On 18 November 2008, while the Maltese registered bulk carrier
Saldanha was anchored off Newcastle, NSW, a ship's
engineer was burned when the auxiliary boiler furnace 'flashed
back' during a routine boiler oil firing unit burner exchange.
The ATSB investigation into the incident found that the ship's
crew were not aware of all of the hazards associated with
maintaining the boiler burner; were not aware of previous
flashbacks involving similar burners; and were not aware of the
appropriate first aid treatment required for burn injuries.
The investigation also found that the safety bulletin that had
been previously issued by the manufacturer did not inform operators
that the oil firing unit could be modified.