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Report on the investigation of the death by asphyxiation of two crewmen on board

Sava Lake
approaching Dover Strait on 18 January 2008

Maritime Administration of Latvia, Division for Investigation of Marine Accidents 5 Trijadibas Street Riga LV-1048

Marine Accident Investigation Branch Carlton House Carlton Place Southampton United Kingdom SO15 2DZ Report No 15/2008 September 2008 Pursuant to the International Maritime Organization’s ‘Code for the Investigation of Marine Casualties’, the UK Marine Accident Investigation Branch (MAIB) has taken the role of lead investigating body in this joint investigation with the Maritime Administration of Latvia. Throughout the investigation, MAIB has enjoyed the full cooperation of the Maritime Administration of Latvia. Extract from TheUnited Kingdom Merchant Shipping (Accident Reporting and Investigation) Regulations 2005 – Regulation 5:
“The sole objective of the investigation of an accident under the Merchant Shipping (Accident Reporting and Investigation) Regulations 2005 shall be the prevention of future accidents through the ascertainment of its causes and circumstances. It shall not be the purpose of an investigation todetermine liability nor, except so far as is necessary to achieve its objective, to apportion blame.”

NOTE
This report is not written with litigation in mind and, pursuant to Regulation 13(9) of the Merchant Shipping (Accident Reporting and Investigation) Regulations 2005, shall be inadmissible in any judicial proceedings whose purpose, or one of whose purposes is to attribute or apportionliability or blame.

Further printed copies can be obtained via our postal address, or alternatively by: Email: maib@dft.gsi.gov.uk Tel: 023 8039 5500 Fax: 023 8023 2459 All reports can also be found at our website: www.maib.gov.uk

CONTENTS
GLOSSARY OF ABBREVIATIONS AND ACRONYMS SYNOPSIS SECTION 1 - FACTUAL INFORMATION
1.1 1.2 Particulars of Sava Lake and accident Background 1.2.1 Sava Lake1.2.2 Trading pattern 1.2.3 Steel turnings 1.2.4 Manning Narrative 1.3.1 Pre-loading 1.3.2 Cargo loading at Copenhagen 1.3.3 Cargo loading at Horsens 1.3.4 The voyage The search for the missing men 1.4.1 The search 1.4.2 Actions on finding the men Post-accident 1.5.1 Diversion The owner / manager Parties involved in cargo fixing 1.7.1 Time charterer 1.7.2 Time charterer’s broker 1.7.3 The shipper1.7.4 The ship broker 1.7.5 The cargo intermediary 1.7.6 Cargo agents 1.7.7 Terminal operators Crew 1.8.1 Employment of the crew 1.8.2 Crew working routine The forward store 1.9.1 Configuration and contents 1.9.2 Ventilation Cargo hold ventilation 1.10.1 Cargo hold ventilation system 1.10.2 Cutting of the ventilation bellows 1.10.3 Planned maintenance Regulation 1.11.1 IMO 1.11.2 Documentationrequirements Cargo documentation 1.12.1 Mate’s Receipt 1.12.2 Bill of Lading 1.12.3 Classification Society - Document of Compliance – Special Requirements for Ships Carrying Dangerous Goods Findings related to cause of death 1.13.1 Oxygen within the hold 1.13.2 Postmortem 1.13.3 The physiological effects of reduced oxygen 1.13.4 Other noxious gasses Enclosed space entry 1.14.1 Procedures 1.14.2Atmosphere test equipment

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1.3

1.4 1.5 1.6 1.7

1.8 1.9 1.10

1.11 1.12

1.13

1.14

SECTION 2 - ANALYSIS
2.1 2.2 2.3 Aim The accident The ventilation system 2.3.1 Design 2.3.2 Ventilation system maintenance 2.3.3 Class approval andcertification The cargo 2.4.1 Ferrous metal turnings 2.4.2 European “steel turnings” exports Terminal operations Cargo documentation Communication of cargo details to the master Enclosed space entry 2.8.1 Onboard procedures 2.8.2 Ship familiarisation 2.8.3 Emergency response Coastal and short sea trades Fatigue Similar accidents Safety issues directly contributing to the accident which have...
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