Entry to enclosed space on fishing vessel Sunbeam with loss of 1 life
Location: Fraserburgh, Scotland.
Accident Investigation Report 19/2020
Investigation report into marine accident including what happened, safety lessons learned, action taken and recommendations:
Summary
On 14 August 2018, a second engineer on board the pelagic trawler Sunbeam was asphyxiated and died in one of the vessel’s refrigerated salt water tanks. Sunbeam was in Fraserburgh and the refrigerated salt water tanks had been emptied of water in preparation for cleaning. Entry into Sunbeam’s refrigerated salt water tanks, which were enclosed spaces, was routine business for the crew, both when operating the tanks at sea and during maintenance in harbour. On this occasion, the atmosphere could not support life because Freon gas had leaked into the tank, displacing the air.
Safety Issues
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Hazards associated with enclosed spaces can include flooding, heat, toxic gasses, flammable gases and oxygen deprivation. It is vital that enclosed spaces are recognised, and safety precautions are put in place before personnel enter them. These include proper ventilation, atmosphere monitoring and a rescue plan.
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Risk assessments help to identify hazards and lead to method statements for the safe control of work. Without control of the maintenance work being undertaken on board Sunbeam, the second engineer was working alone, and in an enclosed space. Lone working presents significant hazards if you get into difficulty, and it is completely unacceptable in enclosed spaces.
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Sunbeam’s refrigeration plants were not well maintained and were not being operated as designed. Repairs to corroded and leaking tubes in the starboard refrigeration plant’s evaporator had been ineffective, resulting in the leak of Freon.
Recommendations
This report makes recommendations to the Maritime and Coastguard Agency to: implement measures for the safe conduct of enclosed space entry on board fishing vessels by extending the application of the Merchant Shipping (Entry into Dangerous Spaces) Regulations 1988 to include fishing vessels (2020/137), and make corresponding updates to the relevant codes of practice; and, review its Letters of Delegation to its Recognised Organisations with respect to the survey of machinery items (2020/138).
Since the accident, the International Labour Organization’s Fishing Convention 188 has come into force and an industry voluntary Fishing Safety Management Code has been developed to assist owners in complying with the Convention. A safety recommendation has, therefore, been made to the owners of Sunbeam to implement a safety management system on board, in accordance with the Fishing Safety Management Code (2020/139). The Scottish Pelagic Fishermen’s Association has also been recommended to encourage its members to maintain safety management systems compliant with the Fishing Safety Management Code (2020/140).
Related publications
A safety flyer to the fishing industry highlighting a number of the safety lessons was produced for this report.
See also our safety bulletin published in 2018, which issued an urgent safety warning to those working in enclosed spaces.