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.
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