The USCG has issued an investigation report into an incident where a crew member aboard the offshore supply vessel Red Stag was fatally electrocuted.
The incident
On October 13, 2023, at approximately 1630, the Red Stag (O.N. 1107980), a 184-foot offshore supply vessel (OSV), was moored at the Adriatic Marine dock located in Port Fourchon, Louisiana. The vessel’s crew consisted of a Master, Relief Captain, and three crewmembers. The vessel had been in dry dock and had recently moved to the Adriatic Marine Dock to prepare for an upcoming work assignment, which was scheduled for the next day.
At approximately 2330, the crewmembers conducted watch relief; the oncoming watch consisted of the Relief Captain, Unqualified Engineer (UE), and Deckhand (DH). As common practice during the watch relief, the off-going and oncoming personnel conducted a pass down, including work completed by the previous watch and work to be completed by the oncoming watch. The off-going 1st Engineer informed the UE that the vessel was leveled off via the mud pump system.
The work assigned to the oncoming watch included cleaning the engine room, cleaning the interior spaces, and preparing for mooring stations. A Job Safety Analysis (JSA) was completed by the UE for the engine room cleaning, the DH completed a JSA for the interior space task, and both the UE and DH completed a JSA for the mooring stations task. Once the watch relief was completed, the crewmembers began their assigned tasks.
At approximately 0530 on October 14, 2023, the UE asked the DH about the location of the voltage meter. The DH did not know the location of the tool. At approximately 0640, the vessel’s Master found the UE unresponsive on the engine room floor next to the open mud pump high voltage panel. The Master immediately notified the crew and emergency medical services (EMS), and the crew began administering first aid. The Port Fourchon Harbor Police and EMS arrived and continued first aid until the UE was pronounced deceased at 0740.
Through this investigation, the Coast Guard determined the initiating event was the presumed material failure of the mud pump system, followed by the death of the UE. The causal factors that contributed to this casualty included:
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Failure to follow company policy and procedures
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Lack of engineering experience
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Missing visual or audible indicator of emergency stop activation
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Missing locking device on high voltage panel
Analysis
Lack of engineering experience
The mud pump systems installed on board Offshore Supply Vessels are equipped with an emergency stop, which is normally located on the aft deck, so that the crewmember using the system can secure the operation remotely, instead of requiring the operator to go to the engine room to secure the system. The emergency stop is activated when the button is pulled, opening the circuit, stopping the flow of electricity to the pump. To re-energize the pump, the circuit must be closed by pushing in the button. It is common practice on OSV’s to secure the system utilizing this method. The Unqualified Engineer’s lack of engineering experience with the electrical system may have led to his belief that the mud pumps suffered an electrical failure due to the open circuit created by the activated emergency stop. It is reasonable to assume that if the Unqualified Engineer was more experienced with the operation of the mud pump system, he may have verified the status of the pump’s emergency stop and de-activated it, preventing him from having to open the 480 volt panel and prevented the incident from occurring.
Failure to follow company policy and procedures
The Company’s Safety Management System (SMS) was in place to prevent or lessen the number of injuries to personnel on board the vessels. The company’s SMS stated that any time a task is to be performed, the work shall be approved by the vessel’s Master. Once approved, a Job Safety Analysis (JSA) must be completed for all task prior to the work being conducted. The Master was neither aware of an issue with the mud pump system, nor was a JSA completed beforehand to conduct troubleshooting on the system. Furthermore, because of the high voltage used by the pump system, the Unqualified Engineer did not hold the qualifications needed to troubleshoot the issue without the 1st Engineer being present. It is reasonable to conclude that if the company’s policy was followed the Master would have been made aware of the presumed issue with the mud pump and the correct procedures may have been followed before the Unqualified Engineer went to troubleshoot the panel.
Missing visual or audible indicator of emergency stop activation
It is common for machinery installed onboard vessels to have indicators, whether visual, audible, or both, incorporated in the systems to alert crew members when an emergency stop has been activated. The intended purpose of the indicators is, first and foremost, to alert crew members of an emergency and secondly to make personnel aware the stop is activated and needs to be deactivated prior to use. It is reasonable to assume that if the mud pump system had a method to alert personnel when the emergency stop was in an activated state, the Unqualified Engineer would have been aware of the need to deactivate the emergency stop and not accessed the energized panel.
Missing locking device on high voltage panel
It is common practice to restrict access to machinery that pose hazards to personnel or the environment. Normally, this is done by an installing a locking device which the Master or highest-ranking engineer has the key and are the only crewmembers who can grant access to the equipment. It is reasonable to conclude that if a locking device was installed on the high voltage panel, the Unqualified Engineer would have had to notify the Master or 1st Engineer for access to the panel, which may have prevented the Unqualified Engineer from entering the panel unsupervised.
Conclusions
Determination of cause
The initiating event for this casualty was the presumed material failure of the mud pump system onboard the RED STAG. Casual factors contributing to this event were:
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Lack of Engineering Experience.
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Failure to Follow Company Policy and Procedures.
The Unqualified Engineer accessed an energized high voltage panel and contacted the electrical conductors which resulted in electrocution. Casual factors leading to this event were:
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Missing Visual or Audible Indicator of Emergency Stop Activation
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Missing Locking Device on High Voltage Panel
Evidence of act(s) or violation(s) of law by Coast Guard credentialed mariner subject to action under 46 USC Chapter 77
There were no acts of misconduct, incompetence, negligence, unskillfulness, or violations of law by a credentialed mariner identified as part of this investigation.
Evidence of act(s) or violation(s) of law by U.S. Coast Guard personnel, or any other person:
There were no acts of misconduct, incompetence, negligence, unskillfulness, or violations of law by Coast Guard employees or any other person that contributed to this casualty.
Evidence of act(s) subject to civil penalty:
This investigation did not identify evidence of acts that would warrant civil penalty.
Evidence of criminal act(s):
This investigation did not identify violations of criminal law.
Need for new or amended U.S. law or regulation:
No matters requiring new or amended laws or regulations were identified during this investigation.
Unsafe actions or conditions that were not causal factors:
This investigation did not identify evidence of unsafe actions or conditions that were not causal factors.
Actions taken since the incident
Since the incident, the company held a fleet wide Safety Stand – down and reinforced the importance of communication between Captains, crews, and following safety policies and procedures.
Safety recommendation:
There were no proposed actions to add new or amend existing U.S. laws or regulations, international requirements, industry standards, or U.S. Coast Guard policies and procedures as part of this investigation.
