A young ambitious officer with the world of command ahead of him but he forgot the golden rule: when you go into a trap, make sure you’ve got two pairs of eyes.

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Let’s talk about Kurt, not his real name but he was a real person. He was 27, German, and completed his maritime studies in 2002 with certificates of competency as second technical officer and navigational watch officer.

Kurt joined the containership CM London Express in 11th July 2003, four months before he died.

With only two months under his belt during training as assistant officer aboard CM London Express and two deployments, each of around four months, with his company, Hapag-Lloyd, he had much to prove. He’d had problems with older officers who didn’t give him the respect he felt he deserved during his previous deployments but was happy enough on London Express to ask for his contract to be extended.

He was ambitious, a stickler for safety when it involved others, but he was also impatient and took short-cuts if it meant the job got done quicker.

At the time, Kurt was about to rotate off the ship and is training his replacement, a second engineer with 20 years sea experience who had joined the ship that month.

A few weeks earlier new Alpha Lubricators had been installed and Kurt is keeping an eye on them, inspecting them at each port of call. To do that he climbs into the Scavenge Air Receiver to carry out wipe tests on individual cylindres.

The scavenge air receiver feeds air to the engine’s individual cylindres for compression. It’s a tube 16.6 metres long and 1.68 metres wide with access hatches at both ends. The hatches open inwards so that when the engine is running the pressure against them helps make a good seal against a ring on the inside of the access opening.

Kurt hasn’t been able to carry out the examination when CM London Express arrives at Savannah because immediate maintenance work is needed on the main engines.

Exactly what happened over the next 24 hours will probably never be known for sure. Crew accounts differ in critical details. Eye witnesses are the least reliable source of information. They can be coloured by honest mistakes, the fear of being found responsible for a man’s death, denial to oneself of that responsibility, even more so when coloured by fears of being innocently tried for murder in a foreign country.

Let’s go back to 24th October 2003. The CM London Express is in Savannah, Georgia, where she arrived the previous morning and is scheduled to depart at 2100. Before then the main engine’s No. 6 piston has to be replaced.

Work begins at 0530. Under Kurt’s supervision is the second engineer, third engineer, the Ship Operations Foreman, two oilers a fitter and a wiper. The Chief Engineer is elsewhere concentrating on bunkering and other preparations for departure.

The men disassemble the cylindre head cover, loosen the screws on the piston rod seal and the nuts on the piston cross head pins, pull out the piston with the engine room gantry crane, and insert its replacement.

It’s hard, exhausting physical work and the engine room is hot.

There are arguments between Kurt and the Second Engineer about who should do what but the job gets done.

After a coffee break in the afternoon, tools are put away and inventoried, used rags are disposed of and workstations tidied. Just after 17.00 the second officer leaves the engine room.

At 17.13, cooling water supply is restored to cylindre 6 and at 17.30 the crew is released from duty. Only Kurt and the Ship Operations Foreman, SOF, remain.

Kurt asks the SOF to help him with a cylindre check. Kurt climbs into the scavenge air receiver through the forward hatch with a torch. The SOF opens the aft hatch and, using a remote controlled electric motor, turns the engine to bring the pistons into position.

Kurt entered the scavenge air receiver through the forward hatch

It’s a process that normally takes an hour but Kurt cuts it short to about 30 minutes. It’s been a long day, prehaps he’s tired and hungry and its time for dinner.

With the scavenge air receiver hatches dogged shut, Kurt gives an indication with his eyes that the SOF takes to mean he can go to dinner. It is the last time Kurt is seen alive.

In the officer’s mess the steward is keen to finish feeding the officers so he can go off duty. He asks the chief engineer where Kurt is, the chief engineer says he doesn’t know. The second officer says nothing.

By 1900 the chief mate is at the bridge management centre. The second engineer is also there handling technical documentation. Kurt should be there but the second officer doesn’t comment on it.

Kurt isn’t in his expected position so at 19.45 the chief engineer telephones the ship operations foreman in his room. He gets a negative response on Kurt’s whereabouts.

At 20.00 the oiler on watch prepares to start the main engines. A half hour later the deck crew go to their departure stations. Ten minutes after that the river pilot comes on board to guide the ship down the Savannah river to the sea.

It’s a time when just about everybody is busy with something to do.

As departure time approaches The Chief engineer is surprised that Kurt isn’t at his post in the bridge management centre. He telephones the engine room and asks the oiler on watch about Kurt but he doesn’t know where he is.

The chief engineer telephones the bridge at 20.40 to report Kurt missing and asks the chief mate to check his cabin.

Kurt isn’t in his cabin. His cellphone lays on a table charging, critical documents remain in place.

The chief engineer checks the engineroom, supposedly opens the aft access door of the scavenge air receiver but there’s no sign of Kurt.

Meanwhile, on the bridge, the Master alerts the port authorities that a man is missing and a search began ashore. Adding to the pressure is that CM London Express must clear the berth by 21.30 to make way for an incoming containership.

The chief mate scans the dock with binoculars but can see nothing of Kurt. He sounds the ship’s horn. Still no sign of Kurt. He talks to the crew at the manouvering stations but can’t get a firm response as to whether or not they’ve seen Kurt.

At 2100 the general alarm sounds to call the crew to organise a ship-wide search.

The main engine alarm monitoring system is switched to the bridge at 21.03.

With the crew assembled the chief engineer says he has checked the engine room and the scavenge air receiver. The chief mate asks if anyone has seen Kurt. One of the Filipino crew thinks he saw him in the changing room changing his shoes.

With the crew tasked to search their individual areas of responsibility the chief engineer and the engine room crew searched the engine room.

One seafarer notices an oily rag jammed in the forward access hatch of the scavenge air receiver and feels air flowing from the imperfectly closed door. The three locking bolts are not fully secured in their groove in the edge of the hatchway. He thinks the cloth might be to complete the seal but, still, has a gut feeling that Kurt might be inside.

Note rag in dotted circle

He was required, however, to follow the strict command hierarchy on the ship. He needed permission to open the hatch from his immediate superior, the third engineer, who needed to get authorisation from the chief engineer. He moves on to join the search in the bilge.

Most of the search concentrates on the bilges, where it is thought Kurt could have fallen.

Sometime later, according to the seafarer, he tells the third engineer about the rag. The third engineer tells him that preparations are already complete to get the ship underway.

Later, the Chief Engineer takes a look at the rag, believes it a minor issue that can be fixed next day and the main search continues elsewhere.

As some stage during the search the Ship Operations Foreman opens the aft end of the scavenge air unit and looks inside and calls. Seeing and hearing nothing, he closes that hatch and heads towards the forward end.

View from aft hatch

One the way he meets the chief engineer and the conversation leads him to believe that the forward access hatch has been opened and checked. It hasn’t.

Meanwhile, the minutes are ticking away towards departure.

At 21.10, with the search still continuing, the harbour pilot boards as tugs tie up forward and aft.

Reports go to the master that the engine room, including the scavenge air receiver have been searched. The available crew are told to keep looking.

The incoming ship is already in sight and asking for the tugs to help manouevre, the same tugs now attached to the CM London. The pressure to move grows.

By 21.48 all lines are off and the engine makes its first movement.

The second engineer now takes over Kurt’s duties. He notices a loud hissing noise from the forward access hatch of the scavenge air receiver. He attempts to close it using a pipe extension but it continues to leak air. To fix it properly, the main engine would have to be stopped. Nobody suggests it.

On 26 October, London Express arrives on schedule at Norfolk, Virginia. At 11.30 berthing operations are completed. The master tells the engine room he’s finished with engines prepares to leave the bridge. The chief mate switches off the unneeded instruments, put others into habour mode.

The scavenge air receiver has to be opened to air it. The ship operations foreman goes to the forward access hatch and is dismayed that the toggle nuts on the bolting mechanism can be opened easily. He rants loudly about someone else’s careless work and opens the hatch.

Inside is Kurt, a broken torch beside him. He’s dead. The cause of death, the COD, is hyperthermia, excessive heat. To put it brutally, he’s been cooked to death.

Only one thing is certain, he died at human hands. The question is, were they his own or someone else’s?

American investigators initially suspected murder. Later they accepted that it was an accident and destroyed the records of their investigations such as witness statements and photographs that might have told us much about Kurt’s last moments. Later statements made to German maritime investigators were confused and contradictory but enough remains for us to get a reasonable answer to two questions: How did Kurt get trapped in the scavenge air receiver and why didn’t anyone find him even though they searched?

It might have gone something like this:

Kurt finishes with the ship operation foreman who goes to dinner but Kurt isn’t happy. Because time is pressing, it’s close to departure time, he’s cut the cylindre check and it goes against the grain. He’s a precise man, things should be done right. And there’s his replacement, the second engineer he’s had arguments with during the day. Perhaps he fears that if there’s anything amiss the second engineer will make sure he gets the blame because of his inexperience.

The worries gnaw at him as he goes to the change room, removes his dirty overalls and dones a clean set of khaki coveralls, removes the boots he wore in the engine room and buckles on a pair of work shoes.

He decides toi make one last check, just to be sure and doesn’t want anyone else to know he’s uncertain. Besides, the crew have been working hard and they’re exhausted

Both he and the chief engineer have been in the scavenge air receiver before without anyone standing by and once more wouldn’t make a lot of difference.

He gets into the 16 metres, long dark tube with a torch and a piece of rag and starts his checks. Exactly what happened next only he knew. Perhaps he slipped, or tripped or otherwise fell against the hatch.

Inside the scavenge air receiver with hatch closed

The hatch closes with enough force to shake one of the dogs outside the hatch and it swivels under gravity. It only just engages in the circular groove around the hatchway, but that’s enough.

A dog part-closed under of gravity

He tugs at the edges of the hatch it won’t open inwards.

He knows he’ll be missed, and there’ll soon be crewmen in the engine room so he’s disturbed but not especially scared. He shouts, but there’s no response. Someone’s sure to find him.

A long time later, he’s almost hoarse. He hears noises, someone’s coming. He bangs on the side of the unit with his hands, then with the torch, so hard the torch shatters. But no-one comes.

Then there’s light from the other end of the unit, someone’s opened the aft hatch. He calls out, there’s the light of a torch. He thinks he’s been found. Then the torch goes out and the aft hatch closes, leaving him in almost darkness.

He sits down. A long while later the after hatch opens again, again there’s a torch. He calls out and begins to stand up but the hatch closes again.

He must have wondered why nobody was opening the forward hatch, they were obviously looking for him.

Around the edge of the forward hatch there’s just a millimetre or so of light – it isn’t fully closed. He needs something to alert those outside of where he is. He takes the piece of rag and eases it through the gap. It might alert someone outside and it’ll prevent the hatch closing fully, so someone’s bound to investigate.

They don’t.

No-one thought the rag was important

Then there’s the ominuous sound of the main auxiliary fans starting. He can feel the build up of pressure on his ears. He tugs again at the forward hatch but, with the added air pressure, they’re even more tight shut.

Then there’s the sound of someone tightening the wingnuts to dog the hatch tight.

Then the engines start and there’s pressure and heat.

Those last moments must have been dreadful.

Searchers went into the engineroom why couldn’t they hear him? Engine rooms are noisy places. For their own safety they wore ear protectors. Plus, sound didn’t travel very far outside the scavenge air receiver.

Yet, if testimony is to be believed, both the Chief Engineer and the ship operations foreman opened the aft hatch. Why didn’t they see him and hear him. The length and construction of the scavenge air receiver meant that even with a torch it would have been difficult to see Kurt in the darkness.

Someone in dark clothes between the throttles, inside dotted circle

As for hearing him, the scavenge air receiver shares some characteristics with what’s popularly called a gun silencer and more properly a suppressor. The choke would have acted as a baffle, reducing the sound significantly to a level where the ship operations foreman, with his ear protectors, would not have heard it, and the choke would have made Kurt difficult to see.

It’s difficult even to see someone in light clothes in this photograph

Still, why wasn’t he found? Why didn’t anyone look into the scavenge air receiver? Because the search wasn’t well organised or co-ordinated in the first place. It might have caught a stowaway but it wasn’t appropriate for looking for a missing seafarer on the ship. There was confusion about whether someone had looked into the forward hatch of scavenge air receiver.

Yet someone saw the piece of rag that Kurt poked through the narrow gap. By then the auxiliary fans had been started. Why didn’t he say anything at the time?

We’ve seen the effects of cultural separation between officers and crew before, in the Case of the Unfamiliar Mariner. There was strict hierarchy on the CM London Express, crew were reluctant to approach or question those in authority or, probably, to take the initiative.

What if the the fans had been stopped, the preparations for departure halted, causing more delay and the seafarer was wrong? He’d be in trouble. So there was a reluctance for the seafarer to express his concerns that Kurt was trapped in the scavenge air receiver.

Cultural factors may have prevented a seafarer from discovering Kurt inside

And, of course, it was supposed to have already been searched, increasing his reluctance to speak up. Fear of being called stupid in front of your workmates can be a powerful deterrent to speaking up.

So, back to Kurt. If he’d had someone on safety watch he’d be alive and, probably, his career would be flourishing. He was a good officer but, as we’ve said before, shortcuts too often lead to dead ends.

So, always, always, always have someone one safety watch if you’re going into an enclosed space. The scavenge air receiver had no way out for someone trapped inside. When going into a confined or enclosed space it’s worthwhile taking a moment to think about how you’re going to get out of it.

It may also be, with a slightly different scenario, that Kurt believed that the Ship operations foreman was still outside the scavenge air receiver. The SOF believed that Kurt had dismissed him with an eye movement, but eye movements can mean different things to different people, from, you can go now, to stay here, to I’m too embarrassed to tell you’re talking crap. It’s better to give instructions in a way in which they can’t be misinterpreted and have that someone repeat the instructions back to you.

If you’re an officer on a multinationality ship think about whether the ship’s culture encourages people to speak up when they should, without fearing punishment if they’re wrong, especially in front of their shipmates. In western cultures a harsh word of criticism might be irksome but quickly forgotten. In cultures in which face is important it can create shyness about speaking up or giving an opinion or suggestion. It’s not a good idea. Remember, The life they save might be your’s.

And, as a seafarer, think about this. Many members of the crew aboard the CM London Express thought that Kurt was trapped in the scavenge air receiver but didn’t speak up, possibly because they feared embarrassment if they were wrong. Had they spoken up, they’d have saved a man’s life. That’s a burden they’ll have to carry. Embarrassment in front your shipmates can be hurtful, but the risk is probably worth a life.

This is Bob Couttie wishing you safe sailing.

German Federal Bureau of Maritime Casualty Investigation Report