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BSafe Case Study 4 — Nobody Knew He Was in There Alone

🕑 5 min read words Safety • Incident

Vessel: Oil tanker, on passage
Date & location: Engine room bottom platform, inert gas scrubber pump starter panel
Outcome: Fatal — the ship's electrician was electrocuted working alone on an energised 440V panel
Human factors: Vague Toolbox Talk · No Lockout/Tag Out · Unchallenged Lone Working
Source: Britannia P&I Club, BSafe Incident Case Study No. 4, drawn from an investigation by the Republic of the Marshall Islands Maritime Administrator

1 real case studyRMI Maritime Administrator~4 min read

‘I Might Work On It’

At the morning Toolbox Talk, the electrician mentioned he might work on the inert gas scrubber pump starter panel — no specifics, no timeframe. No formal risk assessment, permit to work, or lockout/tag out procedure followed, despite all three being required by the SMS for exactly this kind of job. Later, he told the engine cadet he'd be working on it. The cadet didn't question it, and didn't tell any other engineering officer.

A Cabinet With No Barrier Between Safe and Live

The panel cabinet had no horizontal divider separating its upper control sections from the lower section holding the 440V power terminals — and the covers meant to prevent accidental contact with those terminals were missing. When a low-insulation alarm activated in the control room and nobody could identify the cause, the cadet was sent to find the electrician and ask him to investigate. He found him unconscious, head and hands inside the lower section, the power terminal cover removed and set aside. CPR was started immediately; he could not be resuscitated. Cause of death was consistent with electrocution. The investigation concluded he had likely reached in to retrieve a dropped spring or locking pin and made contact with the live terminals.

What the Investigation Found

A formal risk assessment would have identified the 440V hazard and required real mitigation — none was completed.
A permit to work would have triggered lockout/tag out, de-energising the circuit before the panel was even opened.
The SMS required scheduled work to be planned at least a day ahead specifically to allow safety procedures to be completed — this was raised the same morning and not questioned.
He was working alone. A completed permit would have required a second person present — someone who could have challenged what he was doing, or raised the alarm sooner.
A working Stop Work Authority policy existed on paper; the second engineer and cadet, both aware something was happening, were positioned to use it and didn't.
Missing physical barriers inside the cabinet — no divider, no terminal covers — had gone unaddressed through scheduled maintenance.

Recommended Actions

Direct from the investigation's findings:

A mentioned intention (‘I might work on this’) is not a planned job — it needs the same risk assessment, permit, and lockout process as anything scheduled in advance, triggered the moment it's actually going to happen.
Permit-to-work systems that require a second person present exist specifically to prevent exactly this scenario — lone work on live electrical equipment with nobody to notice if something goes wrong.
A panel exposing energised terminals with no cover or divider is a physical hazard needing correction on its own, independent of any single incident.
Stop Work Authority only functions if the people who notice something unplanned happening actually exercise it — awareness without action doesn't prevent the incident.

Human Element Analysis

A vague toolbox talk

‘Might work on the panel’ passed as adequate notice. It told nobody what, when, or with what precautions — leaving no way for colleagues to know he'd actually gone ahead, let alone that he was doing it alone and unprotected.

Lone working on a live hazard

Every safeguard skipped — the permit, the lockout, the second person — converges on the same outcome: nobody present to intervene, notice, or raise the alarm until an unrelated alarm sent someone looking.

Awareness without intervention

The cadet knew what the electrician planned to do and said nothing to anyone else. Not malicious, not even clearly wrong-feeling in the moment — but exactly the gap a functioning Stop Work Authority culture is meant to close.

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