A master on board a chemical tanker decides to deviate from an approved tank cleaning plan calling for a fresh water rinse and instead use a ventilation procedure.

The amendment to the tank cleaning plan was not approved or communicated to the office. The CO overrules the O/S and Pumpman (who objected to the unsafe nature of the operation) and decides to go into the tank anyway to clean out the chemical residue. The deadly chain of events continues when the crew reports hearing the low-level alarm on the CO’s SCBA but does not make a report.

When tragedy strikes there is confusion on how to respond, which leads to delays in the rescue operations.

This case study examines the numerous factors that led to this deadly enclosed space entry incident as well as the company’s response in the ensuing months.