Report on the investigation of the Boiler flashback on M.V. Shirane April 2007

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1 Report on the investigation of the Boiler flashback on M.V. Shirane April

2 Accident Reporting and Investigation The fundamental purpose of investigating an accident under these Regulations is to determine its circumstances and the cause with the aim of improving the safety of life at sea and the avoidance of accidents in the future. It is not the purpose to apportion liability, nor, except so far as is necessary to achieve the fundamental purpose, to apportion blame. 2

3 CONTENTS GLOSSARY OF ABBREVIATIONS AND ACRONYMS PAGE SYNOPSIS 5 SECTION 1 - FACTUAL INFORMATION 1.1 Particulars of vessel Shirane and accident details Background (all times UTC plus 10 hours, Ship s Time) The Crew The Victims Narrative 8,9 SECTION 2 - ANALYSIS 2.1 Aim How the Flashbacks occurred ISM 10 SECTION 3 CONCLUSIONS 3.1 Findings Cause 11 SECTION 4 RECOMMENDATIONS 12 3

4 GLOSSARY OF ABBREVIATIONS, ACRONYMS AND TERMS Short Navigation: depart anchorage and steam for a short period of time. Medivaced: taken by helicopter to the John Hunter Hospital ECR: engine control room ISM: International Safety Management UTC: Universal Time Co-ordinated 4

5 SYNOPSIS On 02 nd April 2007 the vessel Shirane was undertaking a short navigation from her anchorage off Newcastle Harbour, New South Wales, Australia. This was being undertaken as per Company instructions and also due to a tsunami warning issued for the East Australian coast following an earthquake in New Caledonia, to the north east of Australia. The investigation was initiated at the once the situation was informed and Marine Surveyor Peter Murday was appointed to lead the investigation on behalf of the Panama Administration. Marine Surveyor William Burton was appointed as his assistant with full authority to act as principal investigator. He visited the vessel on 16 th April 2007 when the vessel arrived alongside at Koorayang berth 5 to load a cargo of coal. The vessel was empty on arrival at the anchorage 19 March 2007 awaiting a berth to become vacant. At April 2007 the vessel was underway from the anchorage, on a heading to clear all local traffic. At 1010 the first flash back occurred causing injury to the 3/AE. Master informed and 3/AE taken to ship s hospital for immediate first aid. At 1141 the second flashback occured causing injury to C/E, 2/AE and Fitter At 1305 the Rescue helicopter landed two paramedics At 1321 the Rescue helicopter departed with 2/AE, 3/AE and Fitter to shore hospital At 1420 the vessel returned to anchor off Newcastle harbour At 1731 the Rescue helicopter departed with the C/E to shore hospital The weather throughout was fine and clear with little in the way of seas and swell. 5

6 SECTION 1 FACTUAL INFORMATION 1.1 PARTICULARS OF VESSEL SHIRANE AND ACCIDENT Registered Owner Manager Port of Registry Flag Type Built Dorado Maritime Panama Taiheiyo Kisen Kaisha Ltd Panama Panama Bulk Carrier 2000, Imabari, Japan Classification Society Construction Nippon Kaiji Kyokai Steel Length Overall m Gross Tonnage Engine power 1 Diesel motor, DE MITSUI B & W 5S60MC 10233kW at 105 RPM Service speed about 14.5 knots Other relevant info Single screw and no bow thruster Accident details Times and date: At 1010 and 1141 ships time on 02 April

7 Location of incident South East [approx 15 miles off Newcastle] Persons on board Injuries/fatalities Damage 22 crew members, nil passengers oil burns to upper body, arms, lower legs / no fatalities none 1.2 BACKGROUND (all times UTC plus 10 hours) Vessel Shirane is a bulk carrier owned by Dorado Maritima SA Panama and operated by Nippon Yusen Kaisha Ltd Japan. She is employed for the transport of coal from Australian ports to Japanese ports She was built in 2000 in Japan and registered under the Panamanian flag. The five hold total capacity is cu.m. and her maximum load is metric tonnes. The certification issued in respect of Shirane is valid in Newcastle, and the vessel was manned in accordance with her safe manning certificate. The vessel had full International Safety Management (ISM) certification with a safety management system in place. 1.3 THE CREW The Master is 52 years of age with more than 30 years sea time. He had been aboard Shirane for 10 months. The Chief Engineer is 43 years of age. The Shirane was his first appointment as Chief Engineer with the Company. He had been on board for four months. There were another 20 crew members on board to fulfil the different activities to manage and operate the ship safely. 7

8 1.4 THE VICTIMS The Chief Engineer suffered light burns on his left neck, left hand and around the fingernails, with blistering on the palm. Medivaced to John Hunter Hospital for treatment. The 2/AE suffered burns on his right hand around the fingernails, left hand between thumb and index finger, stomach area where overalls were in contact, both ankles were his socks became alight, and eyelash and eyebrows were singed. He had been wearing a welding mask at the time of the flashback but this was blown off by the force of the flashback. Medivac to John Hunter Hospital for treatment. The 3/AE suffered burns to his face and hands. He was medivaced to John Hunter Hospital but eventually taken to Royal North Shore Hospital for treatment. The Fitter suffered burns to right side of face and back of both arms. Medivaced to John Hunter Hospital for treatment. At the time of investigation he was still wearing the bandages on the arms. 1.5 NARRATIVE (all times UTC plus 10 hours) At about 0630 hours on 02 April 2007 the Chief Engineer noticed white smoke coming from the exhaust of the composite boiler. From his experience this showed that the burner needed overhaul and replacement. This type of maintenance had been occurring regularly since arriving at the anchorage. At 0700 the Engine room received One Hours Notice, for the second Short Navigation that was to be conducted since arriving on 19 th March. By 0830 hours the vessel was departing the anchorage. The C/E was in the ECR to supervise the Short Navigation. The 1/AE was stationed in the ECR as the Duty Engineer for the Short Navigation. The 3/AE received orders from the C/E to overhaul the boiler burner and proceeded to do so. This is Item 2 in the Daily Job Orders and Working Hour Schedule. However his signature does not appear against his name in the lower section of the page. The Volcano burner was removed and the ready spare installed. He then manually test fired three times. Each time a Flame Fault alarm sounded. He initiated a manual purge, switched off the power to the boiler and closed the fuel oil valve. He removed the burner unit maintenance cover and while disconnecting the fittings, so as to remove the burner unit, the flashback occurred from the furnace side. The noise was heard in the ECR. The C/E sent the 1/AE out to check for the cause of the sound. 8

9 2/AE assisted the 3/AE to the ships hospital and left him with the 2/Mate to carry out the first aid. He returned to the engine room. The burner cover was replaced and manual purging commenced. This continued for one and a half hours. The 1/AE returned to the ECR and resumed his duties for the Short Navigation. After the 90 minutes of purging, the maintenance cover was removed. There was no smoke. The burner unit was still connected to the stabilizer which made it difficult to sight into the furnace. C/E went up and checked the funnel. There was no more smoke. Power to the boiler was switched off and the burner unit was removed for checking. Rags were used to clean out the burner housing. The C/E was standing on one side of the housing wearing a plastic full face protector. The 2/AE was on the other, wearing a welding mask but with a clear glass window. The Fitter was behind the 2/AE to assist with handling parts and cleaning, and had no additional protection. At 1141 hours another backfire occurred. 1/AE stated this noise was louder than the first. When he came out of the ECR and went to the boiler unit there was a lot of smoke and he could not see the C/E or the Fitter who were about two metres away. He saw the 2/AE running away from the boiler pulling off his burning clothes. The nearest fire extinguisher he found was from the ECR. It is a CO2 extinguisher and he successfully used this to extinguish the flames in the burner housing. C/E used the public address to call for help. The emergency teams were sent to the engine room. The burner housing was again replaced and continuous manual air purging with the force draft fan was started. A small hose using fresh water was used to cool the interior. Between 1305 and 1731 a Rescue Helicopter transported the victims to the John Hunter Hospital for Treatment. By 1420 hours the vessel had returned to anchor off Newcastle Harbour. On 6 th April the boiler was back in service. Instructions from the Company were used for this attempt. On 12 th April the burner overhaul was successfully carried out with Company permission. On arrival at the berth on 15 th April technicians boarded to conduct tests and inspection. 9

10 SECTION 2 ANALYSIS 2.1 AIM The purpose of the analysis is to determine the contributory causes and circumstances of the accident as a basis for making recommendations to prevent similar accidents occurring in the future. 2.2 HOW THE FLASHBACKS OCCURRED The vessel is fitted with a vertical composite boiler manufactured in Japan by the Osaka Boiler Mfg Company (type OEVC2-120/120-20). The water tubes in the upper part of the composite are heated by the main engine exhaust. The water tubes in the lower part (where the flashbacks occurred) are heated by a single Volcano burner (type VJ-140-1) in a truncated hemispherical steel furnace. The bottom of the furnace is lined with refractory material and there is a circular opening on one side for the oil burner unit. The exhaust gases for both pass through the same outlet smoke box before going out the funnel. The main engine had been idle for about a week. The lower part of the composite boiler had been in virtually continuous use since 19 March. There could have been unburnt fuel lying in the hot boiler furnace, after the reported three unsuccessful attempts to relight the burner. The refractory material of the furnace floor could have been hot enough to cause vapours to be given off, but not enough to be a source of ignition. The furnace allows a concentration of fuel vapour to accumulate in areas which are not swept by the flow of air from the burner maintenance opening to the smoke box. And the purge time after the burner was shut down could not disperse the vapour from the unburnt fuel. These vapours would likely have been one part of an explosive mixture. With the purge air stopped to open the burner maintenance housing, there could have been an influx of oxygen to help form an explosive mixture. There appears to have been sufficient unburnt oil to cause the formation of vapours for both incidents. With the main engine running for less than three hours before the incident, it is possible there were still unburnt particles of soot, or lube oil or fuel passing through the outlet smoke box. This spark could be enough to ignite the explosive mixture and cause the flashback through the burner housing and into the engine room. 2.3 ISM The C/E was unable to produce from the Manufacturer s manual an instruction or procedure for a burner overhaul whilst the main engine is running. He was also unable to produce a Job Safety Analysis for this work. There is no signature in Daily Job Orders and Working Hour Schedule against the 3/AE s name that he had received proper instruction and safety briefing. 10

11 SECTION 3 CONCLUSIONS 3.1 FINDINGS 1. Vessel Shirane was correctly manned and had full valid certification at the time of the incident. 2. Vessel Shirane was complying with Company instructions in leaving the anchorage for the Short Navigation. 3. The C/E was guided by his own experience in deciding to overhaul the boiler burner whilst underway. 4. ISM and Maintenance guidelines were breached. 5. After the first flashback the boiler should have been left until the vessel had returned to the anchorage, and a more controlled investigation conducted. 6. There was no Safety Bulletin from the Manufacturers detailing previous incidents that have caused injury to crew. These similar incidents occurred on the vessels Alam Mesra [29 April 2001] and Medi Monaco [17 May 2003 in Geelong, Victoria, Australia]. 3.2 CAUSE The incident was probably caused when an explosive mixture of gas was ignited from the main engine exhaust. 11

SECTION 4 RECOMMENDATIONS Taiheiyo Kisen Kaisha Ltd, is recommended to: Issue Standing orders and amend operating manuals with the instruction that

Osaka Boiler Mfg Company is recommended to: Provide a safety bulletin to operators of OEVC2 boilers warning them of this and previous incidents, and

12 SECTION 4 RECOMMENDATIONS Taiheiyo Kisen Kaisha Ltd, is recommended to: Issue Standing orders and amend operating manuals with the instruction that no overhaul is to be carried out on the boiler whilst the vessel is underway. Osaka Boiler Mfg Company is recommended to: Provide a safety bulletin to operators of OEVC2 boilers warning them of this and previous incidents, and drawing their attention to the correct safety precautions when servicing the fuel burner unit. William Burton Master Mariner Marine Surveyor MCC Marine Pty Ltd Peter Murday Master Mariner Marine Surveyor MCC Marine Pty Ltd 12

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