Marine safety investigations & reports

Thermal oil heater explosion on board the products tanker Qian Chi at Brisbane, Queensland 16 January 2011

Investigation number:
Status: Completed
Investigation completed

Safety summary

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What happened

On 16 January 2011, while the products tanker 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 and fittings. The injured crew members received only rudimentary first aid on board. Shore-based emergency paramedics attended the ship and the injured crew members were evacuated by helicopter for treatment and recuperation.

What the ATSB found

The ATSB found that, during maintenance, the thermal oil heater burner nozzle had been assembled incorrectly. This was because the crew lacked experience with the equipment and the manufacturer supplied instructions were not clear and detailed. As a result, the nozzle leaked fuel into the furnace throughout the pre-ignition start sequence. The furnace exploded when the burner igniter started.

The ATSB also found that the ship’s crew were not aware of the importance of providing immediate and accepted first aid treatment for burn injuries. It was also found that deficiencies in the Brisbane port vessel traffic service procedures and preparedness contributed to delays in providing emergency assistance.

What has been done as a result

The ship’s operators have renewed the burner equipment installed in the ship for both oil-fired thermal oil heaters and altered the control system to better suit the fuel being used and the load demands placed on the heaters.

The heater’s supplier, Garioni Naval, advised they were updating documentation supplied with their machinery. They had also been in contact with the burner equipment manufacturer and others regarding this incident and equipment design.

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.

Safety message

Ship’s crew should remain vigilant to safety even when conducting repeated or seemingly simple tasks. Personnel need to consult equipment documentation and pay increased care and attention when undertaking unfamiliar tasks. To support that process, equipment documentation needs to be comprehensive and accurate.

Ship’s crew should also understand the importance of providing immediate and appropriate first aid to injured persons, especially burn victims. Burn injuries should always be immediately cooled, under clean, cold running water, for at least 10 minutes.

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Alternate: [Download  DOC: 3.61MB]


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Safety Issues

Go to MO-2011-001-SI-01 - Go to MO-2011-001-SI-02 -

Port of Brisbane preparedness for incidents

Brisbane port authorities had not put in place sufficient procedures, checklists and/or supporting documents to ensure VTS staff were adequately prepared, trained and practiced to handle a predictable incident such as this.

Safety issue details
Issue number: MO-2011-001-SI-01
Who it affects: MSQ Port of Brisbane
Status: Adequately addressed

Burner nozzle assembly and documentation

The design of the burner nozzle allowed the nozzle swirl plate and needle valve to be misaligned when being assembled which in turn led to the needle valve stem being damaged during assembly. Furthermore, the maintenance manuals and supporting documentation supplied by Garioni Naval, the thermal oil heater manufacturer, did not provide sufficient guidance to ensure safe and appropriate maintenance of the thermal oil heater burner assembly.

Safety issue details
Issue number: MO-2011-001-SI-02
Who it affects: Garioni Naval SpA
Status: Adequately addressed
General details
Date: 16 January 2011   Investigation status: Completed  
Time: 1512 local (UTC +10)   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): at Brisbane    
State: Queensland    
Release date: 05 October 2012   Occurrence category: Incident  
Report status: Final   Highest injury level: Serious  

Vessel details

Vessel details
Vessel Qian Chi  
Flag Hong Kong  
IMO 9262417  
Type of operation Tanker  
Damage to vessel Minor  
Departure point Hong Kong  
Destination Brisbane  
Last update 03 April 2020