A boiler blowback that injured three crew on a ship at South Port, Bluff, highlights the need to reassess risks when familiar work is carried out in different conditions, says the Transport Accident Investigation Commission.
TAIC today released its final report into the 24 May 2025 accident on the bulk carrier Olivia in which two crew suffered serious burns and a third suffered bruising while cleaning soot from inside the vessel’s boiler.
The ship had been in port for 32 days for extensive maintenance and repairs. Repeated attempts to restart a boiler burner had failed, so the night shift team was using an air lance – a long tube connected to a compressed air hose – to direct a jet of air to clear soot to fix the problem.
The crew regarded boiler cleaning as familiar work. At sea, heat from the main engine’s exhaust supplies the ship’s steam, allowing the oil-fired furnace to be switched off and cool for several days before cleaning. In port, the furnace was used to produce steam because the main engine was stopped. On this occasion, no objective check confirmed that the furnace had cooled to a safe temperature before cleaning began.
Chief Investigator of Accidents Louise Cook says it was likely that disturbed heated soot ignited residual fuel as the air lance was withdrawn.
“Before internal cleaning, a boiler furnace needs to be isolated and verified as safely cooled. Blowing compressed air into that hot furnace with unburned fuel was a recipe for a blowback.”
The Commission’s investigation identified two safety issues: inadequate implementation of the vessel’s safety management system, and a lack of guidance for managing crew during sustained intensive work periods.
Most engineering resources were focused on the daytime generator repairs. The daytime senior engineering officers were very likely fatigued, which adversely affected their decision-making when approving the cleaning job. Then the smaller night shift lacked the capacity to plan and supervise unexpectedly higher-risk work.
“Long repair programmes need continuing attention to workloads, rest and supervision. If an unexpected job is beyond people’s capability, it should be a straightforward decision to stop and get the right support.”
The ship’s operator, Fleet Management Limited, has taken action to address both issues, including reviewing procedures, protective equipment and fleet training, so there was no need for the Commission to issue new recommendations.
The Commission’s report provides a compelling narrative and lessons for other operators and industries to consider reviewing their own arrangements. The lessons are relevant to maritime operators, seafarers, maritime training facilities, boiler-reliant industries and firefighting agencies.
TAIC investigates to establish circumstances and causes of accidents and incidents in order to help the transport sector avoid similar occurrences in future. It does not assign blame.