Publication Date: August 2007 ISBN 978-1-921165-15-3 ISSN 1447-087X

The Australian Transport Safety Bureau AUSTRALIAN TRANSPORT SAFETY INVESTIGATION REPORT
(ATSB) is an operationally independent
multi-modal bureau within the Australian
Marine Occurrence Investigation No. 239
Government Department of Transport
and Regional Services.
The ATSB is responsible for investigating
accidents and other transport safety
matters involving civil aviation, marine
and rail operations in Australia that fall
Crew member seriously burned by steam
within Commonwealth jurisdiction.
The ATSB performs its functions in
accordance with the provisions of the
on board MSC Sonia
Transport Safety Investigation Act At about 09451 on 10 April 2007, MSC Sonia’s The ship’s propulsive power is supplied by two
2003 and, where applicable, relevant boatswain and ordinary seaman were on Mitsui MAN B&W 7K90GFCA single acting,
international agreements.
the top platform of the ship’s funnel casing, direct reversing, two-stroke diesel engines,
ATSB investigations are independent of
regulatory, operator or other external painting the starboard main engine exhaust each delivering 20 300 kW at 117 rpm. Each
bodies. It is not the objective of an pipe, when steam unexpectedly exhausted from engine drives a fixed pitch propeller and
investigation to determine blame or the nearby boiler safety valve vent pipe. The together they give the ship a service speed of
liability.
ordinary seaman was seriously burned by the 21 knots3.
steam.
© Commonwealth of Australia 2007.
At the time of the incident, MSC Sonia had a
This work is copyright. In the interests of
crew of one Myanmar and 30 Indian nationals.
enhancing the value of the information
contained in this publication you may
MSC Sonia
copy, download, display, print, reproduce MSC Sonia (Figure 1) is a 2450 TEU2 cellular The master held an Indian master’s certificate
and distribute this material in unaltered
container ship that operates on a liner service of competency. He had 17 years of seagoing
form (retaining this notice). However,
copyright in the material obtained from between Asia and the Australian east coast experience and had been sailing as master
other Government agencies, private ports of Melbourne, Sydney and Brisbane. for six years. At the time of the incident, he
individuals or organisations, belongs was part way through his second, four month,
to those agencies, individuals or
organisations. Where you want to use The ship was built in 1972 by Mitsubishi Heavy assignment on board MSC Sonia.
their material you will need to contact Industries, Japan. It has an overall length of
them directly. 261 m, a moulded breadth of 32.26 m and The chief engineer had 32 years of seagoing
Subject to the provisions of the Copyright a moulded depth of 21.49 m. At its summer experience and held an Indian class one
Act 1968, you must not make any other certificate of competency. He had sailed as
use of the material in this publication draught of 13.0 m, the ship has a deadweight
unless you have the permission of the of 42 053 tonnes. chief engineer since 1990. He was also part
Australian Transport Safety Bureau. way through his second assignment on board
Please direct requests for further At the time of the incident, MSC Sonia was the ship.
information or authorisation to:
registered in Panama and classed with
Germanischer Lloyd (GL). The ship was owned The chief mate held an Indian first mate’s
Commonwealth Copyright Administration,
Copyright Law Branch by Oreta Enterprises, Panama and managed by certificate of competency. He had 18 years of
Attorney-General’s Department MSC Ship Management, Hong Kong. seagoing experience and had been sailing as
Robert Garran Offices
National Circuit
BARTON ACT 2600
Figure 1: MSC Sonia
www.ag.gov.au/cca

Australian Transport Safety Bureau

PO Box 967, Civic Square ACT 2608

Australia

1800 621 372

www.atsb.gov.au
1 All times referred to in this report are local time,
Coordinated Universal Time (UTC) + 10 hours.
Released in accordance 2 Twenty-foot Equivalent Unit. The nominal size of a
with section 25 of the ship in TEU refers to the number of standard shipping 3 One knot, or one nautical mile per hour, equals
Transport Safety Investigation Act 2003 containers that it can carry. 1.852 kilometres per hour.

1
chief mate for one year. He had been on board two automatically controlled Volcano steam jet
MSC Sonia for about two weeks. burners.

The second engineer had nine years of At full load, the boiler produces 15 000 kg of
seagoing experience and held an Indian class steam per hour at a nominal working pressure
two certificate of competency. He had been on of 7.5 bar4.
board the ship for about six weeks.
The boiler is fitted with two safety valves
The boatswain had 23 years of seagoing (Figure 3). These valves are designed to limit
experience. At the time of the incident, he boiler pressure to a maximum of 13 bar.
had been on board MSC Sonia for about two However, due to the age of the boiler, the safety
months. valve settings had been lowered to 11 bar.
The ordinary seaman had two years of seagoing Each boiler safety valve is fitted with an
experience and had been on board MSC Sonia exhaust pipe which connects into a common
for about two months. line that vents at the top of the funnel casing.
The GL surveyor started his seagoing career in Figure 3: Auxiliary boiler safety valves
1968. He reached the rank of chief engineer
before taking up a shore based position in
1985. He worked for about ten years in various
maritime related industries before becoming
a non-exclusive surveyor. After six years as a
non-exclusive surveyor, he took up a position
as a senior surveyor with GL. At the time of the
incident, he had been a surveyor with GL for
about five years.

The auxiliary boiler

Steam is used on board MSC Sonia by a pair of
turbo alternators. It is also used for fuel tank
heating, fuel treatment, jacket water heating
and domestic heating.

While the ship is at sea, steam is supplied by

The incident
a pair of waste heat boilers that are fitted in MSC Sonia arrived in Kaohsiung, Taiwan on
the main engine exhaust uptakes. They use the 28 March 2007. The ship carried out its normal
residual heat in the exhaust gases to produce cargo exchange and the ship manager’s ‘port
steam. captain’ joined the ship. The plan was for the
port captain to sail on the ship to Brisbane via
Figure 2: Auxiliary boiler Melbourne and Sydney. His task was to carry
out an inspection of the ship and to complete
an audit of the ship’s safety management
system, a requirement of the International
Safety Management (ISM) Code.

The ship sailed from Kaohsiung on 28 March,

en route to Melbourne. The crew carried on with
their normal watchkeeping and maintenance
duties.

On 31 March, the ship’s senior officers held the

regular fortnightly management meeting. They
discussed the maintenance that they planned
to complete in the next two weeks but no
upcoming survey items were discussed.
When in port, the ship’s steam demand
is serviced by a single Osaka Boiler Mfg
Company DE 48030-150 cylindrical smoke 4 1 bar equals 100 KPa or approximately one
tube boiler (Figure 2). The boiler is fitted with atmosphere.

2
About a week later, the port captain informed suggested to the boatswain that if the ordinary
the master that the due date for the annual seaman was not required by the duty mate, he
class survey of the boilers was imminent. The should be able to assist with the work.
master then contacted the ship’s manager,
asking him to arrange for a class surveyor to The boatswain received the duty mate’s
attend the ship in Australia. permission to use the ordinary seaman and,
after getting their equipment, the two men
On 8 April, the master telephoned the ship’s climbed up to the top platform of the funnel
manager and was told that it was unlikely that casing and started painting the exhaust pipes.
a surveyor could attend the ship in Melbourne
because of the upcoming Easter holiday At about 0900, the surveyor arrived on board
period. The master was also notified that the the ship. He was escorted to the master’s
ship would be anchoring for a short time in cabin where he, the master and the chief
Melbourne before berthing. engineer discussed the survey. The surveyor
wanted to see the boiler burner safety cut-out
The chief mate and the boatswain decided to devices tested. He also wished to see the
use the time at anchor to paint the exhaust operation of the boiler safety valves.
pipes at the top of the funnel.
The chief engineer and the surveyor went to the
The chief engineer and the second engineer engine room and met with the second engineer
discussed the work that they wished to carry and the electrical engineer. After an external
out at the anchorage. They planned to use the examination of the boiler they tested the cut­
time to prepare the boilers for the survey. out devices.

The second engineer later met with the chief When the testing of the cut-out devices had
mate and they discussed the need to allocate been successfully completed, the surveyor
as much manpower as possible to prepare for asked for the operation of the safety valves to
the boiler survey while the ship was at anchor. be tested. The turbo-alternator was shut down
The chief mate subsequently met with the to reduce the steam demand and the boiler’s
boatswain and all unnecessary work on deck two burners were fired manually. The steam
was postponed. pressure started to rise and, at about 0945,
when the boiler pressure reached 11 bar, the
The ship arrived off Port Phillip on the morning safety valves lifted.
of 8 April and a pilot boarded for the transit to
the Melbourne anchorage. The anchor was let The boiler burners were then shutdown and
go in the anchorage and finished with engines the steam pressure began to fall. After about
was rung at 1218. five seconds the safety valves re-seated and
the steam pressure continued to fall slowly.
The engineers carried out their checks of the When the pressure had returned to normal,
boilers and the crew spent the time at anchor the engineers set the boiler burners to fire
cleaning the boilers and the surrounding areas. automatically and the turbo-alternator was
placed back in service.
The ship was prepared for the transit from the
anchorage to Swanson Dock in the evening of At about 0945, while the boatswain and the
9 April and, by 1940, it was all fast alongside ordinary seaman were painting the starboard
the berth. main engine exhaust pipe, steam unexpectedly
vented from the nearby boiler safety valve
After attending to some ship’s business, the exhaust pipe, directly onto the ordinary seaman
master went to his cabin to check his computer (Figure 4). The force of the venting steam was
for any emails. He had received a message so strong that it knocked the boatswain off the
from the ship’s manager informing him that platform he was standing on and onto the deck.
a surveyor would attend the vessel at 0900
the next morning to survey the boilers. The The boatswain called out to see if the ordinary
master passed this information on to the chief seaman was alright but he received no reply.
engineer who, in turn, discussed it with the
second engineer. When the steam stopped exhausting, the
ordinary seaman appeared through the cloud of
On the morning of 10 April, the chief mate and steam. He shook off his gloves and said to the
the boatswain met and discussed painting boatswain ‘look what has happened to me’.
the funnel exhaust pipes. The chief mate

3
Figure 4: Funnel casing top platform steam from the boiler safety valves. The chief
engineer returned to the boiler and he and the
surveyor continued with the survey, carrying out
an external inspection of the two waste heat
boilers.

The master had heard the boatswain’s calls

for help on the hand held radio. Before going
to the bridge deck, he called the second mate
and told him to bring up a stretcher. When the
master arrived at the bridge deck and saw what
had happened, he called the ship’s agent on
his mobile telephone and requested emergency
assistance. He also advised the container
terminal staff of the incident.
The master organised the crew’s response and
The boatswain could see that the ordinary they began cutting away the ordinary seaman’s
seaman was wet all over and the skin he could overalls to expose his burns to the water.
see was badly scalded. The boatswain told the
ordinary seaman to stay where he was while he A first aid officer from the container terminal
went for help. arrived on board and he determined that the
ordinary seaman needed more assistance than
The boatswain went down to the main deck and he could provide.
used a hand held radio to call for help.
At 1015, an ambulance team arrived on board
He then returned to the funnel casing top the ship and they took charge of the ordinary
platform with the chief mate. The two men seaman’s medical treatment.
explained to the ordinary seaman that he would
have to climb down the funnel casing ladder The container terminal manager also arrived
because there was no other way of getting on board the ship, and he and the master
him down. With their assistance, the ordinary discussed how they were going to land the
seaman climbed down the ladder and walked ordinary seaman ashore. It was decided that
out of the funnel casing, onto the bridge deck the terminal staff would connect a personnel
(Figure 5). He then lay on the deck while the basket to the shore side gantry crane and
chief mate used a nearby hose to shower him manoeuvre it as close as possible to the ship’s
with water to cool his burns. bridge deck.
Figure 5: Funnel casing and bridge deck When the ambulance team had completed
their initial treatment, the ordinary seaman
was placed onto a solid stretcher. He was then
carried to the side of the ship and placed into
the gantry crane basket.

At about 1100, the ordinary seaman was

landed ashore, placed in the waiting ambulance
and taken to hospital.

Analysis
Awareness
The chief mate and the boatswain had decided
not to paint the funnel exhaust pipes until
the ship’s main engines were shut down. This
At about 0950, the chief engineer was called indicates that they were aware of, and had
to the engine control room. He was told that considered, some of the hazards involved in
one of the ship’s crew members had been working on the funnel casing top platform.
badly burned. However, he was not told, and
was not aware at this time, that the crew However, the chief mate, the boatswain and the
member had been burned by the venting of ordinary seaman were not aware that the large

4
bore pipe on the starboard side of the funnel anchor off Melbourne, that the second engineer
casing top platform was a steam vent pipe. would discuss their needs with the chief mate.
Furthermore, they were not aware that steam
would exhaust from the pipe on every occasion Similarly, the chief mate would discuss
that a boiler safety valve operated. While safety maintenance issues on a daily basis with the
valves do not usually operate very often, they master but would only talk to the engineers if
are a safety device that can operate at any he felt that their technical input was required.
time.
Had the senior deck and engineering officers
The chief engineer, the second engineer and met more frequently and discussed all the work
the surveyor were all aware that steam would that they intended to complete, they probably
exhaust from the funnel top vent pipe when would have identified the hazards associated
the safety valves were operated. However, they with operating the boiler safety valves while
were not aware that anyone was working on the crew members were working on the funnel
funnel casing top platform and they assumed casing top platform.
that the area would be clear of all personnel.
Risk assessment
Had each work group been aware of the other’s
activities, it is likely that the incident would not The ship’s safety management system included
have occurred. a permit to work system. However, it did not
include a requirement for the ship’s crew to
formally assess the risks involved in carrying
Communication out hazardous tasks.
MSC Sonia’s safety management system
required the ship’s senior staff to meet every Both the chief mate and the chief engineer
two weeks to discuss the maintenance that thought the tasks they were carrying out were
had been completed in the previous two weeks routine. However, both tasks included some
and the maintenance that they planned to hazards that had not been identified.
complete in the next two weeks. The record of
Had the chief engineer and the chief mate
this meeting was then forwarded to the ship’s
taken the time to complete an analysis of
manager as a maintenance report.
the risks associated with the tasks they
The records of these meetings indicate that were undertaking, they would probably have
they were an overview of the maintenance identified the venting of steam at the funnel
being carried out and that senior staff were casing top platform as a hazard.
not discussing every task that they planned to
The surveyor was also aware that steam would
complete. Furthermore, because of the ship’s
exhaust at the top of the funnel casing when
age, there was a large amount of unanticipated,
the boiler safety valves operated. However, he
or unplanned, work being carried out.
relied on the ship’s crew to ensure that the
It is common on board many ships for the area was clear of personnel. He did not check
senior deck and engineering officers to meet that they had implemented strategies that
on a daily basis to discuss the tasks that they would effectively control the risks.
plan to complete that day. The aim of these
In submission, the surveyor stated that:
meetings is to utilise their collective knowledge
to increase the group’s awareness of everything During normal survey, like external boiler
that is happening on board the ship at any inspection we discuss the inspection but will
given time. not check that the ship’s management follow
company procedures.
However, MSC Sonia’s safety management
system did not require the crew to carry out Had the surveyor checked the measures the
such daily meetings and the ship’s crew had ship’s crew had in place to control the hazards
not identified the need to implement such a associated with operating the boiler safety
system. valves, he may have realised that they had not
ensured that the funnel casing top platform
The second engineer and the chief engineer
was clear of personnel.
discussed maintenance issues on a daily
basis. However, it was only on occasions when
they required extra manpower in the engine
room, such as the period when the ship was at

5
The vent pipe • The surveyor did not check that the ship’s
crew had implemented strategies that would
The boiler safety valve vent pipe (Figure 4) is effectively control the risks associated with
mounted on the starboard side of the funnel operating the boiler safety valves. [Safety
casing top platform. It stands about 0.5 m issue]
above the deck and is terminated with a right
angle bend. Any exhausting steam is directed Safety actions taken by MSC Ship
inboard towards the main working area of the
platform. Management
The ATSB has been advised that the following
This arrangement is similar to many such vent safety actions have been taken by MSC Ship
pipes. However, the design does not take into Management as a result of the incident on
account the fact that personnel can, at times, board MSC Sonia on 10 April 2007.
be working on the platform.
The company has issued a number of safety
Had the pipe been designed so that it directed circulars to its fleet that have emphasised
the exhausting steam away from the working the need for job planning, analysis and
platform or at a height well above the height of communication.
a person standing on the platform, it is likely
that the ordinary seaman would not have been A new system of job planning has been
injured. implemented. This system calls for the
completion of a formal risk assessment and
Findings toolbox meetings before any job is started.
From the evidence available, the following ATSB safety recommendations
findings are made with respect to the serious
crew member injury that occurred on board MR20070027
MSC Sonia on 10 April 2007. The findings The senior deck and engineering officers did
should not be read as apportioning blame not discuss their work programs frequently
or liability to any particular organisation or enough to ensure that each department was
individual. always aware of the other’s activities.
Contributing safety factors The ATSB recommends that MSC Ship
Management takes action to address this
• The chief mate, the boatswain and the
safety issue.
ordinary seaman were not aware of all of
the hazards associated with working on the
top platform of the funnel casing. ATSB safety advisory notices
MS20070009
• The chief engineer, the second engineer and
the surveyor were not aware that the crew The placement of the steam vent pipe, and the
were working on the top platform of the direction in which it exhausted, meant that any
funnel casing. personnel on the funnel casing top platform
were vulnerable when a boiler safety valve
• The senior deck and engineering officers did operated.
not discuss their work programs frequently
enough to ensure that each department The ATSB advises the owners, operators and
was always aware of the other’s activities. masters of ships to consider the implications
[Safety issue] of this safety issue and take action where it is
considered appropriate.
• The ship’s crew did not adequately consider
the risks associated with either surveying MS20070010
the boiler, or painting the funnel top exhaust The surveyor did not check that the ship’s
pipes. [Safety issue] crew had implemented strategies that would
effectively control the risks associated with
• The placement of the steam vent pipe, and operating the boiler safety valves.
the direction in which it exhausted, meant
that any personnel on the funnel casing The ATSB advises surveyors to consider the
top platform were vulnerable when a boiler implications of this safety issue and take
safety valve operated. [Safety issue] action where it is considered appropriate.

6
Media Release
Crew member severely burned by steam
The ATSB has found that a lack of
communication, hazard awareness and job
safety analysis led to a seaman on board the
Panamanian registered container ship MSC
Sonia being severely burned by steam.

The Australian Transport Safety Bureau

investigation also found that the placement
of the boiler safety valve vent pipe, and the
direction in which it exhausted, meant that any
personnel on the funnel casing top platform
were vulnerable when a boiler safety valve
operated.

At about 0900 on 10 April 2007, a surveyor

arrived on board MSC Sonia to carry out a
scheduled boiler survey while the ship was
alongside Swanson Dock, Melbourne.

The ship’s chief engineer and the surveyor

went to the engine room and, after visually
inspecting the outside of the boiler; they tested
the safety cut-out devices. The surveyor then
asked for the operation of the safety valves to
be tested. The turbo-alternator was shut down
to reduce the steam demand and the boiler’s
two burners were fired manually. The steam
pressure started to rise and, at about 0945,
when the boiler pressure reached 11 bar, the
safety valves operated.

The ship’s boatswain and the ordinary seaman

had spent all morning on the top platform
of the funnel casing painting the main
engine exhaust pipes. At about 0945, steam
unexpectedly exhausted from the nearby boiler
safety valve vent pipe, directly onto the ordinary
seaman.

The ordinary seaman was severely burned by

the steam. He was assisted down the funnel
casing ladder and onto the bridge deck. While
he lay on the deck, the crew used a hose to
shower him with water to cool his burns.

At 1015, an ambulance team arrived on board

the ship and, by about 1100, the ordinary
seaman had been landed ashore, placed in the
waiting ambulance and taken to hospital.

The ATSB is pleased to report safety action

already taken and has issued one safety
recommendation and two safety advisory
notices with the aim of preventing similar
incidents.

7
 www.atsb.gov.au

1800 621 372

8
Aug2007/DOTARS 50330