Hot-work precautions were not fully implemented by the ship's crew.
One of the two recommendations from the report was that ship operator Pacific International Lines take further steps to ensure the safety precautions prescribed in its Safety and Emergency Manual are implemented effectively on board its vessels.
The commission reiterated two recommendations it made in 2018 to Fire and Emergency New Zealand (Fenz) following a ship fire at Tauranga.
Acting chief investigator of accidents Naveen Kozhuppakalam said that responding to the blaze, Fenz took charge of the unified command team – the ship's crew, Fenz firefighters and the port authorities. The ship's master followed Fenz's orders and evacuated people from the ship.
But "valuable time" was lost because Fenz staff didn't initially give due regard to the master's command status and knowledge of the ship and its systems, Kozhuppakalam said.
"The ship's master knew that the crucial firefighting tactic was to close the cargo hold cover and release carbon dioxide into the hold," he said, adding that the master tried to convey the tactics to the Fenz officer in charge.
"To close the cover, the crew needed to go back on board to hoist a crane wire and container spreader out of the hold.
"The commission found that suppression of the fire was further delayed because the parties involved lacked a shared and consistent understanding of each other's roles and objectives," Kozhuppakalam said.
The response to the fire on the Kota Bahagia revealed safety issues similar to those identified by the commission in its November 2018 report on a fire on the Kokopo Chief at Port of Tauranga.
Accepting TAIC's recommendations in that report, Fenz indicated it would complete reviews in 2019, but the reviews had not been finished by the time of the Napier incident.
"To completely implement the commission's 2018 recommendations, Fire and Emergency NZ needs to urgently update its training regime to include the latest procedures and guidance for fighting fire on board ships," said Kozhuppakalam.
Kozhuppakalam said the commission welcomed Fire and Emergency's safety actions so far, which include new documents that cover the status and authority of the master; new procedures for fighting fires on ships; and work with ports to formalise firefighting collaboration.
While the commission identified no safety issues with Napier Port's response to the Kota Bahagia fire, it welcomed Napier Port's proactive safety actions, with fire hydrants and firefighting equipment having distinctive new markings, and the port's strengthened relationship with Fenz including formalised firefighting tactics, site orientation and emergency simulation exercises.
The 161-metre Kota Bahagia, launched in 2011 and under the Singapore flag, had significant damage, including the twisting of steel.
Declared seaworthy again, it was in port for two months before the last of the cargo was unloaded, some of it undamaged, and the ship sailed abroad for repairs and being restored to service.