Proceedings Of The Marine

FALL 2011

Proceedings magazine is a communication tool for the Coast Guard's Marine Safety & Security Council. Each quarterly magazine focuses on a specific theme of interest to the marine industry.

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Page 72 of 79

Analysis and Lessons Learned As with so many cases covered in this "Lessons Learned" series, this calamity was not the result of a single factor, but rather a series of poor decisions and various other causal factors. Follow standardized procedures. ◆ It was policy to require two people for entry into the receiver. The second engineer should have had someone with him before entering. As this incident illustrates, even a one- time deviation from procedure may prove fatal. Avoid complacency. ◆ The scavenge air receiver was checked twice during the search, but never more than a few seconds or at the forward end where the missing man had last been seen. Also, nobody checked inside a third time, soon after the transit to Norfolk began, when a problem was noticed with the dogs on the forward door. Asked later why they had never opened the forward door during the search, crewmembers had no expla- nation other than that they doubted the second engineer was inside. ◆ Despite the fact that the gangway watch reported that he had not seen the missing man go ashore, the captain assumed he had left the ship. Communication is crucial. ◆ The second engineer should have told someone before entering the scav- enge air receiver, and as noted, should not have entered it alone. ◆ Other crewmembers recalled seeing the second engineer cut safety cor- ners, but never relayed this informa- tion to a superior officer. ◆ If the last man to see the second engi- neer alive had told anyone that he had last seen his crewmate by the forward manhole, it might have prompted a search starting at that end of the scav- enge air receiver. Maintain your focus. ◆ The second engineer may have been in a hurry or momentarily distracted, and forgotten his training about the dangers of confined spaces. A brief lapse in situational awareness may have cost him his life. Fall 2011 Proceedings 73

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