It’s often not the complicated procedures that lead to an accident, it’s the apparently simple, as in the case of an explosion aboard the Qian Chi in Brisbane, Australia which seriously injured three crew members and cause significant damage to a thermal oil heater and its surrounding. Part of the problem, though not specifically mentioned in the ATSB report, is that the brain filters out the familiar so that those small things that are different are not noticed, it’s a phenomenon that is often passed off as ‘complacency’.
The ATSB says it found that “.. during maintenance, the thermal oil heater burner nozzle had been assembled incorrectly. This was because the crew lacked experience with the equipment and the manufacturer supplied instructions were not clear and detailed. As a result, the nozzle leaked fuel into the furnace throughout the pre-ignition start sequence. The furnace exploded when the burner igniter started”.
The ATSB also found that the ship’s crew were not aware of the importance of providing immediate and accepted first aid treatment for burn injuries. It was also found that deficiencies in the Brisbane port vessel traffic service procedures and preparedness contributed to delays in providing emergency assistance.