MAIB report RESURGAM death

The MAIB has published its investigation report into a tragic death onboard the FV RESURGAM PZ1001 at Newlyn Harbour in November 2019. Photo: MAIB Report

Location: Newlyn Harbour, Cornwall, England

In a devastating incident on November 15, 2019, an apprentice engineer lost his life when a FirePro condensed aerosol fire-extinguishing system accidentally discharged in the engine room of the fishing vessel RESURGAM PZ1001.

The vessel was stationed alongside the North Pier at Newlyn Harbour, Cornwall, England, at the time of the incident.

The apprentice engineer, working alongside a shore engineer and two installation technicians, was involved in the installation process when the system was inadvertently activated. The engine room quickly filled with the hazardous fire-extinguishing aerosol, leading to the tragic loss of life.

The investigation report revealed several critical safety issues surrounding the incident:

– The fire-extinguishing aerosol, when inhaled in significant quantities, posed health hazards that were not adequately identified in the manufacturer’s safety-related information.

– The installation of the fire-extinguishing system lacked proper planning, and risk mitigation measures were not implemented to protect individuals working in the confined space.

– Ineffective oversight was noted at both the system design and installation stages. Surprisingly, there were no established standards for marine installers, a stark contrast to the framework in place for land-based installations of the same product.

Chief Inspector of Marine Accidents, Andrew Moll OBE, emphasised the gravity of the accident, stating, “The investigation into this deeply tragic accident… 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.”

In response to the investigation findings, several recommendations have been issued:

– The Maritime and Coastguard Agency (MCA) has been advised to take steps to enhance fire-extinguishing system installation standards.

– FirePro has been urged to conduct a specific risk assessment for each of its fire-extinguishing systems and review safety-related documentation to include all system hazards, particularly carbon monoxide production.

– The owner of RESURGAM has been recommended to revise the safety management system to ensure the implementation of personnel safety measures.

The investigation also brought attention to the dangers of working in enclosed spaces. As a result, regulations for fishing vessels will include changes effective from May 14, 2023.

resurgam accident death report

Resurgam PZ1001. Image courtesy of Richard Kiessler (MarineTraftic.com)

Chief Inspector Andrew Moll emphasised the importance of safety measures, including alarms and checks before intentional activation, and precautions during installation and maintenance. He reinforced the need for vessel operators, owners, and personnel working with condensed aerosol fire-extinguishing systems to prioritise safety.

In light of the investigation’s findings, the Maritime and Coastguard Agency has been tasked with improving fire-extinguishing system installation standards, while FirePro and RESURGAM’s owner have specific recommendations to enhance the safety of their systems and operations.

safety flyer to the fishing industry was produced with this report to provide five key safety lessons on working in enclosed spaces and the dangers of exposure to fixed firefighting system media.

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