Inspection Detail

Inspection: 301503694 - Jason Pallas

Inspection Information - Office: Anchorage Area Office

Investigation Summary

On June 27, 2004, Employees #1, #2 and #3 were working on a 60-foot, 44- gross ton commercial fishing vessel operating a fish tender. On June 26 and 27, 2004, several repairs were attempted on the refrigeration system of the F/V Steelhead. The system contained 60 pounds of chloroflouromethane, R 22 freon, which maintained chilled sea water for the fish holds. The following was obtained from Employee #2. Employee #1 reported smoke coming from the forepeak of the commercial fishing vessel. Employee #2 had directed Employee #1 to check chilled sea water temperature in the forepeak, the location of the refrigeration machinery. Employee #2 ascertained that the smoke was actually escaping refrigerant gas. Employees #1 and #2 returned to the forepeak to shut down the compressor pumps. This was initiated. Employee #1 was instructed by Employee #2 not to reenter the forepeak. Employees #2 and #3 left the vessel early on June 27 to visit the city of Valdez. Employee #2 and #3 returned to the vessel at approximately 6:00 a.m. and 8:30 a.m., respectively. Employee #2 reentered the forepeak and the R 22 was still leaking. Employee #2 indicated that he felt woozy after entering the space. He went to bed and awoke at 12:00 and found Employee #1 running around deck with hand tools. Employee #2 was not sure what Employee #1 was doing. Employee #2 did not question Employee#1, but indicated that a lot of items onboard the vessel required repair such as a leaky crane and engine room. Employee #2 proceeded to a shoreside processing plant break room, for coffee. Employee #2 instructed Employee #1 to find him in 20 minutes. Employee #1 did not find Employee #2. Employee #2 returned to the vessel to change clothing and check gauges. At this point Employee #3 was asleep and Employee #1 was not present. Employee #2 returned to break room and found Employee #1. Employees #1 and #2 returned to the forepeak to assess the leak and determined that a cap could be fashioned. Employee #1 went to the processing plant shop to find a cap. Employees #1 and #2 returned to the vessel at 1:30 p.m. to 1:45 p.m. They went to the forepeak and removed the associated tubing where the R 22 leak was thought to have originated. R 22 started leaking again upon the removal of the tubing. Employees #1 and #2 returned to the top-side of the vessel for breaths of fresh air and then returned to the forepeak where the cap was finger-tightened. Employee #1 and #2 returned top-side. Employee #2 sat down at the second hatch, 20 feet away from the forepeak entrance. Employee #1 waited at the forepeak entrance. Employee #2 thought of waiting and getting someone else to perform the repair. Employee #2 told Employee #1 to get out of the forepeak hatch. Employee #2 was attempting to light a cigarette when Employee #1 reentered the forepeak. Employee #2 was not sure how much time elapsed when he realized employee #1 was not top-side. Employee #2 indicated that his thought process was confused. Employee #2 heard a rushing sound as he approached the forepeak entrance. Employee #1 was heard screaming. Employee #2 attempted to retrieve Employee #1 from behind. Employee #2 could not perform this maneuver. Employee #1 and #2 collapsed within the forepeak. Employee #1 was inside the machinery room and Employee #2 was just outside in an adjacent space of the forepeak. Employee #1 and #2 could not be located for several hours. Employee #3 searched and inquired about Employee's #1 and #2 at the shore plant. Between 7:00 p.m. and 7:30 p.m., Employee #3 went to the forepeak and looked in. He saw Employee #2 on his knee. Employee #3 held his breath and entered. Employee #2 was bent over Employee #1. Employee #3 checked Employee#2 pulse. He could tell Employee #1 was dead. Employee #3 ran to the shore plant looking for assistance. Emergency medical services were called. Employee #3 returned with the plant manager. Both held their breath and attempted to retrieve Employee #1 and #2, but could not accompli

Keywords: OXYGEN DEFICIENCY, ASPHYXIATED, INHALATION, GAS, BOAT