No Burst opening

Accident Year / Place Contributory FactorSubcontributory Factor Linearity

of steam
6 1990 / HK EE ME L
manifold end
plate
Burst opening
7 of steam 1990 / HK EE ME L
manifold end
plate

Carbon
44 monoxide 2008 / USA EE ME L
release

Carbon
48 monoxide 2001 / Canada EE ME L
release

8 Casualty 1989 / HK HE ME L

15 Collapse of
boiler furnace 1985 / HK EE, HE ME NL

18 Collapse of
boiler furnace 1976 / HK EE ME L

2 Explosion 1995 / HK HE, EE ME NL

9 Explosion 1988 / HK EE ME L

13 Explosion 1988 / HK EE ME L

14 Explosion 1985/ HK HE ME L
17 Explosion 1976 / HK EE ME L

19 Explosion 1971 / HK EE, HE ME NL

22 Explosion 2000 / USA EE ME L

23 Explosion 1997 / USA HE EE L

24 Explosion 1991 / USA EE ME L

25 Explosion 2000 / USA EE, HE ME L

26 Explosion 1990 / USA EE ME, HE NL

28 Explosion 2002 / France EE HE, ME NL

29 Explosion 2004 / France EE HE, ME NL

32 Explosion 2000 / France HE ME L

33 Explosion 2001 / USA HE ME L

34 Explosion 2000 / USA HE ME L

35 Explosion 1970 / USA HE ME L

37 Explosion 2001 / USA HE ME L

40 Explosion 1989 / USA EE ME L

42 Explosion 2001 / USA HE ME L

43 Explosion 2000 / USA EE ME L

45 Explosion 1994 / France HE ME L

46 Explosion 2008 / USA EE ME L

47 Explosion 2000 / Canada HE ME L

49 Explosion 2000 / Canada HE ME L

50 Explosion 1981 / Canada HE ME L

30 Explosion, Fire 1990 / France HE ME L

1 Fire 1995 / HK HE EE L

3 Fire 1991 / HK EE ME L

4 Fire 1991 / HK EE HE, ME NL

12 Fire 1988 / HK EE ME L

16 Fire 1984 / HK EE ME L

31 Fire 1999 / France HE ME L

27 Fuel Oil Spillage 1984 / USA EE ME L

38 Fuel Oil Spillage 1998 / USA HE ME L

39 Fuel Oil Spillage 1987 / USA EE ME L

21 Furnace 1993 / HK EE ME L
blowback

11 hot fluid 1988 /HK EE, HE ME NL

discharged

36 Rupture 2003 / USA EE ME L

41 Rupture 1980 / USA EE ME L

Steam and hot
5 water rushed 1990 / HK HE, EE ME NL
out
10 steam blown 1988 / HK EE ME L
of

20 Thermal oil 1994 / HK DE, HE ME NL

leakage

51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
Injuries Fatalities Extra Info proper maintenance,
Prevention engage
/ Reccommendation
competent person, register boiler
0 1 under boiler & pressure vessel
authority
engage boiler inspector to
1 0 examine piping system

proper maintenance, provide

0 0 sufficient equipment

Operate at optimal operating

2 0 condition, instill proper working
culture

proper maintenance, provide

training, engage competent
0 1 person, proper operating
procedures & safety precaution
should be displayed properly

proper maintenance, regularly

0 0 check water level in boiler

boiler inspector should test all

severe furnace
0 0 damage and rupture safety protection devices, proper
maintenance
extensive damage to hire competent person, proper
0 0 the premise maintenance

do not tamper with boiler

pressure part without prior
approval, engage competent
serious damage to person, provide suitable pressure
0 1 the premise reducing valve, provide safe
operating procedure, efective
logging and report keeping
system should be introduced

servicing should be done by

competent person, proper
maintenance, engage adequate
1 0 competent person, remind
competent person to comply
with safe working and operating
procedures

severe damage to
0 0 boiler
 severe furnace boiler inspector should test all
0 0 damage safety protection devices
regular examination and
4 1 maintenance

0 2

1 0
2 0 Proper maintenance
Proper operating procedure,
1 2 provide training to operator
Installation should be done by
1 1 expert
Appropriate material selection,
0 0 operate at correct operating
condition
operate at correct operating
0 0 condition
Provide training, hire competent
2 0 person
Provide training, hire competent
2 3 person, provide safe operating
procedure

Provide emergency procedure at

1 2 accessible place, provide training,
hire competent person

1 1 Provide training

Provide training, hire competent

1 0 person

0 0 Proper maintenance
provide training, hire competent
0 3 person

0 1 Proper maintenance

hire competent person, provide

1 2 training
proper maintenance, schedule
10 0 inspection
provide information on rules and
1 0 regulation
provide training, instill proper
0 0 working culture
 provide information on rules and
1 0 regulation, installation should be
done by competent person

6 0

1 0 do not left boiler unattended

minimal damage to proper maintenance, rectify fuel

0 0 the boiler oil leakage
minimal damage to proper maintenance, replace
1 0 the boiler defective fuel valve

proper maintenance, kept boiler

room in clean condition, don't
0 0 leave boiler under steaming
unattended

fan motor and do not operate without the direct

0 0 electrical cable were supervision of the Competent
severely damaged person, proper maintenance

0 0

2 0 Proper maintenance

provide training, hire competent

1 1 person

2 0 Proper maintenance

do not operate without the direct

2 0 supervision of the Competent
person, proper maintenance

servicing should be done by

competent person, proper
maintenance, engage adequate
1 1 competent person, remind
competent person to comply
with safe working and operating
procedures

Provide training & safety

0 0 information
4 2 Proper maintenance
hire competent person, proper
0 1 maintenance, provide training for
boiler operator
 ensure the boiler comply with
Boiler and Pressure Vessel
1 0 Ordinance, ensure correct setting
of safety valve, proper
maintenance

do not operate without the direct

1 0 supervision of the Competent
person, proper maintenance

55 26
Source

US Department of Labor

Columbia Safety Authority

United States Department
of Labor

ARIA

The Commonwealth of
Massachusetts

The National Board of Boiler

ARIA

US Department of Labor

Columbia Safety Authority

Columbia Safety Authority

Columbia Safety Authority

Hong Kong Department of

Labor
 Boiler Failure Incident Pattern

Contributory Factors

Human Error Equipment Design Error Contributory Factors of Boiler Incident

(HE) Error (EE) (DE)
24 32 1
42.11% 56.14% 1.75%

Human Error (HE) Equi pment Error (EE) Des ign Error (DE)

Sub-Contributory Factors

Management Human Equipment

Error (ME) Error (HE) Error (EE) Sub-Contributory Factors of Boiler Incident
48 3 2
90.57% 5.66% 3.77%

Ma nagement Error (ME) Huma n Error (HE)

Equi pment Error (EE)
Cases

Carbon
monoxide Type of Incident
release 2 30
25
20
15
10
5
 Type of Incident
30
25
Collapse of 20
boiler furnace 15
3 10
Explosion 27 5
Fire 7 0
se ce on re ge ck d re
a na i Fi a ba rge tu
Fuel Oil Spillage le ur os ill a p
ow
n
re f pl p ow c h R u
4 de er Ex il
S bl di
s bl
i il O ce am
ox o l
na ui
d
Furnace on o fb Fu
e
ur t fl ste
m F
blowback 1 on ps
e ho
a rb lla
hot fluid C Co
discharged 1
Rupture 2
steam blown
of 4

Severity of
Incident Severity of Incident

Injury Death
55 26
Death
67.90% 32.10%

Injury

0 10 20 30 40 50 60
Linearity

Linear Non-linear
40 10 Linearity Between Contributory and Sub-contributory Factor
80.00% 20.00%

Li near Non-l i nea r

Li near Non-l i nea r
iler Incident

) Des ign Error (DE)

Boiler Incident

ma n Error (HE)

ent
ent

ck d re of
ba a rge ptu n
ow sc
h R u ow
bl di bl
ce d am
ui ste
t fl
ho

40 50 60

-contributory Factor