Flare launched withfatal consequences
On the night of 1 January 2023, on board a Dutch sailing ship in the Pacific Ocean, a crew member died while firing a flare. The flare was fired as instructed, but was not launched as intended in the process. The flare exploded immediately.
On 19 January 2023, the Safety Board, in consultation with the Spanish manufacturer, issued a warning and called on all owners of the Red Rocket Parachute flare L-35/ L-35A (Pirolec) not to use this flare anymore
The investigation focuses primarily on the failure of the flare.
Blind spots in production process
The process of making flares can be improved. The report ‘Flare launched with fatal consequences’ concludes that. The lessons from the report are based on the incidence from new year’s eve 2023. That night someone got fatally injured after using a flare.
The Dutch Safety Board conduced in its investigation that the pressure inside the flare was too high. This build-up of extreme, excessive pressure, causing the flare to burst open explosively. That may have happened due to the matter inside the flare that was burning excessively.
Recommendations
Based on the findings of this investigation, there are lessons to be learned. The Dutch Safety Board has observed that there are gaps in the production process. The fact that an accident has not previously occurred with this type of flare means that it cannot be generically stated that there was a clear system deviation in production. Since an accident has now occurred and given the importance of air temperature and humidity in the phase of filling and pressurizing the engines with mixture that ultimately forms the solid propellant, the Dutch Safety Board makes the following recommendations:
To Lecea as the manufacturer of the Pirolec flare:
- Integrate control measures into the production process to prevent the prepared mixture from being exposed to excessive ambient temperatures and/or excessive humidity for too long.
- Integrate control measures into the process to ensure that the cardboard inlay is always present in the motor unit.
To Lloyd’s Register Marine Deutschland as the notified body.
- Verify whether the working method and the prescribed quality steps, on the basis of which the type approval for this type of flare was issued, are still valid. Include monitoring of air temperature and humidity in the elaboration of this recommendation.
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