Vigilance is vital for safety aboard ships

The ATSB’s investigation MO-2011-001 into a thermal heater explosion on board the products tanker Qian Chi emphasises that ships’ crews need to remain vigilant to safety even when conducting repeated or seemingly simple tasks and need to consult equipment documentation and pay increased attention when tackling unfamiliar tasks. Crews also need to understand the importance of providing immediate and appropriate first aid to injured persons, especially burn victims.

On 16 January 2011, while Qian Chi was at anchor in Moreton Bay, Queensland, the ship’s number two oil-fired thermal oil heater exploded. The explosion seriously injured three crew members and severely damaged the thermal oil heater and surrounding equipment.

The ATSB investigation found that during maintenance the oil heater burner nozzle had been assembled incorrectly. This was because the crew lacked experience with the equipment and the manufacturer’s instructions were not clear and detailed. The nozzle leaked fuel into the furnace through the pre-ignition start sequence, the fuel was ignited when the burner igniter operated and the furnace exploded.

The ATSB also found that the crew were not aware of the importance of providing immediate and accepted first aid treatment for burn injuries. Deficiencies in the Brisbane port vessel traffic service procedures led to delays in providing emergency assistance.

As a result of the incident, the ships operators have renewed the burner equipment and altered the control system to better suit the fuel being used and the load demands on the heaters. The heater’s supplier is updating the documentation supplied with the machinery. Maritime Safety Queensland has undertaken a review of its procedures and practices to take into account the risks associated with ships within port limits but not at a berth and the emergency response required in such situations.

ATSB Investigation Report MO-2011-001

Last update 04 January 2013