Root Cause Analysis of the Fire Incident at Shahid Rajaee Port Using the Fishbone (Ishikawa) Method: A Case Study from Bandar Abbas, Iran

Abstract

The fire and explosion at Shahid Rajaee Port in April 2025 represent a critical industrial incident with significant human, operational, financial, and environmental consequences. This study applies the Fishbone (Ishikawa) method to systematically identify the root causes of the event, based on interviews with port operators, safety experts, and emergency responders. Six main categories of contributing factors were examined: Human, Machine/Equipment, Materials, Methods/Processes, Environment, and Management. Findings reveal that inadequate staff training, fatigue, and poor communication, combined with equipment failures, improper hazardous material storage, weak operational procedures, adverse environmental conditions, and a weak safety culture, collectively created the conditions for the disaster. The analysis underscores that such incidents are rarely the result of a single failure but emerge from the interaction of multiple systemic vulnerabilities. Based on these findings, the study recommends continuous workforce training, systematic preventive maintenance, rigorous hazardous material management, standardized operational and emergency procedures, infrastructure improvements, and strengthened organizational governance to enhance resilience and reduce the likelihood of similar events. This research provides a comprehensive framework for port authorities and policymakers to implement integrated risk management strategies, emphasizing the need for a holistic approach that addresses technical, human, and organizational dimensions of safety.