FATALITY ON BOARD RESURGAM, NEWLYN HARBOUR

Summary:

On 15 November 2019, an apprentice engineer died when a FirePro condensed aerosol fire-extinguishing system was inadvertently activated in the engine room of the fishing vessel Resurgam as it was being installed. The apprentice engineer together with a shore engineer and two installation technicians were working in the engine room when the system activated, filling the engine room with the fire-extinguishing aerosol.

The key safety issues identified were:

• The fire extinguishing aerosol was hazardous to health when inhaled in significant quantities and these hazards were not identified in the manufacturer’s safety related information.
• The installation of the fire extinguishing system had not been properly planned or risk mitigation measures put in place to protect people working in the space.
• There was ineffective oversight at both the system design and installation stages and no standards for marine installers. This contrasted with the framework for land-based installations of the same product.

Safety recommendations:

FirePro is recommended to:

• Undertake a specific risk assessment for the installation and operation of each of its fire-extinguishing systems to identify and mitigate all of the associated hazards, including those identified as part of this investigation, to a level that is considered as low as reasonably practicable.
• Review its safety-related documentation for its fire-extinguishing systems (including, but not limited to, the installation and operational guidance and material safety data sheet) to: incorporate the hazards identified as part of this investigation, specifically those associated with carbon monoxide generation and risk of inhalation injury, and the required control measures.

The Maritime and Coastguard Agency is recommended to:

Take steps to improve the standard of installation of safety critical fire-extinguishing systems in vessels operating under codes of practice (i.e. non-SOLAS vessels) to ensure that, specifically:

• Vessel owners are aware of the obligation to notify the Maritime and Coastguard Agency in advance of the installation, in order to obtain pre-installation approval.
• Equipment installation is undertaken in accordance with manufacturers’ instructions and the relevant statutory requirements.
• In collaboration with industry stakeholders, a competency standard is considered, agreed and prepared for the installers of systems on vessels.
• The information provided in the Marine Survey Instructions for the Guidance of Surveyors for Fire Protection Arrangements (MSIS 12) and the Certificate of Inspections and Tests is consistent.

W. Stevenson & Sons Limited is recommended to:

• Update its safety management system for vessels alongside, specifically to include the control and safe management of contractors, including the provision of rescue plans for people working on board.

Captain Andrew Moll OBE, Chief Inspector of Marine Accidents, said:

“The investigation into this deeply tragic accident in which a young apprentice lost his life has involved a considerable amount of in depth investigation work including the extensive research and testing of the FirePro system at HSE’s Science and Research Centre, Buxton. The investigation report builds on the earlier MAIB safety bulletin issued shortly after the accident which highlighted the danger to human health of inhaling the condensed aerosol produced by the FirePro system.

“As well as the additional safety recommendations made today, it is worth reinforcing the safety lessons from that bulletin and reminding vessel operators, owners and those working with condensed aerosol fire-extinguishing systems that safety measures must be put in place to ensure personnel are not exposed to this hazard. These measures can include alarms and checks prior to intentional activation and precautions during installation and maintenance.

“Our investigation also brought to the attention of the fishing industry the dangers of working in an enclosed space and, from 14 May 2023, the change in regulations to include fishing vessels.”

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