9.5 Handling of a mass casualty situation on board
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In the maritime setting, a mass casualty incident (MCI) can be defined as an event where the number of casualties vastly exceeds the on board healthcare capabilities in a short time period. Any MCI can rapidly exhaust available resources, not only to manage the MCI but also to maintain the normal operations of the ship. The number of casualties does not need to be high in itself, but enough to exceed the available resources.
Various events in the past, such as the fire on the Lisco Gloria ferry, the disaster at the Costa Concordia, the fire on board the ferry KM Karya Indah or the collision of a container ship with a building in the port of Genoa show that mass casualties in the maritime environment can occur at any time and affect a large number of people. The corona pandemic particularly affected cruise ships. While there are tested operational concepts for such situations on shore, this is often not the case for the sea and port sector. The research project KOMPASS, funded by the Ministry of Education and Research in Germany, has reviewed this topic.[1][2] [3] and the project consortium of experts from the maritime and medical sectors has developed proposals on how to effectively process a MCI at sea.
In the past, major ship incidents often resulted in the immediate abandonment and subsequent sinking of the ship. However, with the increase in cruise shipping worldwide and improved management of incidents on board all types of vessels, various situations may and have occurred which can lead to a proportionately high number of injured people without shipwrecking. These include:
In such a case, injured or ill persons must be cared for directly on board with the means available until further assistance arrives. Additional information on many of these situations is available elsewhere in the Textbook
If dealing with a mass casualty incident ashore poses a great challenge to the various helpers, further challenges occur on board a ship [6] [7] [8]:
Every ship should have a procedure to handle a MCI within its Safety Management System (SMS). The details of the response plan will vary depending on many factors including but not limited to:
The response plan should be clearly documented, communicated to the seafarers on board and practiced in appropriate drills. As in all emergency response procedures, all relevant roles and responsibilities at a mass casualty incident at sea should be defined in the muster list.
Essential roles, with specific responsibilities include:
Further information is given below and depending on the number of additional staff available, further roles can be defined. All tasks should be laid down in the job description of every crewmember and the seafarer should be familiar with the tasks involved, before the MCI happens.
As outlined above, a number of scenarios can result in MCIs. It is impossible to guarantee an extensive provision of onboard resources for all eventualities but in order to optimise the response it may be useful to have access to and use:
Such equipment should be included in the SMS and every seafarer on board should know where the MCI equipment is stored.
For infectious diseases, ideally it should be possible to decouple the ventilation system of the treatment area from the main system and to ventilate the treatment area independently. Appropriate ventilation controls should be installed and regularly tested. It should also be possible to install a double door system at the entrance to the treatment area. Once identified and treated, infected people on board should be isolated in an appropriate area as soon as possible.
For the management of an MCI on board, the following roles and responsibilities should be identified and allocated to specific positions on board as part of their emergency duties. These are in addition to other emergency duty teams such as firefighting, stretcher party etc. This should be part of the response plan and contained within the SMS.
Usually taken by the Master, this role involves ensuring that the ship remains a safe platform whilst also managing the MCI. It also includes the safeguarding of the approach of other helping vessels or the landing of external assistance by helicopter. The Head of Operations is ultimately responsible for all of the key decisions on board.
Usually taken by a deck officer this role involves managing communication on board the ship. It includes ensuring clear communication with the leaders of the various emergency response teams on board and
The role also involves clear communication to any passengers on board including:
Usually taken by a deck officer, this role involves communication with external parties such as the Maritime Rescue Coordination Centre, local authorities, shipping company and external assistance such as helicopters or other ships. Essential information to be relayed between the ship and others includes
The search and transport team(s) locate casualties and transport them to the appropriate treatment area. If several teams are available, the areas to be searched must be clearly defined. Depending on the type of incident, suitable personal protective equipment must be worn, for example, helmets and breathing apparatus. It is important to perform a systematic search and to mark the already searched areas so there is no need to re-enter an area.
Responsibilities of the team include:
As the situation develops the search and transport team may also be responsible for the transport of patients to external assistance, for example, to the helicopter winch area.
At the start of the MCI this team is responsible for identifying and preparing the treatment area. The location of appropriate treatment areas should be included in the SMS although some may not be suitable given the type and location of the incident that has occurred.
The preparation of the treatment area can include:
As the incident evolves the team is also responsible for the general logistics including:
Communication with other teams is key to ensure that the correct equipment is available where and when it is needed.
This team triages the casualties arriving at the treatment area using a known triage system [11]. In addition, it has the responsibility to complete the following tasks:
On board a passenger ship, the physically uninjured passengers must be cared for during and after a MCI and this team is usually made up of passenger service staff. The relatively confined space of a ship means that it can be difficult to distance passengers from the incident and there is a high risk of secondary incidents, such as jumping overboard of emotionally distressed people.
Regular announcements with clear information and requests can go a long way to reassuring passengers and crew on board and providing a feeling of safety and confidence in the actions of the ship’s crew. Passengers should not be left in uncertainty and regular information about the extent of the emergency and adopted measures are essential.
Information should:
Other measures that are the responsibility of this team include:
In the case of a MCI on board the number of crewmembers may not be enough to fulfill all the tasks required. Therefore, one of the first acts may be to identify suitably trained and willing passengers and assign them specific tasks as outlined in the ship’s SMS.
Announcements should address the volunteers, explain the skills sought and give assembly points. Passengers may be able to assist with skilled tasks, for example, the delivery of medical care or more general and administrative tasks that may include:
Before tasks are assigned to volunteers, they must be assessed as being physically and mentally fit for the task.
Each ship should have a structured response plan in case of a MCI and this should be part of the ship’s SMS. This includes the assignment of tasks, the storage of necessary equipment to support the handling of a MCI and the identification of treatment areas
In a MCI at sea, the ship’s crew must handle the situation without external support, sometimes for many hours. This requires the seafarers to manage the incident in addition to the restoring the safe operation of the ship. The response to a MCI involves many teams and although regular training is required for firefighting, dealing with an ingress of water etc., this is not currently the case for the management of a MCI. Such training, including drills on board, would improve the response to a MCI in the maritime environment.
[1] https://www.kompassprojekt.de (accessed 20210607)
[2] Meißner D. Unterstützung der Besatzung bei der Bewältigung eines Massenanfalls von Verletzten auf See, Schiff und Hafen, 2018, 4: 24 - 26
[3] Meißner D. Kompetenz und Organisation für den Massenanfall von Patienten in der Seeschifffahrt – Forschungsprojekt KOMPASS, Flugmedizin, Tropenmedizin, Reisemedizin, 2015; 22(6): 289 - 290
[4] https://www.cdc.gov/nceh/vsp/surv/gilist.htm (accessed 20210607)
[5] https://en.wikipedia.org/wiki/COVID-19_pandemic_on_cruise_ships (accessed 20210607)
[6] Flesche C, Hertig J. Notfallmedizin an Bord von Schiffen. Notfallmedizin up2date, 2008; 3: 257–271.
[7] Castan J, Paschen H-R, Wirtz S, Dörges V, Wenderoth S, Peters J, Blunk Y et al. Mass maritime casualty incidents in German waters: structures and resources. Der Anaesthesist, 2012; 61(7): 618–24
[8] Glassberg E, Lipsky AM, Abramovich A, Sergeev I, Hochman O, Nachman A. A dynamic mass casualty incident at sea: Lessons learned from the Mavi Marmara. J Trauma Acute Care Surg. 2013; 75(2): 292 -297
[9] Maritime Labour Convention, 2006, consolidated text established by the International Labour Office, including the Amendments of 2014 and 2016 to the Code of the Convention.
[10] Oldenburg M, Rieger J, Sevenich C, Harth V. Nautical officers at sea: emergency experience and need for medical training, J Occup Med Toxicol. 2014; 9: 19.
[11] Bazyar J, Farrokhi M, Khankeh H. Triage Systems in Mass Casualty Incidents and Disasters: A Review Study with A Worldwide Approach. Open Access Maced J Med Sci. 2019 Feb 15; 7(3): 482–494.
MICHAEL TIPTON
Over the last decades scientific knowledge about immersion in cold water has increased significantly. This has led to modifications and significant technological progress in sea survival material and procedures (1). Abandoning a ship in distress is followed by a potentially prolonged period of using rescue equipment, primarily lifejackets, immersion suits, life rafts or small boats. Once people are on these platforms the hazardous situation is not really resolved, merely altered. Unprotected cold water immersion below 15°C is life threatening from the start. Floating devices and protective garments are crucial. However, all items of protective equipment must fit together and perform effectively as an “integrated survival system” (2). Getting wet inside an immersion suit reduces the chances for survival significantly. Sitting wet inside a life raft without a vaporisation barrier has the same effect.
Survival at sea is not only a matter of material and procedures; it is also a matter of leadership, discipline and determination.
Professional seafarers usually use lifejackets, whereas flotation devices or buoyancy aids have their domain in recreational use.
The key issues of lifejacket designs are (3, 4):
- Requirement for self-righting.
- Integrated spray-hood and light.
- Compatibility with immersion suits.
- Inclusion of a life-jacket retention system (e.g. crotch strap)
- Easy donning for optimal user compliance.
Any lifejacket or flotation device must bring the wearer back to the surface immediately in order to prevent drowning. Back on the surface, it must ensure the airway is kept clear of the water and the body is supported at the surface, preferably at an angle of about 45 °. This should be achieved with as little effort required from the wearer and as much stability and self-righting capability as possible. A retention system will prevent riding up with wear and drowning inside the lifejacket when unconscious in a rough sea (4).
Continuous education on the use of survival systems is mandatory for best performance in a real sea-survival scenario.
Over the last 25 years improvements in fabrics, insulating material, waterproof zippers and introduction of the spray-hood have led to much more reliable suit design. This was initiated by the International Maritime Organisation (IMO) immersion suit standards, the offshore oil industry demands for better quality and international military-commercial developments, such as submarine escape with the requirement for immersion suits with surface survival times of 24 hours under the worst environmental conditions. A common problem is the incompatibility between clothes or survival suits and lifejackets resulting in the inability of lifejackets to self-right immersed persons wearing high buoyancy suits. The best solution is an integrated immersion suit that includes the lifejacket as part of the system (2).
As the name implies, “dry” immersion suits attempt to keep the area under the suit dry using watertight neck and wrist seals and zips. If normal clothing is worn under such suits to provide insulation, as is often the case, water leakage into the suit can significantly reduce the overall level of insulation provided (as can sweat and urine), especially if such leakage is around the torso (5).
A fully functioning dry suit can significantly delay the long-term effects of hypothermia. The key issues of good dry suit design are:
- Reliable neck and wrist seals by continuous rubber collar.
- Easy entry, single-handled with perfect sealing zip closure.
- Fitting neoprene gloves and correctly sized rubber wellington boots.
Sudden and prolonged cold water immersion situations correspond with distinct physiological stages. Death may occur from any one of the four stages of immersion (1):
Stage 1. The first 3 minutes - initial immersion responses (“cold shock”) (6).
Stage 2. The first half hour - short-term immersion (swimming failure).
Stage 3. 30 minutes plus - long-term immersion (hypothermia).
Stage 4. End of immersion (just before, during or immediately flowing rescue) (7).
Cold shock and swimming failure are the leading causes of death due to drowning during immersion, especially in accidental situations without appropriate sea-survival personal protective equipment (PPE). The cold shock response peaks in water below 15 °C and is greater the faster skin temperature falls and the larger the surface area of skin exposed to cooling.
The cold shock response on initial immersion in cold water includes a large uncontrollable inspiratory gasp followed by a period of severe hyperventilation. There is an increase in heart rate and blood pressure, and release of the stress hormones. These cardiovascular responses, especially if combined with face wetting and breath holding, can produce significant cardiac arrhythmias (8).
Death from cold shock by drowning or heart failure in the first three minutes of immersion is common. The inability to breath hold on initial immersion is probably the most dangerous response associated with immersion in cold water, acting as it does as the precursor to drowning, even when only periodically submerged by waves. With repeated cold water immersion most people will be able to reduce the cold shock response and increase their ability to breath hold.
The period between three and thirty minutes after immersion is characterized by cooling of the peripheral nerves and muscle, whilst deep body temperature remains above hypothermic levels (35 °C).
Early swimming failure is related to ineffective swimming due to a mismatch between severe hyperventilation and swimming strokes and the inability to co-ordinate the two. This increases the risk of water aspiration and drowning (10). Delayed swimming failure is the result of neuromuscular incapacitation. Cooling reduces the transmission and contractility of the nerves muscles of the upper and lower limbs. Below 30°C tissue temperature in the extremities, peripheral blood flow reduces, oxygen delivery falls and nerves and muscles become dysfunctional. A muscle temperature of 28°C results in physical incapacitation (11).
An associated problem is the concurrent impact on manual dexterity and strength in the first 10 – 20 minutes of immersion in cold water. This results in an inability to carry out self-rescue procedures, such as activation or use of rescue gear or even climbing into a life raft (1).
Without a flotation device, or a correctly donned lifejacket, death by drowning will occur. Swimming failure is one reason why standards for correctly wearing lifejackets must not be neglected when operating in cold water seas.
The conductivity of water is 25 times that of air and humans cool about 4-5 times faster in water than air at the same temperature (1). Hypothermia is defined as a deep temperature below 35 °C and this is unlikely to occur in an adult in less than 30 minutes (1). As the skin and deep body tissues cool, light shivering is replaced by intermittent and then continuous heavy shivering. If the maximum heat production from shivering, about 1300 W, is less than the rate of heat loss, cooling will continue and unconsciousness will occur at a deep body temperature between 33-30 °C. Unless a properly functioning lifejacket is worn, drowning occurs at this time. Cardiac arrest occurs around a deep body temperature of 28 - 25°C, although this temperature varies significantly between individuals and conditions (1).
A number of environmental, individual and intra-individual factors affect the rate at which hypothermia develops:
Because of the variations between individuals and conditions, it is difficult to predict survival time from hypothermia (1). Again, a crucial factor is whether the person is wearing a lifejacket that keeps the airways clear of the water and protects them from waves when severely impaired or unconscious.
The main cause of death after immersion is drowning, not hypothermia. Rescue-operations are often long lasting, and the survival time can be 24 hours or more under perfect conditions with a good lifejacket, spray-hood and survival suit, even in very cold water (1).
The rescue process has particular risks just before, during or immediately following removal from the water (7). At the time of rescue, the immersed person is likely to be suffering from one or more of the following threatening conditions:
Physiological changes in head-out immersion are primarily the result of a reduction of the influence of gravity, together with the hydrostatic pressure. The most important of these changes are those that influence the cardiovascular system and blood volume, namely:
General cooling of the body induces relative hypovolaemia through fluid shifts into the tissues and diuresis.
“Post-rescue collapse” is a physiological effect of removal from the water and is a consequence of postural hypotension. Following a prolonged period of immersion, rescue from the water removes the hydrostatic assistance to circulatory function at the same time as re-introducing full effect of gravity on the body (7). The circulatory system now becomes functionally hypovolemic. In a vertical posture gravity tends to induce a redistribution of blood, with venous pooling away from the heart and brain. The resulting reduction in blood returning to the heart will affect cardiac output and, if not corrected, the person will faint as the blood supply to the brain falls. Cooling impairs the usual baroreceptor reflex, and physiological adjustments to falling blood pressure fail to occur. Transition from water to air during rescue is likely to be less traumatic if casualties are lifted horizontally. Survivors whose airways are not under threat of aspiration, and who need to be lifted a significant distance, for example into a helicopter or high-sided ship, should be rescued with care, preferably horizontally, and handled as if they were critically ill. However survivors still in the water and whose airways are not protected should be rescued as quickly as possible by whatever means are available (1, 7).
On board the rescue craft, the rescued person should be placed in the optimum position to offset any potential problem in maintaining blood pressure. In a fast rescue craft, it is desirable to lay the casualty in a feet-forward, head-aft attitude (7).
The major aim of immediate management at the rescue site is to ensure that the airway is clear and assisted ventilation is provided if required. The most important cause of post-immersion death is hypoxia (drowning) secondary to the aspiration of water and vomit and drowning victims should receive oxygen as soon as a clear airway is established. All drowning and/or accidental hypothermic survivors should receive medical attention as soon as possible.
It should be clear form the above that drowning rather than hypothermia is the primary concern associated with immersion in cold water. The physiological pathways to drowning (12) include cold shock, physical incapacitation and hypothermia-induced incapacitation or unconsciousness when no lifejacket or an ineffective lifejacket is worn. It should be emphasised that a lifejacket should not be consider suitable for long-term survival in a seaway unless it includes: sufficient buoyancy; a retention system; a spray-hood to protect the airway when incapacitated and turned to face the oncoming waves by the legs acting as sea-anchors; and a light (1, 3, 4). A fully functioning lifejacket significantly extends survival time in cold water by preventing the occurrence of drowning with cooling-induced incapacitation/unconsciousness.
Detailed treatment protocols for drowning and hypothermia are beyond the scope of this chapter, additional information can be found in other publications (13, 14, 15) and the International Medical Guide for Ships or national equivalent.
As the majority of fatalities from immersion in cold water occur in stages 1 and 2 above, before severe hypothermia has had time to develop, sea-survival equipment and strategies must focus on the short term incapacitating effects and on protection from drowning.
The primary aim of the initial treatment of drowning is to interrupt the drowning process by the provision of oxygen. The treatment delivered at the prehospital stage gives the majority of the survival benefit. Ventricular fibrillation in drowning is relatively rare (<10%), so incorporation of an automated external defibrillator in initial minutes of treatment should not interfere with oxygenation and ventilation
Significant gastro-intestinal ingestion of seawater and subsequent repetitive vomiting is frequent on rescue. Aspiration of vomit enhances drowning-related lung lesions, making the clinical situation worse.
Cold survivors must be protected from further heat loss, in particular evaporative heat loss and heat loss through forced convection. Wrapping in blankets with an outer covering of heavy duty plastic will achieve this. Re-warming regimes must start as soon as possible.
This refers to a further drop of deep body temperature following rescue. There is no good evidence about its importance but it is seen with the regular measurement of deep body temperature via the rectum (7). In the case of a sudden and dramatic deterioration following rescue, other causes should be considered first, including the effects of drowning, post-rescue collapse, cardiac problems, internal haemorrhage or re-warming collapse due to excessively rapid re-warming (7).
Unless immediate electrolyte and blood gas measurements are available, great caution should be shown in trying to re-warm patients rapidly. Major changes are likely to have occurred during immersion. Re-warming should only ever be attempted with persons lying down at rest. Allowing hypothermic patients to stand, sit, or exert themselves makes them liable to post-rescue collapse. Excessive heating of the skin can cause re-warming collapse.
Survivors who are cold, shivering, but otherwise well and conscious can be re-warmed by immersing the torso and limbs in a bath at 38-40°C. Continuous supervision is mandatory. Water temperature must be measured using an accurate thermometer, and maintained carefully during re-warming. Once the deep body temperature is rising and has reached about 36.5°C, and before they start to feel hot or start to sweat, they should carefully get out of the bath. Care is needed as an erect posture may again cause circulatory collapse with syncope, due to peripheral vasodilation. Drinking of hot, sweet fluids may be helpful. Alcohol must be avoided.
Without any dedicated equipment for active re-warming, most hypothermic patients should be insulated and rewarmed slowly and passively in a warm, but not hot, room. Frequent monitoring of their vital signs is essential. Rapid evacuation to a specialist centre is critical. Full care, including life support and symptomatic management, should be continued until they can be carefully evacuated.
MICHAEL TIPTON
Immersion after abandoning ship is associated with many other hazards besides cold and drowning. Acute dangers to the individuals in the water include entanglement or traumatic contact with structures from the sinking ship, suction, inhalation and contamination with fuel oil, trauma from surfacing buoyant objects from the sinking ship and underwater explosions.
Protection from the hazards of the environment should have highest priority and, as survival is likely even after some days without water and some weeks without food, water supply should have a far higher priority than nutrition. In water temperatures below 15°C crew must abandon ship wearing cold water immersion suits in addition to modern inflatable lifejackets, even if they are kept initially safe in boats or life rafts. Every effort should be made to board the life raft dry if possible (1).
Avoid contact with surface fuel oil as far as possible. Direct contact is not inherently dangerous due to its negligible systemic toxicity. However, if swallowed it may cause vomiting, if inhaled it may produce pneumonia and if brought into the eyes it will produce conjunctivitis.
Burning oil at the sea’s surface is also a hazard. If a person has to jump from the ship into burning oil they may be able to avoid being burned if they remove their lifejacket and cumbersome clothing and jump feet first through the flames.
Long term survival in life rafts is a specific problem characterized primarily by a cold, wet environment or extreme heat and insufficient potable water and, to a lesser degree, food. Maintaining the discipline and morale of the survivors inside a life raft is of utmost importance.
Disturbances of fluid and energy balance are closely related. They may affect performance, health, discipline, morale and survival. Modern communications and location devices make it rather unlikely that survivors will spend the time needed to develop nutritional deficiencies in a life raft. Thus, supply and conservation of water is crucial (1).
Thermal insulation in a life raft is the highest priority. Free water inside a life raft reduces the insulation significantly and seafarers must take all measures, from the very beginning, to control any ingression of water. A common source of water is partially inflated buoyancy tubes that lead to waves breaking inboard at the open windward entrance.
Sitting positions on the life raft floor contribute to conductive heat transfer. Any free fluids sloshing around the floor will aggravate this, for example, leaking water, condensation, vomit, urine. Fluids will accumulate in the depressions of the inflated floor created by the sitting occupants. Additional blankets are beneficial. If the risk of capsize is small it is recommended that lifejackets are removed inside the life raft and used as insulating cushioned seats instead (1).
Occupants in wet clothing should remove the outer layers, squeeze them dry, and put them back on. The manoeuvre will cost little body heat and will not affect heat balance over the long period.
Heat given off by the occupants will warm up the environment within the life raft reasonably quickly if good sealing of the openings is maintained. Any dry clothing, preferably wind stoppers, capes and head coverings will reduce heat loss. This will lead to prolonged periods without shivering. During shivering, energy (food) demands and discomfort will increase significantly. Unfortunately, good sealing of the life raft is difficult to maintain over time (1).
Dehydration in excess of about 5% body weight may be associated with headache, irritability, and feelings of light-headedness. With losses of 10%, performance declines significantly. Further losses lead to hallucinations and delirium. Death usually occurs with acute losses of 15 to 20% of body weight. In a marine environment this occurs in 6 to 7 days (1).
For the average resting adult, recommended minimum daily requirement for fluid is 1 litre. In a survival situation this may be reduced to a daily in take of 150 to 450 mL of water for a limited 5-6 days period. Survival packs in life rafts contain a water supply of half a litre for a 5 day period per person. Water balance can be maintained best on a diet that is rich in fat and carbohydrate but low in protein (1).
Survivors can reduce water requirements by minimizing energy expenditure and water losses. Methods to achieve this include (1):
The life raft survivor should take anti-seasickness medication to reduce fluid loss by vomiting. This should commence as soon as possible, either before or immediately on entering the life raft.
Alternative safe means of acquiring water should be considered early and include the collection of rain or condensation water. Rain is often the only source of water replenishment available to the survivor at sea. It is a safe source but the initial wetting must not be collected as it will contain salt crystals from the collecting awning or canopy. Other safe alternatives are reverse-osmosis pumps and solar stills, if available, squeezed extracellular fish fluid (lymph) and spinal fluid or turtle blood.
Seawater is never a safe alternative. Deaths in life rafts following the drinking of seawater seem to be the result of rapid onset of respiratory failure, mostly preceded by mental derangement. Delirium leads to apparent insanity, aggressiveness, risk of suicidal actions and death. Usually there are no typical signs of dehydration. There is no beneficial effect in mixing fresh water with seawater. On the contrary, it will lead to the same catastrophic events (1).
Death from starvation takes 40 to 60 days and a lack of food is usually not the main problem in survival at sea. If sufficiently hydrated, physical and mental capabilities will be stable until more than 10% of bodyweight is lost. Furthermore, the absence of vitamins, minerals, or trace elements is unlikely to pose a problem to life raft survivors at sea for less than two months.
For the average resting adult, daily energy expenditure and therefore energy requirement is 1400 kilocalories. In a survival situation this daily requirement may be reduced to an intake of 600 kilocalories for a limited period. For the prevention of catabolism and dehydration, the food taken should be in the form of carbohydrate. This means avoiding eating protein unless fresh water is freely available. Fat reserves are plentiful, but glucose is required to enable the metabolism of fat. Protein reserves are also reasonably plentiful and can be used to provide the glucose to enable fat metabolism, but muscle wasting and protein deficiency disorders will quickly follow. A minimal daily intake of carbohydrate will help offset this. Food packs in life rafts are assembled accordingly (1).
The prospects of survival in this sort of incident increase significantly if survivors manage to react calmly, appropriately and effectively. An assortment of physical and psychological ailments in combination with other stressors can erode morale and decrease survival at sea (1).
A leading person who is acting as the senior survivor in the life raft should set a good example, guide others, and contribute to a positive mental attitude until final rescue. A Ship’s doctor is one of the trusted persons to do this job. Important rules for raising morale and discipline are:
References
RICARDO RODRIGUES MARTOS
In the last decades, the abandonment of seafarers has become a serious problem that affects many and shows the lack of protection seafarers have.
This problem can be considered an attack against human dignity and especially affects seafarers from Third World countries. It leaves entire crews and their families mired in despair and anguish.
A ship is detained in a port, either because it has been seized by a creditor, or because the Harbour Master's Office, or equivalent authority, orders its retention, considering that the ship does not comply with the established minimums in terms of navigability conditions, safety, hygiene, etc., or maybe because the ship has been involved in some illegal activity. In addition, since 2013, when the Maritime Labour Convention (MLC) 2006 (1) entered into force, a ratifying country can retain a ship in a port of if the crew has not been paid.
In order to release the ship and be able to go out to sea, the ship owner must settle his debts, pay the imposed fine or make the necessary repairs, depending on the reason for the detention. In many cases, this occurs smoothly and the ship sails as soon as possible. However, unfortunately this is not always the case. The necessary funds to carry out required repairs, an imposed fine or a failed business, can make the ship no longer profitable and even mean that it’s value will be lower than the debts incurred or the necessary investments to make the ship seaworthy again.
When the ship owner lacks money to resolve the situation, the ship can be arrested and a process begins that, at great economic and human cost, usually results in the sale of the ship at auction.
The type of ship we usually find in these circumstances often sails under a flag of convenience and has many years of service. As for the ship owner, he often limits the capital investment in the ship and pays the operating expenses with the money earnt from each voyage. When, for any reason, a voyage does not produce the expected benefit or an unexpected expense occurs, this ship owner may lack the resources to remedy the situation. In these circumstances, it is not uncommon that, before being detained, seafarers on board were already owed one or more months of salary.
Once a ship is detained for one of the reasons given, the ship owner has two options - to pay the necessary money to release the ship or to abandon it. It is possible that the owner tries to resolve the situation and that at the start, the crew continue to receive funds for provisions and fuel, and even some of their salaries, through the ship’s agent.. As the weeks go by, the owner may repatriate a part of the crew.
Then, in most cases, there comes a time when the ship owner stops sending money and the ship’s agent stops providing necessary items to the ship. The agent has probably advanced funds on behalf of the owner and now ceases to represent the ship owner. From this moment on, seafarers on board will receive no more money and will enter into a real situation of abandonment.
Of course, the owner's attitude is not always the same. In some cases, such as the one mentioned above, the ship owner shows an intention to solve the problem, but then stops in their efforts. In other cases, the ship owner disappears shortly after the ship is detained. However, the final outcome is the same. The crew is abandoned.
For a seafarer there is only one aim - to collect the money owed to them and return home. However, as the days go by, they realize that things are not so simple, that their situation is going to last for a while, and that they need to survive.
Seafarers are far from home, in a strange country, where they do not know anybody, full of uncertainty, worried about their families and eager to find a quick solution. When they find someone who wants to help them, they will place all of their hopes on this person or organization.
When people go on board, they are greeted with great expectation, the seafarers keen to receive good news. However, at the same time the seafarers will have a list of their needs already prepared and they will also hope that the visitor can offer assistance in communication with their families.
During the long period of time it may take to resolve the situation, life on board is hard. Seafarers must live in a deteriorating ship, performing minimal maintenance work, as they do not have the necessary means and facing potential conflict with other seafarers as they coexist in a confined environment with increasing stress.
It is important that seafarers are granted shore leave and have the opportunity to leave the ship for periods of time. Equally, they should have someone to trust and to whom they can explain their concerns. The crew will also appreciate the presence of the media, believing that more publicity will help in resolving their situation.
According to the International Labour Organization (ILO) Convention C166 - Repatriation of Seafarers Convention (Revised), 1987 (2), the first person responsible for the repatriation of the seafarer is the ship owner. This convention was repealed upon the entry into force of the MLC 2006, but its content remains valid because it was incorporated into this new convention. If the owner is insolvent or evades its obligation, the flag state should assume the repatriation, something hardly ever happens, especially considering that these ships often sail under a flag of convenience. Subsequently, the country of nationality of the seafarers should repatriate them, but again, this is often also difficult.
In practice over the years, in most cases none of these parties have assumed responsibility and the International Transport Federation (ITF)[1] (3) has usually been the one to guarantee funds to pay for the repatriation of the crew.
In regards to the collection of wages earned by the crew, when the ship owner disappears or declares himself insolvent, the ship remains as the only guarantee to recover the owed amounts. The most common way to make this guarantee effective is through the arrest of the vessel and its subsequent sale in public auction.
However, this system has its drawbacks:
Because of all the above, the crew's prospects are the collection of an uncertain and long deferred amount. Faced with this situation, seafarers are often asked to sign a power of attorney and agree to be repatriated, in the confidence that, once the ship is sold in auction, the recovered part of their salaries will be transferred to them. Some seafarers accept this solution, but others will not for the following reasons;
It is a complicated situation, both from the legal, economic and human perspective. No two cases are the same and each may be resolved in a different way. Many organisations have a role in managing the situation, legally and financially but particularly in supporting the seafarer.
It is very important that someone in a port takes responsibility for coordinating the situation and ensuring assistance is provided to the crew. Welfare organizations, like Stella Maris (4), or other International Christian Maritime Association (ICMA) (5) centres use to assume that role. A Port Welfare Committee often assists them, where available. According to MLC 2006, Guideline B.4.3.3, it is recommended that ports establish committees responsible for welfare services for seafarers. These committees should include the most relevant maritime entities, including unions and welfare organizations. A key part of this role is to ensure a supply of food, either directly, or with the help of other entities such as Caritas, the Red Cross, etc.
The ITF may also play a very important role through their inspectors. It is usually this organisation that assists in making a lawyer available to the crew and guarantees the money for their repatriation.
The Port Authority should ensure the ship berths in an appropriate dock and that there is a guaranteed supply of water and fuel (or shore power) to the ship.
The Harbour Master Office will ensure that the ship remains in port and that it does not pose any obstacle or danger for the maritime traffic of the port.
As described, the outcome of many cases of an abandoned ship is the arrest of the vessel and its subsequent sale at public auction. Unfortunately this is often a prolonged process, with little guarantee of the seafarer receiving all of the money owed to them. A good predisposition of the Port Authority, which in this case represents the rights of the Port State and of other potential creditors, will occasionally help to find a positive resolution, favorable to the interests of the crew.
In order to avoid situations such as those described here, in 2001, a joint working group of the International Maritime Organisation and the International Labour Organisation adopted the Resolution A.930(22) (6). This establishes the requirement to ensure the provision of an expeditious and effective financial security system
In 2014 this resolution was included as an amendment to the Maritime Labour Convention (MLC), 2006, and entered into force in 2017 (7).
This very important achievement guarantees that in the case of an abandoned ship, the insurance would cover salaries accrued and not paid (for a period of at least two months) as well as repatriation expenses. Each ship has to be in possession of a Maritime Labour Certificate and the Maritime Labour Declaration, in which it should clearly state that the owner has this insurance. However, a problem can still exist if the ship owner has previously stopped paying the insurance premium when the ship arrives at port or if the vessel is abandoned in a port of a country that hasn’t ratified the MLC 2006.
It is still too early to evaluate the results of this amendment to the MLC 2006, but for now it seems that the number of ships abandoned in ports of the European Union has decreased. However, the abandonment of ships and consequently of crews worldwide, continues to be a threatening shadow and continuing work is needed to eradicate it.
References:
https://www.ilo.org/dyn/normlex/en/f?p=NORMLEXPUB:12100:0::NO::P12100_ILO_CODE:C166
and https://www.stellamarisbarcelona.org
[1] The International Transport Federation is a global union federation of transport workers' trade unions
ALAN LOYND
Maritime safety has improved in recent years, driven by continually evolving regulation and the development of a safety culture within the industry [1]. But accidents still occur.
When accidents happen at sea there is no guarantee that emergency responders will arrive promptly. Depending on the location of the incident and the weather prevailing at the time, it may be a matter of days before help can arrive. It is quite possible that the ship’s crew will have to manage an incident without support for a period of time, so training and a robust safety culture are vital.
Many factors have been identified as contributing to the occurrence and/or severity of different shipboard incidents. These include [2][3]:
The likelihood of and the impact of a ship incident can be reduced by such measures as:
Much of this is beyond the scope of this textbook, but the best way to manage these risks is by having a mature safety culture throughout the company, and establishing a system where juniors are not afraid to question their seniors and where there is open dialogue between vessels and management.
The International Regulations for Preventing Collisions at Sea, 1972 (Colregs) [6] describe the safe interaction between vessels at sea. All navigating officers are required to have an in-depth knowledge of Colregs, yet collisions still happen.
A serious collision can lead to cargo damage and death or injury to passengers and crew. Ingress of water can lead to a loss of stability, so the effects should be calculated. If this cannot be done on board then assistance should be sought from the vessel’s managers. Such incidents are particularly traumatic for the officers involved, since they know they will be subject to intense scrutiny and may lose their jobs if they are found to have been at fault. The trauma will be even greater if there have been fatalities, and this can lead to psychological problems that many shipping companies are not equipped to recognise or deal with. Further information in this area is available in Ch. 5.2 and from organisations such as Recall Recover Limited [7]
Groundings can be either hard or soft. In a soft grounding, the vessel touches the bottom on a sandy seabed or the muddy bank of a river and there is little damage. In such cases, it is likely the vessel can be refloated on the next high tide, or after removing some of the cargo, and the medical implications are unlikely to be serious.
Hard groundings tend to involve rocky coastlines or coral reefs, where the vessel can experience severe damage and breaches of the hull. Vessels that break down near a ‘lee shore’ may be pushed onto the rocks by wind and waves, and the same may happen when a ship at anchor starts to drag in bad weather In rough seas a vessel can pound up and down until the damage is so severe that it may capsize or sink. Grounding in environmentally sensitive areas such as coral reefs can lead to massive claims against the ship and her owners and crew.
Hard groundings can lead to injuries from falling objects or equipment breaking loose, but the greatest danger comes when the hull is breached and the vessel is likely to capsize or sink. Once again, it is vital to assess the damaged stability condition (for which management assistance may be required).
A ship may sink or capsize for a number of reasons, including stress of weather, hull damage or cargo liquefaction. Cargo liquefaction occurs when the water content of a bulk cargo is too high, which allows the cargo to shift to one side and cause a dangerous angle of list to develop. Simple tests can be conducted at the loading port, but an experienced surveyor should be employed to monitor the loading and test the cargo. If the moisture content is too high then the cargo should be rejected. DNV/GL [8] and a number of other authorities have published useful guidelines. If time permits, the crew should don survival suits and attempt to get away in survival craft, but there is a danger that these events may happen suddenly, in which case there is a risk of seafarers finding themselves in the water. This may expose them to the risk of hypothermia or drowning.
Shipboard fires can break out at any time and can have many different causes. The most common causes are [9]:
A fire is likely to lead to a number of mishaps and injuries, from collisions as the seafarers rush to fight the fire to slips, trips and falls. There may be injuries from falling cargo and of course severe burns or cases of smoke inhalation. In very serious fires, seafarers may be forced to abandon the vessel before they have time to dress properly or launch the survival craft, which can lead to cases of hypothermia or drowning. If too much water is used to fight a fire and it cannot be pumped out, there is a danger of loss of stability and subsequent capsize or sinking. Free surface effect can also reduce stability when water is allowed to collect, particularly in large, unobstructed spaces.
If the collision causes hull damage and an ingress of seawater, there is a danger of certain cargoes reacting with the water to form compounds or gases that are toxic or explosive. With bulk cargoes the dangers are outlined in the International Maritime Dangerous Goods Code (IMDG Code)[10], but on container ships it is much more difficult because of the huge number of different cargoes carried. There is also a danger that the contents of containers were wrongly stated to avoid extra freight charges or the requirements imposed on dangerous cargoes. Medical responders should be alert for signs of exposure to gas, poison or corrosive liquids. Cargo may also move and cause injuries or a loss of stability.
If hull damage occurs in areas where seafarers are living or working, then serious injuries can result. Typical injuries include crush injuries, broken bones and lacerations that may be beyond the abilities of the surviving seafarers to deal with.
High-speed passenger craft are particularly vulnerable if they are involved in a collision. Normally these are lightweight vessels constructed from aluminium, which tends to split on impact and send very sharp metal edges into the passenger compartment. Very serious wounds and even the amputation of limbs may result. The sudden reduction of speed also causes injuries, particularly if passengers are not wearing their seat belts. Passengers’ legs are often forced under the seat in front, which can cause severe leg injuries. Head injuries are also common.
The crew, and passengers if on board, may be forced to abandon ship and attempt to reach the shore, which can lead to injuries, particularly crush injuries, when attempting to launch lifeboats. In some instances, there may not be time to ensure seafarers and passengers wear appropriate clothing, for example, immersion suits, or to launch lifeboats or life rafts. Immersion in the water can lead to hypothermia, while attempts to clamber ashore can lead to lacerations and near drowning. Seafarers who find themselves in a lifeboat or raft or ashore in an inhospitable landscape may also face problems such as dehydration if they are not rescued immediately. Further information can be found in Ch 9.10.
References
[1] Safety and Shipping Review 2017. Allianz Global Corporate and Speciality. www.agcs.allianz.com
[2] Collisions at Sea – Unavoidable? Capt. R. Wohrn. Gard Insight No. 185 of 2007. www.gard.no
[3] Shipping Accidents, Damage Assessment and Accident Consequences. Styliadis T. and Koliousis I. University of Piraeus. www.onthemosway.com
[5] www.nautinst.org/resource-library/mars/mars-reports.html
[6] Convention on the International Regulations for Preventing Collisions at Sea, 1972. International Maritime Organisation. London. www.imo.org
[8] www.DNV_GL_Bulk_Cargo_Liquefaction.pdf
[9] Ship Fires – Where?How? Prevention! Mullen Dr. E. Burgoyne and Partners. www.swedishclub.com
[10] International Maritime Dangerous Goods Code 2018, with Supplements and Amendments. International Maritime Organisation. London. www.imo.org