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 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
Chief Inspector of Marine Accidents, Andrew Moll OBE, 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, 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 before intentional activation and taking 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.”
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 system’s hazards, specifically carbon monoxide production.
– The owner of Resurgam has been recommended (2023/119) to revise its safety management system to ensure that personnel safety measures are in place.
Download the MAIB pdf report: MAIB Resurgam Report
Download the pdf report annexes: MAIB Resurgam Annexes