Confined space fatality in shipyard

A rope access worker lost his life in a fatal incident at a fabrication site. The rope access worker was tasked to descend into a 90cm diameter and 30m depth Riser Guide Tube (RGT) via the rope access method, to retrieve a piece of foam from the RGT. After descending for about 5 minutes, the worker lost contact with his co-workers on top of the RGT. He was rescued and immediately conveyed to hospital by the yard’s ambulance, but was pronounced dead by the attending doctor.

What went wrong:

  • A Permit to Work was authorized and issued without Job Safety Analysis having taken place for high-risk confined space entry activity;
  • Suitable rescue equipment for confined space entry was not available at site location. No written procedure/method statement was available during Job Safety Analysis (or briefed to the work crew before implementation);
  • No pre-entry gas test immediately before entry into confined space (or recognition that the activity would itself release confined gas).


Corrective actions and recommendations:

  • Elimination of need to enter confined space. Method changed to eliminate need to enter confined space;
  • Risk assessment – Construction supervision/expertise should attend all risk assessments relating to their area of responsibility;
  • Training – shipyard should provide training relating to the correct use of and wearing of personal gas detectors;
  • Job Safety Analysis (JSA) meetings on the project must be approved by all parties prior to the associated work permit being granted;
  • Emergency extraction – shipyard should ensure that mechanical means of man extraction are available at all times during rope access.