Boiler flashback - M/N ¨SHIRANE¨
_____
Peter Murday – Master mariner
Accidents Investigator
Report on the investigation of the
Boiler flashback on
M.V. Shirane
April 2007
1
Panama Maritime Authority
Directorate General of Merchant Marine
Investigation of Wrecks and Maritime Accidents Department
Panama, Republic of Panama
Boiler flashback - M/N ¨SHIRANE¨
_____
Peter Murday – Master mariner
Accidents Investigator
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
Panama Maritime Authority
Directorate General of Merchant Marine
Investigation of Wrecks and Maritime Accidents Department
Panama, Republic of Panama
Boiler flashback - M/N ¨SHIRANE¨
_____
Peter Murday – Master mariner
Accidents Investigator
CONTENTS
PAGE
GLOSSARY OF ABBREVIATIONS AND ACRONYMS
SYNOPSIS
5
SECTION 1 - FACTUAL INFORMATION
1.1 Particulars of vessel Shirane and accident details
1.2 Background (all times UTC plus 10 hours, Ship’s Time)
1.3 The Crew
1.4 The Victims
1.5 Narrative
6
7
7
8
8,9
SECTION 2 - ANALYSIS
2.1 Aim
2.2 How the Flashbacks occurred
2.3 ISM
10
10
10
SECTION 3 – CONCLUSIONS
3.1 Findings
3.2 Cause
11
11
SECTION 4 – RECOMMENDATIONS
12
3
Panama Maritime Authority
Directorate General of Merchant Marine
Investigation of Wrecks and Maritime Accidents Department
Panama, Republic of Panama
Boiler flashback - M/N ¨SHIRANE¨
_____
Peter Murday – Master mariner
Accidents Investigator
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
Panama Maritime Authority
Directorate General of Merchant Marine
Investigation of Wrecks and Maritime Accidents Department
Panama, Republic of Panama
Boiler flashback - M/N ¨SHIRANE¨
_____
Peter Murday – Master mariner
Accidents Investigator
SYNOPSIS
On 02nd 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 Panama Maritime Authority 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 16th 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 0830 02 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
Panama Maritime Authority
Directorate General of Merchant Marine
Investigation of Wrecks and Maritime Accidents Department
Panama, Republic of Panama
Boiler flashback - M/N ¨SHIRANE¨
_____
Peter Murday – Master mariner
Accidents Investigator
SECTION 1 – FACTUAL INFORMATION
1.1 PARTICULARS OF VESSEL SHIRANE AND ACCIDENT
Registered Owner
Dorado Maritime Panama
Manager
Taiheiyo Kisen Kaisha Ltd
Port of Registry
Panama
Flag
Panama
Type
Bulk Carrier
Built
2000, Imabari, Japan
Classification Society
Nippon Kaiji Kyokai
Construction
Steel
Length Overall
229.00m
Gross Tonnage
43376
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 2007
6
Panama Maritime Authority
Directorate General of Merchant Marine
Investigation of Wrecks and Maritime Accidents Department
Panama, Republic of Panama
Boiler flashback - M/N ¨SHIRANE¨
_____
Peter Murday – Master mariner
Accidents Investigator
Location of incident
Newcastle]
33°01.4’South
152°00.8’ East [approx 15 miles off
Persons on board
22 crew members, nil passengers
Injuries/fatalities
oil burns to upper body, arms, lower legs / no fatalities
Damage
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 90493 cu.m. and her maximum load is 77470 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
Panama Maritime Authority
Directorate General of Merchant Marine
Investigation of Wrecks and Maritime Accidents Department
Panama, Republic of Panama
Boiler flashback - M/N ¨SHIRANE¨
_____
Peter Murday – Master mariner
Accidents Investigator
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 19th 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
Panama Maritime Authority
Directorate General of Merchant Marine
Investigation of Wrecks and Maritime Accidents Department
Panama, Republic of Panama
Boiler flashback - M/N ¨SHIRANE¨
_____
Peter Murday – Master mariner
Accidents Investigator
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 6th April the boiler was back in service. Instructions from the Company were used for this
attempt.
On 12th April the burner overhaul was successfully carried out with Company permission.
On arrival at the berth on 15th April technicians boarded to conduct tests and inspection.
9
Panama Maritime Authority
Directorate General of Merchant Marine
Investigation of Wrecks and Maritime Accidents Department
Panama, Republic of Panama
Boiler flashback - M/N ¨SHIRANE¨
_____
Peter Murday – Master mariner
Accidents Investigator
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
Panama Maritime Authority
Directorate General of Merchant Marine
Investigation of Wrecks and Maritime Accidents Department
Panama, Republic of Panama
Boiler flashback - M/N ¨SHIRANE¨
_____
Peter Murday – Master mariner
Accidents Investigator
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
Panama Maritime Authority
Directorate General of Merchant Marine
Investigation of Wrecks and Maritime Accidents Department
Panama, Republic of Panama
Boiler flashback - M/N ¨SHIRANE¨
_____
Peter Murday – Master mariner
Accidents Investigator
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
Panama Maritime Authority
Directorate General of Merchant Marine
Investigation of Wrecks and Maritime Accidents Department
Panama, Republic of Panama