UK MAIB investigation: Crew member dies after entering enclosed space without safety precautions


The incident

At about 1350 on 14 August 2018, a second engineer working onboard the trawler, Sunbeam, was found collapsed inside a refrigerated salt water tank. Although rescued from the tank, he could not be resuscitated.

Sunbeam was in Fraserburgh and the evidence available strongly indicated that the second engineer had entered the tank to sweep away residual water.

When he was found, three of his crewmates went into the tank to help him; they all suffered breathing difficulties and one also collapsed.

Two other crew members then donned breathing apparatus and rescued their struggling crewmates; the second engineer could not be resuscitated.

 

Probable causes

This fatal accident happened because the second engineer entered the tank, which was an enclosed space, without any of the safety precautions normally associated with such an activity; there was no ventilation, the atmosphere was not monitored and he was working alone without communications.

Entry into Sunbeam’s refrigerated salt water tanks without appropriate safety precautions had been normalized by the crew; however, on this occasion, the atmosphere could not support life because Freon gas had leaked into the tank through corroded tubes in the evaporator of the vessel’s starboard refrigeration plant.

Although the Freon gas leak was less foreseeable than other potential hazards in refrigerated salt water tanks, this accident highlights the critical importance of safety precautions and procedures for any enclosed space.

Sunbeam had been subject to regular surveys by both the Flag State and its recognised organisation; however, a lack of clarity regarding responsibility for assessing refrigeration equipment resulted in an inconsistent level of oversight of this machinery.

Additionally, fishing vessels were excluded from UK regulations for personnel entry into dangerous spaces, and guidance on enclosed space working was not included in the MCA’s Code of Practice for Fishing Vessels of 24 metres in length and over.

See also: Enclosed space deaths onboard: Why do they persist?

Conclusions

  • Sunbeam’s 2/E died because he entered an RSW tank, which was an enclosed space, where the presence of Freon gas meant that the atmosphere could not support life.
  • The fatal hazard was present and went undetected due to the absence of safety precautions normally associated with enclosed spaces, specifically ventilation and atmosphere monitoring.
  • Entry into enclosed spaces on board Sunbeam, without safety precautions, had been normalised by the crew through many years’ operations, and without previous consequence.
  • Sunbeam’s risk assessment for maintenance operations did not specifically address the potential hazards associated with RSW tank entry. There was also no safe system of work in place for the maintenance being undertaken.
  • The 2/E had entered the tank alone; as a result, other members of the crew were unaware where he was or when he collapsed. The 2/E’s decision to enter the tank resulted in the unsafe situation of lone working.
  • Sunbeam’s crew was not properly prepared for dealing with the emergency because there were no emergency procedures for tank rescue and no drills had been conducted to test the arrangements in the event of a casualty.

 

Actions taken

-The MAIB has:

  • Published a Safety Bulletin 4/2018. This explained the initial findings and safety lessons of the investigation. It also recommended that the owner of Sunbeam conduct risk assessments specifically for entering and working in RSW tanks, and provide safe operating procedures for its crew to follow and appropriate levels of safety equipment to use.
  • Issued a Safety Flyer to the Fishing Industry.

-The owners of Sunbeam have:

  • In response to the MAIB’s safety recommendation, completed a risk assessment and introduced a safety procedure for enclosed space working, including atmosphere monitoring equipment.

-Lloyds Register has: 

  • Issued a Technical Performance Circular notice to all surveyors. This notice was intended to promote effective communication between LR and the MCA; it also drew surveyors’ attention to their specific responsibilities regarding fishing vessel surveys.

 

Recommendations

–>The Maritime and Coastguard Agency is recommended to: 

-Implement measures for the safe conduct of enclosed space operations onboard fishing vessels, specifically:

  • Amend the Merchant Shipping (Entry into Dangerous Spaces) Regulations, 1988, or any subsequent regulations for potentially hazardous spaces, to include fishing vessels. Consideration should also be given to aligning UK regulations and guidance with the IMO terminology for enclosed spaces.
  • Update fishing vessel codes of practice and surveyor’s checklists to reflect enclosed space safety and operations, specifically including atmosphere monitoring and crew preparation for emergencies.

-Review Letters of Delegation to its Recognised Organisations in order to ensure clarity of understanding with regard to responsibility for survey of machinery items.

–>The owners of Sunbeam are recommended to: 

-Implement an onboard safety management system in accordance with the MCA’s Fishing Safety Management Code, specifcally ensuring that safe systems of work are in place for all operations.

–>The Scottish Pelagic Fishermen’s Association is recommended to:

-Encourage its members to maintain onboard safety management systems in accordance with the MCA’s Fishing Safety Management Code.

 

Explore more herebelow:

UK MAIB report



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