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230 Volts: The Death of Roy Temme on Baton Rouge

🕑 5 min read words Safety • Incident

Vessel: Baton Rouge — 62m steel motor yacht, Isle of Man registered, managed by Nigel Burgess Limited
Date & location: 23 February 2024, approximately 0849–0856, Falmouth Harbour marina, Antigua
Outcome: Chief Engineer Roy Temme (47) electrocuted while repairing a live 230VAC ventilation damper actuator in a ventilation duct compartment
Human factors: Authority Gradient · Complacency · Situational Awareness · Workload
Source: MAIB Very Serious Marine Casualty Report No 1/2025

6 decision points2 outcome paths — isolate and survive / work live and don't~9 min read + Knowledge Checker

230 Volts

Baton Rouge suffered a blackout the evening before. When power came back, a ventilation damper in the starboard overpressure duct compartment failed to reset. The Chief Engineer and Second Engineer opened the space to inspect, removed the failed actuating mechanism, and left it connected to the 230VAC supply. The repair was deferred to the morning.

At 0700, the master and the Chief Engineer agreed a plan: the C/E would work in the space in 10-minute sessions with rehydration breaks, because the ambient temperature inside was 50–55°C. The Chief Officer would monitor by UHF radio from the bridge deck. No permit to work was raised — not for the electrical work, and not for entering the space at all.

Why No Permit Was Raised

Baton Rouge's SMS defined "enclosed space" using COSWP Chapter 11 — a definition built around toxic or oxygen-deficient atmospheres. The overpressure duct compartment had fresh air moving through it, so nobody classified it as an enclosed space requiring entry controls. In fact it met the COSWP Chapter 15 definition, the Merchant Shipping and Fishing Vessels (Entry into Enclosed Spaces) Regulations 2022, and IMO Resolution A.1050(27) — none of which depend on atmosphere at all, only on whether the space is designed for continuous occupation and has limited entry and exit. It wasn't, and it did. The MAIB has since written to the MCA to flag the contradiction between the two COSWP chapters.

Between 0734 and 0848

The Chief Engineer made three entries into the space that morning, calling in by radio each time. After 0848 he entered a final time and began reconnecting the actuator wiring at an open junction box that was still live. COSWP Chapter 20.13 is explicit that the risk of electric shock is much greater on board than ashore — moisture, humidity and heat reduce the body's contact resistance, and severe or fatal shocks become possible at 60V or lower. CCTV showed the C/E visibly hot and sweating.

The Monitoring That Wasn't Watching

At 0856, engine room ventilation alarms activated. The Second Engineer ran to the entrance and found the C/E slumped over the trunking. The Chief Officer, entering the space, touched him and received an electric shock — the circuit was still live. Recovery required an improvised rescue: an endless sling around his chest, crew hauling from above through a cramped locker and vertical ladder. Despite CPR and paramedic treatment, the Chief Engineer's heart could not be restarted.

Recommended Actions

No MAIB recommendations were issued — Nigel Burgess Limited had taken comprehensive corrective action before the report was published. What the company actually did:

Amended the permit-to-work system for electrical work, with greater emphasis on the elevated shock risk on board and a requirement to avoid live working wherever possible
Updated the safety management manual to clarify precisely when a permit to work is required
Revised the fleet's RASOP template to use the COSWP Chapter 15 definition of enclosed space, and required every vessel's enclosed space register to be reviewed against it
Directed a concentrated 2025 audit focus confirming enclosed space entrances are correctly identified, marked and controlled fleet-wide

Separately, the MAIB wrote to the MCA to highlight the contradiction between the Chapter 11 and Chapter 15 enclosed space definitions in the COSWP, and requested it be resolved at the next revision.

Human Element Analysis

Authority Gradient

The master and Chief Officer, as the permit-to-work authorising officers, never challenged the absence of a permit — the MAIB found they likely deferred to the Chief Engineer as the perceived authority on engineering matters. The permit system exists precisely to force a check that doesn't rely on someone junior being willing to question someone senior; here, it was bypassed by exactly the dynamic it's meant to interrupt.

Complacency

The Chief Engineer had worked on Baton Rouge since 2022 and had entered the space without incident the night before. The voltage — 230VAC — matched UK domestic mains, a comparison that made it feel manageable. COSWP's specific warning that shipboard conditions make the same voltage more dangerous than ashore wasn't part of his working assessment.

Workload

Isolating the circuit meant shutting down the main generators and running on emergency power — a significant step affecting hotel services and crew comfort, against a ventilation fault that was already compromising fire suppression. That asymmetry between a small operational cost (isolate and inconvenience everyone) and a large one (don't, and finish the job faster) likely shaped the decision to work live.

How This Pattern Repeats

Industry	Incident	The parallel
Offshore	Piper Alpha, 1988	A permit-to-work handover failure between shifts meant a pump was restarted while safety-critical maintenance was still incomplete — the same underlying gap as a permit system that exists on paper but isn't actually enforced at the moment of highest risk.
Aviation	Tenerife runway collision, 1977	A confident, senior figure's decision went unchallenged by his own crew, despite information available to junior officers that should have prompted a question — the founding case behind Crew Resource Management training industry-wide.
Rail	Clapham Junction rail crash, UK, 1988	A signal wiring fault, left in place by a technician whose work was never independently checked, caused a fatal collision — the same gap as work proceeding without the second-person verification a permit-to-work system is designed to force.

See How You'd Handle It

The scenario opens at 0700, the morning briefing between the master and the Chief Engineer. Do you raise a permit to work, or agree the repair plan and get on with it? Six decision points follow, ending at the point where isolating the circuit stopped being optional.

What Every Engineer and Officer Should Take From This

The legal definition of an enclosed space doesn't depend on the atmosphere — a well-ventilated space with limited entry and exit still qualifies
230VAC on board is not the same risk as 230VAC ashore — heat, humidity and sweat reduce the body's resistance, and COSWP says so explicitly
A permit to work is a forcing function for challenge — if nobody's asking whether one is needed, that's the system already failing
A radio check-in is not a sentry — COSWP requires someone stationed at the entrance throughout, not periodic contact initiated by the person at risk
Isolate before you work on live equipment. If live working is genuinely unavoidable, it needs a second competent person, insulated gloves, a dry mat, and a safe position — not one person, alone, for the fourth time that morning

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