Case Study 13 – Fishing Vessel 3rd March 2001

A welder was working onboard fishing vessel welding transducer housings in the forward lower

cofferdam. He had changed a welding rod when he was electrocuted

Rescue efforts were to no avail and officers were alerted that the welder had died.

On investigation it was determined that whilst the deceased was replacing the welding electrode

in the hand piece, the wet glove (from sweat) on his left hand came into contact with the iron

core of the welding electrode where the insulating flux coating was missing and he received an

electric shock of approximately 72 volts ac. The current flow would have then possibly passed

from his left hand to his neck region (or other parts of his body in contact with the metallic

vessel via the saturated clothing (from sweat).

It appears that the victim may have collapsed and his chest came into contact with the steel pipe

he was installing. This would have then offered another return path for the flow of electric

current from his chest and neck area. When obtaining a confined space permit an assessment

was made by the lead fitter that emergency isolation equipment was not necessary as it was jut

another dry, clean space. The confined space permit should not have been issued or signed off

by the permit controller. It was also uncovered that the deceased had been working in the

confined space for a period of 3 hours with no fluids during that time. The heat contributed to

his mental alertness and the saturated clothing that acted as a path for the circuit.

The deceased had been inducted and trained in confined spaces 3 months earlier. The lead fitter

had identified the confined space, conducted a gas test and obtained a permit. All personnel had

adequate personal protective equipment including welding helmet, coveralls and safety boots as

well as acceptable lighting and ventilation, however no consideration was given to the use of

insulating mats to insulate the welder from the surrounding metal surface. There was a

procedure for working in heat or humid conditions stressing the importance of fluid intake and

regular breaks. This was not adhered to in the case of the deceased.

Although the company had a well documented system it appears it was not being followed at all

times.

Where there appears to be a deficiency is the decision to forego emergency isolation equipment

when filling out the confined space permit. Although there was a spotter, supervision (including

the lead fitter) was inadequate.