This report is predicated on the protection investigation carried out by the Marine Security Investigation Unit (MSIU) concerning a boiler furnace blowback incident that occurred on 31 January 2018, roughly 30 nautical miles from Qingdao Pilot Station. The incident concerned severe accidents to 2 crew members. The aim of the investigation was to determine causes and contributing components to stop recurrence, to not assign blame or legal responsibility
What Occurred
Whereas the vessel was on passage from Dalian to Qingdao, the engineering officer of the watch noticed that the auxiliary boiler was not working usually, and several other alarms had been triggered. The electrician tried to reset the boiler’s management system a number of instances, however the fault persevered. Believing that the flame detector and the low-water-level sensor had been faulty, these had been bypassed, and the boiler was restarted in handbook mode. It continued working on this mode with out abnormalities for a number of hours.
Following session with the boiler producer, the second engineer and electrical engineer shut down the boiler to examine the sensor indicators as suggested. Throughout this inspection at 18:07, a furnace blowback occurred, forcing open the burner housing and releasing sizzling gases and flames, which injured each crew members. Later surveys recognized injury to burner elements, the motor, and the management panel. Additional inspection revealed {that a} defective water degree change and a faulty combustion air circulation timer had contributed to the malfunction. After the alternative of broken digital management items and changes by service engineers, the boiler was restored to regular operate
Sustained Accidents
The second engineer and {the electrical} engineer sustained burns to their faces, chest, and fingers. Each injured crew members had been transferred ashore for remedy and had been stored below statement at a hospital. Their well being situations improved steadily, they usually had been discharged a number of days later after receiving specialised medical care.
Evaluation and Contributing Components
The investigation concluded that the furnace contained an explosive combination of gasoline and air, which was ignited both by residual warmth contained in the furnace or throughout restart actions. There was additionally a risk that marine diesel oil (MDO) leaked into the furnace after shutdown, which might have raised the chance of an explosion. Uncertainty remained about whether or not post-shutdown purging was carried out, or whether or not it lasted lengthy sufficient to take away gasoline vapors and gases. Because the boiler had been working on MDO earlier than shutdown, the chance of an explosive combination forming was greater. Though a danger evaluation was carried out earlier than the occasion, it solely thought of hazards of flame failure and low water contained in the boiler, focusing narrowly on faulty sensors. The evaluation missed hazards related to handbook operation, faulty management methods, and gasoline leakage. Moreover, the injured electrician had not signed the chance evaluation type, exhibiting incomplete crew involvement in hazard identification and analysis.
Security Actions Taken
Through the course of the protection investigation, the corporate issued a Security Alert throughout its fleet, reminding all vessels in regards to the protected operation of boilers throughout fault-finding and the significance of getting ready work plans and danger assessments earlier than beginning any activity. Extra security measures included stronger managerial oversight by technical superintendents and fleet managers for work planning and assessments, engagement of producer service engineers to examine boilers and alter operational parameters, and discussions of the accident in each onboard security conferences and shore-based administration conferences with the engineering division.
Security Suggestions
No further suggestions had been issued by the MSIU, as corrective measures had already been applied by the operator through the investigation.
Classes Discovered
Security-critical sensors should not be bypassed with out complete danger analysis and manufacturer-approved procedures.
Correct furnace purging is crucial after shutdown to stop accumulation of explosive mixtures.
Danger assessments must be complete, figuring out not solely rapid hazards but in addition dangers from working in emergency modes or with defective methods.
All personnel concerned in technical interventions ought to take part in danger assessments to make sure consciousness of hazards.
Clear communication and adherence to producer directions are essential throughout troubleshooting.
Common inspections of management methods, sensors, and security gadgets can stop faults that compromise boiler security.
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Supply: MSIU
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