Report into fatal incident at Newlyn Harbour in Cornwall

On November 15, 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 as it was being installed in Newlyn Harbour. 

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

Unfortunately, only three of the workers managed to escape. One of the four, an apprentice engineer, collapsed at the bottom of the engine room access ladder.

He was recovered onto the open deck about 20 minutes later by the emergency services but could not be resuscitated. The post-mortem report determined that he died from an inhalation injury and carbon monoxide poisoning. 

According to the report, an investigation into the incident was conducted by the Marine Accident Investigation Branch (MAIB) to ensure the lessons from this accident were brought to the attention of the marine industry. 

Its findings revealed several key safety issues, including: 

• The fire extinguishing aerosol was hazardous to health when inhaled in significant quantities and these hazards were not identified in the manufacturer’s safety-related information.
• The installation of 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.

Several safety recommendations were made in the report to FirePro, the Maritime and Coastguard Agency, and W. Stevenson & Sons who owned and operated the vessel. 

Resurgam Flyer (Image: Richard Kiessler Marine Traffic)

FirePro was 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, including those identified as part of this investigation, to a level that is considered as low as reasonably practicable.
• Review its safety-related documentation for its fire-extinguishing systems (including, but not limited to, the installation and operational guidance and material safety data sheet) to: incorporate the hazards identified as part of this investigation, specifically those associated with carbon monoxide generation and risk of inhalation injury, and the required control measures. 

The Maritime and Coastguard Agency was recommended to take steps to improve the standard of installations 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 Maritime and Coastguard Agency in advance of the installation, in order to obtain pre-installation approval.
• Equipment installation is undertaken in accordance with manufacturers' instructions and the relevant statutory requirements.
• In collaboration with industry stakeholders, a competency standard is considered, agreed and prepared for the installers of systems on vessels.
• The 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.

W. Stevenson & Sons Limited was recommended to:

• Update its safety management system for vessels, specifically to include the control and safe management of contractors, including the provision of rescue plans for people working on board.

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.

"The investigation report 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.

"As well as the additional safety recommendations made today, it is worth reinforcing the safety lessons from that bulletin and reminding vessel operators, owners and those working with condensed aerosol fire-extinguishing systems that safety measures must be put in place to ensure personnel are not exposed to this hazard. These measures can include alarms and checks prior to intentional activation and precautions during installation and maintenance.

"Our investigation also brought to the attention of the fishing industry the dangers of working in an enclosed space and, from 14 May 2023, the change in regulations to include fishing vessels."