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TAIB Report: Fatigue, poor communication and a failure to follow safety procedures contributed to a boiler explosion
Fatigue, poor communication and a failure to follow safety procedures contributed to a boiler explosion aboard the 'Olivia', sailing as 'Bao Shine' since Aug 2025, on May 24 that year in Bluff, which seriously injured two crew members and hurt a third, investigators of the Transport Accident Investigation Commission have found out in their final report. The crew cleaned the boiler while it was still hot and after repeated failed attempts to restart it. The blast threw all three members of the night shift backwards. A third engineer and motorman suffered serious burns to their faces and arms, while a fitter suffered bruising to a shoulder. The 'Olivia' had been berthed at South Port in Bluff for 32 days while undergoing extensive repairs to its main engine and generators. Maritime New Zealand had prevented the vessel leaving port until repairs were completed and the cause of the machinery damage identified. The ship’s boiler flamed out late on May 23, and engineers made several unsuccessful attempts to restart it. One restart attempt caused an earlier blowback, sending soot and hot air through the burner intake and triggering a fire alarm. Nobody was injured. Hours later, the night shift began cleaning soot from inside the boiler. The crew proceeded without a documented assessment of the risks posed by residual fuel, heat and the introduction of compressed air. The motorman used an air lance to blast soot from the boiler tubes before directing compressed air into the furnace, where white smoke and glowing material had been visible. As the lance was withdrawn, an explosion occurred at 2.55 a.m. It was likely the motorman disturbed heated soot, igniting residual fuel in the boiler and causing the blowback. Zthe boiler had not been allowed to cool to an objectively verified safe temperature before compressed air was introduced. The senior engineers were very likely fatigued after sustained work on the vessel’s generator repairs. The engineering team had been operating 12-hour shifts, but some senior crew were also working outside those hours. The 2nd engineer was still helping troubleshoot the boiler about five hours after his day shift had ended. The vessel’s superintendent had also worked 21 hours during one period before resting for four hours and returning to work. The timing and circumstances of the call between the night shift 3rd engineer and the chief engineer very likely hindered clear communication and shared understanding of the proposed work and required controls. The chief engineer, who had been asleep when called, believed they had approved cleaning of the burner nozzle, while the night shift engineer understood that the permission had been given to clean soot from inside the boiler. The operator’s safety management system contained controls for unplanned work and boiler maintenance, but they were not consistently followed. The crew treated boiler cleaning as a familiar task, despite the conditions being significantly different from normal cleaning carried out after a boiler had cooled for several days at sea. No formal toolbox meeting, task-specific risk assessment or job hazard analysis was carried out before the work. The three crew members were wearing coveralls, safety shoes and gloves, but no face or eye protection. It was very likely the severity of the injuries would have been reduced if appropriate face protection had been worn. The commission also found the operator’s safety management system did not provide sufficient guidance for managing crews during sustained periods of intensive work, leaving the night shift without a senior engineer able to supervise higher-risk tasks. Fleet Management Limited has since reviewed its safety system, fatigue and risk assessment procedures, PPE requirements and management of prolonged maintenance periods. It has also issued a fleet-wide safety memorandum and developed a boiler safety warning for display aboard its vessels. The TAIC made no new recommendations, saying the action already taken by the operator had addressed the safety issues identified.
TAIC investigation underway into boiler explosion
An investigation was being underway into an explosion on the 'Olivia' in Bluff that has seen a bulk carrier placed under a partial protection order by transport investigators, temporarily preventing it from leaving New Zealand. Three crew members were injured in the incident on the morning of May 24. Four fire trucks had responded to the alert, which was received shortly after 3 .a.m, and assisted ambulance crews with getting the injured off the ship. Hato Hone St John transported the injured crew members to Southland Hospital in Invercargill, two in serious condition and one in a moderate condition. The Transport Accident Investigation Commission (TAIC) was investigating the incident as a serious marine casualty as required under international maritime regulations- The ship will be unable to leave port until the investigation is finished. The order gave TAIC the power to protect and restrict access, and to require people provide papers, documents, records or other items, including voyage and engine data, recording equipment, the boiler and boiler system, and videos and photos taken by the crew. While it did not apply to the entire ship, apart from from urgent safety actions, obeying the order meant the crew cannot operate the boiler system, voyage data system, effectively marooning the ship at the South Port. The three investigators deployed on MAy 25 included experts in ship control and command, engineering and digital data extraction and analysis. The team conducted interviews and collected physical and digital evidence, and wrapped up the on-site investigation on May 28. Different lines of inquiry will be followed over the next few months, with work in later stages - particularly during analysis - potentially requiring further evidence collection. The investigation would determine the broader circumstances and cause, but TAIC investigations did not ascribe blame or liability. The TAIC investigations can take two years or longer to complete. Report with photos: https://www.thepress.co.nz/nz-news/360707271/investigation-bluff-boat-explosion-may-see-carrier-untouched-years
Explosion injured three crew members
On May 24t, 2025, at 3.15 a.m. LT, an explosion and flashback occurred in the engine room of the 'Olivia', which was docked at Berth 11 of the South Port in Bluff. Three crew members were injured. They had been working on a boiler in the engine room at that time. They were provided with medical attention immediately. A small fire was extinguished by the crew before the arrival of the Fire and Emergency NZ with two crews from Bluff and Invercargill. Also the St. John Ambulance responded with one rapid response unit and two ambulances. Its team assessed and treated the three crew members, one of whom was was a moderate condition and the other two in a serious condition They were taken to the Southland hospital. The vessel had arrived in the port on April 22 en route from Bintulu, and was loading a cargo of logs with an ETD as of May 29. The Transport Accident Investigation Commission (TAIC) launched an investigation into the incident. and started collecting evidence and interviewing witnesses to determine the cause and circumstances of the explosion. Report with photo: https://maritime-executive.com/article/three-injured-in-boiler-explosion-on-bulker-in-new-zealand
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