New Zealand’s TAIC published its investigation report on the general cargo vessel Kota Bahagia, that experienced a fire in the cargo hold, making the crew to evacuate the ship immediately.
The incident
At 1700 on 17 December 2020, the Kota Bahagia berthed alongside at Wharf 4, Napier Port, New Zealand. The cargo for discharge at Napier included wind turbine components that had been carried from Taicang, China.
Shore-based staff, including stevedores1 and fitters from a local engineering company, boarded the vessel to commence unlashing the cargo in preparation for discharge.
Cargo-discharge operations commenced at 2212 and continued overnight.
At about 0648 on 18 December 2020, two fitters from a local engineering company commenced hot work3 in number 2 cargo hold ‘tween deck. The number 2 ‘tween deck cargo consisted of nine 40-foot (12-metre) containers at the forward 5 end and six wind turbine nacelles6 at the aft7 end.
Specifically, the fitters’ task was to remove the cargo stoppers8 that had been welded to the ‘tween deck pontoons9 for securing the cargo. The removal of the cargo stoppers required oxygen/acetylene gas-cutting. One of the fitters carried out the cutting operations. The other watched for stray sparks and ejections of hot material, and placed the offcuts in a steel bucket after cooling them with water from a portable fire extinguisher.
The master and the harbour master had issued permits allowing this hot work to take place. The fitters had completed their own job safety analysis prior to the vessel’s arrival.
At about 0942, stevedores commenced discharging containers from number 2 cargo hold. Two stevedores were located inside number 2 cargo hold and one stevedore was driving the vessel’s crane. After discharging four containers, the stevedores took their morning-tea break. No containers were discharged between 1000 and 1030. During this time the master of the Kota Bahagia conducted rounds of the deck and found that all was quiet. The master did not see anybody in number 2 cargo hold. However, the fitters had remained in the cargo hold to finish cutting off the remaining cargo stoppers while the stevedores were on their break.
After resuming cargo operations and discharging one container, one of the stevedores, who was standing next to the remaining containers, noticed white smoke in number 2 cargo hold. The two stevedores and two fitters in the hold discussed whether it was dust or smoke. The fitters had completed their work in the ‘tween deck and were stowing the gas-cutting equipment so that it could be removed from the cargo hold. Shortly afterward, one of the stevedores repeated that it could be smoke. At about 1039, as the crane driver returned the container spreader11 to the cargo hold, the smoke turned black and thickened and the workers in the cargo hold realised there was a fire. Within 10 to 20 seconds the smoke became very thick and the workers in the cargo hold had to pass in close proximity to the fire to get out of the hold.
By 1043 all the workers were out of the cargo hold and the crane driver had stopped the crane, called “fire” over the radio and vacated the crane cab. They all went down to the quay and headed towards the designated muster point for shore-based staff.
The deck cadet, who was on gangway duty, called the chief officer on the radio to report that there was smoke coming from number 2 cargo hold. The chief officer, who was on deck directing the crew as they removed the pontoons from number 4 cargo hold, told the cadet to activate the fire alarm. The master, who had been resting in the master’s cabin, heard an alarm sounding on the bridge at about the same time. The master went to the bridge to investigate the cause of the alarm and saw that the cargo hold smoke-detection system had been activated.
The chief officer went forward, towards number 2 cargo hold, and saw workers who were not crew members running aft towards the gangway. The cargo superintendent was the only other person on deck near number 2 hatch whom the chief officer noticed. The chief officer asked the cargo superintendent if the shore workers had all gone ashore and determined that there were no workers left inside number 2 cargo hold.
By 1045 thick black smoke was visible coming out of number 2 cargo hold and the vessel’s fire alarm was ringing. The chief officer and the cargo superintendent started to rig fire hoses on deck while the vessel’s crew assembled at their emergency muster stations. The Kota Bahagia’s fire response plan designated the crew into five emergency parties with assembly points on the bridge, the engine control room and on deck in front of the accommodation. The crew who assembled on deck made up three of the emergency parties – two firefighting parties and one first-aid party. Once the crew had assembled in their respective emergency parties, the master co-ordinated the initial fire response actions to determine the extent of the fire and the best way to suppress it.
Analysis
#1 Hot work on board
Following the extinction of the fire, number 2 cargo hold and its contents were examined forensically. Burn patterns and damage comparisons provided indicators of the location of the fire’s origin. The most damage was sustained on the ‘tween deck, with mainly heat and smoke damage in the lower hold.
The nacelle that was stowed athwartship32, port side, at the aft end of the ‘tween deck sustained the most damage (see Figures 13 and 14) and it is very likely that the fire originated either underneath this nacelle or between the nacelle and the side of the cargo hold. The presence of clean burn33 on the side of the cargo hold showed that the fire was so hot in this location that the soot deposits were burnt off.
The Transport Accident Investigation Commission (Commission) engaged the services of a specialist fire investigator to complete a report on the origin and cause of the fire. The fire investigator’s conclusion was that the most likely ignition sequence was a hot slag bead from the gas-cutting igniting the sawdust from the dunnage that was used between the cargo and the steel deck, resulting in a smouldering fire.
#2 Safety precautions and the permit-to-work system
The vessel operator had a permit-to-work system in place, which covered high-risk activities that required additional safety assessments and additional safety measures. Hot work is considered high risk as it includes the use of welding, burning or soldering equipment and power tools that generate sparks. It was included in the list of activities that the operator considered to be high risk and there was a section in the Safety and Emergency Manual that provided specific instructions for carrying out hot work safely.
To complete a permit-to-work, one or more checklists must be completed. The checklists used on board the Kota Bahagia contained a series of steps to ensure that a risk assessment was carried out and that safety control measures were in place before hot work was allowed to commence. PIL’s safety management system included the following procedures:
- The Chief Officer or Second Engineer shall conduct safety checks and submit the completed checklist (S-02(1) and S-02(2), as revised) to the Master or Chief Engineer confirming that the work to be carried out satisfies the safety requirement.
- Upon approval, the Master or Chief Engineer signs the application and instruct the Chief Officer or Second Engineer to ensure and monitor the safety requirements.
- While in port, local regulations should be strictly followed, including the seeking of permission from the Port Authorities.
#3 Co-ordinated incident response
Under New Zealand’s Health and Safety at Work Act 2015, an employer must ensure, so far as is reasonably practicable, the health and safety of its workers while at work. The nature of a port environment means that multiple organisations, of which each has its own safety management system, have to work alongside the framework of the port’s health and safety management system. When an emergency situation arises on board a foreign-flagged vessel, the vessel’s own safety management system and its emergency procedures also need to be taken into account.
Fire and Emergency NZ responded to the request for assistance from the master and the port. Responding to maritime incidents is an additional function37 for Fire and Emergency NZ that it performs only to the extent that it has the capability and capacity to do so without compromising its ability to perform its primary functions. Its primary functions 38 include:
- Providing fire prevention, response and suppression services.
- Stabilising and rendering safe incidents that involved hazardous substances.
- Rescuing persons who were trapped as a result of transport accidents or other incidents.
Conclusions
Molten material, ejected during gas-cutting activities, very likely ignited dry sawdust nearby, which created a smouldering fire that ignited the polyvinyl-chloride tarpaulins and other combustible components of the fibre-glass project cargo.
Hot-work precautions, such as crew supervision and the readiness of firefighting equipment, were not fully implemented.
The tight stowage of the project cargo made it difficult for the fitters to control the ejection of hot slag beads and sparks and hampered the view and access of the person assisting with the gas-cutting operations.
Fire and Emergency New Zealand responders did not initially give due regard to the master’s command status and knowledge of the ship and its systems.
The vessel’s carbon dioxide fire-suppression system could not be activated until the cargo hold was closed and sealed. However, the hatch cover could not be closed until the crane wire and container spreader were hoisted out of the hold.
In addition, at the time of the incident the ship’s crew did not implement the requirements set out in PIL’s safety management system and the harbourmaster’s hot-work permit, or ensure the safe execution and supervision of hot work carried out by shore-based contractors on board the vessel.
Moreover, at the time of the incident PIL’s safety management system did not ensure a safe execution of hot work by shore-based contractors.
In addition, the suppression of the fire was delayed because the various parties involved did not have a shared and consistent understanding of each other’s roles and objectives.
Lessons learned
- A risk assessment for hot work should give particular consideration to the contents of and any constraints in the area where the hot work is to be carried out. The risk assessment should be applied systematically and then monitored to ensure compliance.
- A shipboard fire response is based on the vessel’s design, fire protection systems and crew numbers. Shore-based firefighting assistance and incident management systems should enhance and support the response made by the ship’s crew, not erode it.
EXPLORE MORE AT TAIC’S REPORT ON KOTA BAHAGIA
