The Marine Accident Investigation Branch (MAIB) has released its report into the accidental discharge of a fire-extinguishing system onboard the beam trawler Resurgam PZ 1001 in Newlyn harbour on 15 November, 2019, which resulted in one fatality.
Twenty-year-old apprentice engineer Conor Moseley died after a FirePro condensed aerosol fixed fire-extinguishing system inadvertently activated whilst being installed.
The report – the purpose of which is not to attribute fault or blame – states that two engineers from Ocean Engineering (Fire) Ltd were in the engineroom installing and commissioning the system. Conor Moseley and
a mechanical engineer from W Stevenson & Sons Ltd, owner and operator of the vessel, were also in the engineroom, working on the vessel’s exhaust system.
At around 3.35pm, with the installation complete, the Ocean Engineering technicians began to plug the aerosol generators into the sockets fitted to the fire-extinguishing system’s activation cables.
At 3.40pm, the lead technician plugged in the fourth and final generator and ‘almost immediately heard a loud hissing sound behind him’. Realising the system had activated, he unplugged the generator, jumped over the main engine gearbox and ran to the access ladder shouting: “Get out!”
As the space filled up with dense white condensed aerosol, the two Ocean Engineering technicians managed to climb the ladder to the open deck. The report notes that the Stevenson’s engineer ‘grabbed the apprentice’ and guided him towards the ladder.
“When they reached the ladder, visibility in the engineroom was zero, and both were struggling to breathe. Thinking he was following the apprentice, the engineer scrambled up the ladder and out of the engineroom. When he emerged from the engineroom on to the open deck he was on his hands and knees, coughing and spluttering, but quickly realised that the apprentice had not escaped.”
Three separate attempts were made to reach Conor Moseley, including one by the health and safety manager of W Stevenson & Sons, who had arrived at the vessel at 3.50pm.
At approximately 4.05pm, fire and ambulance services arrived on scene. Shortly after, Conor Moseley was recovered unconscious and not breathing. Despite the attempts of paramedics, he could not be resuscitated.
The MAIB issues a number of recommendations in its report.
The MCA is recommended to take steps to improve the standard of installation of safety-critical fire-extinguishing systems in vessels operating under codes of practice to ensure that, specifically, ‘vessel owners are aware of the obligation to notify the MCA in advance of the installation, in order to obtain pre-installation approval’ and that ‘equipment installation is undertaken in accordance with manufacturers’ instructions and the relevant statutory requirements’.
The MCA is also recommended to ensure that a competency standard for the installers of systems on vessels is introduced, and also that ‘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 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.
The company is also recommended to review its safety-related documentation for its fire-extinguishing systems, to ‘incorporate the hazards identified as part of this investigation, specifically those associated with carbon monoxide generation’.
W Stevenson & Sons is recommended to ‘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 onboard’.
Safety bulletins have been issued by the MAIB, MCA, FirePro and FirePro UK.
Captain Andrew Moll OBE, chief inspector of marine accidents, 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.”
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