Marine safety investigations & reports

Fire on board Iron Chieftain, Port Kembla, New South Wales on 18 June 2018

Investigation number:
Status: Completed
Investigation completed
Phase: Final report: Dissemination Read more information on this investigation phase


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Safety summary

What happened

On 18 June 2018, during cargo discharge operations while alongside at Port Kembla, New South Wales (NSW), a fire broke out in the internal cargo handling spaces of the self-unloading (SUL) bulk carrier Iron Chieftain.

The ship’s crew initiated an emergency response but shipboard efforts to control the fire were ineffective. The fire soon established itself and spread to the exterior of the ship, setting the discharge boom on deck alight. The ship’s crew were evacuated and shore firefighting services from Fire and Rescue New South Wales (FRNSW) took charge of the response to the fire. The fire was contained and eventually extinguished about 5 days after it started.

The ship sustained substantial structural damage, including breaches of two fuel oil tanks, and key components of the SUL system were largely destroyed. The ship was declared a constructive total loss and subsequently dispatched to be recycled. There were no serious injuries or pollution of the sea reported.

What the ATSB found

The ATSB investigation concluded that the fire originated in Iron Chieftain’s C-Loop space and was likely the result of a failed bearing in the ship’s conveyor system which created the heat necessary to ignite the rubber conveyor belt. The ATSB also determined that the ship did not have an emergency contingency plan for responding to fire in the ship’s SUL spaces and that there were technical failures of the ship’s alarm systems during the emergency response to the fire. Furthermore, some aspects of the shipboard response likely aided the fire’s development while others increased risk by removing shipboard capability.

The ATSB found that the risk of fire in Iron Chieftain’s C-Loop space was identified and documented by the ship’s operators, CSL Australia, as being unacceptable about 5 years before the fire. This risk rating was primarily due to the absence of an effective means of fire detection and fire suppression for the SUL system spaces. However, measures taken to address the risk were either inadequate or ineffective. Furthermore, the lack of adequate regulatory requirements or standards related specifically to the fire safety of SUL ships has been a factor in several fires, including Iron Chieftain. The ATSB also identified that the regulatory oversight of Iron Chieftain did not identify any deficiencies related to the safety factors identified by this investigation, or to the ship’s inherent high fire safety risk and management of that risk.

In addition, the ATSB identified a safety issue related to the marine firefighting capability of FRNSW as well as other safety factors related to the inconsistent conduct of ship’s drills and Port Kembla’s emergency response plans.

What has been done as a result

In response to this accident, the CSL Group (the parent company of the ship’s owners and managers—CSL Australia) initiated a fire risk mitigation project across its global fleet with the aim of:

  • improving fire detection and suppression technology
  • reviewing firefighting policy
  • setting minimum fire safety standards for early fire detection and suppression at the ship design and build stage.

The ship’s managers advised that linear heat detection systems and/or closed circuit television camera systems integrated with video analytics to provide or enhance the capability for early fire detection were installed on board six conveyor belt-equipped SUL ships operated by CSL Australia with installation of similar systems planned for a seventh ship. A CSL Australia-operated SUL ship with internal conveyor spaces was equipped with a Hi-Fog water mist fixed fire-extinguishing system covering the ship’s internal SUL spaces. In addition, one ship with external conveyor systems was equipped with a deluge system and installation of a deluge system is intended for at least one other ship. Additionally, ship‑specific emergency contingency plans for fires in the SUL spaces have been developed and implemented across the CSL Australia fleet.

The Australian Maritime Safety Authority (AMSA) and Lloyd’s Register have undertaken to approach the International Maritime Organization (IMO) and the International Association of Classification Societies (IACS) respectively, to raise the identified safety issue related to the inadequacy of fire safety standards or regulations for SUL system spaces. However, due to limited detail and a timeframe to seek resolution of the safety issue by the IMO, the ATSB has issued a safety recommendation to AMSA. The ATSB will continue to monitor the safety issue while actively working to highlight and promote awareness of the issue.

With respect to the regulatory oversight of SUL bulk carriers, AMSA has provided its inspectors and delegated organisations with updated guidance related to the focus of audits and inspections particularly with regard to the fire safety risk aspects associated with these ships. In addition, AMSA is progressing an inspection campaign concentrating on SUL bulk carriers operating in Australian waters, with a focus on fire safety and emergency preparedness.

Fire and Rescue New South Wales has advised that work is underway through the Australasian Fire and Emergency Service Authorities Council (AFAC) Working Group for Marine Firefighting to produce a nationally consistent approach to marine firefighting which will inform the development of new FRNSW standard operating guidelines. In addition, FRNSW continues to undertake familiarisation and training exercises to improve marine firefighting capability and awareness. While welcoming the safety action, the ATSB has issued a recommendation that FRNSW takes further action to address the safety issue related to marine firefighting capability.

The PANSW advised that the Port Kembla Marine Oil and Chemical Spill Contingency Plan and the Crisis Management Plan were to be updated to reflect the guidelines for responding to fires on a vessel as described in the NSW State Waters Marine Oil and Chemical Spill Contingency Plan.

In addition, the Memorandum of Understanding in relation to Hazardous Material Incidents on Inland and State Waters between Transport for NSW (NSW Maritime), FRNSW and the PANSW was being updated, with changes including specific handover arrangements being considered.

Safety message

The investigation into the fire on board Iron Chieftain has highlighted the inadequacy of fire safety regulations and standards for the cargo handling spaces on board self-unloading bulk carriers. The effectiveness of a shipboard response to a fire depends primarily on the ability to detect the fire at an early stage and quickly extinguish it at the source. Where it has been identified that the lack of such systems has resulted in the risk of a fire in a space being unacceptable, suitable control measures need to be implemented in order to reduce the risk to an acceptable level.

The introduction of mandatory minimum standards for suitable fire detection and extinguishing systems, to address the known high fire risk spaces of self-unloading bulk carriers, can significantly reduce the risk of major fires in these spaces. Additionally, the introduction of standards governing the fire resistance properties of conveyor belts used in shipboard systems can help reduce the likelihood of ignition in the first place.

Download Final report
[Download  PDF: 4.99MB]

The occurrence


Safety analysis


Safety issues and actions

General details

Sources and submissions


Safety Issues

Go to MO-2018-011-SI-01 - Go to MO-2018-011-SI-02 - Go to MO-2018-011-SI-03 - Go to MO-2018-011-SI-04 - Go to MO-2018-011-SI-05 -

Management of risk

Iron Chieftain's operators had formally identified the fire risk in the ship’s cargo self-unloading system spaces, particularly the C-Loop, as being unacceptably high 5 years before the fire due to the absence of fire detection or fixed fire extinguishing system. However, at the time of the fire, the prevention and recovery risk mitigation measures had not reduced the risk to an acceptable level.

Safety issue details
Issue number: MO-2018-011-SI-01
Status: Closed – Adequately addressed

Inadequate standards and regulation

The cargo handling spaces of specialised self-unloading bulk carriers continue to present a very high fire risk due to the inadequacy of standards or regulations for self-unloading systems, including for conveyor belts, and dedicated fire detection/fixed fire-extinguishing systems. This has been a factor in at least three major fires over a 25-year period, including Iron Chieftain’s constructive total loss.

Safety issue details
Issue number: MO-2018-011-SI-02
Status: Open – Safety action pending

Shipboard emergency contingency plans

Iron Chieftain's Emergency Contingency Plan did not include a response plan to fire in the high fire risk self-unloading system spaces. Consequently, there was no clear plan or practiced sequence of actions that could aid emergency preparedness.

Safety issue details
Issue number: MO-2018-011-SI-03
Status: Closed – Adequately addressed

Fire and Rescue New South Wales marine firefighting capability

The capability of Fire and Rescue New South Wales to effectively respond to a shipboard fire in Port Kembla, was limited by:

  • a lack of specialised marine firefighting expertise
  • outdated marine training for firefighters
  • relative inexperience in shipboard firefighting associated with the rarity of major shipboard fires
  • an absence of marine-specific firefighting resources and aids for use by first responders.
Safety issue details
Issue number: MO-2018-011-SI-04
Status: Open – Safety action pending

Regulatory oversight

Regulatory safety oversight of Iron Chieftain, which comprised flag State audits, surveys and inspections had not identified safety deficiencies with respect to the ship’s fire safety, risk management, emergency preparedness and emergency response.

Safety issue details
Issue number: MO-2018-011-SI-05
Status: Closed – Adequately addressed
General details
Date: 18 June 2018   Investigation status: Completed  
Time: 0300 EST   Investigation level: Systemic - click for an explanation of investigation levels  
Location   (show map): Berth 113, Port Kembla,   Investigation phase: Final report: Dissemination  
State: New South Wales    
Release date: 11 May 2021   Occurrence category: Accident  
Report status: Final   Highest injury level: None  

Vessel details

Vessel details
Operator CSL Australia  
Vessel Iron Chieftain  
Flag Australia  
IMO 9047740  
Sector Bulk carrier  
Type of operation Cargo  
Departure point Ardrossan, South Australia  
Destination Port Kembla, New South Wales  
Last update 11 May 2021