Gemilerde Atmosferik Tehlikeli Kapalı Alan Kazaları: Kaza Soruşturma Raporlarının Bariyer-Temelli Analizi

Abstract

Düzenleyici alandaki art arda reformlara karşın, kapalı alanlara giriş gemi işletmeciliğinin en ölümcül operasyonlarından biri olmayı sürdürmektedir. IMO GISIS veri tabanı taranmış; fiilî giriş, atmosferik etkilenme ve en az bir ölüm ya da yaralanma içeren her vaka çalışmaya dâhil edilmiş ve 2007–2025 döneminde 15 bayrak devleti otoritesince yayımlanmış 39 resmî kaza soruşturma raporuna ulaşılmıştır. Her vaka, IMO A.1050(27) ve ISGOTT esas alınarak tanımlanan yedi bariyer (B1–B7) üzerinden, Kjellén’in (2023) barrier index yaklaşımından uyarlanan üçlü ordinal ölçekle (yok/yetersiz/yeterli) kodlanmıştır; bariyer kavramı Hollnagel’e, bariyerlerin birlikte çöküşünün yorumu ise Reason’ın derinlemesine savunma modeline dayanmaktadır. Vakalarda 53 ölüm ve 33 yaralanma (86 mağdur) meydana gelmiş, bunların %64.1’i çoklu mağdurlu olmuştur. Oksijen azlığı vakaların %79.5’inde rol oynamış ve ölümlerin %83.0’üyle ilişkilendirilmiştir. Önleyici bariyerler sistematik biçimde zayıf bulunmuştur: izinli çalışma (B2) vakaların %89.7’sinde, solunum koruması (B5) %87.2’sinde hiç uygulanmamış; %30.8’inde önleyici bariyerlerin tamamı işlevsiz kalmış ve ortalama skor 14 üzerinden 3.00 olmuştur. Buna karşın acil müdahale (B7) hiçbir vakada bütünüyle çökmemiş ve önleme kalitesiyle ilişkisiz bulunmuş; önleyici bariyerler tutarlı bir ölçek oluşturmuştur (Cronbach α = 0.72). Kurtaran-mağdur paterni, belirlenebilen vakaların yarısında görülmüş ve çoklu ölümlerin başlıca tetikleyicisi olmuştur (U = 55.5; p < 0.001). Zaman içinde ne sonuç şiddeti ne de bariyer uygulaması iyileşmiştir. Revize tavsiyelerin kabulü gerekli ancak tek başına yeterli değildir; belirleyici olan, kuralların her bir girişe fiilen uygulanmasıdır.

Keywords

• Rescuer-victim
• Oxygen deficiency
• Permit-to-work
• Confined space
• Defence in depth
• Seafarer fatalities

Atmospheric-Hazard Enclosed-Space Accidents on Ships: A Barrier-Based Analysis of Accident Investigation Reports

Abstract

Despite successive regulatory reforms, entry into enclosed spaces remains one of the deadliest operations in ship management. The IMO GISIS database was screened, and every case involving actual entry, atmospheric exposure and a death or injury was retained, yielding 39 official reports published between 2007 and 2025 by the authorities of 15 flag states. Each case was coded on seven barriers (B1–B7) defined from IMO A.1050(27) and ISGOTT on a three-level ordinal scale (absent/inadequate/adequate) adapted from Kjellén’s (2023) barrier index; the barrier concept rests on Hollnagel, and the joint failure of the barriers is interpreted through Reason’s defences-in-depth model. The cases resulted in 53 deaths and 33 injuries (86 victims), of which 64.1% were multiple-victim events. Oxygen deficiency was present in 79.5% of cases and associated with 83.0% of deaths. The preventive barriers were systematically weak: permit-to-work (B2) was absent in 89.7% of cases and respiratory protection (B5) in 87.2%; all six failed in 30.8%, and the mean score was 3.00 out of 14. Emergency response (B7), by contrast, never collapsed entirely and was uncorrelated with prevention quality, whereas the preventive barriers formed a coherent scale (Cronbach α = 0.72). A rescuer-victim pattern was observed in half of the determinable cases and was the principal driver of multiple fatalities (U = 55.5; p < 0.001). Neither severity nor barrier performance improved over time. Adopting the revised recommendations is necessary but not sufficient; what is decisive is applying the rules to every entry.

Keywords

• Rescuer-victim
• Oxygen deficiency
• Permit-to-work
• Confined space
• Defence in depth
• Seafarer fatalities

References

1. Başkan, İ.B., Sana, F., Uğurlu, Ö. (2025). Navigational Safety in the Suez Canal: HFACS-PV Analysis of Human-Organizational Factors and Environmental Risks with Comparative Insights, Turkish Journal of Maritime and Marine Sciences, 11(3): 229-252. doi: 10.52998/trjmms.1741624.
2. DMAIB (2016). Proceduralizing marine safety – Procedures in accident causation, Danish Maritime Accident Investigation Board. Accessed Date: 12.06.2026, https://dmaib.com/media/8586/safety-report-proceduralizing-marine-safety-16-june-2016.pdf is retrieved.
3. Gard (2025). Enclosed spaces: When saving a life turns fatal, Gard Insights. Accessed Date: 12.06.2026, https://gard.no/en/insights/enclosed-spaces-when-saving-a-life-turns-fatal/ is retrieved.
4. Gonel, O., Cicek, İ. (2019). Maritime investigation reports involving man-over-board (MOB) casualties: A methodology for evaluation process. Turkish Journal of Maritime and Marine Sciences, 5(2): 141-170.
5. Gulen, M.F., Guedes Soares, C., Arslan, O. (2026). A comprehensive risk assessment of enclosed space operations on ships. Reliability Engineering & System Safety, 265: 111543. doi: 10.1016/j.ress.2025.111543.
6. Gürgen, S. (2025). Evaluation of Environmental, Economic and Safety Impacts of Main Engine Failures of Terminal Tugboats by Fuzzy AHP and Fuzzy TOPSIS Methods. Turkish Journal of Maritime and Marine Sciences, 11(3): 185-197. doi: 10.52998/trjmms.1681535.
7. Hollnagel, E. (2004). Barriers and accident prevention. Ashgate.
8. Hollnagel, E. (2008). Risk + barriers = safety? Safety Science, 46(2): 221-229. doi: 10.1016/j.ssci.2007.06.028.

9. ICS, OCIMF, IAPH (2006). International Safety Guide for Oil Tankers and Terminals (ISGOTT), Fifth Edition. International Chamber of Shipping, Oil Companies International Marine Forum, International Association of Ports and Harbors, London. ISBN 978-1-85609-291-3.
10. IMO (1997). Resolution A.864(20): Recommendations for entering enclosed spaces aboard ships, International Maritime Organization. Accessed Date: 12.06.2026, https://wwwcdn.imo.org/localresources/en/KnowledgeCentre/IndexofIMOResolutions/AssemblyDocuments/A.864(20).pdf is retrieved.
11. IMO (2011). Resolution A.1050(27): Revised recommendations for entering enclosed spaces aboard ships, International Maritime Organization. Accessed Date: 12.06.2026, https://wwwcdn.imo.org/localresources/en/KnowledgeCentre/IndexofIMOResolutions/AssemblyDocuments/A.1050(27).pdf is retrieved.
12. IMO (2014). Resolution MSC.380(94): Amendments to the International Convention for the Safety of Life at Sea (SOLAS), 1974, as amended, International Maritime Organization. Accessed Date: 12.06.2026, https://wwwcdn.imo.org/localresources/en/KnowledgeCentre/IndexofIMOResolutions/MSCResolutions/MSC.380(94).pdf is retrieved.
13. IMO (2015). SOLAS regulation III/19: Emergency training and drills – enclosed space entry and rescue drills, International Maritime Organization (adopted by Resolution MSC.350(92)). Accessed Date: 12.06.2026, https://wwwcdn.imo.org/localresources/en/KnowledgeCentre/IndexofIMOResolutions/MSCResolutions/MSC.350(92).pdf is retrieved.
14. IMO (2025a). Resolution MSC.581(110): Revised recommendations for entering enclosed spaces aboard ships, International Maritime Organization. Accessed Date: 12.06.2026, https://wwwcdn.imo.org/localresources/en/KnowledgeCentre/IndexofIMOResolutions/MSCResolutions/MSC.581(110).pdf is retrieved.
15. IMO (2025b). Global Integrated Shipping Information System (GISIS): Marine casualties and incidents module [Data set], International Maritime Organization. Accessed Date: 30.04.2025, https://gisis.imo.org/Public/MCIR/Search.aspx is retrieved.
16. International Group of P&I Clubs (2021). Enclosed space incidents: Safety animation and research into fatalities 2015-2020, ICHCA International. Accessed Date: 12.06.2026, https://ichca.com/enclosed-space-incidents is retrieved.
17. Karabacak, A., Köseoğlu, B. (2021). Analysis of Ship Accidents in Turkish Territories: A Data Mining Application, Turkish Journal of Maritime and Marine Sciences, 7(1): 54-74. doi: 10.52998/trjmms.789498.
18. Kjellén, U. (2023). Preventing fatal accidents in construction through the management of barriers. Heliyon, 9(11): e21715. doi: 10.1016/j.heliyon.2023.e21715.
19. Laitinen, H., Marjamäki, M., Päivärinta, K. (1999). The validity of the TR safety observation method on building construction. Accident Analysis & Prevention, 31(5): 463-472. doi: 10.1016/S0001-4575(98)00084-0.
20. Li, J., Yao, X., Xu, K. (2024). Human factors analysis of China's confined space accidents from 2013 to 2022: Ensuring the safe and sustainable development of enterprises. Sustainability, 16(23): 10183. doi: 10.3390/su162310183.
21. MCA (2017). Code of Safe Working Practices for Merchant Seafarers, 2015 Edition, Amendment 2 (December 2017), Maritime and Coastguard Agency, London: TSO.
22. Naghavi K. Z., Mortazavi, S.B., Asilian M.H., Hajizadeh, E. (2019). Exploring the contributory factors of confined space accidents using accident investigation reports and semistructured interviews. Safety and Health at Work, 10(3): 305-313. doi: 10.1016/j.shaw.2019.06.007.
23. R Core Team (2025). R: A language and environment for statistical computing (Version 4.5) [Computer software]. R packages retrieved from CRAN snapshot 2025-05-25. Accessed Date: 12.06.2026, https://cran.r-project.org is retrieved.
24. Reason, J. (1990). Human Error, Cambridge, Cambridge University Press.
25. Reason, J. (1997). Managing the risks of organizational accidents. Ashgate.
26. Revelle, W. (2025). psych: Procedures for Psychological, Psychometric, and Personality Research [R package]. Accessed Date: 12.06.2026, https://cran.r-project.org/package=psych is retrieved.
27. SAFETY4SEA (2025). Statistics show worrying trend of enclosed space related deaths. Accessed Date: 12.06.2026, https://safety4sea.com/statistics-show-worrying-trend-of-enclosed-space-related-deaths/ is retrieved.
28. Sakar, C., Buber, M., Koseoglu, B., Toz, A.C. (2022). Risk analysis for confined space accidents onboard ship using fuzzy bow-tie methodology. Ocean Engineering, 263: 112386. doi: 10.1016/j.oceaneng.2022.112386.
29. Seatrade Maritime (2024). Tackling the tragedy of enclosed space fatalities at sea. Accessed Date: 12.06.2026, https://www.seatrade-maritime.com/maritime-safety/tackling-the-tragedy-of-enclosed-space-fatalities-at-sea is retrieved.
30. Sharabidze, I., Kakhidze, A., Gegenava, A., Babilodze, J. (2026). Challenges in developing maritime safety training courses in Georgian MET centers. Turkish Journal of Maritime and Marine Sciences, 12(2): 190-202. doi: 10.52998/trjmms.1827865.
31. Soner, O. (2021). Application of fuzzy DEMATEL method for analysing of accidents in enclosed spaces onboard ships. Ocean Engineering, 220: 108507. doi: 10.1016/j.oceaneng.2020.108507.
32. Soner, O., Celik, M. (2021). A human reliability assessment through enclosed space entry operation onboard ships. Proceedings of the Institution of Mechanical Engineers, Part M: Journal of Engineering for the Maritime Environment, 235(2): 410-420. doi: 10.1177/1475090220979867.
33. The jamovi project (2025). jamovi (Version 2.7) [Computer software]. Accessed Date: 12.06.2026, https://www.jamovi.org is retrieved.
34. Töz, A.C., Büber, M., Köseoğlu, B., Şakar, C. (2022). Analysis of collision accidents in maritime transportation by FTA method, Turkish Journal of Maritime and Marine Sciences, 8(1): 15-30. doi: 10.52998/trjmms.971042.
35. Uğurlu, Ö., Yıldız, S., Loughney, S., Wang, J. (2018). Modified human factor analysis and classification system for passenger vessel accidents (HFACS-PV). Ocean Engineering, 161: 47-61. doi: 10.1016/j.oceaneng.2018.04.086.
36. Viran, A., Barlas, B. (2018). Gemilerde kapalı alanlarda yapılan çalışmalar ve iş kazalarının analizi. Gemi ve Deniz Teknolojisi, 214: 19-36.
37. Xia, J., Liu, Y., Zhao, D., Tian, Y., Li, J., Zhong, Y., Roy, N. (2021). Human factors analysis of China's confined space operation accidents from 2008 to 2018. Journal of Loss Prevention in the Process Industries, 71: 104480. doi: 10.1016/j.jlp.2021.104480.