Confined Space Incident Kills 3: The Never Ending Threat

Confined space fatalities are a continual threat that seem to defy training and experience.  How do we prevent them?

The  Marine Accident Investigation Branch (MAIB) just released the investigation report on an confined space incident on a ship that killed three.   This tragedy played out in two parts:

  • Multiple deaths as one crewmember after another went in to help a fallen co-worker.  In this case, one and possibly two crewmembers went into the oxygen-deprived environment of a forward hatch.  The third victim, the Chief Officer, yelled down to them and then, without any consideration of the danger, climbed down after them.
  • The failed rescue effort that followed.  According to the investigation a fourth crewmember donned a  breathing apparatus (BA) set with a mask that didn’t fit.  Two stevedores working onboard also went in, one with an emergency escape breathing device (EEBD) and the other with no apparatus at all.   The three managed to recover the bodies and get out but all of them suffered severe breathing problems.

The full report can be viewed here.  Thanks to Maritime Executive for calling attention to it.

quesion mark guy 2Confined space fatalities may be the most heartbreaking of incidents because they so often involve multiple deaths, as one person after another ignores the danger to save a co-worker.   From a training perspective, confined space is different from so many safety topics.  You can teach someone to use safety gloves and wear steel-toed shoes.  But teaching about confined space means overcoming hard-wired instincts and that means looking at how our brains work.

Here’s what happens – When you a worker passed out in a confined space, it triggers a 100,000 year-old response that has been with us since early man was wandering around the African plains trying not to get eaten.  One of the most primitive parts of your brain, the amygdala, hits the panic button and takes over.   It is fight or flee time and your nervous system floods your body with adrenalin.  It is common for people in an emergency to say they can’t “think straight” and they are right.  Scientists say the amygdala “hijacks” the pre-frontal cortex, the part of your brain that thinks things through and makes decisions.

In the case of a confined space incident, your amygdala makes the decision to go in and pull your buddy our, to fight instead of flee. The rush of hormones surging through your brain makes it impossible for your steady-thinking pre-frontal cortex to assess the risk.  All of that training you got in a classroom goes out the window.

So how do we address this problem?   Training under hand-on conditions with scenario role-playing, company rescue plans that are actually stressed to workers and drilled and routine reminders at safety meetings and other venues.

We need to start bu recognizing that confined space is one of those topics that can’t just be taught in a half an hour in the classroom.

2 Replies to “Confined Space Incident Kills 3: The Never Ending Threat”

  1. Thanks for drawing attention to this Ken and you are right, Hands On training with scenario role-playing needs to be done.

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