Poorly implemented hot-work precautions led to fire on general cargo ship

The Transport Accident Investigation Commission (TAIC) of New Zealand has published an investigation report on the general cargo vessel Kota Bahagia, which experienced a fire in the cargo hold forcing the crew to evacuate the ship.

At about 0648 on 18 December 2020, two fitters from a local engineering company commenced hot works 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 nacelles at the aft end.

Specifically, the fitters’ task was to remove the cargo stoppers that had been welded to the ‘tween deck pontoons 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.

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 spreader 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 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.


TAIC 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.

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. 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.

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.

– 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.
– 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.
– 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.

Download the report: TAIC Kota Bahagia Report

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