The death of an apprentice engineer following an industrial accident at a harbour in Cornwall was caused by "ineffective oversight" of safety issues, a watchdog has found.
The Marine Accident Investigation Branch (MAIB) investigated the "accidental discharge" of the fire extinguishing system on a fishing vessel moored in Newlyn, in November 2019.
Conor Moseley, 20, died on board the Resurgam after breathing in fire-extinguishing aerosol which is hazardous to health when inhaled in significant quantities.
The apprentice was working on the vessel's engine at the time of the incident.
At the same time, another engineer was installing the FirePro condensed aerosol fire-extinguishing system when it "inadvertently activated" in the Resurgam's engine room.
The MAIB said that the installation of the fire extinguishing system "had not been properly planned".
The investigation said that the risks of inhaling the aerosol "were not identified" in the manufacturer's safety information.
It added there were "no standards for marine installers" and that there was "ineffective oversight" at both the system design and the installation stages.
This contrasted with the framework for land-based installations of the same product, the investigation found.
'Hazards were not identified'
Captain Andrew Moll OBE, Chief Inspector of Marine Accidents, said: "The investigation report builds on the earlier MAIB safety bulletin which highlighted the danger to human health of inhaling the condensed aerosol produced by the FirePro system.
"It is worth reinforcing the safety lessons from that bulletin and reminding vessel operators, owners and those working with condensed aerosol fire-extinguishing systems that safety measures must be put in place to ensure personnel are not exposed to this hazard.
"These measures can include alarms and checks prior to intentional activation and precautions during installation and maintenance."
The MAIB carried out "extensive research and testing" of the FirePro system at HSE’s Science and Research Centre, in Buxton as part of the investigation.
The report made several recommendations to improve safety measures following the accident.
It was recommended that FirePro undertake "a specific risk assessment" and "review its safety-related documentation" for each of its fire-extinguishing systems.
The Maritime and Coastguard Agency was also recommended to take steps "to improve the standard of installation of safety-critical fire-extinguishing systems" in marine vessels.
An agency spokesperson said: “Our thoughts are with the family and friends of Conor Moseley.
“We take all aspects of maritime safety very seriously and continually review approvals with respect to aerosol fixed fighting systems to make these as safe as possible.
"Following the findings of this latest MAIB report, the MCA is taking further steps to improve the safety standard for aerosol fixed firefighting systems including a new Marine Guidance Note and raising awareness with stakeholders."
FirePro manufacturers said: “We extend our deepest sympathies to the family and friends of Conor Moseley and welcome the MAIB report.
“We note that the report concludes that the fire extinguishing system was inadvertently activated by a third party in their attempt to install it onboard the Resurgam, and the installation procedures were not followed.
“Irrespective of this, as a responsible manufacturer that takes extremely seriously the safety of people, FirePro has since issued worldwide safety guidance and alerts to vessel operators, fire system distributors and installers.”