A bulk carrier was contracted to carry a cargo of grain on a voyage taking 4-5 days. In order to kill insects in the cargo, the shippers asked for the cargo to be fumigated during the voyage. Aluminium phosphide tablets were used for the fumigation. They develop hydrogen phosphide gas when in contact with water or the moist atmosphere in the cargo holds. The rate of development of gas from such tablets depends heavily on the humidity of the cargo and the most favourable conditions for the complete release are in tropical and subtropical climates, where 4-5 days are normally sufficient. At the time of loading the weather was cold and dry.
The fumigator came onboard and, together with the Chief Officer, carried out an inspection of the hatch coamings, hatch covers and deck areas and also had a quick look at the empty cargo holds. Upon completion of the inspection, the fumigator briefed the Chief Officer about the dangers of hydrogen phosphide gas, that the gas can be deadly to humans even in very low concentrations, and told him to alert the crew to its distinctive smell of garlic. Two sets of gas masks with filters and one gas detection kit were supplied during the briefing and the fumigator explained to the Chief Officer how to use the equipment and warning signs for toxic gas were placed in relevant areas onboard. It was further agreed that the doors into the accommodation area should be kept closed at all times and the ventilation system for the accommodation area should be shut down. The crew members were only allowed to use the extraction fans from bathroom and toilets. The vessel was loaded and the fumigation tablets placed in the cargo. The formal handover of the responsibility for maintaining safe conditions onboard was carried out between the fumigator and the Chief Officer.
Two days into the voyage, the vessel experienced some bad weather and when one crew member fell ill, he was thought to be either seasick or experiencing some gastric problems. As he had a headache, felt dizzy and vomited, he was told to lie down in his cabin until he felt better. Gas concentration safety checks were carried out once a day but the crew members delegated to the task were not familiar with the supplied test equipment. It was also discovered that the expiry date of the test tubes had passed. No recordings were made in the ship’s logbook. After having spent two days in his cabin without getting better, the sick crew member was found dead the next morning. Other crew members had also experienced dizziness and headaches during the voyage but they had recovered by working outside in the fresh air.
When arriving in port, an expert from a fumigation company came onboard the vessel and found high concentrations of hydrogen phosphide gas in various parts of the accommodation area, including the cabin of the diseased crew member. When stripping down the lining and the insulation inside the superstructure, some small corroded holes were found in the common bulkhead between a ventilator from the cargo hold and the front of the superstructure. The extraction fans in the bathrooms and toilets had created a slight under-pressure in the accommodation area and made it possible for the dangerous gases to be drawn into the cabins located on the lower deck. At the receiving port, there was gas emission in the cargo holds for a full month, delaying the discharge of the cargo.
Keywords for discussion:
- The crew’s knowledge of IMO’s “Recommendations on the safe use of pesticides in ships”
- Pre-fumigation inspection (general condition of the vessel and cargo holds, gas-tightness vis-à-vis accommodation and work spaces)
- Fumigator’s and Master’s responsibilities (formal written handover, warning signs, crew briefing)Vessel and voyage specific procedures (length of voyage, climate and cargo conditions during voyage, operation of mechanical ventilation systems)
- Safety equipment available onboard (adequacy and condition of equipment, crew training)
- Safety checks during the voyage (test intervals, recordings)
- Illness amongst crew (knowledge of symptoms of gas inhalation, treatment onboard)
See attached file : Gard AS – Case study no 28 Fumigation of bulk cargoes.pdf
案例学习：因散装货物熏蒸导致船员死亡案例
一艘散货船签订了一份4-5天谷物运输航次合同。为了杀灭货物里的害虫，托运人要求在航程中熏蒸货物，熏蒸采用磷化铝药片。磷化铝药片与船舱内的水或潮湿的空气接触时产生磷化氢气体。气体产生的速度主要取决于货物的湿度，让气体完全释放的最佳环境是热带及亚热带气候，通常只需要4-5的时间。但装货时，天气又冷又干。
熏蒸人员和大副一起来到船上，对舱口围板、舱盖、甲板区进行了检查，并快速看了看空货舱。在完成检查后，熏蒸人员向大副简单介绍了磷化氢气体的危险性，这种气体即便浓度很低也会致命。并告诉大副警告船员其独特的大蒜气味。谈话期间，熏蒸人员提供了两套带过滤器的防毒面具和一个气体快速检测箱，熏蒸人员向大副解释如何使用这些设备，并在船上相关区域放置有毒气体警告标志。双方进一步认同，船员生活区的大门应该始终关闭，生活区的通风系统也应一并关闭。船员只能使用浴室和卫生间的排风扇。装货完毕，熏蒸药片被放置在货物中。熏蒸人员将保持船上安全的责任正式转交给大副。
航行2天后，船舶遭遇了恶劣天气，当时一名船员感觉身体不适，被认为是晕船或者肠胃问题。该船员发生头痛、晕眩和呕吐症状时，被告知到房间躺着，直到感觉好一点。船上每天进行一次气体浓度安全检查，但是接受委派的船员对提供的测试设备并不熟悉。并且发现试管已经过了有效期。船上航海日志并没有记录。在舱室内休息了2天的船员病情不见好转，隔天早上发现他已经死亡。在航程中其他船员也感到过头晕、头痛，但是他们因为在有新鲜空气的室外工作而恢复过来。
船舶到港时，一名熏蒸公司的专家上船后发现船员生活区到处都是高浓度的磷化氢气体，包括生病船员的房间。当拆下上层建筑中的内衬和绝缘层时发现，货舱通风设备和上层建筑前端的共有舱壁上有一些被腐蚀的小孔。同时浴室和卫生间的排风扇降低了生活区的气压，使危险气体得以进入位于主甲板以下的船员房间。在卸货港，花了整整一个月时间清除货舱中气体，导致卸货延迟。
协会希望通过该案例，使相关人员注意：
- 船员对国际海事组织 “船上安全使用杀虫剂建议案” 方面的知识
- 熏蒸前的检查（船舶和货舱的一般状况，船员生活区和工作区的气密性）
- 熏蒸人员和船长的责任（正式书面交接，警告标志，船员简报）船舶和航程的具体程序（航程距离，航程中的气候和货物状况，机械通风系统的运作）
- 有效的船上安全设备（设备的适当性和状况，船员培训）
- 航行期间的安全检查（测试间隔，记录）
- 生病船员（吸入气体后的症状和船上治疗的知识）
协会希望通过这个案例，提醒会员高度重视熏蒸时对杀虫剂的使用。加强船员培训，确保安全设备状况良好，认真做好熏蒸的交接工作。在航程中，时刻注意安全检查并做好记录，学习船上急救措施，以防船员中毒事件的发生。
详细信息请参阅附件。
