Introduction
Prolonged repairs can change workloads, staffing and the risks of tasks normally regarded as routine. Safety management systems need to help people recognise those changes and bring the right controls into use. This report has lessons for maritime operators, seafarers, training facilities, boiler-reliant industries and firefighting agencies.
What happened
The Malta-registered Olivia arrived at Bluff on 23 April 2025 after engine and generator problems at sea. Maritime NZ required satisfactory repairs before the ship could leave. All three generators needed extensive refurbishment, extending a planned five-day port stay to more than a month.
The operator, Fleet Management Limited, provided additional people and technical support. Engineering work ran around the clock in 12-hour shifts. Most resources and senior engineering expertise were assigned to the day shift for generator repairs; three staff on the night shift were assigned routine cleaning and preparation tasks for the next day shift activities.
On the night of 23 May, the boiler burner failed. Repeated attempts to restart it had failed, and one had caused a blowback with nobody hurt. To fix this, the engineering team decided that accumulated soot should be cleaned from inside the boiler.
In the early hours of 24 May, the night crew used an air lance – a long tube connected to a compressed air hose – to direct a jet of air to blow away soot or other deposits. Unlike the usual cleaning task at sea, when the boiler would have cooled for days, the furnace was still hot and contained residual fuel. No objective check confirmed that it had reached a safe condition.
At about 0255, a blowback threw the three crew backwards. Two sustained serious burns and the third suffered bruising. All three were taken to hospital.
Why it happened
The initial burner failure was likely due to a combination of a malfunctioning air-intake flap, a faulty ignition transformer and accumulated soot. And it is likely that heated soot was inadvertently disturbed as the air lance was withdrawn, igniting residual fuel inside the furnace.
It is very likely that senior engineering officers were fatigued, adversely affecting decision-making. A telephone discussion with the chief engineer, who had been asleep, very likely hindered a shared understanding of the proposed cleaning work and the controls required.
Safety Issues and TAIC Recommendations
Using safety controls when conditions change
The safety management system included controls for unplanned work and boiler maintenance, but they weren’t being used. The crew discussed tools and the cleaning sequence but did not reassess the changed conditions of having to work on the failed furnace which was still hot.
- Takeaway: Recognise changed conditions, stop and reassess. Isolate the furnace and verify safe cooling before internal cleaning. Where a generic assessment does not cover the task, involve people with the technical knowledge and authority to assess the actual risks.
Managing people during prolonged repairs
The operator’s safety management system lacked guidance for managing crew during sustained periods of intensive work. Resources were concentrated on the generator repairs. The night shift lacked capacity to plan and supervise the unexpected higher risk task, and some senior personnel worked beyond their scheduled hours.
- Takeaway: Reassess staffing, supervision and rest when work extends. Clear escalation arrangements should delay work that is beyond a shift’s capability until appropriate support is available.
Operator safety actions and recommendations
The Olivia’s operator, Fleet Management Limited, has taken action to address both safety issues. It reports issuing a company-wide safety memorandum; reviewing risk assessment, unplanned work, fatigue and resource management procedures; enhancing its protective equipment matrix; developing a boiler safety warning poster; and incorporating the lessons into fleet training for joining seafarers.
There was no need for the Commission to issue new recommendations.
The report provides a compelling narrative and lessons for other operators and industries to consider reviewing their own arrangements.