GovWire

Accident Investigation Report 9/2023

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 (PZ1001) 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.

Safety issues

• the fire-extinguishing aerosol was hazardous to health when inhaled in significant quantities and these hazards were not identified in the manufacturers 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

Statement from the Chief Inspector of Marine Accidents

Recommendations

The Maritime and Coastguard Agency has been recommended (2023/116) to take steps to improve fire-extinguishing system installation standards.

FirePro has been recommended (2023/117 and 2023/118) to undertake a specific risk assessment for the installation and operation of each of its fire-extinguishing systems; and, to review its safety-related documentation and incorporate all of the systems hazards, specifically carbon monoxide production.

Resurgams owner has been recommended (2023/119) to revise its safety management system to ensure that personnel safety measures are in place.

Related publications

A safety flyer to the fishing industry was produced with this report to provide five key safety lessons on working in enclosed spaces and the dangers of exposure to fixed firefighting system media.

MGN 659 (M+F) Entry into enclosed spaces.