UK Marine Investigation Branch (MAIB) has published an investigation report, of the accidental discharge of a FirePro condensed aerosol fire-extinguishing system during its installation on board the fishing vessel Resurgam (PZ1001) resulting in one fatality in Newlyn Harbour, Cornwall, England on 15 November 2019.
The incident
On 15 November 2019, a FirePro condensed aerosol fixed fire-extinguishing system, which was undergoing installation, inadvertently activated in the engine room of the UK registered fishing vessel Resurgam, in Newlyn, Cornwall, England. Four shore workers were in the space but only three managed to escape. One of the four, an apprentice engineer, collapsed at the bottom of the engine room access ladder. He was recovered onto the open deck about 20 minutes later by the emergency services but could not be resuscitated.
The postmortem report determined that he died from an inhalation injury and carbon monoxide poisoning. Although the investigation of the accident fell under the remit of the Health and Safety Executive, the MAIB also conducted an independent marine safety investigation to ensure the lessons from this accident were brought to the attention of the marine industry. Resurgam was undergoing maintenance and two Ocean Engineering (Fire) Limited technicians were on board installing the FirePro system. Also on board were a shore-based maintenance engineer and an apprentice engineer from W. Stevenson & Sons Limited, Resurgam’s owner and operator, who were repairing the main engine exhaust. In the final stages of the installation the aerosol generators were connected to a live electrical circuit, triggering the discharge process and rapidly filling the engine room with a dense cloud of fire-extinguishing aerosol particles.
Background
The UK registered fishing vessel Resurgam was berthed alongside in Newlyn harbour for maintenance work at the time of the accident. The work was being
carried out by shore workers and was not under the control of the fishing vessel’s skipper or its crew. The main work to be completed in the vessel’s engine room was a repair to the main engine exhaust and the installation of a FirePro condensed aerosol fixed fire-extinguishing system. Resurgam’s owners, W. Stevenson & Sons Limited (Stevenson) operated a fleet of fishing vessels and employed a team of shore-based mechanical and electrical engineers to help maintain them. The engine exhaust repair was to be carried out by shore-based Stevenson engineers, while the installation of the fixed fireextinguishing system had been contracted to Firewatch South West Ltd (Firewatch), which then subcontracted to Ocean Engineering (Fire) Limited (Ocean Engineering).
As the work on board Resurgam was being undertaken by shore workers and was not under the control of the vessel’s skipper or crew, the health and safety of those involved was subject to shoreside regulations, namely the Health and Safety at Work etc. Act 1974. In accordance with a memorandum of understanding and an operational working agreement between the Health and Safety Executive (HSE), the Maritime and Coastguard Agency (MCA) and the Marine Accident Investigation Branch (MAIB), the investigation of this accident fell under the remit of HSE. However, based on the initial findings of MAIB’s preliminary assessment of the accident, the Chief Inspector of Marine Accidents assessed that there were significant safety lessons for the maritime industry and opened an independent marine safety investigation.
Lessons learned
- Any gaseous or particulate fire-extinguishing medium is hazardous to health when inhaled in significant quantities. The apprentice engineer died because he inhaled a concentrated mixture of hot particles and carbon monoxide and collapsed in a reduced oxygen atmosphere. Skippers of fishing vessels are to ensure that both they and their crew are aware of the hazards of exposure to fixed firefighting system media.
- In the event that installation or maintenance of a fixed firefighting system is being undertaken, work in the area protected by the fixed firefighting system should be restricted to the people carrying out the work.
- Fishing vessel crew do not usually consider an engine compartment an enclosed space. However, an engine space can become an enclosed space under the new regulations on enclosed spaces, MGN 659 (M+F) Amendment 1 The Merchant Shipping and Fishing Vessels (Entry into Enclosed Spaces) Regulations 2022, which came into force in May 2022 and applied to fishing vessels from May 2023.
- The atmosphere in an engine space can rapidly change from a safe to a hazardous atmosphere for a number of reasons, including fumes emanating from hot work being carried out, leaking fluids and smoke emissions from overheating or smouldering machinery. In this case the inadvertent activation of a fire-extinguishing system adversely affected the breathable atmosphere and was harmful to anyone working in the engine room at the time. Make sure plans and procedures are in place so crew and contractors know how to react to such a situation.
- The person in charge of the work in the engine space is responsible for ensuring that appropriate risk mitigation measures are taken before the work starts. This includes the completion of risk assessments and a detailed plan of the work, and identification of any conflicts with other tasks. As above, personnel working in the engine space need to know how to respond in an emergency.
Actions taken
MAIB ACTIONS
The MAIB has:
- Issued a safety bulletin (Annex E) that warned of the inadvertent discharge of a FirePro condensed aerosol system and included a recommendation
(S2020/144) to FirePro UK to issue a safety alert to the owner/operators of vessels fitted with its systems and its network of marine installation/maintenance engineers, highlighting the circumstances of this accident and advising them of appropriate measures to take to reduce the risk of exposure to fire-extinguishing particles. - Issued a safety flyer to the fishing industry (Annex F).
Actions taken by other organisations
FirePro UK has:
- Issued a safety alert to the owner/operators of vessels fitted with its systems and its network of marine installation/maintenance engineers highlighting the circumstances of this accident and advising them of appropriate measures to take to reduce the risk of exposure to fire-extinguishing particles.
- Issued a safety bulletin to all marine distributors of the FirePro system highlighting the requirement to provide a safe system of work when installing the
FirePro system. This is to include method statements, risk assessments and the requirements for working in confined spaces. - Issued basic guidance information in the form of a quick start guide highlighting the requirements for designing, installing and commissioning of the system, including periodical inspection and testing.
FirePro has:
- Undertaken qualitative and quantitative assessment of the by-products of FirePro aerosol generators in a total flooding application.
- Updated its Annex 2 Marine Manual for small vessels to include a more comprehensive description of the installation of FirePro systems, including
maintenance and inspection. - Issued a safety bulletin worldwide to all master distributors highlighting the dangers of exposure to the suppressant agent as it is discharged from the
aerosol generator and the requirement to follow the FirePro installation information.
Recommendations
The Maritime and Coastguard Agency is recommended to:
2023/116 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, introduce a competency standard 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.
FirePro is recommended to:
2023/117 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.
2023/118 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.
W. Stevenson & Sons Limited is recommended to:
- 2023/119 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.
