Procedural and Safety Failures Implicit in High-Voltage Panel Fatality

The US Coast Guard has released its report into the death of a crewmember onboard the Red Stag while moored at the Adriatic Marine Dock, in Port Fourchon, LA, on October 14, 2023. The incident occurred when an unqualified engineer (UE) opened the panel for the mud pump system and touched the high voltage conductors containing 480 volts.

The 184-foot OSV moored at the dock the previous day with a crew consisting of a Master, Relief Captain and three crewmembers. The vessel had been in dry dock and had recently moved to the Adriatic Marine Dock to prepare for an upcoming work assignment, which was scheduled for the next day.

At approximately 2330, the crewmembers conducted watch relief; the oncoming watch consisted of the Relief Captain, UE, and Deckhand (DH). As common practice during the watch relief, the off-going and oncoming personnel conduct a pass down, to include work completed by the previous watch and work to be completed by the oncoming watch.

The off going 1st Engineer passed to the UE that the vessel was leveled off via the mud pump system. The work assigned to the oncoming watch included cleaning the engine room, cleaning the interior spaces, and preparing for mooring stations.

A Job Safety Analysis (JSA) was completed by the UE for the engine room cleaning, the DH completed a JSA for the interior space task, and both the UE and DH completed a JSA for the mooring stations task. Once the watch relief was completed the crewmembers set off to complete their assigned task.

At approximately 0530, the next day on October 14, 2023, the UE asked the DH the location of the voltage meter. The DH did not know the location of the tool. At approximately 0640, the vessel’s Master found the UE unresponsive on the engine room floor next to the open mud pump high voltage panel.

The Master of the vessel immediately notified the crew and emergency medical services (EMS), then the crew started administering first aid. The Port Fourchon Harbor Police and EMS arrived and continued first aid until the UE was pronounced deceased at 0740.

Through this investigation, the Coast Guard determined the initiating event was the presumed material failure of the mud pump system. This was followed by the death of UE. The causal factors that contributed to this casualty included: (1) Failure to follow company policy and procedures, (2) Lack of engineering experience, (3) Missing visual or audible indicator of emergency stop activation, and (4) Missing locking device on high voltage panel.  

Activation of the emergency stop cut power to the mud pump but not to the 480 volt panel. The emergency stop was still activated at the time of the incident.

The report states that it is reasonable to conclude that if a locking device was installed on the high voltage panel, the UE would have had to notify the Master or 1st Engineer for access to the panel, which may have prevented the UE from entering the panel unsupervised.

Since the incident, the company held a fleet wide safety stand-down and reinforced the importance of communication between captains, crews and following safety policies and procedures.