Accident to chief. The SMS required permits for electrical work and enclosed-space entry.
The fatal job had neither.
Baton Rouge. 23 February 2024.
The chief engineer was replacing a ventilation damper actuator inside an overpressure duct compartment.
The temperature inside was between 50°C and 55°C.
The master and chief engineer agreed on ten-minute entries, followed by rehydration. The chief officer would monitor from the bridge deck.
They had recognised the heat.
But heat was only part of the exposure.
The actuator remained connected to a 230VAC supply. The circuit breaker was still on.
The chief engineer worked alone.
During his final entry, he continued working on wiring inside an open electrical junction box.
He was electrocuted.
The obvious explanation is failure to isolate.
That is correct. But incomplete.
Isolating this circuit required shutting down the main generators and operating on emergency power until the work was finished.
The report considered that avoiding the loss of hotel services and ventilation, combined with familiarity with 230VAC domestic voltage, might have made the job appear low risk.
Operational inconvenience had entered the risk decision.
Now look at the controls.
The SMS required a permit for electrical maintenance and repair. Its risk assessment required isolation and tag-out.
It also required a permit for enclosed-space entry.
But the onboard SMS definition of an enclosed space focused on toxic atmospheres. It did not match the wider industry definition.
The compartment was therefore absent from the mental map of enclosed spaces onboard.
No enclosed-space procedure. No dedicated sentry. No continuous visual contact. No rescue plan.
There was still another barrier.
The master and chief officer were permit-authorising officers. Neither challenged the decision to proceed without a permit.
This is where a permit-to-work system can become dangerously passive.
It waits for the person doing the job to classify the task correctly, request the permit and stop for authorisation.
But the person doing the job was the chief engineer.
Technically competent. Senior. Familiar with the equipment. Already committed to completing the repair.
After the accident, many enclosed-space precautions were used during the subsequent repair.
Yet the yacht's crew still did not consider the compartment an enclosed space for entry purposes.
That detail matters.
Additional precautions did not correct the classification error underneath them.
For a DPA, checking whether a PTW procedure exists is not enough.
Test what activates it.
Who classifies an unusual compartment?
Who must challenge a senior officer when no permit appears?
And how would shore management know that operational inconvenience is quietly redefining electrical work as low risk?
#MaritimeSafety #OccupationalSafety #RiskAssessment #SafetyManagement #HumanFactors
