The accident report for the explosion of the Qian Chi, a commercial vessel, in Brisbane Australia in January 2011 has been released. The report shows that it was a simple oversight that contributed to the explosion, rather than the complicated processes often expected in the case of a damaging explosion such as this.

The Qian Chi went up in flames on the 16th of January 2011, while the vessel was anchored in Moreton Bay, Queensland. Three crew members were seriously injured in the explosion, and the thermal oil heater and surrounding equipment and fittings were irreparably damaged. The injured seamen received rudimentary first aid on board the vessel and then were airlifted to a local hospital for treatment of their injuries.

Following the incident, the Australian Transport Safety Bureau (ATSB) conducted a thorough investigation to determine the cause of the explosion. According to the accident report, released earlier this month, the thermal oil heater burner nozzle had been incorrectly assembled during routine maintenance of the vessel. The error occurred most likely due to inexperienced crew members and unclear instructions supplied by the manufacturers. As a result of the incorrect assembly, the nozzle leaked oil into the ship’s furnace, which then exploded once the burner ignited.

In addition, the ATSB found that the crew members onboard the vessel did not have adequate knowledge regarding first aid treatment for burn injuries. As a result, the injured seamen suffered more severe injuries and only received appropriate first aid when they were attended to by shore-based emergency paramedics. The Brisbane port authorities were also found to be unprepared to deal with such an emergency, leading to delays in providing emergency treatment for the sailors.

As a result of the investigation findings, the operators of the vessel have replaced the oil burner system on the ship and have made changes to the control system being used by the burner to allow easier maintenance and decrease the demands being placed on the heater. In addition, the manufacturers of the heater, Garioni Naval, have been advised to update the instruction manual for their equipment, to make it clearer and easier to follow. Maritime Safety Queensland have also taken action following the report, and are reviewing their current procedures regarding explosions of vessels in the port and the emergency response protocols in such a situation.

The major safety message to come from this incident is that crew members should take care, even when performing relatively simple tasks, as small errors can have significant consequences and lead to injury or even death.

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