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.
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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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.
|Who it affects:||MSQ Port of Brisbane|
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.
|Who it affects:||Garioni Naval SpA|
|Date:||16 January 2011||Investigation status:||Completed|
|Time:||1512 local (UTC +10)||Investigation level:||Systemic - click for an explanation of investigation levels|
|Release date:||05 October 2012||Occurrence category:||Incident|
|Report status:||Final||Highest injury level:||Serious|
|Type of operation||Tanker|
|Damage to vessel||Minor|
|Departure point||Hong Kong|