230 Volts: The Death of Roy Temme on Baton Rouge

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:

1. 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
2. Updated the safety management manual to clarify precisely when a permit to work is required
3. 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
4. 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