Investigation into inadvertent release of fire extinguishing system that led to fatality of fisher

On 15 November 2019, an apprentice engineer died when a FirePro condensed aerosol fire-extinguishing system was inadvertently activated in the engine room of the fishing vessel Resurgam (PZ1001) as it was being installed.

The apprentice engineer was working in the engine room with a shore engineer and two installation technicians when the system activated, filling the engine room with the fire-extinguishing aerosol.

The investigation found:

The manufacturer’s safety related information did not identify that the aerosol was hazardous to health when inhaled in significant quantities.

• The work to install the fire-extinguishing system had not been properly planned or risk mitigation measures put in place to protect people working in the space.
• There was ineffective oversight at both the system design and installation stages and no standards for marine installers: this contrasted with the framework for land-based installations of the same product.

The MAIB report can be read here

A safety flyer accompanies the report which can be read here