BBC Rhonetal’s managers had not effectively implemented the shipboard safety management system procedures in place to prevent the fire. This was the tenth such fire on a company ship in the past 14 years, and the fourth investigated by the ATSB, identifying similar contributing factors.
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.
The capability of Fire and Rescue New South Wales to effectively respond to a shipboard fire in Port Kembla, was limited by:
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.
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.
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.
No procedure or system was in place to ensure critical spares were identified and their inventory controlled to ensure availability when required. As a consequence, the fan belts for the emergency generator had been on order for several months.
The ship’s manager’s (Yang Ming) cargo-planning process ashore did not ensure that the proposed container stowage plan complied with the stowage and lashing forces requirements of the ship's Cargo Securing Manual. Consequently, compliance with these requirements relied entirely on shipboard checks, made at a late stage, with limited options available for amendments without unduly impacting commercial operations.
Tugs were to be available to escort the mini cape-size ships until they had entered the South Channel, where they were stood down. However, the tug masters had not been trained in the specifics of escort towage nor in emergency response.
In pre-trial simulations, the risks associated with engine failure during departure were only considered up to when a ship had entered the South Channel. Consequently, the tugs were not in attendance to assist if propulsion was lost.
The fall arrest equipment used was incorrectly attached to the workers on the suspended platform. Consequently, had either of them fallen from the platform the equipment would not have worked correctly, resulting in serious or fatal injuries.
The hydrographic use of point feature objects to represent physical features of relatively significant spatial extent on an Electronic Navigational Chart can increase the risk of the hazard posed by such features being misinterpreted by mariners and potentially reduce the effectiveness of the ECDIS safety checking functions.
ECDIS on board most Australian Border Force cutters, including ABFC Roebuck Bay, operated with a non-type-approved naval software version that was not updated to the latest applicable standards of the International Hydrographic Organization. The ECDIS therefore did not comply with the minimum requirements of an ECDIS being used to meet the chart carriage requirements of the regulations. As a result, the enhanced safety features of the new presentation library, which would have potentially alerted the officers to the danger posed by the reef, were not available.
Most Australian Border Force cutters, including ABFC Roebuck Bay, were installed with ECDIS operating on non-type-approved naval software. Subsequently, DNV GL, acting on behalf of the Australian Maritime Safety Authority, incorrectly certified these vessels as using type-approved ECDIS to meet the chart carriage requirements of the regulations. This removed an opportunity to put in place controls to ensure ongoing safety compliance.
Although the online VisionMaster FT ECDIS type-specific familiarisation training included the relevant content, the training as undertaken by Australian Border Force deck officers was not effective in preparing ABFC Roebuck Bay's officers for the operational use of the ECDIS.
Guidelines for the provision, care and use of shipboard equipment were not supported by suitable documentation. The only documentation was for mobile scaffolding equipment of different design and not for that in use on the ship.
The regional harbour master and the pilotage service did not have processes in place to follow up audit findings, to ensure that they were appropriately monitored, actioned and closed out in a timely manner.
The Port Procedures manual for Townsville allowed shipping agents to request a tug reduction without the knowledge of the ship’s master.
The Port of Townsville Limited Pilotage Services’ Pilotage Service Safety Management System did not have documented guidance on berthing manoeuvres nor any associated contingencies.
The Port of Townsville Limited Pilotage Service risk management processes were not sufficiently mature nor resilient enough to effectively identify and mitigate risks during pilotage.