have been fatal, especially in the challenging environment of a shipyard or during vessel maintenance. It underlines the importance of clear responsibilities between the ship’s crew and the shipyard’s contractors.
Dry docks are among the most dangerous workplaces for seafarers and shore workers. With so many tasks happening simultaneously and a shortage of qualified personnel, there is often pressure to finish work quickly. Many shipyards rely heavily on contractors and temporary workers. This places an obligation on shipyard management to ensure these contractors have the skills and knowledge to perform their jobs safely, and to oversee them to ensure that they adhere to documented safe systems of work.
In general, the ship’s master is responsible for the safety of the ship, its crew, and anyone else on board, including shipyard workers and contractors. The master also has to ensure that all work areas are safe, typically through a Permit to Work system. Meanwhile, the shipyard must ensure that its workers are properly trained and capable of doing the work safely, with risk assessments and inspections in place to maintain high standards. The provision of welding sentries and other safety personnel is usually agreed upon in formal meetings between the ship and the shipyard unless specified in the contract. CHIRP recommends that company SMS documents are reviewed and updated on drydock safety management to ensure they include all identifiable risks to the crew and the shipyard workers.
In this incident, the space was a confined space rather than an ‘enclosed space’ (see definitions below), and not properly risk-assessed by the shipyard for hazards arising from the intended work. The company failed to monitor the space while the worker was inside, failed to provide a trained welding sentry, and failed to supply the correct protective equipment for the welder.
Enclosed Space- Defined as a space with limited openings for entry or exit, inadequate ventilation, and not designed for regular occupancy.
Confined space- Defined as a space that is large enough for an employee to enter and work in, with limited or restricted entry and exit, and not designed for continuous occupancy.
Confined space permits require clear communication between workers inside and a safety person outside, usually through radios or visual signals. However, these methods were not in place during this incident, worsening the situation.
Key Issues relating to this report
Culture- Shipyards must ensure that the proper equipment is available for safe use and provide appropriate training programs, especially for drydock safety. Given that drydock work is one of the most dangerous environments, the lack of training and experienced personnel was a serious oversight.
Capability- While shipyards do have safety teams, they are often overworked and stretched thin. This means the ship’s crew needs to be extra vigilant about enforcing safety measures that are usually routine on board, particularly in a drydock or repair dock setting. Both the welder and the standby crew lacked adequate training, and safety protocols require that only experienced and trained personnel be assigned to such tasks. Furthermore, the task was conducted without the necessary personal protective equipment (PPE), highlighting a lack of operational knowledge. The use of an incorrect half-face respirator further emphasises this gap.
Pressure- Drydocks often have a line of ships waiting for access, creating intense pressure to complete work quickly. Effective management, with careful daily planning, is essential to ensure that all tasks are properly assessed for safety risks. Does your company have tools to ensure that work is being carried out safely under such pressures?
Communications- There was a critical breakdown in communication between the welder and the standby person who was supposed to be monitoring both the work and the atmosphere in the confined space. This lack of communication further endangered the worker.
Teamwork- Teamwork in this situation was inadequate. The standby crew member abandoned their position for over 40 minutes, showing a clear lack of awareness of the dangers involved. Proper teamwork is crucial in ensuring safety in high-risk environments like drydocks.