Three dock workers who died aboard an Isle of Man-registered vessel were not trained in working in enclosed spaces, a report has found.

The Marine Accident Investigation Branch has published its report into the deaths of the three men aboard the Berge Mawson when it was docked at Bunyu Island Anchorage, Indonesia.

Recommendations have now been made to those in the industry to improve safety and training.

On the morning of June 27, 2022, three unconscious stevedores (dock workers) were found in a cargo hold access space on the Manx-registered bulk carrier. Despite medical treatment at the scene, all three men died.

The vessel was loading coal from barges using a floating crane and, during a pause due to heavy rain, all hatches were closed.

After the rain stopped, a stevedore attempted to access a bulldozer in a cargo hold but mistakenly entered the access space of a different cargo hold and was overcome.

Two other stevedores collapsed while attempting to rescue him as crew collected rescue equipment.

Investigations found the three stevedores died because the access space had an oxygen-depleted atmosphere that could not sustain human life.

The access hatches leading into cargo spaces were not locked when not in use when they should have been.

The investigation also found the stevedores had not been trained on safe cargo work on board bulk carriers or on the dangers of enclosed spaces.

The MAIB report noted that on December 9, 2019, the Isle of Man Ship Registry issued a notice on the dangers of enclosed spaces on board ships.

It said: ‘We would like to re-iterate to all ship managers that they must ensure all the vessels they manage have sufficient information and procedures on the correct identification of enclosed spaces and have safe procedures for personnel entering an enclosed space.’

A recommendation has been made to the Maritime and Coastguard Agency to review and revise the Code of Safe Working Practices for Merchant Seafarers to ensure that emergency drill scenarios for enclosed space rescues include the possible presence of shoreside staff or third parties.

Recommendations over safety, guidance and training have also been made to Berge Bulk Maritime Pte. Ltd, cargo operators and Indonesian port groups.

Chief Inspector of Marine Accidents, Andrew Moll OBE, said: ‘Although Berge Mawson’s crew were well-trained in their emergency response to enclosed space accidents, their drill scenarios did not involve shore workers who could be on board at the time.

‘In the crew’s rush to collect rescue equipment they left the entry point to an enclosed space containing a noxious atmosphere unguarded, and this oversight tragically led to the second and third stevedores dying in a well-intentioned but misguided attempt to rescue their colleague.

‘Despite international and industry guidance on the training stevedores should receive before working on bulk carriers, InterManager data shows that, of the 257 enclosed space fatalities reported between 1999 and 2023, 67 were stevedores or shore workers.

‘To help prevent further loss of life it is essential that bulk carrier and terminal operating procedures, practices and training equip shore workers to operate safely on board the vessels they attend.’