Immediate causes are the direct actions, conditions, or failures that led straight to an accident or incident.In our case, the immediate causes were:✔️Entry into an enclosed space without a permit✔️No atmospheric testing before entry✔️Inadequate ventilation of the tank✔️Lack of effective supervisionThe following factors were not immediate causes, but could be considered possible contributing factors:🟦Poor weather conditions🟦Slippery deck surface🟦Defective ladder🟦PPE failureContributing factors are those that influenced the situation or increased the risk, but did not directly trigger the accident.What are the lessons learned?☑️ Enclosed spaces remain high-risk areas on board, even during routine inspections.☑️ Ventilation alone does not make a space safe. Gas testing must always be carried out and confirmed before entry.☑️ Any symptoms such as dizziness or weakness are warning signs and require immediate evacuation from the space.☑️ Failure to follow enclosed space entry procedures can lead to serious injury within seconds.#casestudy