On the morning of 23 February 2024, the chief engineer on the Isle of Man registered motor yacht Baton Rouge was electrocuted while working on the engine room ventilation system. The chief engineer was replacing a damper actuator, which was situated in a ventilation overpressure duct compartment. The chief engineer’s heart could not be restarted, and he was pronounced dead later that morning.
The investigation found that the chief engineer commenced the actuator replacement without isolating the electric supply and without a permit to work for electrical maintenance in place. This was likely because he had rationalised the risk and wanted to avoid the limitations of restricting the vessel to emergency power.
It was also found that the location of the overpressure duct compartment and the means of access to it met the definition of an enclosed space in industry guidance. However, the definition in the onboard safety management system was not aligned to this and instead focused on toxic atmospheres. As a result, the crew did not consider the overpressure duct compartment to be an enclosed space and did not follow enclosed space working and entry procedures.
Since the accident the yacht’s manager, Nigel Burgess Limited, has updated its permit to work guidance for electrical systems; revised the enclosed space definition in the safety management systems of vessels under its management; and promulgated fleet guidance on the changes to the enclosed space definition, permits to work and the need for on board risk controls, training and drills.
Safety issues
• the chief engineer was working on live equipment without suitable arrangements in place to guard against electrical shock
• the chief engineer was working in an enclosed space without enclosed space working procedures being in place
• a permit to work was not issued for the task and the associated hazards were not identified
• the yacht’s safety management system definition of an enclosed space was incorrect and focused solely on toxic atmospheres
• there was a mismatch in the definitions of an enclosed space in the Code of Safe Working Practices for Merchant Seafarers
Recommendations
In view of the actions taken by the yacht’s operating company no recommendations have been made.
Download the PDF: MAIB accident report 1-2025 Baton Rouge
